KAISER PERMANENTE OF GEORGIA MULTI-CHOICE FORMULARY

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1 KAISER PERMANENTE OF GEORGIA MULTI-CHOICE FORMULARY This document includes Kaiser Permanente Georgia s Multi-Choice formulary as of March 15, 2017 For an updated formulary, please visit our website at members.kp.org or call , Monday through Friday 7:00 a.m. to 7:00 p.m. TTY/TDD users should call

2 What is the Kaiser Permanente MultiChoice Formulary? A formulary is a list of drugs determined to be safe and effective for our members by our Pharmacy and Therapeutics committee. Use of the formulary enables Kaiser Permanente to provide optimal care to you and your family at reasonable costs. Kaiser Permanente continually updates the formulary throughout the year based on new medical evidence, considering the recommendations of appropriate physician experts. Our physicians and pharmacists work closely together to ensure that our formulary meets your needs. This formulary is only for use at PPO Provider (Tier 2) and Non-Participating Provider (Tier 3) pharmacies. To see which medications are covered at a Select Provider (Tier 1) pharmacy, please reference the Kaiser Permanente HMO Formulary. Does the formulary ever change? Yes, Kaiser Permanente periodically updates the formulary based on new medical evidence, considering the recommendations of appropriate physician experts and notifies our doctors, pharmacists, and other clinicians about any changes. If a change in the formulary affects any of your prescriptions, your doctor or pharmacist will let you know. The enclosed formulary is current as of March 15, 2017 and represents the most commonly prescribed medications. To get updated information about the drugs covered by Kaiser Permanente, please visit our website at members.kp.org or call Member Services at , Monday through Friday 7:00 a.m. to 7:00 p.m. TTY/TDD users should call How do I use the Formulary? There are two easy ways to find your drug within the formulary: Medical Condition The drug list begins on page 4. The drugs on this formulary are grouped into categories depending on the type of medical condition 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, simply look for the category name in the list that begins on page 4. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you can look for the drug in the Index that begins on page 41. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to the 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 on the list. You may also use the search function on your computer to search this document for the medication by name. **All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary, check with your Kaiser Permanente pharmacist for Kaiser Permanente of Georgia Multi Choice Formulary 1

3 What are generic drugs? Kaiser Permanente covers both brandname drugs and generic drugs. Brand name drugs are drugs that are produced and sold under the original manufacturer s name. drugs are produced and sold under their chemical names after the patent of the brand name drug expires. Although the price is lower, the quality and effectiveness of generic drugs is the same as brand name drugs. The Federal Food and Drug Administration (FDA) requires that generic drugs contain the same active ingredients in the same amount as the brand name drug. drugs are listed in lower-case italics (e.g., amoxicillin) within the formulary on page 4. If a drug is available as a generic, it is only listed with the generic name. Brand-name drugs are capitalized in the formulary (e.g., FLOVENT). Generally, if a drug is available generically, the generic is on Tier 1 and the brand Tier 3. Because all drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed. How much will I pay for Covered Drugs? What you pay for covered drugs is determined by the outpatient prescription drug benefit outlined in your Evidence of Coverage. Multichoice plans have a three tier open formulary benefit. Open formulary benefits have a generic cost sharing requirement. This means that if you fill a brand name drug when a generic is available, that in addition to your standard copayment or coinsurance, you will also pay the difference in cost between the brand name and generic drug. s are those covered at the lowest co-payment amount defined as Tier 1. Preferred brands are those brands which will be covered at your preferred brand copayment amount defined as Tier 2. Nonpreferred brands are covered at the nonpreferred co-payment defined as Tier 3 coverage amount. Coverage for prescription drugs is limited to drugs for which a prescription is required by law and those that are listed on the Kaiser Permanente MultiChoice drug formulary. Certain diabetic supplies do not require a prescription, but must still be listed in our formulary in order to be covered under the benefit. Each prescription refill is provided on the same basis as the original prescription. Copayments are applied on a per prescription basis, for up to the lesser of the dispensing amount listed in the Schedule of Benefits or the standard prescription amount. The standard prescription amount for the following items is: Migraine medications the smallest package size commercially available Ophthalmic and otic medications the smallest package size commercially available Oral and nasal inhalers the smallest standard package unit **All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary, check with your Kaiser Permanente pharmacist for Kaiser Permanente of Georgia Multi Choice Formulary 2

4 Are there any other restrictions on coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Quantity Limits (QL): For certain drugs, Kaiser Permanente limits the amount of the drug that will be covered. Age Restriction (Age): For certain drugs, Kaiser Permanente limits coverage based on a designated age. Criteria Restricted Medication (QRM): For certain drugs, Kaiser Permanente requires review and authorization prior to dispensing. Your Provider must obtain this review and authorization. The list of prescription drugs requiring review and authorization is subject to periodic review and modification by our Pharmacy and Therapeutics Committee. looking in the formulary that begins on page 4. What if my drug is not on the Formulary? You can contact Member Services at , Monday through Friday 7:00 a.m. to 7:00 p.m. TTY/TDD users should call and ask Member Services for a list of similar drugs that are covered or MedImpact at MedImpact. 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 Kaiser Permanente, please call Member Services at , Monday through Friday 7:00 a.m. to 7 p.m. TTY/TDD users should call Or visit members.kp.org. You can find out if the drug has any additional requirements or limits by **All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary, check with your Kaiser Permanente pharmacist for Kaiser Permanente of Georgia Multi Choice Formulary 3

5 Restrictions Tier Name Brand Name Coverage Status Antihistamine Drugs Antihitamine Drugs 1 carbinoxamine maleate PALGIC 1 cyproheptadine PERIACTIN 1 chlorphenirmine, phenylephrine & pyrilamine POLY HIST FORTE 1 promethazine & phenylephrine PHENERGAN VC QL 1 promethazine PHENERGAN Anti-infective Agents Anthelmintics 2 albendazole ALBENZA Preferred Brand 1 ivermectin STROMECTOL 3 ivermectin SOOLANTRA Anti-infetives, Miscellaneous 3 bismuth subcitrate & metronidazole PYLERA 3 metronidazole, tetracycline & bismuth HELIDAC subsalicylate Antibacterials 1 amoxicillin AMOXIL 1 amoxicillin & clavulanate potassium AUGMENTIN 1 amoxicillin & clavulanate potassium extended-release AUGMENTIN XR 1 ampicillin sodium AMPICILLIN 1 azithromycin ZITHROMAX 1 cefaclor CECLOR 1 cefadroxil DURICEF 1 cefdinir OMNICEF 1 cefditoren SPECTRACEF 3 cefixime SUPRAX solution 1 cefixime SUPRAX 1 cefpodoxime VANTIN 1 cefprozil CEFZIL 3 ceftibuten CEDAX 1 cefuroxime axetil CEFTIN 1 cephalexin KEFLEX 1 ciprofloxacin CIPRO 1 clarithromycin BIAXIN 1 clarithromycin extended-release BIAXIN XL 1 clindamycin hcl CLEOCIN HCL 1 clindamycin palmitate CLEOCIN PEDIATRIC 1 demeclocycline DECLOMYCIN 1 dicloxacillin DYNAPEN 3 doxycycline ORACEA Kaiser Permanente of Georgia Multi Choice Formulary 4

6 1 doxycycline hyclate PERIOSTAT 3 doxycycline hyclate DORYX 1 doxycycline monohydrate ADOXA 1 doxycycline monohydrate MONODOX 1 erythromycin & sulfisoxazole E.S.P 1 erythromycin base ERYTHROMYCIN 1 erythromycin base delayed-release ERY-TAB 1 erythromycin ethylsuccinate E.E.S. 3 erythromycin ethylsuccinate ERYPED 3 erythromycin sterate ERYTHROCIN 3 fidaxomicin DIFICID 3 gemifloxacin FACTIVE 1 gentamicin sulfate GARAMYCIN 1 levofloxacin LEVAQUIN 1 linezolid ZYVOX 1 minocycline DYNACIN 1 minocycline MINOCIN 1 minocycline SOLODYN 1 moxifloxacin AVELOX 1 neomycin sulfate MYCIFRADIN 3 norfloxacin NOROXIN 1 penicillin v potassium PEN-VEE K 3 rifaximin XIFAXAN 1 sulfadiazine SULFADIAZINE 1 sulfamethoxazole & trimethoprim BACTRIM DS 1 sulfamethoxazole & trimethoprim SEPTRA 1 sulfasalazine AZULFIDINE 3 tedizolid SIVEXTRO 3 telithromycin KETEK 3 tetracycline TETRACYCLINE 3 tobramycin inhalation powder TOBI PODHALER 1 tobramycin inhalation solution TOBI 1 vancomycin hcl VANCOCIN HCL Antifungals 3 efinaconazole JUBLIA QL 1 fluconazole DIFLUCAN 1 flucytosine ANCOBON 1 griseofulvin microsize GRIFULVIN V 1 griseofulvin ultramicrosize GRIS-PEG 3 isavuconazonium CRESEMBA 1 itraconazole SPORANOX 2 itraconazole (solution) SPORANOX Preferred Brand 1 ketoconazole NIZORAL 3 luliconazole LUZU 1 nystatin MYCOSTATIN 3 posaconazole NOXAFIL Kaiser Permanente of Georgia Multi Choice Formulary 5

7 3 tavaborole KERYDIN 1 terbinafine LAMISIL 1 voriconazole VFEND Antimycobacterials 1 cycloserine SEROMYCIN 1 dapsone AVLOSULFON 1 ethambutol MYAMBUTOL 1 isoniazid NYDRAZID 1 pyrazinamide PYRAZINAMIDE 1 rifabutin MYCOBUTIN 1 rifampin RIFADIN 1 rifampin & isoniazid RIFAMATE 3 rifapentine PRIFTIN Antiprotozoals 1 atovaquone MEPRON 1 atovaquone & proguanil MALARONE 1 chloroquine phosphate ARALEN 1 hydroxychloroquine sulfate PLAQUENIL 1 mefloquine LARIAM 1 metronidazole FLAGYL 3 metronidazoleextended-release FLAGYL ER 3 nitazoxanide ALINIA 1 paromomycin sulfate HUMATIN 2 primaquine phosphate PRIMAQUINE Preferred Brand 2 pyrimethamine DARAPRIM Preferred Brand 1 quinine sulfate QUALAQUIN Antiviral QL 1 abacavir sulfate & lamivudine EPZICOM QL 2 abacavir sulfate solution ZIAGEN Preferred Brand QL 1 abacavir sulfate tablet ZIAGEN 3 abacavir, dolutegravir & lamivudine TRIUMEQ QL 1 abacavir, lamivudine & zidovudine TRIZIVIR 1 acyclovir ZOVIRAX QL 1 adefovir dipivoxil HEPSERA 3 atazanavir & cobicistat EVOTAZ QL 2 atazanavir sulfate REYATAZ Preferred Brand QL 3 boceprevir VICTRELIS QRM 3 daclatasvir DAKLINZA 2 darunavir & cobicistat PREZCOBIX QL 2 darunavir ethanolate PREZISTA Preferred Brand QL 2 delavirdine mesylate RESCRIPTOR Preferred Brand QL 1 didanosine VIDEX EC QL 2 didanosine solution VIDEX Preferred Brand 2 dolutegravir TIVICAY Preferred Brand QL 2 efavirenz SUSTIVA Preferred Brand QL 2 efavirenz, emtricitab & tenofovir ATRIPLA Preferred Brand Kaiser Permanente of Georgia Multi Choice Formulary 6

8 QRM 3 elbasvir & grazoprevir ZEPATIER QL 3 elvitegravir, cobicistat, emtricitabine, & tenofovir STRIBILD 2 elvitegravir, cobicistat, emtricitabine, & tenofovir GENVOYA Preferred Brand QL 2 emtricitabine EMTRIVA Preferred Brand QL 2 emtricitabine & tenofovir TRUVADA Preferred Brand 2 emtricitabine & tenofovir DESCOVY Preferred Brand QL 2 emtricitabine, rilpivirine, & tenofovir COMPLERA Preferred Brand 2 emtricitabine, rilpivirine, & tenofovir ODEFSEY QL 2 enfuvirtide FUZEON Preferred Brand QL 1 entecavir BARACLUDE QL 2 etravirine INTELENCE Preferred Brand 1 famciclovir FAMVIR QL 2 fosamprenavir calcium LEXIVA Preferred Brand 1 ganciclovir CYTOVENE QL 2 indinavir sulfate CRIXIVAN Preferred Brand 3 interferon alfacon-1 INFERGEN QL 3 lamivudine EPIVIR HBV QL 1 lamivudine EPIVIR QL 1 lamivudine & zidovudine COMBIVIR QL, QRM 3 ledipasvir & sofosbuvir HARVONI QL 2 lopinavir & ritonavir KALETRA Preferred Brand QL 2 maraviroc SELZENTRY Preferred Brand QL 2 nelfinavir mesylate VIRACEPT Preferred Brand QL 1 nevirapine solution VIRAMUNE QL 1 nevirapine tablet VIRAMUNE QRM 3 ombitasvir, paritaprevir & ritonavir TECHNIVIE QRM 3 ombitasvir, paritaprevir, ritonavir, & dasabuvir VIEKIRA QL 1 oseltamivir phosphate TAMIFLU 3 palivizumab SYNAGIS QL 2 peginterferon alfa-2a PEGASYS Preferred Brand 2 peginterferon-alfa 2b PEG-INTRON Preferred Brand QL 2 raltegravir ISENTRESS Preferred Brand 1 ribavirin REBETOL QL 3 rilpivirine EDURANT QL 1 rimantadine FLUMADINE QL 2 ritonavir NORVIR Preferred Brand QL 2 saquinavir mesylate INVIRASE Preferred Brand QL, QRM 3 simeprevir OLYSIO QL, QRM 3 sofosbuvir SOVALDI QL, QRM 3 sofosbuvir & velpatasvir EPCLUSA QL 1 stavudine ZERIT QL 3 telaprevir INCIVEK QL 3 tenofovir VIREAD Kaiser Permanente of Georgia Multi Choice Formulary 7

9 QL 2 tipranavir APTIVUS Preferred Brand 1 valacyclovir VALTREX 1 valganciclovir VALCYTE QL 2 zanamivir RELENZA Preferred Brand QL 1 zidovudine RETROVIR Urinary Antiinfectives 1 methenamine hippurate HIPREX methenamine, sodium biphosphate, 3 phenyl salicylate, methylene blue, URELLE and hyoscyamine 2 nitrofurantoin FURADANTIN Preferred Brand 1 nitrofurantoin macrocrystal MACRODANTIN 1 nitrofurantoin monohydrate MACROBID 1 trimethoprim PROLOPRIM Antineoplastic Agents Antineoplastic Agents 2 abiraterone ZYTIGA Preferred Brand 1 anastrozole ARIMIDEX 3 axitinib INLYTA 2 bexarotene TARGRETIN Preferred Brand 1 bicalutamide CASODEX 3 bosutinib BOSULIF 2 busulfan MYLERAN Preferred Brand 1 capecitabine XELODA 3 ceritinib ZYKADIA 2 chlorambucil LEUKERAN Preferred Brand 2 crizotinib XALKORI Preferred Brand 1 cyclophosphamide CYTOXAN 2 dasatinib SPRYCEL Preferred Brand 2 enzalutamide XTANDI Preferred Brand 2 erlotinib TARCEVA Preferred Brand 2 estramustine EMCYT Preferred Brand 2 everolimus AFINITOR Preferred Brand 1 exemestane AROMASIN 1 flutamide EULEXIN 1 hydroxyurea HYDREA 2 hydroxyurea DROXIA Preferred Brand 2 ibrutinib IMBRUVICA Preferred Brand 2 imatinib mesylate GLEEVEC Preferred Brand 2 lapatinib TYKERB Preferred Brand 2 lenalidomide REVLIMID Preferred Brand 2 lenvatinib LENVIMA Preferred Brand 1 letrozole FEMARA 1 leuprolide acetate LUPRON 3 lomustine CEENU 3 mechlorethamine VALCHLOR Kaiser Permanente of Georgia Multi Choice Formulary 8

10 2 melphalan ALKERAN Preferred Brand 1 mercaptopurine PURINETHOL 3 methotrexate RASUVO 3 methotrexate OTREXUP 1 methotrexate sodium RHEUMATREX 3 methotrexate sodium TREXALL 2 mitotane LYSODREN Preferred Brand 2 nilotinib TASIGNA Preferred Brand 2 palbociclib IBRANCE Preferred Brand 2 pazopanib VOTRIENT Preferred Brand 2 pomalidomide POMALYST Preferred Brand 3 ponatinib ICLUSIG 2 procarbazine MATULANE Preferred Brand 3 ruxolitinib JAKAFI 2 sorafenib tosylate NEXAVAR Preferred Brand 2 sunitinib malate SUTENT Preferred Brand 1 tamoxifen citrate NOLVADEX 1 temozolomide TEMODAR 2 thioguanine TABLOID Preferred Brand 2 topotecan HYCAMTIN Preferred Brand 1 tretinoin VESANOID 2 vandetanib CAPRELSA Preferred Brand 2 vemurafenib ZELBORAF Preferred Brand 2 vorinostat ZOLINZA Preferred Brand Autonomic Drugs Anticholinergic Agents 1 atropine sulfate ATROPINE SULFATE 1 dicyclomine BENTYL 1 glycopyrrolate ROBINUL 1 glycopyrrolate ROBINULFORTE 1 hyoscyamine sulfate LEVBID 1 hyoscyamine sulfate LEVSIN 1 hyoscyamine sulfate SYMAX 3 hyoscyamine sulfate SYMAX DUOTAB 1 ipratropium bromide ATROVENT 2 ipratropium bromide ATROVENTHFA Preferred Brand 1 methscopolamine PAMINE 1 propantheline bromide PRO-BANTHINE 3 tiotropium SPIRIVA 2.5 mcg 2 tiotropium SPIRIVA RESPIMAT Preferred Brand 1.25 mcg 3 tiotropium SPIRIVA RESPIMAT 3 umeclidinium INCRUSE ELLIPTA Autonomic Drugs, Miscellaneous 3 varenicline CHANTIX Parasympathomimetic (Cholinergic) Agents 1 bethanechol chloride URECHOLINE Kaiser Permanente of Georgia Multi Choice Formulary 9

