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 January, 208 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 ) 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 January, 208 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 4. 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 *Multi-Choice Formulary is for medications covered at Network Pharmacies. Please see HMO Formulary for medications covered at KP Pharmacies* **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 Kaiser Permanente of Georgia Multi Choice Formulary

3 drug on the list. You may also use the search function on your computer to search this document for the medication by name. 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 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. Preferred brands are those brands which will be covered at your preferred brand co-payment amount defined as Tier 2. Non-preferred brands are covered at the non-preferred copayment 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 *Multi-Choice Formulary is for medications covered at Network Pharmacies. Please see HMO Formulary for medications covered at KP Pharmacies* **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 Kaiser Permanente of Georgia Multi Choice Formulary 2

4 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 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. Prior Authorization (PA): 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. You can find out if the drug has any additional requirements or limits by 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 -800-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. *Multi-Choice Formulary is for medications covered at Network Pharmacies. Please see HMO Formulary for medications covered at KP Pharmacies* **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 Kaiser Permanente of Georgia Multi Choice Formulary 3

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

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

7 3 luliconazole LUZU nystatin MYCOSTATIN 3 posaconazole NOXAFIL 3 tavaborole KERYDIN terbinafine LAMISIL voriconazole VFEND Antimycobacterials cycloserine SEROMYCIN dapsone AVLOSULFON ethambutol MYAMBUTOL isoniazid NYDRAZID pyrazinamide PYRAZINAMIDE rifabutin MYCOBUTIN rifampin RIFADIN rifampin & isoniazid RIFAMATE 3 rifapentine PRIFTIN Antiprotozoals atovaquone MEPRON atovaquone & proguanil MALARONE chloroquine phosphate ARALEN hydroxychloroquine sulfate PLAQUENIL mefloquine LARIAM metronidazole FLAGYL 3 metronidazoleextended-release FLAGYL ER PA 3 miltefosine IMPAVIDO 3 nitazoxanide ALINIA paromomycin sulfate HUMATIN 2 primaquine phosphate PRIMAQUINE Preferred Brand 2 pyrimethamine DARAPRIM Preferred Brand quinine sulfate QUALAQUIN Antiviral QL abacavir sulfate & lamivudine EPZICOM QL 2 abacavir sulfate solution ZIAGEN Preferred Brand QL abacavir sulfate tablet ZIAGEN 3 abacavir, dolutegravir & lamivudine TRIUMEQ QL abacavir, lamivudine & zidovudine TRIZIVIR acyclovir ZOVIRAX QL adefovir dipivoxil HEPSERA 3 atazanavir & cobicistat EVOTAZ QL 2 atazanavir sulfate REYATAZ Preferred Brand QL 3 boceprevir VICTRELIS PA 3 daclatasvir DAKLINZA 2 darunavir & cobicistat PREZCOBIX Kaiser Permanente of Georgia Multi Choice Formulary 6

8 QL 2 darunavir ethanolate PREZISTA Preferred Brand QL 2 delavirdine mesylate RESCRIPTOR Preferred Brand QL 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 PA 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 3 emtricitabine, rilpivirine, & tenofovir COMPLERA 2 emtricitabine, rilpivirine, & tenofovir ODEFSEY Preferred Brand QL 2 enfuvirtide FUZEON Preferred Brand QL entecavir BARACLUDE QL 2 etravirine INTELENCE Preferred Brand famciclovir FAMVIR QL 2 fosamprenavir calcium LEXIVA Preferred Brand ganciclovir CYTOVENE QL 2 indinavir sulfate CRIXIVAN Preferred Brand 3 interferon alfacon- INFERGEN QL 3 lamivudine EPIVIR HBV QL lamivudine EPIVIR QL lamivudine & zidovudine COMBIVIR QL, PA 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 nevirapine solution VIRAMUNE QL nevirapine tablet VIRAMUNE PA 3 ombitasvir, paritaprevir & ritonavir TECHNIVIE PA 3 ombitasvir, paritaprevir, ritonavir, & dasabuvir VIEKIRA QL 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 3 raltegravir (600mg) ISENTRESS HD ribavirin REBETOL Kaiser Permanente of Georgia Multi Choice Formulary 7

9 QL 3 rilpivirine EDURANT QL rimantadine FLUMADINE QL 2 ritonavir NORVIR Preferred Brand QL 2 saquinavir mesylate INVIRASE Preferred Brand QL, PA 3 simeprevir OLYSIO QL, PA 3 sofosbuvir SOVALDI QL, PA 3 sofosbuvir & velpatasvir EPCLUSA QL stavudine ZERIT QL 3 telaprevir INCIVEK QL 3 tenofovir VIREAD QL 2 tipranavir APTIVUS Preferred Brand valacyclovir VALTREX valganciclovir VALCYTE QL 2 zanamivir RELENZA Preferred Brand QL zidovudine RETROVIR Urinary Antiinfectives methenamine hippurate HIPREX methenamine, sodium 3 biphosphate, phenyl salicylate, methylene blue, and URELLE hyoscyamine 2 nitrofurantoin FURADANTIN Preferred Brand nitrofurantoin macrocrystal MACRODANTIN nitrofurantoin monohydrate MACROBID trimethoprim PROLOPRIM Antineoplastic Agents Antineoplastic Agents 2 abiraterone ZYTIGA Preferred Brand anastrozole ARIMIDEX 3 axitinib INLYTA 2 bexarotene TARGRETIN Preferred Brand bicalutamide CASODEX 3 bosutinib BOSULIF 2 busulfan MYLERAN Preferred Brand capecitabine XELODA 3 ceritinib ZYKADIA 2 chlorambucil LEUKERAN Preferred Brand 2 crizotinib XALKORI Preferred Brand 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 exemestane AROMASIN flutamide EULEXIN Kaiser Permanente of Georgia Multi Choice Formulary 8

10 hydroxyurea HYDREA 2 hydroxyurea DROXIA Preferred Brand 2 ibrutinib IMBRUVICA Preferred Brand 2 imatinib mesylate GLEEVEC Preferred Brand 2 ixazomib NINLARO Preferred Brand 2 lapatinib TYKERB Preferred Brand 2 lenalidomide REVLIMID Preferred Brand 2 lenvatinib LENVIMA Preferred Brand letrozole FEMARA leuprolide acetate LUPRON 3 lomustine CEENU 3 mechlorethamine VALCHLOR 2 melphalan ALKERAN Preferred Brand mercaptopurine PURINETHOL 3 methotrexate RASUVO 3 methotrexate OTREXUP 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 tamoxifen citrate NOLVADEX temozolomide TEMODAR 2 thioguanine TABLOID Preferred Brand 2 topotecan HYCAMTIN Preferred Brand tretinoin VESANOID 2 vandetanib CAPRELSA Preferred Brand 2 vemurafenib ZELBORAF Preferred Brand 2 vorinostat ZOLINZA Preferred Brand Autonomic Drugs Anticholinergic Agents atropine sulfate ATROPINE SULFATE dicyclomine BENTYL glycopyrrolate ROBINUL glycopyrrolate ROBINULFORTE 3 glycopyrrolate inhalation pow SEEBRI NEOHALER hyoscyamine sulfate LEVBID hyoscyamine sulfate LEVSIN hyoscyamine sulfate SYMAX Kaiser Permanente of Georgia Multi Choice Formulary 9