11 1 cevimeline hcl EVOXAC 1 donepezil ARICEPT 1 donepezil ARICEPT ODT 1 galantamine hydrobromide RAZADYNE 1 galantamine hydrobromide RAZADYNEER 1 neostigmine bromide PROSTIGMIN 1 pilocarpine SALAGEN 1 pyridostigmine MESTION TIMESPAN 1 pyridostigmine MESTION 1 rivastigmine tartrate EXELON 2 rivastigmine tartrate (solution) EXELON Preferred brand Skeletal Muscle Relaxants 1 baclofen LIORESAL 1 carisoprodol SOMA 1 carisoprodol/aspirin SOMA COMPOUND 1 chlorzoxazone PARAFON FORTE DSC 1 cyclobenzaprine FLEXERIL 3 cyclobenzaprine extended-release AMRIX 1 dantrolene sodium DANTRIUM 1 metaxalone SKELAXIN 1 methocarbamol ROBAXIN 1 orphenadrine citrate NORFLEX 1 orphenadrine, aspirin, & caffeine NORGESIC 1 tizanidine ZANAFLEX Sympatholytic (Adrenergic Blocking) Agents 1 alfuzosin hcl UROXATRAL 1 dihydroergotamine mesylate D.H.E.45 2 dihydroergotamine mesylate MIGRANAL Preferred Brand 1 ergoloid mesylates HYDERGINE 1 ergotamine & caffeine CAFERGOT 1 phenoxybenzamine DIBENZYLINE 3 silodosin RAPAFLO 1 tamsulosin hcl FLOMAX Sympathomimetic (Adrenergic) Agents 1 albuterol nebulizer solution ACCUNEB 3 albuterol sulfate PROAIR HFA 3 albuterol sulfate PROVENTIL HFA 2 albuterol sulfate VENTOLIN HFA Preferred Brand 2 albuterol sulfate & ipratropium COMBIVENT RESPIMAT Preferred Brand 1 albuterol sulfate & ipratropium DUONEB 1 albuterol sulfate tablet VOSPIRE ER 3 arformoterol BROVANA 3 droxidopa NORTHERA 1 epinephrine ADRENACLICK 3 epinephrine AUVI-Q 3 epinephrine EPIPEN Kaiser Permanente of Georgia Multi Choice Formulary 10

12 3 epinephrine EPIPEN JR 3 epinephrine TWINJECT 3 formoterol fumarate FORADIL 1 levalbuterol nebulizer solution XOPENEX NEBULIZER 3 levalbuterol tartrate XOPENEX HFA 1 midodrine hcl PROAMATINE 2 olodaterol STRIVERDI RESPIMAT Preferred Brand 3 pirbuterol acetate MAXAIR AUTOHALER 1 terbutaline sulfate BRETHINE 3 umeclidinium & vilanterol ANORO ELLIPTA Blood Formation, Coagulation, and Thrombosis Coagulants and Anticoagulants 2 aminocaproic acid AMICAR Preferred Brand 1 anagrelide AGRYLIN 3 apixaban ELIQUIS 1 aspirin & dipyridamole AGGRENOX 1 cilostazol PLETAL 1 clopidogrel PLAVIX QL 2 dabigatran PRADAXA Preferred Brand 3 dalteparin FRAGMIN 1 dipyridamole PERSANTINE 3 edoxaban SAVAYSA 1 enoxaparin LOVENOX 1 fondaparinux ARIXTRA 1 heparin HEPARIN SODIUM 1 pentoxifylline TRENTAL QL 3 rivaroxaban XARELTO 2 ticagrelor BRILINTA Preferred brand 1 ticlopidine TICLID 3 vorapaxar ZONTIVITY 1 warfarin COUMADIN Hematopoietic Agents 2 darbepoetin alfa ARANESP Preferred Brand 2 eltrombopag PROMACTA Preferred Brand 2 epoetin alfa PROCRIT Preferred Brand 3 epoetin alfa EPOGEN 3 filgrastim NEUPOGEN 2 filgrastim ZARXIO Preferred Brand 2 oprelvekin NEUMEGA Preferred Brand 3 pegfilgrastim NEULASTA 2 sargramostim LEUKINE Preferred Brand Cardiovascular Drugs α-adrenergic Blocking Agents 1 doxazosin CARDURA 1 prazosin MINIPRESS 1 terazosin HYTRIN Kaiser Permanente of Georgia Multi Choice Formulary 11

13 Antilipemic Agents 1 atorvastatin LIPITOR 1 cholestyramine light QUESTRAN LIGHT 1 cholestyramine QUESTRAN 3 colesevelam WELCHOL 1 colestipol COLESTID 3 ezetimibe ZETIA 3 ezetimibe & simvastatin VYTORIN 1 fenofibrate LOFIBRA TAB 1 fenofibrate TRICOR 1 fenofibrate, micronized LOFIBRA CAP 1 fenofibric acid TRILIPIX 1 fluvastatin extended-release LESCOL XL 1 fluvastatin LESCOL 1 gemfibrozil LOPID QRM 3 lomitapide JUXTAPID 1 lovastatin MEVACOR 3 lovastatine extended-release ALTOPREV QRM 3 mipomersen sodium KYNAMRO 3 niacin NIASPAN 3 niacin & lovastatin ADVICOR 1 omega-3 acid ethyl esters LOVAZA 3 omega-3-carboxylic acid EPANOVA 3 pitavastatin LIVALO 1 pravastatin PRAVACHOL 1 rosuvastatin CRESTOR 1 simvastatin ZOCOR Calcium Channel Blocking Agents 1 amlodipine NORVASC 1 amlodipine & benazepril LOTREL 1 amlodipine & atorvastatin CADUET 3 amlodipine & olmesartan AZOR 3 amlodipine & valsartan EXFORGE 3 amlodipine, valsartan & hydrochlorothiazide EXFORGE HCT 3 amlodipine, olmesartan & hydrochlorothiazide TRIBENZOR 1 diltiazem extended-release CARDIZEM CD 1 diltiazem extended-release TIAZAC 1 diltiazem extended-release CARTIA XT 1 diltiazem extended-release CARDIZEM LA 1 diltiazem CARDIZEM 1 felodipine PLENDIL 1 isradipine DYNACIRC 3 isradipine DYNACIRC CR 1 nicardipine CARDENE Kaiser Permanente of Georgia Multi Choice Formulary 12

14 1 nifedipine PROCARDIA 1 nifedipine extended-release ADALAT CC 1 nifedipine extended-release PROCARDIA XL 1 nimodipine NIMOTOP 3 nisoldipine SULAR 1 trandolapril & verapamil TARKA 1 verapamil sustained-release cap VERELAN 3 verapamil COVERA-HS 1 verapamil extended-release cap VERELAN PM 1 verapamil sustained-release cap CALAN SR 1 verapamil sustained-release tab ISOPTIN SR Cardiac Drugs 1 amiodarone PACERONE 1 digoxin LANOXIN 1 disopyramide NORPACE 2 disopyramide controlled-release NORPACE CR Preferred Brand 1 dofetilide TIKOSYN 3 dronedarone MULTAQ 1 flecainide TAMBOCOR 3 Ivabradine CORLANOR 1 mexiletine MEXITIL 1 propafenone RYTHMOL 3 propafenone RYTHMOL SR 1 quinidine gluconate QUINAGLUTE 1 quinidine QUINIDINE SULFATE QL 3 ranolazine RANEXA 3 sacubitril & valsartan ENTRESTO Hypotensive Agents 1 clonidine extended-release KAPVAY 1 clonidine CATAPRES 1 clonidine transdermal CATAPRES-TTS 1 guanfacine TENEX 1 hydralazine APRESOLINE 1 methyldopa ALDOMET 1 methyldopa & hydrochlorothiazide ALDORIL-25 1 minoxidil LONITEN 3 reserpine SERPASIL Renin-Angiotensin-Aldosterone System Inhibitors 3 aliskiren TEKTURNA 3 aliskiren, amlodipine & hydrochlorothiazide AMTURNIDE 3 aliskiren & amlodipine TEKAMLO 3 aliskiren & hydrochlorothiazide TEKTURNA HCT 3 aliskiren & valsartan VALTURNA 3 azilsartan EDARBI 1 benazepril LOTENSIN Kaiser Permanente of Georgia Multi Choice Formulary 13

15 1 benazepril & hydrochlorothiazide LOTENSIN HCT 1 candesartan ATACAND 1 candesartan & hydrochlorothiazide ATACAND HCT 1 captopril CAPOTEN 1 captopril & hydrochlorothiazide CAPOZIDE 1 enalapril VASOTEC 1 enalapril & hydrochlorothiazide VASERETIC 1 eplerenone INSPRA 3 eprosartan TEVETEN 3 eprosartan & hydrochlorothiazide TEVETEN 1 fosinopril MONOPRIL 1 fosinopril & hydrochlorothiazide MONOPRIL HCT 1 irbesartan AVAPRO 1 irbesartan & hydrochlorothiazide AVALIDE 1 lisinopril ZESTRIL 1 lisinopril & hydrochlorothiazide ZESTORETIC 1 losartan COZAAR 1 losartan & hydrochlorothiazide HYZAAR 1 moexipril UNIVASC 1 moexipril & hydrochlorothiazide UNIRETIC 3 olmesartan BENICAR 3 olmesartn & hydrochlorothiazide BENICAR HCT 1 perindopril ACEON 1 quinapril hcl ACCUPRIL 1 quinapril & hydrochlorothiazide ACCURETIC 1 ramipril ALTACE 1 spironolactone & hydrochlorothiazide ALDACTAZIDE 1 spironolactone ALDACTONE 1 telmisartan MICARDIS 1 telmisartan & hydrochlorothiazide MICARDIS HCT 1 trandolapril MAVIK 1 valsartan DIOVAN 1 valsartan & hydrochlorothiazide DIOVAN HCT Vasodilating Agents 2 ambrisentan LETAIRIS Preferred Brand 2 bosentan TRACLEER Preferred Brand 3 isosorbide dinitrate & hydralazine BIDIL 1 isosorbide dinitrate ISORDIL 1 isosorbide mononitrate IMDUR 2 macitentan OPSUMIT Preferred Brand 3 nitroglycerin aerosol NITROMIST 1 nitroglycerin solution NITROLINGUAL 2 nitroglycerin subligual NITROSTAT Preferred Brand 2 nitroglycerin topical ointment NITRO-BID Preferred Brand Kaiser Permanente of Georgia Multi Choice Formulary 14

16 Excludes 0.8mg strength Only 0.8mg strength Kaiser Permanente of Georgia Multi Choice Formulary 1 nitroglycerin transdermal patch NITRO-DUR 2 nitroglycerin transdermal patch NITRO-DUR Preferred Brand 1 papaverine PAVABID 3 riociguat ADEMPAS 1 sildenafil REVATIO 3 tadalafil ADCIRCA 3 treprostinil ORENITRAM 2 treprostinil REMODULIN Preferred Brand β-adrenergic Blocking Agents 1 acebutolol SECTRAL 1 atenolol TENORMIN 1 atenolol & chlorthalidone TENORETIC 1 betaxolol KERLONE 1 bisoprol & hydrochlorothiazide ZIAC 1 bisoprolol ZEBETA 1 carvedilol COREG 3 carvedilol phosphate COREG CR 1 labetalol TRANDATE 1 metoprol & hydrochlorothiazide LOPRESSOR HCT 1 metoprolol succinate TOPROL XL 1 metoprolol tartrate LOPRESSOR 1 nadolol CORGARD 1 nadolol & bendroflumethiazide CORZIDE 3 nebivolol BYSTOLIC 3 penbutolol LEVATOL 1 pindolol VISKEN 1 propranolol & hydrochlorothiazide INDERIDE 3 propranolol extended-release INNOPRAN XL 1 propranolol INDERAL 1 propranolol sustained-release INDERAL LA 1 sotalol BETAPACE 1 sotalol BETAPACE AF 1 timolol BLOCADREN Central Nervous System Agents Analgesics and Antipyretics 1 acetaminophen & codeine TYLENOL W/ CODEINE 1 acetaminophen, caffeine, & dihydrocodine PANLOR SS 1 buprenorphine SUBUTEX QL 1 buprenorphine& naloxone tablet SUBOXONE QL 3 buprenorphine & naloxone film SUBOXONE QL 3 buprenorphine transdermal BUTRANS 1 butalbital & acetaminophen PHRENILIN Kaiser Permanente of Georgia Multi Choice Formulary 15

17 3 butalbital & acetaminophen PHRENILIN FORTE 1 butalbital, acetaminophen, & caffeine FIORICET 1 butalbital, acetaminophen, caffeine, & codeine FIORICET W/ CODEINE 1 butalbital, aspirin, & caffeine FIORINAL 1 butalbital, aspirin, caffeine, & codeine FIORINAL W/ CODEINE 1 butorphanol tartrate STADOL 1 carisoprodol, aspirin, & codeine SOMA COMPOUND W/ CODEINE 1 celecoxib CELEBREX 1 codeine CODEINE SULF 1 diclofenac potassium CATAFLAM 1 diclofenac sodium VOLTAREN 1 diclofenac sodium PENNSAID 2 diclofenac sodium & misoprostol ARTHROTEC 1 diclofenac sodium extended release VOLTAREN XR 1 diflunisal DIFLUNISAL 1 etodolac LODINE 3 fenoprofen calcium NALFON 3 fentanyl film ONSOLIS 3 fentanyl intranasal LAZANDA 1 fentanyl lozenge ACTIQ 3 fentanyl sublingual ABSTRAL 3 fentanyl tablet FENTORA QL 1 fentanyl transdermal DURAGESIC 1 flurbiprofen ANSAID 3 hydrocodone ZOHYDRO ER 3 hydrocodone er HYSINGLA ER 1 hydrocodone & acetaminophen NORCO 1 hydrocodone & ibuprofen VICOPROFEN 3 hydromorphone oral suspension DILAUDID 1 hydromorphone tablet DILAUDID 3 hydromorphone tablet EXALGO 1 ibuprofen MOTRIN 1 indomethacin INDOCIN 1 ketoprofen KETOPROFEN QL 1 ketorolac tablet TORADOL 1 levorphanol LEVO-DROMORAN 1 meclofenamate MECLOMEN QL 1 mefenamic acid PONSTEL 1 meloxicam MOBIC 1 meperidine tablet DEMEROL 1 methadone DOLOPHINE 2 morphine MORPHINE SULFATE Preferred Brand 1 morphine MSIR 3 morphine beads AVINZA Kaiser Permanente of Georgia Multi Choice Formulary 16

18 3 morphine extended-relase capsule KADIAN 1 morphine extended-release tablet MS CONTIN 1 nabumetone RELAFEN 1 nalbuphine NUBAIN 1 naproxen NAPROSYN 1 naproxen sodium ANAPROX 3 naproxen sodium NAPRELAN 1 opium & belladonna alkaloids B & O SUPPRETTES 3 opium tincture OPIUM 1 oxaprozin DAYPRO 1 oxycodone ROXICODONE 1 oxycodone & acetaminophen PERCOCET 2 oxycodone & acetaminophen ROXICET Preferred Brand 3 oxycodone & acetaminophen er XARTEMIS XR 1 oxycodone & aspirin PERCODAN QL 3 oxycodone & ibuprofen COMBUNOX QL 3 oxycodone controlled-release OXYCONTIN 3 oxymorphone OPANA 3 oxymorphone extended-release OPANA ER 1 pentazocine & naloxone TALWIN NX 1 piroxicam FELDENE 1 salsalate DISALCID 1 sulindac CLINORIL QL 3 tapentadol NUCYNTA 1 tolmetin sodium TOLECTIN tramadol ULTRAM 1 tramadol & acetaminophen ULTRACET 1 tramadol extended-release ULTRAM ER Anorexigenic Agents and Respiratory and Cerebral Stimulants 1 amphetamine & dextroamphetamine ADDERALL 1 amphetamine & dextroamphetamine extended-release ADDERALL XR QL 1 armodafinil NUVIGIL QL 1 dexmethylphenidate FOCALIN 3 dexmethylphenidate extendedrelease FOCALIN XR QL 1 dextroamphetamine sulfate DEXTROSTAT QL 1 dextroamphetamine sulfate extended-release DEXEDRINE 3 lisdexamfetamine VYVANSE 1 methamphetamine DESOXYN 1 methylphenidate METHYLIN 1 methylphenidate RITALIN QL 1 methylphenidate extended-release METADATE ER QL 1 methylphenidate extended-release CONCERTA 1 methylphenidate extended-release METADATE CD Kaiser Permanente of Georgia Multi Choice Formulary 17

19 QL 3 methylphenidate extended-release RITALIN LA QL 1 methylphenidate sustained release RITALIN SR QL 3 methylphenidate transdermal patch DAYTRANA QL 1 modafinil PROVIGIL Anticonvulsants 1 carbamazepine TEGRETOL 1 carbamazepine extended-release cap CARBATROL 3 carbamazepine extended-release cap EQUETRO 1 carbamazepine extended-release tab TEGRETOL XR 3 clobazam ONFI 1 clonazepam KLONOPIN 1 diazepam DIASTAT 2 diazepam DIASTAT ACUDIAL Preferred Brand 1 divalproex sodium DEPAKOTE 1 divalproex sodium capsule DEPAKOTE SPRINKLE 1 divalproex sodium extended release DEPAKOTE ER 3 eslicarbazepine APTIOM 3 ethontoin PEGANONE 1 ethosuximide ZARONTIN 3 ezogaine POTIGA 1 felbamate FELBATOL 1 gabapentin NEURONTIN QL 3 lacosamide VIMPAT 1 lamotrigine LAMICTAL 1 lamotrigine extended-release LAMICTAL XR 1 levetiracetam KEPPRA 1 levetiracetam extended-release KEPPRA XR 2 methsuximide CELONTIN Preferred Brand 1 oxcarbazepine TRILEPTAL 3 perampanel FYCOMPA 1 phenytoin sodium extended-release DILANTIN 1 phenytoin sodium extended-release PHENYTEK 1 phenytoin suspension DILANTIN 3 pregabalin LYRICA 1 primidone MYSOLINE 3 rufinamide BANZEL 1 tiagabine GABITRIL 1 topiramate capsule TOPAMAX SPRINKLE 1 topiramate tablet TOPAMAX 1 valproate sodium DEPAKENE 1 valproic acid DEPAKENE QRM 3 vigabatrin SABRIL 1 zonisamide ZONEGRAN Antimigraine Agents QL 1 almotriptan AXERT 1 ergotamine & caffeine MIGERGOT Kaiser Permanente of Georgia Multi Choice Formulary 18