11 3 hyoscyamine sulfate SYMAX DUOTAB ipratropium bromide ATROVENT 2 ipratropium bromide ATROVENTHFA Preferred Brand methscopolamine PAMINE propantheline bromide PRO-BANTHINE 3 tiotropium SPIRIVA 2.5 mcg 2 tiotropium SPIRIVA RESPIMAT Preferred Brand.25 mcg 3 tiotropium SPIRIVA RESPIMAT 3 umeclidinium INCRUSE ELLIPTA Autonomic Drugs, Miscellaneous 3 varenicline CHANTIX Parasympathomimetic (Cholinergic) Agents bethanechol chloride URECHOLINE cevimeline hcl EVOXAC donepezil ARICEPT donepezil ARICEPT ODT galantamine hydrobromide RAZADYNE galantamine hydrobromide RAZADYNEER neostigmine bromide PROSTIGMIN pilocarpine SALAGEN pyridostigmine MESTION TIMESPAN pyridostigmine MESTION rivastigmine tartrate EXELON 2 rivastigmine tartrate (solution) EXELON Preferred brand Skeletal Muscle Relaxants baclofen LIORESAL carisoprodol SOMA carisoprodol/aspirin SOMA COMPOUND chlorzoxazone PARAFON FORTE DSC cyclobenzaprine FLEXERIL 3 cyclobenzaprine extendedrelease AMRIX dantrolene sodium DANTRIUM metaxalone SKELAXIN methocarbamol ROBAXIN orphenadrine citrate NORFLEX orphenadrine, aspirin, & caffeine NORGESIC tizanidine ZANAFLEX Sympatholytic (Adrenergic Blocking) Agents alfuzosin hcl UROXATRAL dihydroergotamine mesylate D.H.E.45 2 dihydroergotamine mesylate MIGRANAL Preferred Brand ergoloid mesylates HYDERGINE ergotamine & caffeine CAFERGOT phenoxybenzamine DIBENZYLINE 3 silodosin RAPAFLO Kaiser Permanente of Georgia Multi Choice Formulary 0

12 tamsulosin hcl FLOMAX Sympathomimetic (Adrenergic) Agents 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 albuterol sulfate & ipratropium DUONEB albuterol sulfate tablet VOSPIRE ER 3 arformoterol BROVANA 3 droxidopa NORTHERA epinephrine ADRENACLICK 3 epinephrine AUVI-Q 3 epinephrine EPIPEN 3 epinephrine EPIPEN JR 3 epinephrine TWINJECT 3 formoterol fumarate FORADIL levalbuterol nebulizer solution XOPENEX NEBULIZER 3 levalbuterol tartrate XOPENEX HFA midodrine hcl PROAMATINE 2 olodaterol STRIVERDI RESPIMAT Preferred Brand 3 pirbuterol acetate MAXAIR AUTOHALER terbutaline sulfate BRETHINE 3 umeclidinium & vilanterol ANORO ELLIPTA Blood Formation, Coagulation, and Thrombosis Coagulants and Anticoagulants 2 aminocaproic acid AMICAR Preferred Brand anagrelide AGRYLIN 3 apixaban ELIQUIS aspirin & dipyridamole AGGRENOX cilostazol PLETAL 2 clopidogrel PLAVIX QL 2 dabigatran PRADAXA Preferred Brand 3 dalteparin FRAGMIN dipyridamole PERSANTINE 3 edoxaban SAVAYSA enoxaparin LOVENOX fondaparinux ARIXTRA heparin HEPARIN SODIUM pentoxifylline TRENTAL prasugrel EFFIENT QL 3 rivaroxaban XARELTO 2 ticagrelor BRILINTA Preferred brand ticlopidine TICLID 3 vorapaxar ZONTIVITY warfarin COUMADIN Kaiser Permanente of Georgia Multi Choice Formulary

13 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 doxazosin CARDURA prazosin MINIPRESS terazosin HYTRIN Antilipemic Agents atorvastatin LIPITOR cholestyramine light QUESTRAN LIGHT cholestyramine QUESTRAN 3 colesevelam WELCHOL colestipol COLESTID 3 ezetimibe ZETIA 3 ezetimibe & simvastatin VYTORIN fenofibrate LOFIBRA TAB fenofibrate TRICOR fenofibrate, micronized LOFIBRA CAP fenofibric acid TRILIPIX fluvastatin extended-release LESCOL XL fluvastatin LESCOL gemfibrozil LOPID PA 3 lomitapide JUXTAPID lovastatin MEVACOR 3 lovastatine extended-release ALTOPREV PA 3 mipomersen sodium KYNAMRO 3 niacin NIASPAN 3 niacin & lovastatin ADVICOR omega-3 acid ethyl esters LOVAZA 3 omega-3-carboxylic acid EPANOVA 3 pitavastatin LIVALO pravastatin PRAVACHOL rosuvastatin CRESTOR simvastatin ZOCOR Calcium Channel Blocking Agents amlodipine NORVASC amlodipine & benazepril LOTREL amlodipine & atorvastatin CADUET Kaiser Permanente of Georgia Multi Choice Formulary 2

14 3 amlodipine & olmesartan AZOR 3 amlodipine & valsartan EXFORGE 3 amlodipine, valsartan & hydrochlorothiazide EXFORGE HCT 3 amlodipine, olmesartan & hydrochlorothiazide TRIBENZOR diltiazem extended-release CARDIZEM CD diltiazem extended-release TIAZAC diltiazem extended-release CARTIA XT diltiazem extended-release CARDIZEM LA diltiazem CARDIZEM felodipine PLENDIL isradipine DYNACIRC 3 isradipine DYNACIRC CR nicardipine CARDENE nifedipine PROCARDIA nifedipine extended-release ADALAT CC nifedipine extended-release PROCARDIA XL nimodipine NIMOTOP 3 nisoldipine SULAR trandolapril & verapamil TARKA verapamil sustained-release cap VERELAN 3 verapamil COVERA-HS verapamil extended-release cap VERELAN PM verapamil sustained-release cap CALAN SR verapamil sustained-release tab ISOPTIN SR Cardiac Drugs amiodarone PACERONE digoxin LANOXIN disopyramide NORPACE 2 disopyramide controlled-release NORPACE CR Preferred Brand dofetilide TIKOSYN 3 dronedarone MULTAQ flecainide TAMBOCOR 3 Ivabradine CORLANOR mexiletine MEXITIL propafenone RYTHMOL 3 propafenone RYTHMOL SR quinidine gluconate QUINAGLUTE quinidine QUINIDINE SULFATE QL 3 ranolazine RANEXA 3 sacubitril & valsartan ENTRESTO Hypotensive Agents clonidine extended-release KAPVAY clonidine CATAPRES clonidine transdermal CATAPRES-TTS Kaiser Permanente of Georgia Multi Choice Formulary 3

15 guanfacine TENEX hydralazine APRESOLINE methyldopa ALDOMET methyldopa & hydrochlorothiazide ALDORIL-25 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 benazepril LOTENSIN benazepril & hydrochlorothiazide LOTENSIN HCT candesartan ATACAND candesartan & hydrochlorothiazide ATACAND HCT captopril CAPOTEN captopril & hydrochlorothiazide CAPOZIDE enalapril VASOTEC enalapril & hydrochlorothiazide VASERETIC eplerenone INSPRA 3 eprosartan TEVETEN 3 eprosartan & hydrochlorothiazide TEVETEN fosinopril MONOPRIL fosinopril & hydrochlorothiazide MONOPRIL HCT irbesartan AVAPRO irbesartan & hydrochlorothiazide AVALIDE lisinopril ZESTRIL lisinopril & hydrochlorothiazide ZESTORETIC losartan COZAAR losartan & hydrochlorothiazide HYZAAR moexipril UNIVASC moexipril & hydrochlorothiazide UNIRETIC 3 olmesartan BENICAR 3 olmesartn & hydrochlorothiazide BENICAR HCT perindopril ACEON quinapril hcl ACCUPRIL quinapril & hydrochlorothiazide ACCURETIC ramipril ALTACE spironolactone & hydrochlorothiazide ALDACTAZIDE spironolactone ALDACTONE Kaiser Permanente of Georgia Multi Choice Formulary 4