20 QL 3 eletriptan RELPAX QL 1 frovatriptan FROVA QL 1 naratriptan AMERGE QL 1 rizatriptan MAXALT QL 1 rizatriptan orally disentigrating MAXALT MLT QL 1 sumatriptan IMITREX QL 1 zolmitriptan ZOMIG QL 1 zolmitriptan orally disentigrating ZOMIG ZMT Antiparkinsonian Agents 1 amantadine SYMMETREL 1 benztropine COGENTIN 1 bromocriptine PARLODEL 3 bromocriptine CYCLOSET 1 cabergoline DOSTINEX 3 carbidopa LODOSYN 1 carbidopa & levodopa SINEMET 3 carbidopa & levodopa PARCOPA 1 carbidopa & levodopa extended release SINEMET CR 2 carbidopa, levodopa, & entacapone STALEVO Preferred Brand 1 entacapone COMTAN 1 pramipexole MIRAPEX 1 pramipexole extended-release MIRAPEX ER 3 rasagiline AZILECT 1 ropinirole REQUIP 1 ropinirole extended-release REQUIP XL 3 rotigotine NEUPRO 1 selegiline ELDEPRYL 3 selegiline ZELAPAR 3 selegiline transdermal EMSAM 2 tolcapone TASMAR Preferred Brand 1 trihexyphenidyl ARTANE Anxiolytics, Sedatives, and Hypnotics 1 alprazolam XANAX 1 alprazolam extended-release XANAX XR 3 alprazolam orally disintegrating NIRAVAM 1 buspirone BUSPAR 1 chlordiazepoxide LIBRIUM 1 clorazepate TRANXENE 1 diazepam VALIUM 1 estazolam PROSOM 1 eszopiclone LUNESTA 1 flurazepam DALMANE 1 hydroxyzine hcl ATARAX 1 hydroxyzine pamoate VISTARIL 1 lorazepam ATIVAN Kaiser Permanente of Georgia Multi Choice Formulary 19

21 1 meprobamate MILTOWN 1 oxazepam SERAX 1 phenobarbital PHENOBARBITAL 3 ramelteon ROZEREM 3 suvorexant BELSOMRA QRM 3 tasimelteon HETLIOZ 1 temazepam RESTORIL 1 triazolam HALCION 1 zaleplon SONATA 3 zolipdem sublingual EDLUAR 1 zolpidem AMBIEN 1 zolpidem extended-release AMBIEN CR 3 zolpidem oral spray ZOLPIMIST Central Nervous System Agents Miscellaneous 1 acamprosate CAMPRAL 3 atomoxetine STRATTERA 3 dextromethorphan & quinidine NUEDEXTA 1 guanfacine extended-release INTUNIV 1 memantine NAMENDA 3 memantine er & donepezil NAMZARIC QL 3 milnacipran SAVELLA 1 riluzole RILUTEK 3 sodium oxybate XYREM QRM 3 tetrabenazine XENAZINE Opioid Antagonists 1 naloxone NARCAN QL 2 naloxone nasal spray NARCAN Preferred Brand 1 naltrexone REVIA Psychotherapeutic Agents 1 amitriptyline ELAVIL 1 amitriptyline & perphenazine TRIAVIL 1 amoxapine ASENDIN 1 aripiprazole ABILIFY 3 asenapine SAPHRIS 3 brexpiprazole REXULTI 1 bupropion WELLBUTRIN 1 bupropion extended-release WELLBUTRIN XL 3 bupropion hydrobromide APLENZIN 1 bupropion sustained-release WELLBUTRIN SR 1 chlordiazepoxide & amitriptyline LIMBITROL DS 1 chlorpromazine THORAZINE 1 citalopram CELEXA 1 clomipramine ANAFRANIL 1 clozapine CLOZARIL 1 clozapine FAZACLO 1 desipramine NORPRAMIN Kaiser Permanente of Georgia Multi Choice Formulary 20

22 1 desvenlafaxine base extended release PRISTIQ 1 doxepin SINEQUAN 1 duloxetine CYMBALTA 1 escitalopram LEXAPRO 1 fluoxetine PROZAC 3 fluoxetine PROZAC WEEKLY 3 fluoxetine SARAFEM 1 fluphenazine PROLIXIN 1 fluvoxamine LUVOX 1 haloperidol HALDOL 3 iloperidone FANAPT 1 imipramine TOFRANIL 1 imipramine pamoate TOFRANIL-PM 3 isocarboxazid MARPLAN 3 levomilnacipran FETZIMA 1 lithium carbonate capsule LITHIUM CARBONATE 1 lithium carbonate extended release LITHOBID 1 lithium citrate CIBALITH-S 1 loxapine LOXITANE 3 lurasidone LATUDA 1 maprotiline LUDIOMIL 1 mirtazapine REMERON 1 nefazodone SERZONE 1 nortriptyline PAMELOR 1 olanzapine ZYPREXA 1 olanzapine & fluoxetine hcl SYMBYAX 1 olanzapine orally disintegrating ZYPREXA ZYDIS 1 paliperidone INVEGA 1 paroxetine PAXIL 3 paroxetine extended-release PAXIL CR 3 paroxetine mesylate PEXEVA 1 perphenazine TRILAFON 1 phenelzine NARDIL 1 pimozide ORAP 3 protriptyline VIVACTIL 1 quetiapine SEROQUEL 3 quetiapine extended-release SEROQUEL XR 1 risperidone RISPERDAL 3 risperidone orally disintegrating RISPERDALM-TAB 1 sertraline ZOLOFT 1 thioridazine MELLARIL 1 thiothixene NAVANE 1 tranylcypromine sulfate PARNATE 1 trazodone DESYREL 3 trazodone extended-release OLEPTRO Kaiser Permanente of Georgia Multi Choice Formulary 21

23 1 trifluoperazine STELAZINE 3 trimipramine SURMONTIL 1 venlafaxine EFFEXOR 1 venlafaxine extended-release EFFEXOR XR QL 3 vilazodone VIIBRYD 3 vortioxetine BRINTELLIX 1 ziprasidone GEODON Diabetic Supplies Diabetic Supplies QL 3 blood sugar diagnostic ONE TOUCH ULTRA TEST STRIPS QL 1 blood sugar diagnostic ONE TOUCH VERIO TEST STRIPS Preferred Brand QL 3 blood sugar diagnostic ACCU-CHEK TEST STRIPS QL 3 blood sugar diagnostic ASCENSIA TEST STRIPS QL 3 blood sugar diagnostic FREESTYLE TEST STRIPS QL 3 blood sugar diagnostic PRODIGY TEST STRIPS QL 3 blood-glucose meter ONE TOUCH ULTRA 2 QL 1 blood-glucose meter ONE TOUCH VERIO IQ Preferred Brand QL 3 blood-glucose meter ACCU-CHEK QL 3 blood-glucose meter ASCENSIA BREEZE QL 3 blood-glucose meter FREESTYLE SYSTEM QL 3 blood-glucose meter ONE TOUCH ULTRA SMART QL 3 blood-glucose meter ONE TOUCH ULTRAMINI QL 3 blood-glucose meter PRODIGY QL 1 syringe with needle,disposable BD INSULIN SYRINGE Electrolytic, Caloric and Water Balance Acidifying and Alkalinizing Agents 3 citric acid, sodium citrate, & potassium citrate CYTRA-3 1 potassium citrate UROCIT-K 2 potassium citrate & citric acid POLYCITRA-K Preferred Brand 3 sodium citrate & citric acid BICITRA Ammonia Detoxicants 3 carglumic acid CARBAGLU QRM 3 glycerol phenylbutyrate RAVICTI 3 sodium phenylbutyrate BUPHENYL 3 lactulose CHRONULAC 1 lactulose ENULOSE 3 lactulose KRISTALOSE Diuretics 1 amiloride MIDAMOR 1 amiloride & hydrochlorothiazide MODURETIC 1 bumetanide BUMEX 1 chlorothiazide DIURIL Kaiser Permanente of Georgia Multi Choice Formulary 22

24 1 chlorthalidone HYGROTON 3 ethacrynic acid EDECRIN 1 furosemide LASIX 1 hydrochlorothiazide MICROZIDE 1 indapamide LOZOL 1 metolazone ZAROXOLYN QL 3 tolvaptan SAMSCA 1 torsemide DEMADEX 3 triamterene DYRENIUM 1 triamterene & hydrochlorothiazide DYAZIDE 1 triamterene & hydrochlorothiazide MAXZIDE Ion-Removing Agnets 1 sevelamer carbonate RENVELA 2 sodium polystyrene sulfonate SPS Preferred Brand 3 sucroferric oxyhydroxide VELPHORO 3 lanthanum carbonate FOSRENOL 3 patiromer VELTASSA 3 sevelamer hcl RENAGEL Replacement Products 2 calcium acetate ELIPHOS Preferred Brand 1 calcium acetate PHOSLO 2 calcium acetate PHOSLYRA Preferred Brand 1 potassium bicarbonate & potassium chloride K-LYTE/CL 1 potassium chloride K-DUR 1 potassium chloride K-TAB 2 potassium chrloide powder KLOR-CON 20 MEQ Preferred Brand 1 potassium gluconate KAON 2 potassium phosphate PHOSPHA Preferred Brand 3 potassium phosphate, monobasic K-PHOS NEUTRAL 2 potassium phosphate, monobasic K-PHOS ORIGINAL Preferred Brand Uricosuric Agents 1 colchicine & probenecid COL-BENEMID 1 probenecid BENEMID Enzymes Enzymes 2 dornase alfa PULMOZYME Preferred Brand Eye, Ear, Nose and Throat (EENT) Anti-infectives 3 azithromycin (ophth) AZASITE 1 bacitracin & polmyxin B (ophth) POLYSPORIN 1 bacitracin (ophth) AK-TRACIN 3 besilfoxacin BESIVANCE 1 chlorhexidine (mouth-throat) PERIDEX 3 ciprofloxacin (ophth) ointment CILOXAN 1 ciprofloxacin (ophth) solution CILOXAN Kaiser Permanente of Georgia Multi Choice Formulary 23

25 1 erythromycin (ophth) ROMYCIN 3 ganciclovir (ophth) ZIRGAN 2 gatifloxacin (ophth) ZYMAXID Preferred Brand 1 gentamicin (ophth) GENTAK 1 levofloxacin (ophth) QUIXIN 3 moxifloxacin (ophth) VIGAMOX 2 natamycin NATACYN Preferred Brand 1 neomycin, bacitracin & polymyxin b (ophth) NEO-POLYCIN 1 neomycin, polymycin b & gramicidin (ophth) NEOSPORIN 1 ofloxacin (ophth) OCUFLOX 1 ofloxacin (otic) FLOXIN 1 polymyxin b & trimethoprim (ophth) POLYTRIM 1 sulfacetamide sodium (ophth) ointment SULFAC 1 sulfacetamide sodium (ophth) solution BLEPH-10 2 tobramycin sulfate (ophth) ointment TOBREX Preferred Brand 1 tobramycin sulfate (ophth) solution TOBREX 1 trifluridine VIROPTIC Anti-Inflammatory Agents 1 bacitracin, neomycin, polymyxin B & hydrocortisone (ophth) NEO-POLYCIN HC 3 bromfenac (ophth) XIBROM 2 ciprofloxacin & dexamethasone (ophth) CIPRODEX Preferred Brand 3 ciprofloxacin & hydrocortisone (otic) CIPRO HC QL 3 cyclosporine (ophth) RESTASIS 1 dexamethasone (ophth) solution DECADRON 2 dexamethasone (ophth) suspension MAXIDEX Preferred Brand 1 diclofenac sodium (ophth) VOLTAREN 3 difluprednate DUREZOL 3 fluocinolone acetonide (otic) DERMOTIC 1 fluorometholone (ophth) FML 3 fluorometholone (ophth) FML FORTE 2 fluorometholone acetate FLAREX Preferred Brand 1 flurbiprofen (ophth) OCUFEN 2 gentamicin & prednisolone PRED-G Preferred Brand 1 hydrocortisone & acetic acid (otic) ACETASOL HC 1 ketorolac (ophth) ACULAR 1 ketorolac (ophth) ACULAR LS QL 3 lifitegrast XIIDRA Non-preferrred 3 loteprednol ALREX 3 loteprednol LOTEMAX 3 loteprednol & tobramycin ZYLET Kaiser Permanente of Georgia Multi Choice Formulary 24

26 3 neomycin, colistin, hydrocortisone & thonzonium (otic) CORTISPORIN-TC 1 neomycin, polymyxin B & dexamethasone (ophth) MAXITROL 3 neomycin, polymyxin B & hydrocortisone (ophth) CORTISPORIN 1 neomycin, polymyxin B & hydrocortisone (otic) CORTISPORIN 3 nepafenac NEVANAC 1 prednisolone acetate (ophth) OMNIPRED 1 prednisolone acetate (ophth) PRED FORTE 2 prednisolone acetate (ophth) PRED MILD Preferred Brand 3 prednisolone sodium phosphate (ophth) INFLAMASE FORTE 1 prednisolone sodium phosphate (ophth) PREDNISOL 3 rimexolone VEXOL 1 sulfacetamide sodium & prednisolone BLEPHAMIDE 2 tobramycin & dexamethasone ointment TOBRADEX Preferred Brand 1 tobramycin & dexamethasone suspension TOBRADEX Antiallergic Agents 3 aflcaftadine LASTACAFT 1 azelastine ASTELIN 1 azelastine ASTEPRO 3 azelastine & fluticasone DYMISTA 1 azelastine (ophth) OPTIVAR 3 bepotastine BEPREVE 1 cromolyn sodium (ophth) OPTICROM 3 emedastine EMADINE 1 epinastine (ophth) ELESTAT 3 grass pollen allergen extract (5 glass extract) ORALAIR 3 lodoxamide tromethamine ALOMIDE 3 nedocromil sodium (ophth) ALOCRIL 3 olopatadine PATADAY 3 olopatadine (nasal) PATANASE 1 olopatadine (ophth) PATANOL 3 short ragweed pollen allergen extract RAGWITEK 3 timothy grass pollen allergen extract GRASTEK Antiglaucoma Agents 1 acetazolamide DIAMOX 1 acetazolamide DIAMOX SEQUELS 1 betaxolol hcl BETOPTIC 2 betaxolol hcl BETOPTIC S Preferred Brand Kaiser Permanente of Georgia Multi Choice Formulary 25

27 3 bimatoprost LUMIGAN 1 brimonidine ALPHAGAN 1 brimonidine tartrate ALPHAGAN P 3 brinzolamide AZOPT 2 carbachol ISOPTO CARBACHOL Preferred Brand 1 carteolol (ophth) OCUPRESS 1 dorzolamide TRUSOPT 1 dorzolamide & timolol COSOPT 2 ecothiophate PHOSPHOLINE IODIDE Preferred Brand 1 latanoprost XALATAN 1 levobunolol BETAGAN 1 methazolamide NEPTAZANE 1 metipranolol OPTIPRANOLOL 1 pilocarpine ISOPTO CARPINE 3 pilocarpine gel PILOPINE HS 3 timolol BETIMOL 3 timolol ISTALOL 1 timolol TIMOPTIC 3 timolol TIMOPTIC-XE 3 travoprost TRAVATAN Z 3 unoprostone isopropyl RESCULA EENT Drugs, Miscellaneous 1 acetic acid VOSOL 2 apraclonidine IOPIDINE Preferred Brand 3 artificial tear insert LACRISERT Local Anesthetics 1 antipyrine & benzocaine AURODEX 1 lidocaine (mouth-throat) XYLOCAINE VISCOUS 1 proparacaine OPTHETIC Mydriatics 1 atropine ISOPTO ATROPINE 2 homatropine ISOPTO HOMATROPINE Preferred Brand 2 scopolamine (ophth) ISOPTO HYOSCINE Preferred Brand Vasoconstrictors 1 tetrahydrozoline TYZINE Gastrointestinal Drugs Anti-inflammatory Agents 1 alosetron LOTRONEX 1 balsalazide COLAZAL 3 balsalazide GIAZO 3 eluxadoline VIBERZI 2 mesalamine controlled-release PENTASA Preferred Brand 2 mesalamine suppository CANASA Preferred Brand 1 mesalamine suspension ROWASA 2 mesalamine tablet LIALDA Preferred Brand 3 olsalazine DIPENTUM Kaiser Permanente of Georgia Multi Choice Formulary 26

28 Antidiarrhea Agents 3 difenoxin & atropine MOTOFEN 1 diphenoxylate & atropine LOMOTIL 3 paregoric PAREGORIC Antiemetics 2 aprepitant EMEND Preferred Brand 3 dolasetron ANZEMET 1 dronabinol MARINOL 3 granisetron KYTRIL 3 granisetron SANCUSO 3 netupitant & palonosetron AKYNZEO 1 ondansetron ZOFRAN 1 ondansetron (orally disentigrating) ZOFRAN ODT QL 1 prochlorperazine COMPAZINE 3 rolapitant VARUBI 3 scopolamine hydrobromide TRANSDERM-SCOP 1 trimethobenzamide TIGAN Antiulcer Agents and Acid Suppressants 3 amoxicillin, clarithromycin, & PREVPAC Only 75 mg/5 ml syrup lansoprazole 1 cimetidine TAGAMET 1 misoprostol CYTOTEC 1 nizatidine AXID 1 ranitidine ZANTAC 1 sucralfate tablets CARAFATE 3 sucralfate suspension CARAFATE Cathartics and Laxatives 3 polyethylene glycol-electrolyte solution HALFLYTELY 3 polyethylene glycol-electrolyte solution MOVIPREP 1 polyethylene glycol-electrolyte solution COLYTE 1 polyethylene glycol-electrolyte solution GOLYTELY 1 polyethylene glycol-electrolyte solution GAVILYTE-C 1 polyethylene glycol-electrolyte solution NULYTELY 3 sodium phosphates OSMOPREP 3 sodium phosphates VISICOL Digestants 3 pancrelipase (lipase-proteaseamylase) CREON Kaiser Permanente of Georgia Multi Choice Formulary 27