16 telmisartan MICARDIS telmisartan & hydrochlorothiazide MICARDIS HCT trandolapril MAVIK valsartan DIOVAN valsartan & hydrochlorothiazide DIOVAN HCT Vasodilating Agents 2 ambrisentan LETAIRIS Preferred Brand 2 bosentan TRACLEER Preferred Brand 3 isosorbide dinitrate & hydralazine BIDIL isosorbide dinitrate ISORDIL isosorbide mononitrate IMDUR 2 macitentan OPSUMIT Preferred Brand 3 nitroglycerin aerosol NITROMIST nitroglycerin solution NITROLINGUAL 2 nitroglycerin subligual NITROSTAT Preferred Brand 2 nitroglycerin topical ointment NITRO-BID Preferred Brand Excludes 0.8mg nitroglycerin transdermal patch NITRO-DUR strength Only 0.8mg strength 2 nitroglycerin transdermal patch NITRO-DUR Preferred Brand papaverine PAVABID 3 riociguat ADEMPAS sildenafil REVATIO 3 tadalafil ADCIRCA 3 treprostinil ORENITRAM 2 treprostinil REMODULIN Preferred Brand β-adrenergic Blocking Agents acebutolol SECTRAL atenolol TENORMIN atenolol & chlorthalidone TENORETIC betaxolol KERLONE bisoprol & hydrochlorothiazide ZIAC bisoprolol ZEBETA carvedilol COREG 3 carvedilol phosphate COREG CR labetalol TRANDATE metoprol & hydrochlorothiazide LOPRESSOR HCT metoprolol succinate TOPROL XL metoprolol tartrate LOPRESSOR nadolol CORGARD nadolol & bendroflumethiazide CORZIDE 3 nebivolol BYSTOLIC 3 penbutolol LEVATOL pindolol VISKEN propranolol & hydrochlorothiazide INDERIDE Kaiser Permanente of Georgia Multi Choice Formulary 5

17 3 propranolol extended-release INNOPRAN XL propranolol INDERAL propranolol sustained-release INDERAL LA sotalol BETAPACE sotalol BETAPACE AF timolol BLOCADREN Central Nervous System Agents Analgesics and Antipyretics acetaminophen & codeine TYLENOL W/ CODEINE acetaminophen, caffeine, & dihydrocodine PANLOR SS buprenorphine SUBUTEX QL buprenorphine& naloxone tablet SUBOXONE QL 3 buprenorphine & naloxone film SUBOXONE QL 3 buprenorphine transdermal BUTRANS butalbital & acetaminophen PHRENILIN 3 butalbital & acetaminophen PHRENILIN FORTE butalbital, acetaminophen, & caffeine FIORICET butalbital, acetaminophen, caffeine, & codeine FIORICET W/ CODEINE butalbital, aspirin, & caffeine FIORINAL butalbital, aspirin, caffeine, & codeine FIORINAL W/ CODEINE butorphanol tartrate STADOL carisoprodol, aspirin, & codeine SOMA COMPOUND W/ CODEINE celecoxib CELEBREX codeine CODEINE SULF diclofenac potassium CATAFLAM diclofenac sodium VOLTAREN diclofenac sodium PENNSAID 2 diclofenac sodium & misoprostol ARTHROTEC diclofenac sodium extended release VOLTAREN XR diflunisal DIFLUNISAL etodolac LODINE 3 fenoprofen calcium NALFON 3 fentanyl film ONSOLIS 3 fentanyl intranasal LAZANDA fentanyl lozenge ACTIQ 3 fentanyl sublingual ABSTRAL 3 fentanyl tablet FENTORA QL fentanyl transdermal DURAGESIC flurbiprofen ANSAID 3 hydrocodone ZOHYDRO ER Kaiser Permanente of Georgia Multi Choice Formulary 6

18 3 hydrocodone er HYSINGLA ER hydrocodone & acetaminophen NORCO hydrocodone & ibuprofen VICOPROFEN 3 hydromorphone oral suspension DILAUDID hydromorphone tablet DILAUDID 3 hydromorphone tablet EXALGO ibuprofen MOTRIN indomethacin INDOCIN ketoprofen KETOPROFEN QL ketorolac tablet TORADOL levorphanol LEVO-DROMORAN meclofenamate MECLOMEN QL mefenamic acid PONSTEL meloxicam MOBIC meperidine tablet DEMEROL methadone DOLOPHINE 2 morphine MORPHINE SULFATE Preferred Brand morphine MSIR 3 morphine beads AVINZA 3 morphine extended-relase capsule KADIAN morphine extended-release tablet MS CONTIN nabumetone RELAFEN nalbuphine NUBAIN naproxen NAPROSYN naproxen sodium ANAPROX 3 naproxen sodium NAPRELAN opium & belladonna alkaloids B & O SUPPRETTES 3 opium tincture OPIUM oxaprozin DAYPRO oxycodone ROXICODONE oxycodone & acetaminophen PERCOCET 2 oxycodone & acetaminophen ROXICET Preferred Brand 3 oxycodone & acetaminophen er XARTEMIS XR oxycodone & aspirin PERCODAN QL 3 oxycodone & ibuprofen COMBUNOX QL 3 oxycodone controlled-release OXYCONTIN 3 oxymorphone OPANA 3 oxymorphone extended-release OPANA ER pentazocine & naloxone TALWIN NX piroxicam FELDENE salsalate DISALCID sulindac CLINORIL QL 3 tapentadol NUCYNTA tolmetin sodium TOLECTIN 600 tramadol ULTRAM Kaiser Permanente of Georgia Multi Choice Formulary 7

19 tramadol & acetaminophen ULTRACET tramadol extended-release ULTRAM ER Anorexigenic Agents and Respiratory and Cerebral Stimulants amphetamine & dextroamphetamine ADDERALL amphetamine & dextroamphetamine extendedrelease ADDERALL XR QL armodafinil NUVIGIL QL dexmethylphenidate FOCALIN 3 dexmethylphenidate extendedrelease FOCALIN XR QL dextroamphetamine sulfate DEXTROSTAT QL dextroamphetamine sulfate extended-release DEXEDRINE 3 lisdexamfetamine VYVANSE methamphetamine DESOXYN methylphenidate METHYLIN methylphenidate RITALIN QL methylphenidate extendedrelease METADATE ER QL methylphenidate extendedrelease CONCERTA methylphenidate extendedrelease METADATE CD QL 3 methylphenidate extendedrelease RITALIN LA QL methylphenidate sustained release RITALIN SR QL 3 methylphenidate transdermal patch DAYTRANA QL modafinil PROVIGIL Anticonvulsants carbamazepine TEGRETOL carbamazepine extended-release cap CARBATROL 3 carbamazepine extended-release cap EQUETRO carbamazepine extended-release tab TEGRETOL XR 3 clobazam ONFI clonazepam KLONOPIN diazepam DIASTAT 2 diazepam DIASTAT ACUDIAL Preferred Brand divalproex sodium DEPAKOTE divalproex sodium capsule DEPAKOTE SPRINKLE Kaiser Permanente of Georgia Multi Choice Formulary 8