29 2 pancrelipase (lipase-proteaseamylase) ZENPEP Preferred Brand 2 pancrelipase (lipase-proteaseamylase) PANCREAZE Preferred Brand 3 pancrelipase (lipase-proteaseamylase) VIOKACE 3 pancrelipase (lipase-proteaseamylase) PERTZYE GI Drugs, Miscellaneous 1 clidinium & chlordiazepoxide LIBRAX 3 linaclotide LINZESS 3 lubiprostone AMITIZA 1 metoclopramide REGLAN 3 phenobarbital and belladonna alkaloids DONNATAL 3 teduglutide GATTEX 1 ursodiol ACTIGALL 1 ursodiol URSO 1 ursodiol URSO FORTE Gold Compounds Gold Compounds 2 auranofin RIDAURA Preferred Brand Heavy Metal Antagonists Heavy Metal Antagonists 2 deferasirox EXJADE Preferred Brand 3 deferiprone FERRIPROX 2 penicillamine CUPRIMINE Preferred Brand 2 penicillamine DEPEN Preferred Brand 3 succimer CHEMET 3 trientine SYPRINE Hormones and Synthetic Substitutes Adrenals 1 budesonide ENTOCORT EC 3 budesonide UCERIS 1 cortisone acetate CORTONE ACETATE 1 dexamethasone DECADRON 1 fludrocortisone FLORINEF ACETATE 1 hydrocortisone CORTEF 1 methylprednisolone MEDROL 1 prednisolone PRELONE 1 prednisolone acetate PREDNISOLONE 1 prednisolone sodium phosphate ORAPRED 1 prednisolone sodium phosphate ORAPRED ODT 1 prednisolone sodium phosphate PEDIAPRED 1 prednisone PREDNISONE 3 prednisone RAYOS Kaiser Permanente of Georgia Multi Choice Formulary 28

30 Androgens 1 danazol DANOCRINE 2 fluoxymesterone ANDROXY Preferred Brand 2 methyltestosterone ANDROID 10 Preferred Brand 3 methyltestosterone METHITEST 1 methyltestosterone TESTRED 1 oxandrolone OXANDRIN 3 testosterone ANDRODERM 3 testosterone AXIRON 1 testosterone ANDROGEL 1 testosterone TESTIM 3 testosterone FORTESTA 1 testosterone cypionate DEPO-TESTOSTERONE Contraceptives QL 1 desogestrel & ethinyl estradiol APRI QL 3 desogestrel & ethinyl estradiol DESOGEN QL 3 desogestrel & ethinyl estradiol ORTHO-CEPT QL 1 desogestrel & ethinyl estradiol RECLIPSEN QL 1 desogestrel & ethinyl estradiol (biphasic) KARIVA QL 1 desogestrel & ethinyl estradiol (triphasic) CYCLESSA QL 1 desogestrel & ethinyl estradiol (triphasic) VELIVET QL 1 drospirenone & ethinyl estradiol GIANVI QL 1 drospirenone & ethinyl estradiol OCELLA QL 3 drospirenone & ethinyl estradiol YASMIN Non-PReferred QL 3 drospirenone & ethinyl estradiol YAZ QL 3 drospirenone & ethinyl estradiol w/ folate BEYAZ QL 3 drospirenone & ethinyl estradiol w/ folate SAFYRAL 1 estradiol cypionate DELESTROGEN 1 estradiol valerate DEPO-ESTRADIOL QL 3 estradiol valerate & dienogest NATAZIA QL 1 ethynodiol diacetate & ethinyl estradiol KELNOR QL 1 ethynodiol diacetate & ethinyl estradiol ZOVIA QL 2 etonogestrel & ethinyl estradiol NUVARING Preferred Brand AGE 1 levonorgestrel PLAN B QL 1 levonorgestrel & ethinyl estradiol AVIANE QL 1 levonorgestrel & ethinyl estradiol LESSINA QL 1 levonorgestrel & ethinyl estradiol LEVORA QL 3 levonorgestrel & ethinyl estradiol NORDETTE-28 QL 1 levonorgestrel & ethinyl estradiol (91- day) INTROVALE Kaiser Permanente of Georgia Multi Choice Formulary 29

31 QL 3 levonorgestrel & ethinyl estradiol (91- day) LOSEASONIQUE QL 3 levonorgestrel & ethinyl estradiol (91- day) SEASONALE QL 3 levonorgestrel & ethinyl estradiol (91- day) SEASONIQUE QL 1 levonorgestrel & ethinyl estradiol (continuous) AMYTHYST QL 3 levonorgestrel & ethinyl estradiol (continuous) LYPREL QL 1 levonorgestrel & ethinyl estradiol (triphasic) TRIVORA QL 3 norelgestromin & ethinyl estradiol ORTHO EVRA QL 1 norelgestromin & ethinyl estradiol XULANE QL 1 norethindrone CAMILA QL 1 norethindrone NORA-BE QL 3 norethindrone NOR-QD QL 1 norethindrone & ethinyl estradiol BALZIVA QL 3 norethindrone & ethinyl estradiol BREVICON QL 1 norethindrone & ethinyl estradiol JUNEL QL 1 norethindrone & ethinyl estradiol MICROGESTIN QL 3 norethindrone & ethinyl estradiol MODICON QL 1 norethindrone & ethinyl estradiol NECON QL 3 norethindrone & ethinyl estradiol NORINYL 1+35 QL 1 norethindrone & ethinyl estradiol NORTREL 1/35 QL 1 norethindrone & ethinyl estradiol OVCON-35 QL 3 norethindrone & ethinyl estradiol OVCON-50 QL 1 norethindrone & ethinyl estradiol (biphasic) NECON 10/11 QL 1 norethindrone & ethinyl estradiol (triphasic) ARANELLE QL 1 norethindrone & ethinyl estradiol (triphasic) NORTREL 7/7/7 QL 3 norethindrone & ethinyl estradiol (triphasic) ORTHO-NOVUM QL 3 norethindrone & ethinyl estradiol (triphasic) TRI-NORINYL QL 3 norethindrone & ethinyl estradiol w/ ferrous fumarate ESTROSTEP FE QL 3 norethindrone & ethinyl estradiol w/ ferrous fumarate FEMCON FE QL 1 norethindrone & ethinyl estradiol w/ ferrous fumarate GENERESS FE QL 3 norethindrone & ethinyl estradiol w/ ferrous fumarate JUNEL FE QL 1 norethindrone & ethinyl estradiol w/ ferrous fumarate MICROGESTIN FE Kaiser Permanente of Georgia Multi Choice Formulary 30

32 QL 3 norethindrone acetate & ethinyl estradiol w/ ferrous fumarate LOESTRIN 24 FE QL 3 norethindrone acetate & ethinyl estradiol w/ ferrous fumarate LOESTRIN FE QL 1 norethindrone acetate & ethinyl estradiol w/ ferrous fumarate TILIA norethindrone acetate & ethinyl QL 3 estradiol w/ ferrous fumarate LO LOESTRIN FE (biphasic) QL 3 norethindrone-mestranol NORINYL 1+50 QL 3 norethindrone-mestranol ORTHO-NOVUM QL 1 norgestimate & ethinyl estradiol CRYSELLE QL 1 norgestimate & ethinyl estradiol MONONESSA QL 3 norgestimate & ethinyl estradiol ORTHO-CYCLEN QL 1 norgestimate & ethinyl estradiol SPRINTEC QL 1 norgestimate & ethinyl estradiol TRINESSA QL 3 norgestimate & ethinyl estradiol (triphasic) ORTHO TRI-CYCLEN QL 1 norgestimate & ethinyl estradiol (triphasic) ORTHO TRI-CYCLEN LO QL 1 norgestimate & ethinyl estradiol (triphasic) TRI-SPRINTEC QL 3 norgestrel & ethinyl estradiol LO/OVRAL-28 QL 1 norgestrel & ethinyl estradiol LOW-OGESTREL QL 1 norgestrel & ethinyl estradiol OGESTREL 2 ulipristal ELLA Preferred Brand Diabetic Agents 1 acarbose PRECOSE QRM 3 albiglutide TANZEUM 3 alirocumab PRALUENT QRM 1 alogliptin NESINA QRM 1 alogliptin & metformin KAZANO QRM 1 alogliptin & pioglitazone OSENI QRM 3 canagliflozin INVOKANA QRM 3 canagliflozin & metformin INVOKAMET 1 chlorpropamide CHLORPROPAMIDE QRM 3 dapagliflozin FARXIGA QRM 3 dapagliflozin & metformin XIGDUO XR QRM 3 dulaglutide TRULICITY QRM 3 empagliflozin JARDIANCE QRM 3 empagliflozin & linagliptan GLYXAMBI QRM 3 empagliflozin & metformin SYNJARDY 3 Evolocumab REPATHA QRM 3 exenatide BYETTA QRM 3 exenatide extended-release BYDUREON 1 glimepiride AMARYL 1 glipizide GLUCOTROL Kaiser Permanente of Georgia Multi Choice Formulary 31

33 1 glipizide & metformin METAGLIP 1 glipizide extended-release GLUCOTROL XL 2 glucagon GLUCAGON EMERGENCY KIT Preferred Brand 3 glucagon GLUCAGEN HYPOKIT 1 glyburide DIABETA 1 glyburide & metformin GLUCOVANCE 1 glyburide micronized GLYNASE 3 insulin (oral inhalation) AFREZZA 3 insulin aspart NOVOLOG 3 insulin aspart protamine & insulin aspart NOVOLOG MIX 70/30 3 insulin degludec TRESIBA 3 insulin degludec/insulin aspart RYZODEG 70/30 3 insulin detemir LEVEMIR 3 insulin glargine LANTUS, BASAGLAR 3 insulin glulisine APIDRA 3 insulin isophane NOVOLIN N 2 insulin isophane HUMULIN N Preferred Brand 3 insulin isophane & regular insulin NOVOLIN 70/30 3 insulin isophane & regular insulin HUMULIN 50/50 2 insulin isophane & regular insulin HUMULIN 70/30 Preferred Brand 3 insulin lispro HUMALOG 3 insulin lispro protamine & insulin lispro HUMALOG MIX 50/50 3 insulin lispro protamine & insulin lispro HUMALOG MIX 75/25 3 insulin regular NOVOLIN R 2 insulin regular HUMULIN R Preferred Brand QRM 3 linagliptin TRADJENTA QRM 3 linagliptin & metformin JENTADUETO QRM 3 liraglutide VICTOZA QRM 3 lixisenatide ADLYXIN 1 metformin GLUCOPHAGE 1 metformin FORTAMET 1 metformin GLUMETZA 3 metformin RIOMET 1 metformin extended-release GLUCOPHAGE XR QRM 3 mifepristone KORLYM 3 miglitol GLYSET 1 nateglinide STARLIX 1 pioglitazone ACTOS 3 pioglitazone & glimepiride DUETACT 3 pioglitazone & metformin ACTOPLUS MET QRM 3 pramlintide acetate SYMLIN 1 repaglinide PRANDIN Kaiser Permanente of Georgia Multi Choice Formulary 32

34 1 repaglinide & metformin PRANDIMET QRM 3 saxagliptin ONGLYZA QRM 3 saxagliptin & metformin extendedrelease KOMBIGLYZE XR QRM 3 sitagliptin & metformin JANUMET QRM 3 sitagliptin & simvastatin JUVISYNC QRM 3 sitagliptin phosphate JANUVIA 1 tolazamide TOLINASE 1 tolbutamide ORINASE Estrogens and Antiestrogens 3 conjugated estrogens & bazedoxifene DUAVEE 3 conjugated estrogens & medroxyprogesterone acetate PREMPHASE 3 conjugated estrogens & medroxyprogesterone acetate PREMPRO 3 drospirenone & estradiol ANGELIQ 3 esterified estrogens MENEST 1 estradiol ESTRACE TAB 1 estradiol GYNODIOL 3 estradiol & levonorgestrel CLIMARA PRO 1 estradiol & norethindrone ACTIVELLA 3 estradiol & norethindrone COMBIPATCH 3 estradiol & norgestimate PREFEST 3 estradiol acetate FEMTRACE 3 estradiol acetate vaginal tablets FEMRING 3 estradiol gel DIVIGEL 3 estradiol gel ELESTRIN GEL 3 estradiol transdermal ALORA 1 estradiol transdermal CLIMARA DIS 3 estradiol transdermal ESTRADERM 3 estradiol transdermal MENOSTAR 1 estradiol transdermal VIVELLE-DOT 1 estradiol vaginal ESTRACE CREAM 2 estradiol vaginal ESTRING Preferred Brand Only 10mg strength 2 estradiol vaginal VAGIFEM Preferred Brand All other strengths 3 estradiol vaginal VAGIFEM 1 estradiol vaginal YUVAFEM 1 estrogen,ester/me-testosterone ESTRATEST 3 estrogens, conjugated PREMARIN 3 estrogens, conjugated synthetic a CENESTIN 3 estrogens, conjugated synthetic b ENJUVIA 2 estrogens, conjugated vaginal PREMARIN CREAM Preferred Brand 1 estropipate ORTHO-EST Kaiser Permanente of Georgia Multi Choice Formulary 33

35 1 norethindrone acetate & ethinyl estradiol FEMHRT 3 ospemifene OSPHENA 1 raloxifene hcl EVISTA Gonadatropins 2 nafarelin SYNAREL Preferred Brand Parathyroid 1 calcitonin salmon FORTICAL 1 calcitonin salmon MIACALCIN 3 teriparatide FORTEO Pitutary QRM 3 corticotropin ACTHAR 1 desmopressin (non-refrigerated) DDAVP 3 desmopressin acetate STIMATE Progestins 1 medroxyprogesterone acetate PROVERA 1 megestrol acetate MEGACE 1 norethindrone acetate AYGESTIN 1 progesterone, micronized PROMETRIUM Somatotropin Agonists and Antagonists QRM 3 somatropin GENTROPIN QRM 3 somatropin HUMATROPE QRM 3 somatropin NORDITROPIN QRM 3 somatropin NUTROPIN AQ QRM 3 somatropin OMNITROPE QRM 3 somatropin SAIZEN QRM 3 somatropin SEROSTIM QRM 3 pegvisomant SOMAVERT QRM 3 somatropin ZORBTIVE Thyroid and Antihyroid Agent 1 levothyroxine LEVOTHROID 1 levothyroxine LEVOXYL 1 levothyroxine SYNTHROID 3 levothyroxine TIROSINT 1 levothyroxine UNITHROID 1 liothyronine CYTOMEL 3 liotrix THYROLAR 1 methimazole TAPAZOLE 1 propylthiouracil PROPYLTHIOURACIL 3 thyroid ARMOUR THYROID Miscellaneous Therapeutic Agents Miscellanous Therapeutic Agents 2 abatacept ORENCIA Preferred Brand 1 acetylcysteine MUCOMYST-10 2 adalimumab HUMIRA Preferred Brand 1 alendronate FOSAMAX Kaiser Permanente of Georgia Multi Choice Formulary 34

36 3 alendronate & cholecalciferol FOSAMAX PLUS D 1 allopurinol ZYLOPRIM 3 anakinra KINERET 2 apremilast OTEZLA Preferred Brand 1 azathioprine AZASAN 1 azathioprine IMURAN 3 bedaquiline SIRTURO QRM 3 canakinumab ILARIS QRM 3 cholic acid CHOLBAM 2 cinacalcet SENSIPAR Preferred Brand 3 colchicine COLCRYS 1 cyclosporine SANDIMMUNE 1 cyclosporine, modified NEORAL QRM 3 cysteamine delayed-release PROCYSBI 3 cysteamine immediate-release CYSTAGON QRM 3 daclizumab ZINBRYTA Non-preferred QRM 3 dalfampridine AMPYRA QRM 3 dimethyl fumarate TECFIDERA 1 disulfiram ANTABUSE 1 dutasteride AVODART 1 dutasteride & tamsulosin JALYN QRM 3 eliglustat CERDELGA 2 etanercept ENBREL Preferred Brand 1 etidronate DIDRONEL 3 everolimus ZORTRESS 3 febuxostat ULORIC QRM 3 fingolimod GILENYA QRM 3 glatiramer acetate COPAXONE QRM 1 glatiramer acetate GLATOPA 3 golimumab SIMPONI 1 ibandronate BONIVA QRM 3 icatibant FIRAZYR 3 immune globulin HYQVIA QRM 3 interferon beta-1a AVONEX QRM 3 interferon beta-1a PLEGRIDY 2 interferon beta-1a REBIF Preferred Brand 2 interferon beta-1a REBIF REBIDOSE Preferred Brand 3 interferon beta-1b BETASERON 2 Interferon beta-1b EXTAVIA Preferred Brand 2 interferon gamma-1b ACTIMMUNE Preferred Brand 3 lanreotide SOMATULINE DEPOT 3 lesinurad ZURAMPIC Non-preferred 1 leflunomide ARAVA 1 leucovorin LEUCOVORIN 2 mesna MESNEX Preferred Brand Kaiser Permanente of Georgia Multi Choice Formulary 35

37 methenamine, sodium biphosphate, 1 phenyl salicylate, methylene blue, URO-MP and hyoscyamine 1 methylergonovine maleate METHERGINE 3 metreleptin MYALEPT 3 mifepristone MIFEPREX QRM 3 miglustat ZAVESCA 1 mycophenolate mofetil CELLCEPT 1 mycophenolate sodium MYFORTIC 3 nitisinone ORFADIN 1 octreotide acetate SANDOSTATIN QRM 3 parathyroid hormone NATPARA QRM 3 pasireotide SIGNIFOR Non-preferred 1 pediatric multivitamins w/ fluoride POLY-VI-FLOR 1 pediatric multivitamins w/ fluoride & iron POLY-VI-FLOR W/IRON 1 pediatric vitamins a, c, & d, w/ fluoride TRI-VI-FLOR 1 pediatric vitamins a, c, & d, w/ fluoride & iron TRI-VI-FLOR W/IRON 2 pentosan polysulfate sodium ELMIRON Preferred Brand 2 plerixafor MOZOBIL Preferred Brand 3 risedronate sodium ACTONEL 3 risedronate sodium ATELVIA QRM 3 sapropterin dihydrochlorid KUVAN 3 secukinumab COSENTYX solution 3 sirolimus RAPAMUNE 1 sirolimus RAPAMUNE 3 sodium fluoride FLUORABON BASIC 1 sodium fluoride FLUORITAB 1 sodium fluoride LURIDE CHEW 1 sodium fluoride (dental) PREVIDENT 1 sodium fluoride (dental) PREVIDENT 5000 PLUS 1 sodium fluoride drops LURIDE DROPS 2 stannous fluoride GEL-KAM Preferred Brand 1 tacrolimus PROGRAF QRM 3 teriflunomide AUBAGIO 2 thalidomide THALOMID Preferred Brand 3 tocilizumab ACTEMRA 2 tofacitinib XELJANZ Preferred Respiratory Tract Agents Antitussives 1 benzonatate TESSALON PERLES 1 guaifenesin & codeine CHERATUSSIN AC 3 hydrocodone & chlorpheniramine TUSSIONEX 1 hydrocodone & homatropine HYCODAN Kaiser Permanente of Georgia Multi Choice Formulary 36