20 divalproex sodium extended release DEPAKOTE ER 3 eslicarbazepine APTIOM 3 ethontoin PEGANONE ethosuximide ZARONTIN 3 ezogaine POTIGA felbamate FELBATOL gabapentin NEURONTIN QL 3 lacosamide VIMPAT lamotrigine LAMICTAL lamotrigine extended-release LAMICTAL XR levetiracetam KEPPRA levetiracetam extended-release KEPPRA XR 2 methsuximide CELONTIN Preferred Brand oxcarbazepine TRILEPTAL 3 perampanel FYCOMPA phenytoin sodium extendedrelease DILANTIN phenytoin sodium extendedrelease PHENYTEK phenytoin suspension DILANTIN 3 pregabalin LYRICA primidone MYSOLINE 3 rufinamide BANZEL tiagabine GABITRIL topiramate capsule TOPAMAX SPRINKLE topiramate tablet TOPAMAX valproate sodium DEPAKENE valproic acid DEPAKENE PA 3 vigabatrin SABRIL zonisamide ZONEGRAN Antimigraine Agents QL almotriptan AXERT ergotamine & caffeine MIGERGOT QL 3 eletriptan RELPAX QL frovatriptan FROVA QL naratriptan AMERGE QL rizatriptan MAXALT QL rizatriptan orally disentigrating MAXALT MLT QL sumatriptan IMITREX QL zolmitriptan ZOMIG QL zolmitriptan orally disentigrating ZOMIG ZMT Antiparkinsonian Agents amantadine SYMMETREL benztropine COGENTIN bromocriptine PARLODEL Kaiser Permanente of Georgia Multi Choice Formulary 9

21 3 bromocriptine CYCLOSET cabergoline DOSTINEX 3 carbidopa LODOSYN carbidopa & levodopa SINEMET 3 carbidopa & levodopa PARCOPA carbidopa & levodopa extended release SINEMET CR 2 carbidopa, levodopa, & entacapone STALEVO Preferred Brand entacapone COMTAN pramipexole MIRAPEX pramipexole extended-release MIRAPEX ER 3 rasagiline AZILECT ropinirole REQUIP ropinirole extended-release REQUIP XL 3 rotigotine NEUPRO selegiline ELDEPRYL 3 selegiline ZELAPAR 3 selegiline transdermal EMSAM 2 tolcapone TASMAR Preferred Brand trihexyphenidyl ARTANE Anxiolytics, Sedatives, and Hypnotics alprazolam XANAX alprazolam extended-release XANAX XR 3 alprazolam orally disintegrating NIRAVAM buspirone BUSPAR chlordiazepoxide LIBRIUM clorazepate TRANXENE diazepam VALIUM estazolam PROSOM eszopiclone LUNESTA flurazepam DALMANE hydroxyzine hcl ATARAX hydroxyzine pamoate VISTARIL lorazepam ATIVAN meprobamate MILTOWN oxazepam SERAX phenobarbital PHENOBARBITAL 3 ramelteon ROZEREM 3 suvorexant BELSOMRA PA 3 tasimelteon HETLIOZ temazepam RESTORIL triazolam HALCION zaleplon SONATA 3 zolipdem sublingual EDLUAR zolpidem AMBIEN Kaiser Permanente of Georgia Multi Choice Formulary 20

22 zolpidem extended-release AMBIEN CR 3 zolpidem oral spray ZOLPIMIST Central Nervous System Agents Miscellaneous acamprosate CAMPRAL 3 atomoxetine STRATTERA PA 3 deutetrabenazine AUSTEDO 3 dextromethorphan & quinidine NUEDEXTA guanfacine extended-release INTUNIV memantine NAMENDA 3 memantine er & donepezil NAMZARIC QL 3 milnacipran SAVELLA riluzole RILUTEK 3 sodium oxybate XYREM PA 3 tetrabenazine XENAZINE PA 3 valbenazine INGREZZA Opioid Antagonists naloxone NARCAN QL 2 naloxone nasal spray NARCAN Preferred Brand naltrexone REVIA Psychotherapeutic Agents amitriptyline ELAVIL amitriptyline & perphenazine TRIAVIL amoxapine ASENDIN aripiprazole ABILIFY 3 asenapine SAPHRIS 3 brexpiprazole REXULTI bupropion WELLBUTRIN bupropion extended-release WELLBUTRIN XL 3 bupropion hydrobromide APLENZIN bupropion sustained-release WELLBUTRIN SR 3 cariprazine VRAYLAR chlordiazepoxide & amitriptyline LIMBITROL DS chlorpromazine THORAZINE citalopram CELEXA clomipramine ANAFRANIL clozapine CLOZARIL clozapine FAZACLO desipramine NORPRAMIN 3 desvenlafaxine succinate extended release PRISTIQ doxepin SINEQUAN duloxetine CYMBALTA escitalopram LEXAPRO fluoxetine PROZAC 3 fluoxetine PROZAC WEEKLY 3 fluoxetine SARAFEM Kaiser Permanente of Georgia Multi Choice Formulary 2

23 fluphenazine PROLIXIN fluvoxamine LUVOX haloperidol HALDOL 3 iloperidone FANAPT imipramine TOFRANIL imipramine pamoate TOFRANIL-PM 3 isocarboxazid MARPLAN 3 levomilnacipran FETZIMA lithium carbonate capsule LITHIUM CARBONATE lithium carbonate extended release LITHOBID lithium citrate CIBALITH-S loxapine LOXITANE 3 lurasidone LATUDA maprotiline LUDIOMIL mirtazapine REMERON nefazodone SERZONE nortriptyline PAMELOR olanzapine ZYPREXA olanzapine & fluoxetine hcl SYMBYAX olanzapine orally disintegrating ZYPREXA ZYDIS paliperidone INVEGA paroxetine PAXIL 3 paroxetine extended-release PAXIL CR 3 paroxetine mesylate PEXEVA perphenazine TRILAFON phenelzine NARDIL 3 pimavanserin NUPLAZID pimozide ORAP 3 protriptyline VIVACTIL quetiapine SEROQUEL 3 quetiapine extended-release SEROQUEL XR risperidone RISPERDAL 3 risperidone orally disintegrating RISPERDALM-TAB sertraline ZOLOFT thioridazine MELLARIL thiothixene NAVANE tranylcypromine sulfate PARNATE trazodone DESYREL 3 trazodone extended-release OLEPTRO trifluoperazine STELAZINE 3 trimipramine SURMONTIL venlafaxine EFFEXOR venlafaxine extended-release EFFEXOR XR QL 3 vilazodone VIIBRYD 3 vortioxetine BRINTELLIX ziprasidone GEODON Kaiser Permanente of Georgia Multi Choice Formulary 22

24 Diabetic Supplies Diabetic Supplies QL 3 blood sugar diagnostic ONE TOUCH ULTRA TEST STRIPS QL 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 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 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 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 PA 3 glycerol phenylbutyrate RAVICTI 3 sodium phenylbutyrate BUPHENYL 3 lactulose CHRONULAC lactulose ENULOSE 3 lactulose KRISTALOSE Diuretics amiloride MIDAMOR amiloride & hydrochlorothiazide MODURETIC bumetanide BUMEX chlorothiazide DIURIL chlorthalidone HYGROTON 3 ethacrynic acid EDECRIN furosemide LASIX hydrochlorothiazide MICROZIDE indapamide LOZOL metolazone ZAROXOLYN QL 3 tolvaptan SAMSCA Kaiser Permanente of Georgia Multi Choice Formulary 23

25 torsemide DEMADEX 3 triamterene DYRENIUM triamterene & hydrochlorothiazide DYAZIDE triamterene & hydrochlorothiazide MAXZIDE Ion-Removing Agnets 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 calcium acetate PHOSLO 2 calcium acetate PHOSLYRA Preferred Brand potassium bicarbonate & potassium chloride K-LYTE/CL potassium chloride K-DUR potassium chloride K-TAB 2 potassium chrloide powder KLOR-CON 20 MEQ Preferred Brand 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 colchicine & probenecid COL-BENEMID probenecid BENEMID Enzymes Enzymes 2 dornase alfa PULMOZYME Preferred Brand Eye, Ear, Nose and Throat (EENT) Anti-infectives 3 azithromycin (ophth) AZASITE bacitracin & polmyxin B (ophth) POLYSPORIN bacitracin (ophth) AK-TRACIN 3 besilfoxacin BESIVANCE chlorhexidine (mouth-throat) PERIDEX 3 ciprofloxacin (ophth) ointment CILOXAN ciprofloxacin (ophth) solution CILOXAN erythromycin (ophth) ROMYCIN 3 ganciclovir (ophth) ZIRGAN 2 gatifloxacin (ophth) ZYMAXID Preferred Brand gentamicin (ophth) GENTAK levofloxacin (ophth) QUIXIN 3 moxifloxacin (ophth) VIGAMOX 2 natamycin NATACYN Preferred Brand Kaiser Permanente of Georgia Multi Choice Formulary 24

26 neomycin, bacitracin & polymyxin b (ophth) NEO-POLYCIN neomycin, polymycin b & gramicidin (ophth) NEOSPORIN ofloxacin (ophth) OCUFLOX ofloxacin (otic) FLOXIN polymyxin b & trimethoprim (ophth) POLYTRIM sulfacetamide sodium (ophth) ointment SULFAC sulfacetamide sodium (ophth) solution BLEPH-0 2 tobramycin sulfate (ophth) ointment TOBREX Preferred Brand tobramycin sulfate (ophth) solution TOBREX trifluridine VIROPTIC Anti-Inflammatory Agents 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 dexamethasone (ophth) solution DECADRON 2 dexamethasone (ophth) suspension MAXIDEX Preferred Brand diclofenac sodium (ophth) VOLTAREN 3 difluprednate DUREZOL 3 fluocinolone acetonide (otic) DERMOTIC fluorometholone (ophth) FML 3 fluorometholone (ophth) FML FORTE 2 fluorometholone acetate FLAREX Preferred Brand flurbiprofen (ophth) OCUFEN 2 gentamicin & prednisolone PRED-G Preferred Brand hydrocortisone & acetic acid (otic) ACETASOL HC ketorolac (ophth) ACULAR 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 25

27 3 neomycin, colistin, hydrocortisone & thonzonium (otic) CORTISPORIN-TC neomycin, polymyxin B & dexamethasone (ophth) MAXITROL 3 neomycin, polymyxin B & hydrocortisone (ophth) CORTISPORIN neomycin, polymyxin B & hydrocortisone (otic) CORTISPORIN 3 nepafenac NEVANAC prednisolone acetate (ophth) OMNIPRED prednisolone acetate (ophth) PRED FORTE 2 prednisolone acetate (ophth) PRED MILD Preferred Brand 3 prednisolone sodium phosphate (ophth) INFLAMASE FORTE prednisolone sodium phosphate (ophth) PREDNISOL 3 rimexolone VEXOL sulfacetamide sodium & prednisolone BLEPHAMIDE 2 tobramycin & dexamethasone ointment TOBRADEX Preferred Brand tobramycin & dexamethasone suspension TOBRADEX Antiallergic Agents 3 aflcaftadine LASTACAFT azelastine ASTELIN azelastine ASTEPRO 3 azelastine & fluticasone DYMISTA azelastine (ophth) OPTIVAR 3 bepotastine BEPREVE cromolyn sodium (ophth) OPTICROM 3 emedastine EMADINE 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 olopatadine (ophth) PATANOL 3 short ragweed pollen allergen extract RAGWITEK 3 timothy grass pollen allergen extract GRASTEK Antiglaucoma Agents acetazolamide DIAMOX Kaiser Permanente of Georgia Multi Choice Formulary 26

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

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

30 Digestants 3 pancrelipase (lipase-proteaseamylase) CREON 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 clidinium & chlordiazepoxide LIBRAX 3 linaclotide LINZESS 3 lubiprostone AMITIZA metoclopramide REGLAN 3 phenobarbital and belladonna alkaloids DONNATAL 3 teduglutide GATTEX ursodiol ACTIGALL ursodiol URSO 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 budesonide ENTOCORT EC 3 budesonide UCERIS cortisone acetate CORTONE ACETATE dexamethasone DECADRON fludrocortisone FLORINEF ACETATE hydrocortisone CORTEF methylprednisolone MEDROL prednisolone PRELONE prednisolone acetate PREDNISOLONE prednisolone sodium phosphate ORAPRED prednisolone sodium phosphate ORAPRED ODT Kaiser Permanente of Georgia Multi Choice Formulary 29

31 prednisolone sodium phosphate PEDIAPRED prednisone PREDNISONE 3 prednisone RAYOS Androgens danazol DANOCRINE 2 fluoxymesterone ANDROXY Preferred Brand 2 methyltestosterone ANDROID 0 Preferred Brand 3 methyltestosterone METHITEST methyltestosterone TESTRED oxandrolone OXANDRIN 3 testosterone ANDRODERM 3 testosterone AXIRON testosterone ANDROGEL testosterone TESTIM 3 testosterone FORTESTA testosterone cypionate DEPO-TESTOSTERONE Contraceptives QL desogestrel & ethinyl estradiol APRI QL 3 desogestrel & ethinyl estradiol DESOGEN QL 3 desogestrel & ethinyl estradiol ORTHO-CEPT QL desogestrel & ethinyl estradiol RECLIPSEN QL desogestrel & ethinyl estradiol (biphasic) KARIVA QL desogestrel & ethinyl estradiol (triphasic) CYCLESSA QL desogestrel & ethinyl estradiol (triphasic) VELIVET QL drospirenone & ethinyl estradiol GIANVI QL 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 estradiol cypionate DELESTROGEN estradiol valerate DEPO-ESTRADIOL QL 3 estradiol valerate & dienogest NATAZIA QL ethynodiol diacetate & ethinyl estradiol KELNOR QL ethynodiol diacetate & ethinyl estradiol ZOVIA QL 2 etonogestrel & ethinyl estradiol NUVARING Preferred Brand AGE levonorgestrel PLAN B QL levonorgestrel & ethinyl estradiol AVIANE QL levonorgestrel & ethinyl estradiol LESSINA Kaiser Permanente of Georgia Multi Choice Formulary 30

32 QL levonorgestrel & ethinyl estradiol LEVORA QL 3 levonorgestrel & ethinyl estradiol NORDETTE-28 QL levonorgestrel & ethinyl estradiol (9-day) INTROVALE QL 3 levonorgestrel & ethinyl estradiol (9-day) LOSEASONIQUE QL 3 levonorgestrel & ethinyl estradiol (9-day) SEASONALE QL 3 levonorgestrel & ethinyl estradiol (9-day) SEASONIQUE QL levonorgestrel & ethinyl estradiol (continuous) AMYTHYST QL 3 levonorgestrel & ethinyl estradiol (continuous) LYPREL QL levonorgestrel & ethinyl estradiol (triphasic) TRIVORA QL 3 norelgestromin & ethinyl estradiol ORTHO EVRA QL norelgestromin & ethinyl estradiol XULANE QL norethindrone CAMILA QL norethindrone NORA-BE QL 3 norethindrone NOR-QD QL norethindrone & ethinyl estradiol BALZIVA QL 3 norethindrone & ethinyl estradiol BREVICON QL norethindrone & ethinyl estradiol JUNEL QL norethindrone & ethinyl estradiol MICROGESTIN QL 3 norethindrone & ethinyl estradiol MODICON QL norethindrone & ethinyl estradiol NECON QL 3 norethindrone & ethinyl estradiol NORINYL +35 QL norethindrone & ethinyl estradiol NORTREL /35 QL norethindrone & ethinyl estradiol OVCON-35 QL 3 norethindrone & ethinyl estradiol OVCON-50 QL norethindrone & ethinyl estradiol (biphasic) NECON 0/ QL norethindrone & ethinyl estradiol (triphasic) ARANELLE QL 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 Kaiser Permanente of Georgia Multi Choice Formulary 3