38 1 promethazine & codeine PHENERGAN W/ CODEINE 1 promethazine & dextromethorphan PROMETHAZINE-DM 1 promethazine, phenylephrine & PHENERGAN VC codeine W/CODEINE 3 pseudoephedrine, brompheniramine & codeine M-END MAX D Anti-Inflammatory Agents 3 cromolyn sodium GASTROCROM 1 cromolyn sodium INTAL 1 montelukast SINGULAIR 3 zafirlukast ACCOLATE 3 zileuton ZYFLO Respiratory Agents, Miscellaneous 2 beclomethasone dipropionate QVAR Preferred Brand 3 budesonide PULMICORT FLEXHALER 1 budesonide PULMICORT RESPULES 3 budesonide & formoterol SYMBICORT 3 ciclesonide ALVESCO 3 fluticasone & salmeterol ADVAIR DISKUS 3 fluticasone & vilanterol BREO ELLIPTA 3 fluticasone propionate FLOVENT DISKUS AER 3 fluticasone propionate FLOVENT HFA QRM 3 ivacaftor KALYDECO QRM 3 lumacaftor& ivacaftor ORKAMBI 2 mometasone & formoterol DULERA Preferred Brand 2 mometasone furoate ASMANEX Preferred Brand QRM 3 mepolizumab NUCALA 3 nintedanib OFEV QRM 3 omalizumab XOLAIR 3 pirfenidone ESBRIET 3 roflumilast DALIRESP 3 salmeterol SEREVENT DISKUS 3 sodium chloride HYPERSAL 2 tiotropium bromide and olodaterol STIOLTO RESPIMAT Preferred Brand Skin and Mucous Membrane Agents Anti-infectives (Skin and Mucous Membranes) 3 acyclovir ZOVIRAX 3 benzoyl peroxide & erythromycin BENZAMYCIN 3 butenafine MENTAX 3 butoconazole nitrate (vaginal) GYNAZOLE-1 1 ciclopirox LOPROX 1 ciclopirox PENLAC 1 clindamycin & benzoyl peroxide BENZACLIN 1 clindamycin & benzoyl peroxide DUAC 1 clindamycin phosphate (topical) CLEOCIN T Kaiser Permanente of Georgia Multi Choice Formulary 37

39 1 clindamycin phosphate (topical) CLINDAGEL 3 clindamycin phosphate (topical) EVOCLIN 1 clindamyinc phosphate (vaginal) CLEOCIN 1 clotrimazole MYCELEX 1 clotrimazole & betametmethasone LOTRISONE 3 crotamiton EURAX 1 econazole nitrate SPECTAZOLE 3 erythromycin (acne acid) AKNE-MYCIN 1 erythromycin (acne acid) ERYGEL 1 gentamicin sulfate (topical) GARAMYCIN 3 hexachlorophene PHISOHEX 1 iodoquinol & hydrocortisone VYTONE 1 ketoconazole (topical) NIZORAL 1 lindane KWELL 3 mafenide acetate SULFAMYLON 1 malathion OVIDE 1 metronidazole (topical) METROCREAM 1 metronidazole (topical) METROGEL 1 metronidazole (topical) METROLOTION 1 metronidazole (vaginal) METROGEL-VAGINAL 3 miconazole nitrate & zinc oxide VUSION 1 mupirocin BACTROBAN 3 mupirocin calcium BACTROBAN NASAL 3 na sulfacetm/avobenzone/sulfur ROSAC 3 naftifine NAFTIN 1 nystatin (topical) NYSTATIN 3 oxiconazole nitrate OXISTAT 3 penciclovir DENAVIR 1 permethrin ELIMITE 3 retapamulin ALTABAX 3 selenium sulfide SELSEB 3 selenium sulfide SELSUN RX 3 sertaconazole nitrate ERTACZO 1 silver sulfadiazine SILVADENE 3 spinosad NATROBA 3 sulconazole nitrate EXELDERM 1 sulfacetamide sodium (acne) KLARON 3 sulfacetamide sodium (acne) SEB-PREV 3 sulfanilamide AVC 1 terconazole TERAZOL 7 1 terconazole (vaginal) TERAZOL 3 Anti-inflammatory Agents (Skin and Mucous Membranes) 1 alclometasone dipropionate ACLOVATE 1 amcinonide CYCLOCORT 3 bacitracin, polymyxin, neomycin & hydrocortisone CORTISPORIN Kaiser Permanente of Georgia Multi Choice Formulary 38

40 3 benzoyl peroxide & hydrocortisone VANOXIDE-HC 1 betamethasone dipropionate (topical) DIPROSONE 1 betamethasone dipropionate augmented DIPROLENE 1 betamethasone valerate LUXIQ 1 betamethasone valerate VALISONE 1 calcipotriene & betamethasone TACLONEX 1 clobetasol propionate CLOBEX 1 clobetasol propionate TEMOVATE 1 clobetasol propionate emollient TEMOVATE E 3 clobetasol propionate emulsion OLUX-E 1 clocortolone pivalate CLODERM QL 1 desonide DESOWEN 1 desoximetasone TOPICORT 1 diflorasone diacetate APEXICON 3 fluocinolone acetonide CAPEX SHAMPOO 1 fluocinolone acetonide DERMA-SMOOTHE/FS OIL 1 fluocinolone acetonide SYNALAR 1 fluocinonide LIDEX 3 fluocinonide VANOS 1 fluocinonide emollient LIDEX-E 1, 3 flurandrenolide CORDRAN 1 fluticasone propionate (topical) CUTIVATE 3 halcinonide HALOG 1 halobetasol propionate ULTRAVATE 1 hydrocortisone (intrarectal) CORTENEMA 1 hydrocortisone (rectal) ANUSOL-HC 1 hydrocortisone (rectal) PROCTOCORT 1 hydrocortisone (topical) HYTONE 1 hydrocortisone acetate & urea CARMOL HC 3 hydrocortisone acetate (intrarectal) CORTIFOAM 1 hydrocortisone butyrate LOCOID 3 hydrocortisone butyrate hydrophilic lipo base LOCOID LIPOCREAM 3 hydrocortisone probutate PANDEL 1 hydrocortisone valerate WESTCORT 1 mometasone furoate ELOCON 1 nystatin & triamcinolone MYCOLOG II 1 prednicarbate DERMATOP 1 triamcinolone acetonide (topical) KENALOG Antipruritics and Local Anesthetics 3 doxepin (antipuritic) ZONALON 3 hydrocortisone & pramoxine ANALPRAM HC 3 hydrocortisone & pramoxine PRAMOSONE 3 hydrocortisone & pramoxine PRAMOSONE-E Kaiser Permanente of Georgia Multi Choice Formulary 39

41 3 hydrocortisone & pramoxine PROCTOFOAM-HC 1 lidocaine (Jelly, topical) XYLOCAINE 3 lidocaine & hydrocortisone LIDAMANTLE 1 lidocaine & prilocaine EMLA 1 pramoxine PROCTOFOAM Astringents 2 aluminum chloride hexahydrate HYPERCARE Preferred Brand Keratolytic Agents 3 sulfacetamide sodium & sulfur AVAR 1 sulfacetamide sodium & sulfur PLEXION 3 sulfacetamide sodium & sulfur PLEXION SCT 1 sulfacetamide sodium & sulfur ROSULA 1 urea CARMOL Keratoplastic Agents 3 anthralin DRITHOCREME HP 3 anthralin DRITHO-SCALP 3 anthralin PSORIATEC Cell Stimulants and Proliferants QL, AGE 1 tretinoin RETIN-A QL, AGE 3 tretinoin microspheres RETIN-A MICRO Skin and Mucous Membrane Agents, Miscellaneous 1 acitretin SORIATANE QL, AGE 1 adapalene DIFFERIN QL, AGE 3 alitretinoin PANRETIN 1 ammonium lactate LAC-HYDRIN 3 azelaic acid FINACEA 3 azelaic acid (acne) AZELEX 2 becaplermin REGRANEX Preferred Brand 3 bexarotene (topical) TARGRETIN 3 brimonidine (topical) MIRVASO 1 calcipotriene DOVONEX 3 calcipotriene SORILUX 2 calcitriol (topical) VECTICAL Preferred Brand AGE 3 clindamycin & tretinoin VELTIN AGE 3 clindamycin & tretinoin ZIANA 2 collagenase SANTYL Preferred Brand 3 dapsone (topical) ACZONE 3 diclofenac epolamine FLECTOR 1 diclofenac sodium VOLTAREN GEL 3 diclofenac sodium (actinic keratosis) SOLARAZE 3 doxepin (antipuritic) PRUDOXIN 3 doxycycline (rosacea) ORACEA 3 fluorouracil (topical) CARAC 1 fluorouracil (topical) EFUDEX 2 fluorouracil (topical) FLUOROPLEX Preferred Brand 1 imiquimod ALDARA Kaiser Permanente of Georgia Multi Choice Formulary 40

42 3 imiquimod ZYCLARA 3 ingenol mebutate PICATO 1 isotretinoin ACCUTANE 1 isotretinoin CLARAVIS 3 lactic acid (ammonium lactate) LACTINOL 2 methoxsalen 8-MOP Preferred Brand 1 methoxsalen, rapid OXSORALEN-ULTRA 2 pimecrolimus ELIDEL Preferred Brand 1 podofilox CONDYLOX 3 sinecatechins VEREGEN 1 tacrolimus (topical) PROTOPIC QL, AGE 3 tazarotene TAZORAC Smooth Muscle Relaxants Smooth Muscle Relaxants 1 darifenacin ENABLEX 3 dyphylline LUFYLLIN 3 fesoterodine TOVIAZ 3 flavoxate FLAVOXATE 3 mirabegron MYRBETRIQ 1 oxybutynin DITROPAN 1 oxybutynin extended-release DITROPAN XL 3 oxybutynin transdermal OXYTROL 3 solifenacin VESICARE 1 theophylline UNIPHYL 1 tolterodine DETROL 1 tolterodine extended-release DETROL LA 1 trospium SANCTURA 3 trospium extended-release SANCTURA XR Vitamins Vitamins 1 calcitriol ROCALTROL 1 doxercalciferol HECTOROL 1 ergocalciferol DRISDOL 1 niacin NIACOR 1 paricalcitol ZEMPLAR 2 phytonadione MEPHYTON Preferred Brand Kaiser Permanente of Georgia Multi Choice Formulary 41

43 Index of Drugs Kaiser Permanente of Georgia Multi Choice Formulary 8 8-MOP A abacavir sulfate & lamivudine... 6 abacavir sulfate solution... 6 abacavir sulfate tablet... 6 abacavir, dolutegravir & lamivudine... 6 abacavir, lamivudine & zidovudine... 6 abatacept ABILIFY abiraterone... 8 ABSTRAL acamprosate acarbose ACCOLATE ACCU-CHEK ACCU-CHEK TEST STRIPS ACCUNEB ACCUPRIL ACCURETIC ACCUTANE acebutolol ACEON acetaminophen & codeine acetaminophen, caffeine, & dihydrocodine ACETASOL HC acetazolamide acetic acid... 24, 26 acetylcysteine acitretin ACLOVATE ACTEMRA ACTHAR ACTIGALL ACTIMMUNE ACTIQ ACTIVELLA ACTONEL ACTOPLUS MET ACTOS ACULAR ACULAR LS acyclovir... 6, 37 ACZONE ADALAT CC adalimumab adapalene ADCIRCA ADDERALL ADDERALL XR adefovir dipivoxil... 6 ADEMPAS ADLYXIN ADOXA... 5 ADRENACLICK ADVAIR DISKUS ADVICOR AFINITOR... 8 aflcaftadine AFREZZA AGGRENOX AGRYLIN AKNE-MYCIN AK-TRACIN AKYNZEO albendazole... 4 ALBENZA... 4 albiglutide albuterol nebulizer solution albuterol sulfate albuterol sulfate & ipratropium albuterol sulfate tablet alclometasone dipropionate ALDACTAZIDE ALDACTONE ALDARA ALDOMET ALDORIL alendronate... 34, 35 alendronate & cholecalciferol... 35, 36 alfuzosin hcl ALINIA... 6 alirocumab aliskiren aliskiren & amlodipine aliskiren & hydrochlorothiazide aliskiren & valsartan aliskiren, amlodipine & hydrochlorothiazide alitretinoin ALKERAN... 9 allopurinol almotriptan ALOCRIL alogliptin alogliptin & metformin alogliptin & pioglitazone ALOMIDE ALORA alosetron Kaiser Permanente of Georgia Multi Choice Formulary 42

44 ALPHAGAN ALPHAGAN P alprazolam alprazolam extended-release alprazolam orally disintegrating ALREX ALTABAX ALTACE ALTOPREV aluminum chloride hexahydrate ALVESCO amantadine AMARYL AMBIEN AMBIEN CR ambrisentan amcinonide AMERGE AMICAR amiloride amiloride & hydrochlorothiazide aminocaproic acid amiodarone AMITIZA amitriptyline amitriptyline & perphenazine amlodipine... 12, 13 amlodipine & atorvastatin amlodipine & benazepril amlodipine & olmesartan amlodipine & valsartan amlodipine, olmesartan & hydrochlorothiazide amlodipine, valsartan & hydrochlorothiazide ammonium lactate... 40, 41 amoxapine amoxicillin... 2, 4, 27 amoxicillin & clavulanate potassium... 4 amoxicillin & clavulanate potassium extended-release... 4 amoxicillin, clarithromycin, & lansoprazole AMOXIL... 4 amphetamine & dextroamphetamine amphetamine & dextroamphetamine extended-release AMPICILLIN... 4 ampicillin sodium... 4 AMPYRA AMRIX AMTURNIDE AMYTHYST ANAFRANIL anagrelide anakinra ANALPRAM HC ANAPROX anastrozole... 8 Kaiser Permanente of Georgia Multi Choice Formulary ANCOBON... 5 ANDRODERM ANDROGEL ANDROID ANDROXY ANGELIQ ANORO ELLIPTA ANSAID ANTABUSE anthralin antipyrine & benzocaine ANUSOL-HC ANZEMET APEXICON APIDRA apixaban APLENZIN apraclonidine apremilast aprepitant APRESOLINE APRI APTIOM APTIVUS... 8 ARALEN... 6 ARANELLE ARANESP ARAVA arformoterol ARICEPT ARICEPT ODT ARIMIDEX... 8 aripiprazole ARIXTRA armodafinil ARMOUR THYROID AROMASIN... 8 ARTANE ARTHROTEC artificial tear insert ASCENSIA BREEZE ASCENSIA TEST STRIPS asenapine ASENDIN ASMANEX aspirin & dipyridamole ASTELIN ASTEPRO ATACAND ATACAND HCT ATARAX atazanavir & cobicistat... 6 atazanavir sulfate... 6 ATELVIA Kaiser Permanente of Georgia Multi Choice Formulary 43

45 atenolol atenolol & chlorthalidone ATIVAN atomoxetine atorvastatin atovaquone... 6 atovaquone & proguanil... 6 ATRIPLA... 6 atropine... 9, 26, 27 atropine sulfate... 9 ATROPINE SULFATE... 9 ATROVENT... 9 ATROVENTHFA... 9 AUBAGIO AUGMENTIN... 4 AUGMENTIN XR... 4 auranofin AURODEX AUVI-Q AVALIDE AVAPRO AVAR AVC AVELOX... 5 AVIANE AVINZA AVLOSULFON... 6 AVODART AVONEX AXERT AXID AXIRON axitinib... 8 AYGESTIN AZASAN AZASITE azathioprine azelaic acid azelaic acid (acne) azelastine azelastine & fluticasone azelastine (ophth) AZELEX azelstine AZILECT azilsartan azithromycin... 4, 23 azithromycin (ophth) AZOPT AZOR AZULFIDINE... 5 Kaiser Permanente of Georgia Multi Choice Formulary B B & O SUPPRETTES bacitracin & polmyxin B (ophth) bacitracin (ophth) bacitracin, neomycin, polymyxin B & hydrocortisone (ophth). 24 bacitracin, polymyxin, neomycin & hydrocortisone baclofen BACTRIM DS... 5 BACTROBAN BACTROBAN NASAL balsalazide BALZIVA BANZEL BARACLUDE... 7 BD INSULIN SYRINGE becaplermin beclomethasone dipropionate bedaquiline BELSOMRA benazepril... 12, 13, 14 benazepril & hydrochlorothiazide BENEMID BENICAR BENICAR HCT BENTYL... 9 BENZACLIN BENZAMYCIN benzonatate benzoyl peroxide & erythromycin benzoyl peroxide & hydrocortisone benztropine bepotastine BEPREVE besilfoxacin BESIVANCE BETAGAN betamethasone dipropionate (topical) betamethasone dipropionate augmented betamethasone valerate BETAPACE BETAPACE AF BETASERON BETASERON] betaxolol... 15, 25 betaxolol hcl bethanechol chloride... 9 BETIMOL BETOPTIC BETOPTIC S bexarotene... 8, 40 bexarotene (topical) BEYAZ BIAXIN... 4 Kaiser Permanente of Georgia Multi Choice Formulary 44