33 QL norethindrone & ethinyl estradiol w/ ferrous fumarate GENERESS FE QL 3 norethindrone & ethinyl estradiol w/ ferrous fumarate JUNEL FE QL norethindrone & ethinyl estradiol w/ ferrous fumarate MICROGESTIN FE QL 3 norethindrone acetate & ethinyl estradiol w/ ferrous fumarate LOESTRIN 24 FE QL 3 norethindrone acetate & ethinyl estradiol w/ ferrous fumarate LOESTRIN FE QL 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 +50 QL 3 norethindrone-mestranol ORTHO-NOVUM QL norgestimate & ethinyl estradiol CRYSELLE QL norgestimate & ethinyl estradiol MONONESSA QL 3 norgestimate & ethinyl estradiol ORTHO-CYCLEN QL norgestimate & ethinyl estradiol SPRINTEC QL norgestimate & ethinyl estradiol TRINESSA QL 3 norgestimate & ethinyl estradiol (triphasic) ORTHO TRI-CYCLEN QL norgestimate & ethinyl estradiol (triphasic) ORTHO TRI-CYCLEN LO QL norgestimate & ethinyl estradiol (triphasic) TRI-SPRINTEC QL 3 norgestrel & ethinyl estradiol LO/OVRAL-28 QL norgestrel & ethinyl estradiol LOW-OGESTREL QL norgestrel & ethinyl estradiol OGESTREL 2 ulipristal ELLA Preferred Brand Diabetic Agents acarbose PRECOSE PA 3 albiglutide TANZEUM PA 3 alirocumab PRALUENT PA alogliptin NESINA PA alogliptin & metformin KAZANO PA alogliptin & pioglitazone OSENI PA 3 canagliflozin INVOKANA PA 3 canagliflozin & metformin INVOKAMET chlorpropamide CHLORPROPAMIDE PA 3 dapagliflozin FARXIGA PA 3 dapagliflozin & metformin XIGDUO XR PA 3 dulaglutide TRULICITY PA 3 empagliflozin JARDIANCE Kaiser Permanente of Georgia Multi Choice Formulary 32

34 PA 3 empagliflozin & linagliptan GLYXAMBI PA 3 empagliflozin & metformin SYNJARDY PA 3 evolocumab REPATHA PA 3 exenatide BYETTA PA 3 exenatide extended-release BYDUREON glimepiride AMARYL glipizide GLUCOTROL glipizide & metformin METAGLIP glipizide extended-release GLUCOTROL XL 2 glucagon GLUCAGON EMERGENCY KIT Preferred Brand 3 glucagon GLUCAGEN HYPOKIT glyburide DIABETA glyburide & metformin GLUCOVANCE 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 PA 3 Insulin degludec/ liraglutide XULTOPHY 3 insulin detemir LEVEMIR 3 insulin glargine LANTUS, BASAGLAR PA 3 Insulin glargine/ lixisenatide SOLIQUA 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 PA 3 linagliptin TRADJENTA PA 3 linagliptin & metformin JENTADUETO PA 3 liraglutide VICTOZA PA 3 lixisenatide ADLYXIN metformin GLUCOPHAGE metformin FORTAMET metformin GLUMETZA 3 metformin RIOMET Kaiser Permanente of Georgia Multi Choice Formulary 33

35 metformin extended-release GLUCOPHAGE XR PA 3 mifepristone KORLYM 3 miglitol GLYSET nateglinide STARLIX pioglitazone ACTOS 3 pioglitazone & glimepiride DUETACT 3 pioglitazone & metformin ACTOPLUS MET PA 3 pramlintide acetate SYMLIN repaglinide PRANDIN repaglinide & metformin PRANDIMET PA 3 saxagliptin ONGLYZA PA 3 saxagliptin & metformin extendedrelease KOMBIGLYZE XR PA 3 sitagliptin & metformin JANUMET PA 3 sitagliptin & simvastatin JUVISYNC PA 3 sitagliptin phosphate JANUVIA tolazamide TOLINASE 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 estradiol ESTRACE TAB estradiol GYNODIOL 3 estradiol & levonorgestrel CLIMARA PRO 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 estradiol transdermal CLIMARA DIS 3 estradiol transdermal ESTRADERM 3 estradiol transdermal MENOSTAR estradiol transdermal VIVELLE-DOT estradiol vaginal ESTRACE CREAM 2 estradiol vaginal ESTRING Preferred Brand Only 0mg strength 2 estradiol vaginal VAGIFEM Preferred Brand Kaiser Permanente of Georgia Multi Choice Formulary 34

36 All other strengths 3 estradiol vaginal VAGIFEM estradiol vaginal YUVAFEM 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 estropipate ORTHO-EST norethindrone acetate & ethinyl estradiol FEMHRT 3 ospemifene OSPHENA raloxifene hcl EVISTA Gonadatropins 2 nafarelin SYNAREL Preferred Brand Parathyroid calcitonin salmon FORTICAL calcitonin salmon MIACALCIN PA 3 teriparatide FORTEO Pitutary PA 3 corticotropin ACTHAR desmopressin (non-refrigerated) DDAVP 3 desmopressin acetate STIMATE Progestins medroxyprogesterone acetate PROVERA megestrol acetate MEGACE norethindrone acetate AYGESTIN progesterone, micronized PROMETRIUM Somatotropin Agonists and Antagonists PA 3 somatropin GENTROPIN PA 3 somatropin HUMATROPE PA 3 somatropin NORDITROPIN PA 3 somatropin NUTROPIN AQ PA 3 somatropin OMNITROPE PA 3 somatropin SAIZEN PA 3 somatropin SEROSTIM PA 3 pegvisomant SOMAVERT PA 3 somatropin ZORBTIVE Thyroid and Antihyroid Agent levothyroxine LEVOTHROID levothyroxine LEVOXYL levothyroxine SYNTHROID 3 levothyroxine TIROSINT levothyroxine UNITHROID liothyronine CYTOMEL 3 liotrix THYROLAR Kaiser Permanente of Georgia Multi Choice Formulary 35

37 methimazole TAPAZOLE propylthiouracil PROPYLTHIOURACIL 3 thyroid ARMOUR THYROID Miscellaneous Therapeutic Agents Miscellanous Therapeutic Agents 2 abatacept ORENCIA Preferred Brand acetylcysteine MUCOMYST-0 2 adalimumab HUMIRA Preferred Brand alendronate FOSAMAX 3 alendronate & cholecalciferol FOSAMAX PLUS D allopurinol ZYLOPRIM 3 anakinra KINERET 2 apremilast OTEZLA Preferred Brand azathioprine AZASAN azathioprine IMURAN 3 bedaquiline SIRTURO PA 3 c- esterase inhibitor HAEGARDA PA 3 canakinumab ILARIS PA 3 cholic acid CHOLBAM 2 cinacalcet SENSIPAR Preferred Brand 3 colchicine COLCRYS cyclosporine SANDIMMUNE cyclosporine, modified NEORAL PA 3 cysteamine delayed-release PROCYSBI 3 cysteamine immediate-release CYSTAGON PA 3 daclizumab ZINBRYTA Non-preferred PA 3 dalfampridine AMPYRA QL,PA 3 dichlorphenamide KEVEYIS PA 3 dimethyl fumarate TECFIDERA PA 3 dupilumab DUPIXENT disulfiram ANTABUSE dutasteride AVODART dutasteride & tamsulosin JALYN PA 3 eliglustat CERDELGA 2 etanercept ENBREL Preferred Brand etidronate DIDRONEL 3 everolimus ZORTRESS 3 febuxostat ULORIC PA 3 fingolimod GILENYA PA 3 glatiramer acetate COPAXONE PA glatiramer acetate GLATOPA 3 golimumab SIMPONI ibandronate BONIVA PA 3 icatibant FIRAZYR 3 immune globulin HYQVIA PA 3 interferon beta-a AVONEX Kaiser Permanente of Georgia Multi Choice Formulary 36