46 BIAXIN XL... 4 bicalutamide... 8 BICITRA BIDIL bimatoprost bismuth subcitrate & metronidazole... 4 bisoprol & hydrochlorothiazide bisoprolol BLEPH BLEPHAMIDE BLOCADREN blood sugar diagnostic blood-glucose meter boceprevir... 6 BONIVA bosentan BOSULIF... 8 bosutinib... 8 BREO ELLIPTA BRETHINE BREVICON brexpiprazole BRILINTA brimonidine... 26, 40 brimonidine (topical) brimonidine tartrate BRINTELLIX brinzolamide bromfenac (ophth) bromocriptine BROVANA budesonide... 28, 37 budesonide & formoterol bumetanide BUMEX BUPHENYL buprenorphine buprenorphine & naloxone film buprenorphine transdermal buprenorphine& naloxone tablet bupropion bupropion extended-release bupropion hydrobromide bupropion sustained-release BUSPAR buspirone busulfan... 8 butalbital & acetaminophen... 15, 16 butalbital, acetaminophen, & caffeine butalbital, acetaminophen, caffeine, & codeine butalbital, aspirin, & caffeine butalbital, aspirin, caffeine, & codeine butenafine butoconazole nitrate (vaginal) Kaiser Permanente of Georgia Multi Choice Formulary butorphanol tartrate BUTRANS BYDUREON BYETTA BYSTOLIC C cabergoline CADUET CAFERGOT CALAN SR calcipotriene... 39, 40 calcipotriene & betamethasone calcitonin salmon calcitriol... 40, 41 calcitriol (topical) calcium acetate CAMILA CAMPRAL canagliflozin canagliflozin & metformin canakinumab CANASA candesartan candesartan & hydrochlorothiazide capecitabine... 8 CAPEX SHAMPOO CAPOTEN CAPOZIDE CAPRELSA... 9 captopril captopril & hydrochlorothiazide CARAC CARAFATE carbachol CARBAGLU carbamazepine carbamazepine extended-release cap carbamazepine extended-release tab CARBATROL carbidopa carbidopa & levodopa carbidopa & levodopa extended release carbidopa, levodopa, & entacapone carbinoxamine maleate... 4 CARDENE CARDIZEM CARDIZEM CD CARDIZEM LA CARDURA carglumic acid carisoprodol... 10, 16 carisoprodol, aspirin, & codeine Kaiser Permanente of Georgia Multi Choice Formulary 45

47 carisoprodol/aspirin CARMOL... 39, 40 CARMOL HC carteolol (ophth) CARTIA XT carvedilol carvedilol phosphate CASODEX... 8 CATAFLAM CATAPRES CATAPRES-TTS CECLOR... 4 CEDAX... 4 CEENU... 8 cefaclor... 4 cefadroxil... 4 cefdinir... 4 cefditoren... 4 cefixime... 4 cefpodoxime... 4 cefprozil... 4 ceftibuten... 4 CEFTIN... 4 cefuroxime axetil... 4 CEFZIL... 4 CELEBREX celecoxib CELEXA CELLCEPT CELONTIN CENESTIN cephalexin... 4 CERDELGA ceritinib... 8 cevimeline hcl CHANTIX... 9 CHEMET CHERATUSSIN AC chlorambucil... 8 chlordiazepoxide... 19, 20, 28 chlordiazepoxide & amitriptyline chlorhexidine (mouth-throat) chloroquine phosphate... 6 chlorothiazide chlorphenirmine, phenylephrine & pyrilamine... 4 chlorpromazine chlorpropamide CHLORPROPAMIDE chlorthalidone... 15, 23 chlorzoxazone CHOLBAM cholestyramine cholestyramine light cholic acid Kaiser Permanente of Georgia Multi Choice Formulary CHRONULAC CIBALITH-S ciclesonide ciclopirox cilostazol CILOXAN cimetidine cinacalcet CIPRO... 4, 24 CIPRO HC CIPRODEX ciprofloxacin... 4, 23, 24 ciprofloxacin & dexamethasone (ophth) ciprofloxacin & hydrocortisone (otic) ciprofloxacin (ophth) ointment ciprofloxacin (ophth) solution citalopram citric acid, sodium citrate, & potassium citrate CLARAVIS clarithromycin... 4, 27 clarithromycin extended-release... 4 CLEOCIN... 4, 37, 38 CLEOCIN HCL... 4 CLEOCIN PEDIATRIC... 4 CLEOCIN T clidinium & chlordiazepoxide CLIMARA DIS CLIMARA PRO CLINDAGEL clindamycin & benzoyl peroxide clindamycin & tretinoin clindamycin hcl... 4 clindamycin palmitate... 4 clindamycin phosphate (topical)... 37, 38 clindamyinc phosphate (vaginal) CLINORIL clobazam clobetasol propionate clobetasol propionate emollient clobetasol propionate emulsion CLOBEX clocortolone pivalate CLODERM clomipramine clonazepam clonidine clonidine extended-release clonidine transdermal clopidogrel clorazepate clotrimazole clotrimazole & betametmethasone clozapine CLOZARIL Kaiser Permanente of Georgia Multi Choice Formulary 46

48 codeine... 15, 16, 36, 37 CODEINE SULF COGENTIN COLAZAL COL-BENEMID colchicine... 23, 35 colchicine & probenecid COLCRYS colesevelam COLESTID colestipol collagenase COLYTE COMBIPATCH COMBIVENT RESPIMAT COMBIVIR... 7 COMBUNOX COMPAZINE COMPLERA... 7 COMTAN CONCERTA CONDYLOX conjugated estrogens & bazedoxifene conjugated estrogens & medroxyprogesterone acetate COPAXONE CORDRAN COREG COREG CR CORGARD CORLANOR CORTEF CORTENEMA corticotropin CORTIFOAM cortisone acetate CORTISPORIN... 25, 38 CORTISPORIN-TC CORTONE ACETATE CORZIDE COSENTYX COSOPT COUMADIN COVERA-HS COZAAR CREON CRESEMBA... 5 CRESTOR CRIXIVAN... 7 crizotinib... 8 cromolyn sodium... 25, 37 cromolyn sodium (ophth) crotamiton CRYSELLE CUPRIMINE Kaiser Permanente of Georgia Multi Choice Formulary CUTIVATE CYCLESSA cyclobenzaprine cyclobenzaprine extended-release CYCLOCORT cyclophosphamide... 8 cycloserine... 6 CYCLOSET cyclosporine... 24, 35 cyclosporine (ophth) cyclosporine, modified CYMBALTA cyproheptadine... 4 CYSTAGON cysteamine cysteamine delayed-release cysteamine immediate-release CYTOMEL CYTOTEC CYTOVENE... 7 CYTOXAN... 8 CYTRA D D.H.E dabigatran daclatasvir... 6 daclizumab DAKLINZA... 6 dalfampridine DALIRESP DALMANE dalteparin danazol DANOCRINE DANTRIUM dantrolene sodium dapagliflozin dapagliflozin & metformin dapsone... 6, 40 dapsone (topical) DARAPRIM... 6 darbepoetin alfa darifenacin darunavir & cobicistat... 6 darunavir ethanolate... 6 dasatinib... 8 DAYPRO DAYTRANA DDAVP DECADRON... 24, 28 DECLOMYCIN... 4 deferasirox Kaiser Permanente of Georgia Multi Choice Formulary 47

49 deferiprone delavirdine mesylate... 6 DELESTROGEN DEMADEX demeclocycline... 4 DEMEROL DENAVIR DEPAKENE DEPAKOTE DEPAKOTE ER DEPAKOTE SPRINKLE DEPEN DEPO-ESTRADIOL DEPO-TESTOSTERONE DERMA-SMOOTHE/FS OIL DERMATOP DERMOTIC DESCOVY... 7 desipramine desmopressin (non-refrigerated) desmopressin acetate DESOGEN desogestrel & ethinyl estradiol desogestrel & ethinyl estradiol (biphasic) desogestrel & ethinyl estradiol (triphasic) desonide DESOWEN desoximetasone DESOXYN desvenlafaxine desvenlafaxine base extended release DESYREL DETROL DETROL LA dexamethasone... 24, 25, 28 dexamethasone (ophth) solution dexamethasone (ophth) suspension DEXEDRINE dexmethylphenidate dexmethylphenidate extended-release dextroamphetamine sulfate dextroamphetamine sulfate extended-release dextromethorphan & quinidine DEXTROSTAT DIABETA DIAMOX DIAMOX SEQUELS DIASTAT DIASTAT ACUDIAL diazepam... 18, 19 DIBENZYLINE diclofenac epolamine diclofenac potassium diclofenac sodium... 16, 24, 40 Kaiser Permanente of Georgia Multi Choice Formulary diclofenac sodium & misoprostol diclofenac sodium (actinic keratosis) diclofenac sodium (ophth) diclofenac sodium extended release dicloxacillin... 4 dicyclomine... 9 didanosine... 6 didanosine solution... 6 DIDRONEL difenoxin & atropine DIFFERIN DIFICID... 5 diflorasone diacetate DIFLUCAN... 5 diflunisal DIFLUNISAL difluprednate digoxin dihydroergotamine mesylate DILANTIN DILAUDID diltiazem diltiazem extended-release dimethyl fumarate DIOVAN DIOVAN HCT DIPENTUM diphenoxylate & atropine DIPROLENE DIPROSONE dipyridamole DISALCID disopyramide disopyramide controlled-release disulfiram DITROPAN DITROPAN XL DIURIL divalproex sodium divalproex sodium capsule divalproex sodium extended release DIVIGEL dofetilide dolasetron DOLOPHINE dolutegravir... 6 donepezil... 10, 20 DONNATAL dornase alfa DORYX... 5 dorzolamide dorzolamide & timolol DOSTINEX DOVONEX Kaiser Permanente of Georgia Multi Choice Formulary 48

50 doxazosin doxepin... 21, 39, 40 doxepin (antipuritic)... 39, 40 doxercalciferol doxycycline... 4, 5, 40 doxycycline (rosacea) doxycycline hyclate... 5 doxycycline monohydrate... 5 DRISDOL DRITHOCREME HP DRITHO-SCALP dronabinol dronedarone drospirenone & estradiol drospirenone & ethinyl estradiol drospirenone & ethinyl estradiol w/ folate DROXIA... 8 droxidopa DUAC DUAVEE DUETACT dulaglutide DULERA duloxetine DUONEB DURAGESIC DUREZOL DURICEF... 4 dutasteride dutasteride & tamsulosin DYAZIDE DYMISTA DYNACIN... 5 DYNACIRC DYNACIRC CR DYNAPEN... 4 dyphylline DYRENIUM E E.E.S... 5 E.S.P... 5 econazole nitrate ecothiophate EDARBI EDECRIN EDLUAR edoxaban EDURANT... 7 efavirenz... 6 efavirenz, emtricitab & tenofovir... 6 EFFEXOR EFFEXOR XR Kaiser Permanente of Georgia Multi Choice Formulary efinaconazole... 5 EFUDEX ELAVIL elbasvir & grazoprevir... 7 ELDEPRYL ELESTAT ELESTRIN GEL eletriptan ELIDEL eliglustat ELIMITE ELIPHOS ELIQUIS ELLA ELMIRON ELOCON eltrombopag eluxadoline elvitegravir, cobicistat, emtricitabine, & tenofovir... 7 EMADINE EMCYT... 8 emedastine EMEND EMLA empagliflozin empagliflozin & linagliptan empagliflozin & metformin EMSAM emtricitabine... 7 emtricitabine & tenofovir... 7 emtricitabine, rilpivirine, & tenofovir... 7 EMTRIVA... 7 ENABLEX enalapril enalapril & hydrochlorothiazide ENBREL enfuvirtide... 7 ENJUVIA enoxaparin entacapone entecavir... 7 ENTOCORT EC ENTRESTO ENULOSE enzalutamide... 8 EPANOVA EPCLUSA... 7 epinastine (ophth) epinephrine... 10, 11 EPIPEN... 10, 11 EPIPEN JR EPIVIR... 7 EPIVIR HBV... 7 eplerenone Kaiser Permanente of Georgia Multi Choice Formulary 49

51 epoetin alfa EPOGEN eprosartan eprosartan & hydrochlorothiazide EPZICOM... 6 EQUETRO ergocalciferol ergoloid mesylates ergotamine & caffeine... 10, 18 erlotinib... 8 ERTACZO ERYGEL ERYPED... 5 ERY-TAB... 5 ERYTHROCIN... 5 ERYTHROMYCIN... 5 erythromycin & sulfisoxazole... 5 erythromycin (acne acid) erythromycin (ophth) erythromycin base... 5 erythromycin base delayed-release... 5 erythromycin ethylsuccinate... 5 erythromycin sterate... 5 ESBRIET escitalopram eslicarbazepine estazolam esterified estrogens ESTRACE CREAM ESTRACE TAB ESTRADERM estradiol... 29, 30, 31, 33, 34 estradiol & levonorgestrel estradiol & norethindrone estradiol & norgestimate estradiol acetate estradiol acetate vaginal tablets estradiol cypionate estradiol gel estradiol transdermal estradiol vaginal estradiol valerate estradiol valerate & dienogest estramustine... 8 ESTRATEST ESTRING estrogen,ester/me-testosterone estrogens, conjugated estrogens, conjugated synthetic a estrogens, conjugated synthetic b estrogens, conjugated vaginal estropipate ESTROSTEP FE eszopiclone Kaiser Permanente of Georgia Multi Choice Formulary etanercept ethacrynic acid ethambutol... 6 ethontoin ethosuximide ethynodiol diacetate & ethinyl estradiol etidronate etodolac etonogestrel & ethinyl estradiol etravirine... 7 EULEXIN... 8 EURAX everolimus... 8, 35 EVISTA EVOCLIN Evolocumab EVOTAZ... 6 EVOXAC EXALGO EXELDERM EXELON exemestane... 8 exenatide exenatide extended-release EXFORGE EXFORGE HCT EXJADE EXTAVIA ezetimibe ezetimibe & simvastatin ezogaine F FACTIVE... 5 famciclovir... 7 FAMVIR... 7 FANAPT FARXIGA FAZACLO febuxostat felbamate FELBATOL FELDENE felodipine FEMARA... 8 FEMCON FE FEMHRT FEMRING FEMTRACE fenofibrate fenofibrate, micronized fenofibric acid fenoprofen calcium Kaiser Permanente of Georgia Multi Choice Formulary 50

52 fentanyl film fentanyl intranasal fentanyl lozenge fentanyl sublingual fentanyl tablet fentanyl transdermal FENTORA FERRIPROX fesoterodine FETZIMA fidaxomicin... 5 filgrastim FINACEA fingolimod FIORICET FIORICET W/ CODEINE FIORINAL FIORINAL W/ CODEINE FIRAZYR FLAGYL... 6 FLAGYL ER... 6 FLAREX flavoxate FLAVOXATE flecainide FLECTOR FLEXERIL FLOMAX FLORINEF ACETATE FLOVENT DISKUS AER FLOVENT HFA FLOXIN fluconazole... 5 flucytosine... 5 fludrocortisone FLUMADINE... 7 fluocinolone acetonide... 24, 39 fluocinolone acetonide (otic) fluocinonide fluocinonide emollient FLUORABON BASIC FLUORITAB fluorometholone (ophth) fluorometholone acetate FLUOROPLEX fluorouracil (topical) fluoxetine fluoxymesterone fluphenazine flurandrenolide flurazepam flurbiprofen... 16, 24 flurbiprofen (ophth) flutamide... 8 Kaiser Permanente of Georgia Multi Choice Formulary fluticasone & salmeterol fluticasone & vilanterol fluticasone propionate... 37, 39 fluticasone propionate (topical) fluvastatin fluvastatin extended-release fluvoxamine FML FML FORTE FOCALIN FOCALIN XR fondaparinux FORADIL formoterol fumarate FORTAMET FORTEO FORTESTA FORTICAL FOSAMAX... 34, 35 FOSAMAX PLUS D fosamprenavir calcium... 7 fosinopril fosinopril & hydrochlorothiazide FOSRENOL FRAGMIN FREESTYLE SYSTEM FREESTYLE TEST STRIPS FROVA frovatriptan FURADANTIN... 8 furosemide FUZEON... 7 FYCOMPA G gabapentin GABITRIL galantamine hydrobromide ganciclovir... 7, 24 ganciclovir (ophth) GARAMYCIN... 5, 38 GASTROCROM gatifloxacin (ophth) GATTEX GAVILYTE-C GEL-KAM gemfibrozil gemifloxacin... 5 GENERESS FE GENTAK gentamicin & prednisolone gentamicin (ophth) gentamicin sulfate... 5, 38 Kaiser Permanente of Georgia Multi Choice Formulary 51

53 gentamicin sulfate (topical) GENTROPIN GENVOYA... 7 GEODON GIANVI GIAZO GILENYA glatiramer acetate GLATOPA GLEEVEC... 8 glimepiride... 31, 32 glipizide... 31, 32 glipizide & metformin glipizide extended-release GLUCAGEN HYPOKIT glucagon GLUCAGON EMERGENCY KIT GLUCOPHAGE GLUCOPHAGE XR GLUCOTROL... 31, 32 GLUCOTROL XL GLUCOVANCE GLUMETZA glyburide glyburide & metformin glyburide micronized glycerol phenylbutyrate glycopyrrolate... 9 GLYNASE GLYSET GLYXAMBI golimumab GOLYTELY granisetron grass pollen allergen extract (5 glass extract) GRASTEK GRASTEK GRIFULVIN V... 5 griseofulvin microsize... 5 griseofulvin ultramicrosize... 5 GRIS-PEG... 5 guaifenesin & codeine guanfacine... 13, 20 guanfacine extended-release GYNAZOLE GYNODIOL H halcinonide HALCION HALDOL HALFLYTELY halobetasol propionate Kaiser Permanente of Georgia Multi Choice Formulary HALOG haloperidol HARVONI... 7 HARVONI... 7 HECTOROL HELIDAC... 4 heparin HEPARIN SODIUM HEPSERA... 6 HETLIOZ hexachlorophene HIPREX... 8 homatropine... 26, 36 HUMALOG HUMALOG MIX 50/ HUMALOG MIX 75/ HUMATIN... 6 HUMATROPE HUMIRA HUMULIN 50/ HUMULIN 70/ HUMULIN N HUMULIN R HYCAMTIN... 9 HYCODAN HYDERGINE hydralazine... 13, 14 HYDREA... 8 hydrochlorothiazide...12, 13, 14, 15, 22, 23 hydrocodone... 16, 36 hydrocodone & acetaminophen hydrocodone & chlorpheniramine hydrocodone & homatropine hydrocodone & ibuprofen hydrocodone er hydrocortisone...24, 25, 28, 38, 39, 40 hydrocortisone & acetic acid (otic) hydrocortisone & pramoxine... 39, 40 hydrocortisone (intrarectal) hydrocortisone (rectal) hydrocortisone (topical) hydrocortisone acetate & urea hydrocortisone acetate (intrarectal) hydrocortisone butyrate hydrocortisone butyrate hydrophilic lipo base hydrocortisone probutate hydrocortisone valerate hydromorphone oral suspension hydromorphone tablet hydroxychloroquine sulfate... 6 hydroxyurea... 8 hydroxyzine hcl hydroxyzine pamoate HYGROTON Kaiser Permanente of Georgia Multi Choice Formulary 52