38 PA 3 interferon beta-a PLEGRIDY PA 3 interferon beta-a REBIF PA 3 interferon beta-a REBIF REBIDOSE 3 interferon beta-b BETASERON 2 Interferon beta-b EXTAVIA Preferred Brand 2 interferon gamma-b ACTIMMUNE Preferred Brand PA 3 ixekizumab TALTZ 3 lanreotide SOMATULINE DEPOT 3 lesinurad ZURAMPIC Non-preferred leflunomide ARAVA leucovorin LEUCOVORIN 2 mesna MESNEX Preferred Brand methenamine, sodium biphosphate, phenyl salicylate, methylene blue, and URO-MP hyoscyamine methylergonovine maleate METHERGINE 3 metreleptin MYALEPT 3 mifepristone MIFEPREX PA 3 miglustat ZAVESCA mycophenolate mofetil CELLCEPT mycophenolate sodium MYFORTIC 3 nitisinone ORFADIN octreotide acetate SANDOSTATIN PA 3 parathyroid hormone NATPARA PA 3 pasireotide SIGNIFOR Non-preferred pediatric multivitamins w/ fluoride POLY-VI-FLOR pediatric multivitamins w/ fluoride & iron POLY-VI-FLOR W/IRON pediatric vitamins a, c, & d, w/ fluoride TRI-VI-FLOR 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 PA 3 sapropterin dihydrochlorid KUVAN 3 secukinumab COSENTYX solution 3 sirolimus RAPAMUNE sirolimus RAPAMUNE 3 sodium fluoride FLUORABON BASIC sodium fluoride FLUORITAB sodium fluoride LURIDE CHEW sodium fluoride (dental) PREVIDENT sodium fluoride (dental) PREVIDENT 5000 PLUS Kaiser Permanente of Georgia Multi Choice Formulary 37

39 sodium fluoride drops LURIDE DROPS 2 stannous fluoride GEL-KAM Preferred Brand tacrolimus PROGRAF PA 3 teriflunomide AUBAGIO 2 thalidomide THALOMID Preferred Brand 3 tocilizumab ACTEMRA 2 tofacitinib XELJANZ Preferred PA 3 ustekinumab STELARA Respiratory Tract Agents Antitussives benzonatate TESSALON PERLES guaifenesin & codeine CHERATUSSIN AC 3 hydrocodone & chlorpheniramine TUSSIONEX hydrocodone & homatropine HYCODAN promethazine & codeine PHENERGAN W/ CODEINE promethazine & dextromethorphan PROMETHAZINE-DM promethazine, phenylephrine & PHENERGAN VC codeine W/CODEINE 3 pseudoephedrine, brompheniramine & codeine M-END MAX D Anti-Inflammatory Agents 3 cromolyn sodium GASTROCROM cromolyn sodium INTAL montelukast SINGULAIR 3 zafirlukast ACCOLATE 3 zileuton ZYFLO Respiratory Agents, Miscellaneous 2 beclomethasone dipropionate QVAR Preferred Brand 3 budesonide PULMICORT FLEXHALER budesonide PULMICORT RESPULES 3 budesonide & formoterol SYMBICORT 3 ciclesonide ALVESCO 3 fluticasone & salmeterol (00/50 mcg) ADVAIR DISKUS 2 fluticasone & salmeterol (250/50 mcg and 500/50 mcg) ADVAIR DISKUS Preferred Brand 3 fluticasone & vilanterol BREO ELLIPTA 3 fluticasone propionate FLOVENT DISKUS AER 3 fluticasone propionate FLOVENT HFA 3 glycopyrrolate & indacaterol UTIBRON NEOHALER Non-Preferrred PA 3 ivacaftor KALYDECO PA 3 lumacaftor& ivacaftor ORKAMBI 3 mometasone & formoterol DULERA 2 mometasone furoate ASMANEX Preferred Brand Kaiser Permanente of Georgia Multi Choice Formulary 38

40 PA 3 mepolizumab NUCALA 3 nintedanib OFEV PA 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- ciclopirox LOPROX ciclopirox PENLAC clindamycin & benzoyl peroxide BENZACLIN clindamycin & benzoyl peroxide DUAC clindamycin phosphate (topical) CLEOCIN T clindamycin phosphate (topical) CLINDAGEL 3 clindamycin phosphate (topical) EVOCLIN clindamyinc phosphate (vaginal) CLEOCIN clotrimazole MYCELEX clotrimazole & betametmethasone LOTRISONE 3 crotamiton EURAX econazole nitrate SPECTAZOLE 3 erythromycin (acne acid) AKNE-MYCIN erythromycin (acne acid) ERYGEL gentamicin sulfate (topical) GARAMYCIN 3 hexachlorophene PHISOHEX iodoquinol & hydrocortisone VYTONE ketoconazole (topical) NIZORAL lindane KWELL 3 mafenide acetate SULFAMYLON malathion OVIDE metronidazole (topical) METROCREAM metronidazole (topical) METROGEL metronidazole (topical) METROLOTION metronidazole (vaginal) METROGEL-VAGINAL 3 miconazole nitrate & zinc oxide VUSION mupirocin BACTROBAN 3 mupirocin calcium BACTROBAN NASAL 3 na sulfacetm/avobenzone/sulfur ROSAC 3 naftifine NAFTIN Kaiser Permanente of Georgia Multi Choice Formulary 39

41 nystatin (topical) NYSTATIN 3 oxiconazole nitrate OXISTAT 3 penciclovir DENAVIR permethrin ELIMITE 3 retapamulin ALTABAX 3 selenium sulfide SELSEB 3 selenium sulfide SELSUN RX 3 sertaconazole nitrate ERTACZO silver sulfadiazine SILVADENE 3 spinosad NATROBA 3 sulconazole nitrate EXELDERM sulfacetamide sodium (acne) KLARON 3 sulfacetamide sodium (acne) SEB-PREV 3 sulfanilamide AVC terconazole TERAZOL 7 terconazole (vaginal) TERAZOL 3 Anti-inflammatory Agents (Skin and Mucous Membranes) alclometasone dipropionate ACLOVATE amcinonide CYCLOCORT 3 bacitracin, polymyxin, neomycin & hydrocortisone CORTISPORIN 3 benzoyl peroxide & hydrocortisone VANOXIDE-HC betamethasone dipropionate (topical) DIPROSONE betamethasone dipropionate augmented DIPROLENE betamethasone valerate LUXIQ betamethasone valerate VALISONE calcipotriene & betamethasone TACLONEX clobetasol propionate CLOBEX clobetasol propionate TEMOVATE clobetasol propionate emollient TEMOVATE E 3 clobetasol propionate emulsion OLUX-E clocortolone pivalate CLODERM 3 crisaborole EUCRISA QL desonide DESOWEN desoximetasone TOPICORT diflorasone diacetate APEXICON 3 fluocinolone acetonide CAPEX SHAMPOO fluocinolone acetonide DERMA-SMOOTHE/FS OIL fluocinolone acetonide SYNALAR fluocinonide LIDEX 3 fluocinonide VANOS fluocinonide emollient LIDEX-E, 3 flurandrenolide CORDRAN Kaiser Permanente of Georgia Multi Choice Formulary 40