54 hyoscyamine sulfate... 9 HYPERCARE HYPERSAL HYQVIA HYSINGLA ER HYTONE HYTRIN HYZAAR I ibandronate IBRANCE... 9 ibrutinib... 8 ibuprofen... 16, 17 icatibant ICLUSIG... 9 ILARIS iloperidone imatinib mesylate... 8 IMBRUVICA... 8 IMDUR imipramine imipramine pamoate imiquimod... 40, 41 IMITREX immune globulin IMURAN INCIVEK... 7 INCRUSE ELLIPTA... 9 indapamide INDERAL INDERAL LA INDERIDE indinavir sulfate... 7 INDOCIN indomethacin INFERGEN... 7 INFLAMASE FORTE ingenol mebutate INLYTA... 8 INNOPRAN XL INSPRA insulin (oral inhalation) insulin aspart insulin aspart protamine & insulin aspart insulin degludec insulin degludec/insulin aspart insulin detemir insulin glargine insulin glargine,hum.rec.anlog insulin glulisine insulin isophane insulin isophane & regular insulin Kaiser Permanente of Georgia Multi Choice Formulary insulin lispro insulin lispro protamine & insulin lispro insulin regular INTAL INTELENCE... 7 interferon alfacon interferon beta-1a interferon beta-1b Interferon beta-1b interferon gamma-1b INTROVALE INTUNIV INVEGA INVIRASE... 7 INVOKAMET INVOKANA iodoquinol & hydrocortisone IOPIDINE ipratropium bromide... 9 irbesartan irbesartan & hydrochlorothiazide isavuconazonium... 5 ISENTRESS... 7 isocarboxazid isoniazid... 6 ISOPTIN SR ISOPTO ATROPINE ISOPTO CARBACHOL ISOPTO CARPINE ISOPTO HOMATROPINE ISOPTO HYOSCINE ISORDIL isosorbide dinitrate isosorbide dinitrate & hydralazine isosorbide mononitrate isotretinoin isradipine ISTALOL itraconazole... 5 itraconazole (solution)... 5 Ivabradine ivacaftor ivermectin... 4 J JAKAFI... 9 JALYN JANUMET JANUVIA JARDIANCE JENTADUETO JUBLIA... 5 JUNEL Kaiser Permanente of Georgia Multi Choice Formulary 53

55 JUNEL FE JUVISYNC JUXTAPID K KADIAN KALETRA... 7 KALYDECO KAON KAPVAY KARIVA KAZANO K-DUR KEFLEX... 4 KELNOR KENALOG KEPPRA KEPPRA XR KERLONE KERYDIN... 6 KETEK... 5 ketoconazole... 5, 38 ketoconazole (topical) ketoprofen KETOPROFEN ketorolac (ophth) ketorolac tablet KINERET KLARON KLONOPIN KLOR-CON 20 MEQ K-LYTE/CL KOMBIGLYZE XR KORLYM K-PHOS NEUTRAL K-PHOS ORIGINAL KRISTALOSE K-TAB KUVAN KWELL KYNAMRO KYTRIL L labetalol LAC-HYDRIN lacosamide LACRISERT lactic acid (ammonium lactate) LACTINOL lactulose LAMICTAL Kaiser Permanente of Georgia Multi Choice Formulary LAMICTAL XR LAMISIL... 6 lamivudine... 6, 7 lamivudine & zidovudine... 6, 7 lamotrigine lamotrigine extended-release LANOXIN lanreotide lanthanum carbonate LANTUS LANTUS, BASAGLAR lapatinib... 8 LARIAM... 6 LASIX LASTACAFT latanoprost LATUDA LAZANDA ledipasvir & sofosbuvir... 7 ledipasvir & sofosbuvir... 7 LEENA leflunomide lenalidomide... 8 lenvatinib... 8 LENVIMA... 8 LESCOL LESCOL XL lesinurad LESSINA LETAIRIS letrozole... 8 leucovorin LEUCOVORIN LEUKERAN... 8 LEUKINE leuprolide acetate... 8 levalbuterol nebulizer solution levalbuterol tartrate LEVAQUIN... 5 LEVATOL LEVBID... 9 LEVEMIR levetiracetam levetiracetam extended-release levobunolol LEVO-DROMORAN levofloxacin... 5, 24 levofloxacin (ophth) levomilnacipran levonorgestrel... 29, 30, 33 levonorgestrel & ethinyl estradiol... 29, 30 levonorgestrel & ethinyl estradiol (91-day)... 29, 30 levonorgestrel & ethinyl estradiol (continuous) levonorgestrel & ethinyl estradiol (triphasic) Kaiser Permanente of Georgia Multi Choice Formulary 54

56 LEVORA levorphanol LEVOTHROID levothyroxine LEVOXYL LEVSIN... 9 LEXAPRO LEXIVA... 7 LIALDA LIBRAX LIBRIUM LIDAMANTLE LIDEX LIDEX-E lidocaine... 26, 40 lidocaine & hydrocortisone lidocaine & prilocaine lidocaine (Jelly, oral solution) lidocaine (Jelly, topical) lidocaine (mouth-throat) lifitegrast LIMBITROL DS linaclotide linagliptin linagliptin & metformin lindane linezolid... 5 LINZESS LIORESAL liothyronine liotrix LIPITOR liraglutide lisdexamfetamine lisinopril lisinopril & hydrochlorothiazide LITHIUM CARBONATE lithium carbonate capsule lithium carbonate extended release lithium citrate LITHOBID LIVALO lixisenatide LO LOESTRIN FE LO/OVRAL LOCOID LOCOID LIPOCREAM LODINE LODOSYN lodoxamide tromethamine LOESTRIN 24 FE LOESTRIN FE LOFIBRA CAP LOFIBRA TAB Kaiser Permanente of Georgia Multi Choice Formulary lomitapide LOMOTIL lomustine... 8 LONITEN LOPID lopinavir & ritonavir... 7 LOPRESSOR LOPRESSOR HCT LOPROX lorazepam losartan losartan & hydrochlorothiazide LOSEASONIQUE LOTEMAX LOTENSIN... 13, 14 LOTENSIN HCT loteprednol loteprednol & tobramycin LOTREL LOTRISONE LOTRONEX lovastatin lovastatine extended-release LOVAZA LOVENOX LOW-OGESTREL loxapine LOXITANE LOZOL lubiprostone LUDIOMIL LUFYLLIN luliconazole... 5 lumacaftor& ivacaftor LUMIGAN LUNESTA LUPRON... 8 lurasidone LURIDE CHEW LURIDE DROPS LUVOX LUXIQ LUZU... 5 LYPREL LYRICA LYSODREN... 9 M macitentan MACROBID... 8 MACRODANTIN... 8 mafenide acetate MALARONE... 6 Kaiser Permanente of Georgia Multi Choice Formulary 55

57 malathion maprotiline maraviroc... 7 MARINOL MARPLAN MATULANE... 9 MAVIK MAXAIR AUTOHALER MAXALT MAXALT MLT MAXIDEX MAXITROL MAXZIDE mechlorethamine... 8 mechlorethamine... 8 meclofenamate MECLOMEN MEDROL medroxyprogesterone acetate... 33, 34 mefenamic acid mefloquine... 6 MEGACE megestrol acetate MELLARIL meloxicam melphalan... 9 memantine memantine er & donepezil M-END MAX D MENEST MENOSTAR MENTAX meperidine tablet MEPHYTON mepolizumab meprobamate MEPRON... 6 mercaptopurine... 9 mesalamine controlled-release mesalamine suppository mesalamine suspension mesalamine tablet mesna MESNEX MESTION MESTION TIMESPAN METADATE CD METADATE ER METAGLIP metaxalone metformin... 31, 32, 33 metformin extended-release... 32, 33 methadone methamphetamine Kaiser Permanente of Georgia Multi Choice Formulary methazolamide methenamine hippurate... 8 methenamine, sodium biphosphate, phenyl salicylate, methylene blue, and hyoscyamine... 8, 36 METHERGINE methimazole METHITEST methocarbamol methotrexate... 9 methotrexate sodium... 9 methoxsalen methoxsalen, rapid methscopolamine... 9 methsuximide methyldopa methyldopa & hydrochlorothiazide methylergonovine maleate METHYLIN methylphenidate... 17, 18 methylphenidate extended-release... 17, 18 methylphenidate sustained release methylphenidate transdermal patch methylprednisolone methyltestosterone metipranolol metoclopramide metolazone metoprol & hydrochlorothiazide metoprolol succinate metoprolol tartrate metreleptin METROCREAM METROGEL METROGEL-VAGINAL METROLOTION metronidazole... 4, 6, 38 metronidazole (topical) metronidazole (vaginal) metronidazole, tetracycline & bismuth subsalicylate... 4 metronidazoleextended-release... 6 MEVACOR mexiletine MEXITIL MIACALCIN MICARDIS MICARDIS HCT miconazole nitrate & zinc oxide MICROGESTIN MICROGESTIN FE MICROZIDE MIDAMOR midodrine hcl MIFEPREX mifepristone... 32, 36 Kaiser Permanente of Georgia Multi Choice Formulary 56

58 MIGERGOT miglitol miglustat MIGRANAL milnacipran MILTOWN MINIPRESS MINOCIN... 5 minocycline... 5 minoxidil mipomersen sodium mirabegron MIRAPEX MIRAPEX ER mirtazapine MIRVASO misoprostol... 16, 27 mitotane... 9 MOBIC modafinil MODICON MODURETIC moexipril moexipril & hydrochlorothiazide mometasone & formoterol mometasone furoate... 37, 39 MONODOX... 5 MONONESSA MONOPRIL MONOPRIL HCT montelukast morphine... 16, 17 morphine beads morphine extended-relase capsule morphine extended-release tablet MORPHINE SULFATE MOTOFEN MOTRIN MOVIPREP moxifloxacin... 5, 24 moxifloxacin (ophth) MOZOBIL MS CONTIN MSIR MUCOMYST MULTAQ mupirocin mupirocin calcium MYALEPT MYAMBUTOL... 6 MYCELEX MYCIFRADIN... 5 MYCOBUTIN... 6 MYCOLOG II Kaiser Permanente of Georgia Multi Choice Formulary mycophenolate mofetil mycophenolate sodium MYCOSTATIN... 5 MYFORTIC MYLERAN... 8 MYRBETRIQ MYSOLINE N na sulfacetm/avobenzone/sulfur nabumetone nadolol nadolol & bendroflumethiazide nafarelin naftifine NAFTIN nalbuphine NALFON naloxone... 15, 17, 20 naloxone nasal spray naltrexone NAMENDA NAMZARIC NAPRELAN NAPROSYN naproxen naproxen sodium naratriptan NARCAN NARDIL NATACYN natamycin NATAZIA nateglinide NATPARA NATROBA NAVANE nebivolol NECON NECON 10/ nedocromil sodium (ophth) nefazodone nelfinavir mesylate... 7 neomycin sulfate... 5 neomycin, bacitracin & polymyxin b (ophth) neomycin, colistin, hydrocortisone & thonzonium (otic) neomycin, polymycin b & gramicidin (ophth) neomycin, polymyxin B & dexamethasone (ophth) neomycin, polymyxin B & hydrocortisone (ophth)... 24, 25 neomycin, polymyxin B & hydrocortisone (otic) NEO-POLYCIN NEO-POLYCIN HC NEORAL Kaiser Permanente of Georgia Multi Choice Formulary 57

59 NEOSPORIN neostigmine bromide nepafenac NEPTAZANE NESINA netupitant & palonosetron NEULASTA NEUMEGA NEUPOGEN NEUPRO NEURONTIN NEVANAC nevirapine solution... 7 nevirapine tablet... 7 NEXAVAR... 9 niacin... 12, 41 niacin & lovastatin NIACOR NIASPAN nicardipine nifedipine nifedipine extended-release nilotinib... 9 nimodipine NIMOTOP nintedanib NIRAVAM nisoldipine nitazoxanide... 6 nitisinone NITRO-BID NITRO-DUR nitrofurantoin... 8 nitrofurantoin macrocrystal... 8 nitrofurantoin monohydrate... 8 nitroglycerin aerosol nitroglycerin solution nitroglycerin subligual nitroglycerin topical ointment nitroglycerin transdermal patch NITROLINGUAL NITROMIST NITROSTAT nizatidine NIZORAL... 5, 38 NOLVADEX... 9 NORA-BE NORCO NORDETTE NORDITROPIN norelgestromin & ethinyl estradiol norethindrone... 30, 31, 33, 34 norethindrone & ethinyl estradiol norethindrone & ethinyl estradiol (biphasic) Kaiser Permanente of Georgia Multi Choice Formulary norethindrone & ethinyl estradiol (triphasic) norethindrone & ethinyl estradiol w/ ferrous fumarate norethindrone acetate... 31, 34 norethindrone acetate & ethinyl estradiol... 31, 34 norethindrone acetate & ethinyl estradiol w/ ferrous fumarate norethindrone acetate & ethinyl estradiol w/ ferrous fumarate (biphasic) norethindrone-mestranol NORFLEX norfloxacin... 5 NORGESIC norgestimate & ethinyl estradiol norgestimate & ethinyl estradiol (triphasic) norgestrel & ethinyl estradiol NORINYL NORINYL NOROXIN... 5 NORPACE NORPACE CR NORPRAMIN NOR-QD NORTHERA NORTREL NORTREL 1/ NORTREL 7/7/ nortriptyline NORVASC NORVIR... 7 NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG MIX 70/ NOXAFIL... 5 NUBAIN NUCALA NUCYNTA NUEDEXTA NULYTELY NUTROPIN AQ NUVARING NUVIGIL NYDRAZID... 6 nystatin... 5, 38, 39 NYSTATIN nystatin & triamcinolone nystatin (topical) O OCELLA octreotide acetate OCUFEN Kaiser Permanente of Georgia Multi Choice Formulary 58

60 OCUFLOX OCUPRESS ODEFSEY... 7 OFEV ofloxacin (ophth) ofloxacin (otic) OGESTREL olanzapine olanzapine & fluoxetine hcl olanzapine orally disintegrating OLEPTRO olmesartan... 12, 14 olmesartn & hydrochlorothiazide olodaterol... 11, 37 olopatadine olopatadine (nasal) olopatadine (ophth) olsalazine OLUX-E OLYSIO... 7 omalizumab ombitasvir, paritaprevir & ritonavir... 7 ombitasvir, paritaprevir, ritonavir, & dasabuvir... 7 omega-3 acid ethyl esters omega-3-carboxylic acid OMNICEF... 4 OMNIPRED OMNITROPE ondansetron ondansetron (orally disentigrating) ONE TOUCH ULTRA ONE TOUCH ULTRA SMART ONE TOUCH ULTRA TEST STRIPS ONE TOUCH ULTRAMINI ONE TOUCH VERIO IQ ONE TOUCH VERIO TEST STRIPS ONFI ONGLYZA ONSOLIS OPANA OPANA ER OPIUM opium & belladonna alkaloids opium tincture oprelvekin OPSUMIT OPTHETIC OPTICROM OPTIPRANOLOL OPTIVAR ORACEA... 4, 40 ORALAIR ORALAIR ORAP Kaiser Permanente of Georgia Multi Choice Formulary ORAPRED ORAPRED ODT ORENCIA ORENITRAM ORFADIN ORINASE ORKAMBI orphenadrine citrate orphenadrine, aspirin, & caffeine ORTHO EVRA ORTHO TRI-CYCLEN ORTHO TRI-CYCLEN LO ORTHO-CEPT ORTHO-CYCLEN ORTHO-EST ORTHO-NOVUM... 30, 31 oseltamivir phosphate... 7 OSENI OSMOPREP ospemifene OSPHENA OTEZLA OTREXUP... 9 OVCON OVCON OVIDE OXANDRIN oxandrolone oxaprozin oxazepam oxcarbazepine oxiconazole nitrate OXISTAT OXSORALEN-ULTRA oxybutynin oxybutynin extended-release oxybutynin transdermal oxycodone oxycodone & acetaminophen oxycodone & acetaminophen er oxycodone & aspirin oxycodone & ibuprofen oxycodone controlled-release OXYCONTIN oxymorphone oxymorphone extended-release OXYTROL P PACERONE palbociclib... 9 PALGIC... 4 paliperidone Kaiser Permanente of Georgia Multi Choice Formulary 59

61 palivizumab... 7 PAMELOR PAMINE... 9 PANCREAZE pancrelipase (lipase-protease-amylase)... 27, 28 PANDEL PANLOR SS PANRETIN papaverine PARAFON FORTE DSC parathyroid hormone PARCOPA paregoric PAREGORIC paricalcitol PARLODEL PARNATE paromomycin sulfate... 6 paroxetine paroxetine extended-release paroxetine mesylate pasireotide PATADAY PATANASE PATANOL patiromer PAVABID PAXIL PAXIL CR pazopanib... 9 PEDIAPRED pediatric multivitamins w/ fluoride pediatric multivitamins w/ fluoride & iron pediatric vitamins a, c, & d, w/ fluoride pediatric vitamins a, c, & d, w/ fluoride & iron PEGANONE PEGASYS... 7 pegfilgrastim peginterferon alfa-2a... 7 peginterferon-alfa 2b... 7 PEG-INTRON... 7 pegvisomant penbutolol penciclovir penicillamine penicillin v potassium... 5 PENLAC PENNSAID PENTASA pentazocine & naloxone pentosan polysulfate sodium pentoxifylline PEN-VEE K... 5 perampanel Kaiser Permanente of Georgia Multi Choice Formulary PERCOCET PERCODAN PERIACTIN... 4 PERIDEX perindopril PERIOSTAT... 5 permethrin perphenazine... 20, 21 PERSANTINE PERTZYE PEXEVA phenelzine PHENERGAN... 4, 37 PHENERGAN VC... 4, 37 PHENERGAN VC W/CODEINE PHENERGAN W/ CODEINE phenobarbital... 20, 28 PHENOBARBITAL phenobarbital and belladonna alkaloids phenoxybenzamine PHENYTEK phenytoin sodium extended-release phenytoin suspension PHISOHEX PHOSLO PHOSLYRA PHOSPHA PHOSPHOLINE IODIDE PHRENILIN... 15, 16 PHRENILIN FORTE phytonadione PICATO pilocarpine... 10, 26 pilocarpine gel PILOPINE HS pimecrolimus pimozide pindolol pioglitazone... 31, 32 pioglitazone & glimepiride pioglitazone & metformin pirbuterol acetate pirfenidone piroxicam pitavastatin PLAN B PLAQUENIL... 6 PLAVIX PLEGRIDY PLENDIL plerixafor PLETAL PLEXION PLEXION SCT Kaiser Permanente of Georgia Multi Choice Formulary 60

62 podofilox POLY HIST FORTE... 4 POLYCITRA-K polyethylene glycol-electrolyte solution polymyxin b & trimethoprim (ophth) POLYSPORIN POLYTRIM POLY-VI-FLOR POLY-VI-FLOR W/IRON pomalidomide... 9 POMALYST... 9 ponatinib... 9 PONSTEL posaconazole... 5 potassium bicarbonate & potassium chloride potassium chloride potassium chrloide powder potassium citrate potassium citrate & citric acid potassium gluconate potassium phosphate potassium phosphate, monobasic POTIGA PRADAXA PRALUENT pramipexole pramipexole extended-release pramlintide acetate PRAMOSONE PRAMOSONE-E pramoxine... 39, 40 PRANDIMET PRANDIN PRAVACHOL pravastatin prazosin PRECOSE PRED FORTE PRED MILD PRED-G prednicarbate PREDNISOL prednisolone... 24, 25, 28 PREDNISOLONE prednisolone acetate... 25, 28 prednisolone acetate (ophth) prednisolone sodium phosphate... 25, 28 prednisolone sodium phosphate (ophth) prednisone PREDNISONE PREFEST pregabalin PRELONE PREMARIN Kaiser Permanente of Georgia Multi Choice Formulary PREMARIN CREAM PREMPHASE PREMPRO PREVIDENT PREVIDENT 5000 PLUS PREVPAC PREZCOBIX... 6 PREZISTA... 6 PRIFTIN... 6 PRIMAQUINE... 6 primaquine phosphate... 6 primidone PRISTIQ PROAIR HFA PROAMATINE PRO-BANTHINE... 9 probenecid procarbazine... 9 PROCARDIA PROCARDIA XL prochlorperazine PROCRIT PROCTOCORT PROCTOFOAM PROCTOFOAM-HC PROCYSBI PRODIGY PRODIGY TEST STRIPS progesterone, micronized PROGRAF PROLIXIN PROLOPRIM... 8 PROMACTA promethazine... 4, 37 promethazine & codeine promethazine & dextromethorphan promethazine & phenylephrine... 4 promethazine, phenylephrine & codeine PROMETHAZINE-DM PROMETRIUM propafenone propantheline bromide... 9 proparacaine propranolol propranolol & hydrochlorothiazide propranolol extended-release propranolol sustained-release propylthiouracil PROPYLTHIOURACIL PROSOM PROSTIGMIN PROTOPIC protriptyline PROVENTIL HFA Kaiser Permanente of Georgia Multi Choice Formulary 61

63 PROVERA PROVIGIL PROZAC PROZAC WEEKLY PRUDOXIN pseudoephedrine, brompheniramine & codeine PSORIATEC PULMICORT FLEXHALER PULMICORT RESPULES PULMOZYME PURINETHOL... 9 PYLERA... 4 pyrazinamide... 6 PYRAZINAMIDE... 6 pyridostigmine pyrimethamine... 6 Q QUALAQUIN... 6 QUESTRAN QUESTRAN LIGHT quetiapine quetiapine extended-release QUINAGLUTE quinapril & hydrochlorothiazide quinapril hcl quinidine... 13, 20 quinidine gluconate QUINIDINE SULFATE quinine sulfate... 6 QUIXIN QVAR R RAGWITEK RAGWITEK raloxifene hcl raltegravir... 7 ramelteon ramipril RANEXA ranitidine ranolazine RAPAFLO RAPAMUNE rasagiline RASUVO... 9 RAVICTI RAYOS RAZADYNE RAZADYNEER REBETOL... 7 Kaiser Permanente of Georgia Multi Choice Formulary REBIF REBIF REBIDOSE RECLIPSEN REGLAN REGRANEX RELAFEN RELENZA... 8 RELPAX REMERON REMODULIN RENAGEL RENVELA repaglinide... 32, 33 repaglinide & metformin REPATHA REQUIP REQUIP XL RESCRIPTOR... 6 RESCULA reserpine RESTASIS RESTORIL retapamulin RETIN-A RETIN-A MICRO RETROVIR... 8 REVATIO REVIA REVLIMID... 8 REXULTI REYATAZ... 6 RHEUMATREX... 9 ribavirin... 7 RIDAURA rifabutin... 6 RIFADIN... 6 RIFAMATE... 6 rifampin... 6 rifampin & isoniazid... 6 rifapentine... 6 rifaximin... 5 rilpivirine... 7 RILUTEK riluzole rimantadine... 7 rimexolone riociguat RIOMET risedronate sodium RISPERDAL RISPERDALM-TAB risperidone risperidone orally disintegrating RITALIN... 17, 18 Kaiser Permanente of Georgia Multi Choice Formulary 62

64 RITALIN LA RITALIN SR ritonavir... 7 rivaroxaban rivastigmine tartrate rivastigmine tartrate (solution) rizatriptan rizatriptan orally disentigrating ROBAXIN ROBINUL... 9 ROBINULFORTE... 9 ROCALTROL roflumilast rolapitant ROMYCIN ropinirole ropinirole extended-release ROSAC ROSULA rosuvastatin rotigotine ROWASA ROXICET ROXICODONE ROZEREM rufinamide ruxolitinib... 9 RYTHMOL RYTHMOL SR RYZODEG 70/ S SABRIL sacubitril & valsartan SAFYRAL SAIZEN SALAGEN salmeterol salsalate SAMSCA SANCTURA SANCTURA XR SANCUSO SANDIMMUNE SANDOSTATIN SANTYL SAPHRIS sapropterin dihydrochlorid saquinavir mesylate... 7 SARAFEM sargramostim SAVAYSA SAVELLA Kaiser Permanente of Georgia Multi Choice Formulary saxagliptin saxagliptin & metformin extended-release scopolamine (ophth) scopolamine hydrobromide SEASONALE SEASONIQUE SEB-PREV SECTRAL secukinumab selegiline selegiline transdermal selenium sulfide SELSEB SELSUN RX SELZENTRY... 7 SENSIPAR SEPTRA... 5 SERAX SEREVENT DISKUS SEROMYCIN... 6 SEROQUEL SEROQUEL XR SEROSTIM SERPASIL sertaconazole nitrate sertraline SERZONE sevelamer carbonate sevelamer hcl short ragweed pollen allergen extract short ragweed pollen allergen extract SIGNIFOR sildenafil silodosin SILVADENE silver sulfadiazine simeprevir... 7 SIMPONI simvastatin... 12, 33 sinecatechins SINEMET SINEMET CR SINEQUAN SINGULAIR sirolimus SIRTURO sitagliptin & metformin sitagliptin & simvastatin sitagliptin phosphate SIVEXTRO... 5 SKELAXIN sodium chloride sodium citrate & citric acid sodium fluoride Kaiser Permanente of Georgia Multi Choice Formulary 63

65 sodium fluoride (dental) sodium fluoride drops sodium oxybate sodium phenylbutyrate sodium phosphates sodium polystyrene sulfonate sofosbuvir... 7 sofosbuvir & velpatasvir... 7 sofusbuvir... 7 SOLARAZE solifenacin SOLODYN... 5 SOMA... 10, 16 SOMA COMPOUND... 10, 16 SOMA COMPOUND W/ CODEINE somatropin SOMATULINE DEPOT SOMAVERT SONATA SOOLANTRA... 4 sorafenib tosylate... 9 SORIATANE SORILUX sotalol SOVALDI... 7 SPECTAZOLE SPECTRACEF... 4 spinosad SPIRIVA... 9 SPIRIVA RESPIMAT... 9 SPIRIVA RESPIMAT... 9 SPIRIVA RESPIMAT... 9 spironolactone spironolactone & hydrochlorothiazide SPORANOX... 5 SPRINTEC SPRYCEL... 8 SPS STADOL STALEVO stannous fluoride STARLIX stavudine... 7 STELAZINE STIMATE STIOLTO RESPIMAT STRATTERA STRIBILD... 7 STRIVERDI RESPIMAT STROMECTOL... 4 SUBOXONE SUBUTEX succimer sucralfate Kaiser Permanente of Georgia Multi Choice Formulary sucralfate suspension sucralfate tablets sucroferric oxyhydroxide SULAR sulconazole nitrate SULFAC sulfacetamide sodium & prednisolone sulfacetamide sodium & sulfur sulfacetamide sodium (acne) sulfacetamide sodium (ophth) ointment sulfacetamide sodium (ophth) solution sulfadiazine... 5, 38 SULFADIAZINE... 5 sulfamethoxazole & trimethoprim... 5 SULFAMYLON sulfanilamide sulfasalazine... 5 sulindac sumatriptan sunitinib malate... 9 SUPRAX... 4 SURMONTIL SUSTIVA... 6 SUTENT... 9 suvorexant SYMAX... 9 SYMAX DUOTAB... 9 SYMBICORT SYMBYAX SYMLIN SYMMETREL SYNAGIS... 7 SYNALAR SYNAREL SYNJARDY SYNTHROID SYPRINE syringe with needle,disposable T TABLOID... 9 TACLONEX tacrolimus... 36, 41 tacrolimus (topical) tadalafil TAGAMET TALWIN NX TAMBOCOR TAMIFLU... 7 tamoxifen citrate... 9 tamsulosin hcl TANZEUM TAPAZOLE Kaiser Permanente of Georgia Multi Choice Formulary 64

66 tapentadol TARCEVA... 8 TARGRETIN... 8, 40 TARKA TASIGNA... 9 tasimelteon TASMAR tavaborole... 6 tazarotene TAZORAC TECFIDERA TECHNIVIE... 7 tedizolid... 5 teduglutide TEGRETOL TEGRETOL XR TEKAMLO TEKTURNA TEKTURNA HCT telaprevir... 7 telithromycin... 5 telmisartan telmisartan & hydrochlorothiazide temazepam TEMODAR... 9 TEMOVATE TEMOVATE E temozolomide... 9 TENEX tenofovir... 6, 7 TENORETIC TENORMIN TERAZOL TERAZOL terazosin terbinafine... 6 terbutaline sulfate terconazole terconazole (vaginal) teriflunomide teriparatide TESSALON PERLES TESTIM testosterone... 29, 33 testosterone cypionate TESTRED tetrabenazine tetracycline... 4, 5 TETRACYCLINE... 5 tetrahydrozoline TEVETEN thalidomide THALOMID theophylline Kaiser Permanente of Georgia Multi Choice Formulary thioguanine... 9 thioridazine thiothixene THORAZINE thyroid THYROLAR tiagabine TIAZAC ticagrelor TICLID ticlopidine TIGAN TIKOSYN TILIA timolol... 15, 26 TIMOPTIC TIMOPTIC-XE timothy grass pollen allergen extract timothy grass pollen allergen extract tiotropium... 9, 37 tiotropium bromide and olodaterol tipranavir... 8 TIROSINT TIVICAY... 6 tizanidine TOBI... 5 TOBI Podhaler... 5 TOBI PODHALER... 5 TOBRADEX tobramycin & dexamethasone ointment tobramycin & dexamethasone suspension tobramycin inhalation powder... 5 tobramycin inhalation solution... 5 tobramycin sulfate (ophth) ointment tobramycin sulfate (ophth) solution TOBREX tocilizumab tofacitinib TOFRANIL TOFRANIL-PM tolazamide tolbutamide tolcapone TOLECTIN TOLINASE tolmetin sodium tolterodine tolterodine extended-release tolvaptan TOPAMAX TOPAMAX SPRINKLE TOPICORT topiramate capsule topiramate tablet Kaiser Permanente of Georgia Multi Choice Formulary 65

67 topotecan... 9 TOPROL XL TORADOL torsemide TOVIAZ TRACLEER TRADJENTA tramadol tramadol & acetaminophen tramadol extended-release TRANDATE trandolapril... 13, 14 trandolapril & verapamil TRANSDERM-SCOP TRANXENE tranylcypromine sulfate TRAVATAN Z travoprost trazodone trazodone extended-release TRENTAL treprostinil TRESIBA tretinoin... 9, 40 tretinoin microspheres TREXALL... 9 triamcinolone acetonide (topical) triamterene triamterene & hydrochlorothiazide TRIAVIL triazolam TRIBENZOR TRICOR trientine trifluoperazine trifluridine trihexyphenidyl TRILAFON TRILEPTAL TRILIPIX trimethobenzamide trimethoprim... 5, 8, 24 trimipramine TRINESSA TRI-NORINYL TRI-SPRINTEC TRIUMEQ... 6 TRI-VI-FLOR TRI-VI-FLOR W/IRON TRIVORA TRIZIVIR... 6 trospium trospium extended-release TRULICITY Kaiser Permanente of Georgia Multi Choice Formulary TRUSOPT TRUVADA... 7 TUSSIONEX TWINJECT TYKERB... 8 TYLENOL W/ CODEINE TYZINE U UCERIS ulipristal ULORIC ULTRACET ULTRAM ULTRAM ER ULTRAVATE umeclidinium... 9, 11 umeclidinium & vilanterol UNIPHYL UNIRETIC UNITHROID UNIVASC unoprostone isopropyl urea... 39, 40 URECHOLINE... 9 URELLE... 8 UROCIT-K URO-MP UROXATRAL URSO URSO FORTE ursodiol V VAGIFEM valacyclovir... 8 VALCHLOR... 8 VALCHLOR... 8 VALCYTE... 8 valganciclovir... 8 VALISONE VALIUM valproate sodium valproic acid valsartan... 12, 13, 14 valsartan & hydrochlorothiazide... 12, 14 VALTREX... 8 VALTURNA VANCOCIN HCL... 5 vancomycin hcl... 5 vandetanib... 9 VANOS Kaiser Permanente of Georgia Multi Choice Formulary 66

68 VANOXIDE-HC VANTIN... 4 varenicline... 9 VARUBI VASERETIC VASOTEC VECTICAL VELIVET VELPHORO VELTASSA VELTIN vemurafenib... 9 venlafaxine venlafaxine extended-release VENTOLIN HFA verapamil verapamil extended-release cap verapamil sustained-release cap verapamil sustained-release tab VEREGEN VERELAN VERELAN PM VESANOID... 9 VESICARE VEXOL VFEND... 6 VIBERZI VICOPROFEN VICTOZA VICTRELIS... 6 VIDEX... 6 VIDEX EC... 6 VIEKIRA... 7 vigabatrin VIGAMOX VIIBRYD vilazodone VIMPAT VIOKACE VIRACEPT... 7 VIRAMUNE... 7 VIREAD... 7 VIROPTIC VISICOL VISKEN VISTARIL VIVACTIL VIVELLE-DOT VOLTAREN... 16, 24, 40 VOLTAREN GEL VOLTAREN XR vorapaxar voriconazole... 6 vorinostat... 9 Kaiser Permanente of Georgia Multi Choice Formulary vortioxetine VOSOL VOSPIRE ER VOTRIENT... 9 VUSION VYTONE VYTORIN VYVANSE W warfarin WELCHOL WELLBUTRIN WELLBUTRIN SR WELLBUTRIN XL WESTCORT X XALATAN XALKORI... 8 XANAX XANAX XR XARELTO XARTEMIS XR XELJANZ XELODA... 8 XENAZINE XIBROM XIFAXAN... 5 XIGDUO XR XIIDRA XOLAIR XOPENEX HFA XOPENEX NEBULIZER XTANDI... 8 XULANE XYLOCAINE... 26, 40 XYLOCAINE VISCOUS XYREM Y YASMIN YAZ YUVAFEM Z zafirlukast zaleplon ZANAFLEX zanamivir... 8 ZANTAC Kaiser Permanente of Georgia Multi Choice Formulary 67

69 ZARONTIN ZAROXOLYN ZARXIO ZAVESCA ZEBETA ZELAPAR ZELBORAF... 9 ZEMPLAR ZENPEP ZEPATIER... 7 ZERIT... 7 ZESTORETIC ZESTRIL ZETIA ZIAC ZIAGEN... 6 ZIANA zidovudine... 6, 7, 8 zileuton ZINBRYTA ziprasidone ZIRGAN ZITHROMAX... 4 ZOCOR ZOFRAN ZOFRAN ODT ZOHYDRO ER ZOLINZA... 9 zolipdem sublingual Kaiser Permanente of Georgia Multi Choice Formulary zolmitriptan zolmitriptan orally disentigrating ZOLOFT zolpidem zolpidem extended-release zolpidem oral spray ZOLPIMIST ZOMIG ZOMIG ZMT ZONALON ZONEGRAN zonisamide ZONTIVITY ZORBTIVE ZORTRESS ZOVIA ZOVIRAX... 6, 37 ZURAMPIC ZYCLARA ZYFLO ZYKADIA... 8 ZYLET ZYLOPRIM ZYMAXID ZYPREXA ZYPREXA ZYDIS ZYTIGA... 8 ZYVOX... 5 Kaiser Permanente of Georgia Multi Choice Formulary 68

70 Non-Discrimination Kaiser Permanente of Georgia Multi Choice Formulary Kaiser Foundation Health Plan of Georgia, Inc. (Kaiser Health Plan) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We also: Provide free aids and services to people with disabilities to communicate effectively with us, such as: o o Qualified sign language interpreters Written information in other formats, such as large print, audio, and accessible electronic formats Provide free language services to people whose primary language is not English, such as: o o Qualified interpreters Information written in other languages If you need these services, call the number provided below. Georgia: 1-(888) , (TTY) 711 If you believe that Kaiser Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with the Kaiser Civil Rights Coordinator, Nine Piedmont Center, 3495 Piedmont Road, NE, Atlanta, GA , telephone number: 1- (888) You can file a grievance by mail or phone. If you need help filing a grievance, the Kaiser 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 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, , (TDD). Complaint forms are available at Kaiser Permanente of Georgia Multi Choice Formulary 69

71 Help in Your Language Kaiser Permanente of Georgia Multi Choice Formulary English: You have the right to get help in your language at no cost. If you have questions about your application or coverage through Kaiser Permanente, or if this is a notice that requires you to take action by a specific date, call the number provided for your state of region to talk to an interpreter. Kaiser Foundation Health Plan, Inc., in Northern and Southern California and Hawaii Kaiser Foundation Health Plan of Colorado Kaiser Foundation Health Plan of Georgia, Inc., Nine Piedmont Center, 3495 Piedmont Road NE, Atlanta, GA 30305, Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., in Maryland, Virginia, and Washington, D.C., 2101 E. Jefferson St., Rockville, MD Kaiser Foundation Health Plan of the Northwest, 500 NE Multnomah St., Suite 100, Portland, OR Kaiser Permanente of Georgia Multi Choice Formulary 70

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