42 fluticasone propionate (topical) CUTIVATE 3 halcinonide HALOG halobetasol propionate ULTRAVATE hydrocortisone (intrarectal) CORTENEMA hydrocortisone (rectal) ANUSOL-HC hydrocortisone (rectal) PROCTOCORT hydrocortisone (topical) HYTONE hydrocortisone acetate & urea CARMOL HC 3 hydrocortisone acetate (intrarectal) CORTIFOAM hydrocortisone butyrate LOCOID 3 hydrocortisone butyrate hydrophilic lipo base LOCOID LIPOCREAM 3 hydrocortisone probutate PANDEL hydrocortisone valerate WESTCORT mometasone furoate ELOCON nystatin & triamcinolone MYCOLOG II prednicarbate DERMATOP 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 3 hydrocortisone & pramoxine PROCTOFOAM-HC lidocaine (Jelly, topical) XYLOCAINE 3 lidocaine & hydrocortisone LIDAMANTLE lidocaine & prilocaine EMLA pramoxine PROCTOFOAM Astringents 2 aluminum chloride hexahydrate HYPERCARE Preferred Brand Keratolytic Agents 3 sulfacetamide sodium & sulfur AVAR sulfacetamide sodium & sulfur PLEXION 3 sulfacetamide sodium & sulfur PLEXION SCT sulfacetamide sodium & sulfur ROSULA urea CARMOL Keratoplastic Agents 3 anthralin DRITHOCREME HP 3 anthralin DRITHO-SCALP 3 anthralin PSORIATEC Cell Stimulants and Proliferants QL, AGE tretinoin RETIN-A QL, AGE 3 tretinoin microspheres RETIN-A MICRO Skin and Mucous Membrane Agents, Miscellaneous acitretin SORIATANE Kaiser Permanente of Georgia Multi Choice Formulary 4

43 QL, AGE adapalene DIFFERIN QL, AGE 3 alitretinoin PANRETIN 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 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 diclofenac sodium VOLTAREN GEL 3 diclofenac sodium (actinic keratosis) SOLARAZE 3 doxepin (antipuritic) PRUDOXIN 3 doxycycline (rosacea) ORACEA 3 fluorouracil (topical) CARAC fluorouracil (topical) EFUDEX 2 fluorouracil (topical) FLUOROPLEX Preferred Brand imiquimod ALDARA 3 imiquimod ZYCLARA 3 ingenol mebutate PICATO isotretinoin ACCUTANE isotretinoin CLARAVIS 3 lactic acid (ammonium lactate) LACTINOL 2 methoxsalen 8-MOP Preferred Brand methoxsalen, rapid OXSORALEN-ULTRA 2 pimecrolimus ELIDEL Preferred Brand podofilox CONDYLOX 3 sinecatechins VEREGEN tacrolimus (topical) PROTOPIC QL, AGE 3 tazarotene TAZORAC Smooth Muscle Relaxants Smooth Muscle Relaxants darifenacin ENABLEX 3 dyphylline LUFYLLIN 3 fesoterodine TOVIAZ 3 flavoxate FLAVOXATE 3 mirabegron MYRBETRIQ oxybutynin DITROPAN oxybutynin extended-release DITROPAN XL Kaiser Permanente of Georgia Multi Choice Formulary 42

44 3 oxybutynin transdermal OXYTROL 3 solifenacin VESICARE theophylline UNIPHYL tolterodine DETROL tolterodine extended-release DETROL LA trospium SANCTURA 3 trospium extended-release SANCTURA XR Vitamins Vitamins calcitriol ROCALTROL doxercalciferol HECTOROL ergocalciferol DRISDOL niacin NIACOR paricalcitol ZEMPLAR 2 phytonadione MEPHYTON Preferred Brand Kaiser Permanente of Georgia Multi Choice Formulary 43

45 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... 2 abiraterone... 8 ABSTRAL... 6 acamprosate... 2 acarbose ACCOLATE ACCU-CHEK ACCU-CHEK TEST STRIPS ACCUNEB... ACCUPRIL... 4 ACCURETIC... 4 ACCUTANE acebutolol... 5 ACEON... 4 acetaminophen & codeine... 6 acetaminophen, caffeine, & dihydrocodine... 6 ACETASOL HC acetazolamide... 26, 27 acetic acid... 25, 27 acetylcysteine acitretin... 4 ACLOVATE ACTEMRA ACTHAR ACTIGALL ACTIMMUNE ACTIQ... 6 ACTIVELLA ACTONEL ACTOPLUS MET ACTOS ACULAR ACULAR LS acyclovir... 6, 39 ACZONE ADALAT CC... 3 adalimumab adapalene ADCIRCA... 5 ADDERALL... 8 ADDERALL XR... 8 adefovir dipivoxil... 6 ADEMPAS... 5 ADLYXIN ADOXA... 5 ADRENACLICK... ADVAIR DISKUS ADVICOR... 2 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... 4 ALDACTONE... 4 ALDARA ALDOMET... 4 ALDORIL alendronate alendronate & cholecalciferol... 36, 37 alfuzosin hcl... 0 ALINIA... 6 alirocumab aliskiren... 4 aliskiren & amlodipine... 4 aliskiren & hydrochlorothiazide... 4 aliskiren & valsartan... 4 aliskiren, amlodipine & hydrochlorothiazide... 4 alitretinoin ALKERAN... 9 allopurinol almotriptan... 9 ALOCRIL alogliptin alogliptin & metformin Kaiser Permanente of Georgia Multi Choice Formulary 44

46 alogliptin & pioglitazone ALOMIDE ALORA alosetron ALPHAGAN ALPHAGAN P alprazolam alprazolam extended-release alprazolam orally disintegrating ALREX ALTABAX ALTACE... 4 ALTOPREV... 2 aluminum chloride hexahydrate... 4 ALVESCO amantadine... 9 AMARYL AMBIEN... 20, 2 AMBIEN CR... 2 ambrisentan... 5 amcinonide AMERGE... 9 AMICAR... amiloride amiloride & hydrochlorothiazide aminocaproic acid... amiodarone... 3 AMITIZA amitriptyline... 2 amitriptyline & perphenazine... 2 amlodipine... 2, 3, 4 amlodipine & atorvastatin... 2 amlodipine & benazepril... 2 amlodipine & olmesartan... 3 amlodipine & valsartan... 3 amlodipine, olmesartan & hydrochlorothiazide... 3 amlodipine, valsartan & hydrochlorothiazide... 3 ammonium lactate amoxapine... 2 amoxicillin... 2, 4, 28 amoxicillin & clavulanate potassium... 4 amoxicillin & clavulanate potassium extended-release... 4 amoxicillin, clarithromycin, & lansoprazole AMOXIL... 4 amphetamine & dextroamphetamine... 8 amphetamine & dextroamphetamine extended-release... 8 AMPICILLIN... 4 ampicillin sodium... 4 AMPYRA AMRIX... 0 AMTURNIDE... 4 Kaiser Permanente of Georgia Multi Choice Formulary AMYTHYST... 3 ANAFRANIL... 2 anagrelide... anakinra ANALPRAM HC... 4 ANAPROX... 7 anastrozole... 8 ANCOBON... 5 ANDRODERM ANDROGEL ANDROID ANDROXY ANGELIQ ANORO ELLIPTA... ANSAID... 6 ANTABUSE anthralin... 4 antipyrine & benzocaine ANUSOL-HC... 4 ANZEMET APEXICON APIDRA apixaban... APLENZIN... 2 apraclonidine apremilast aprepitant APRESOLINE... 4 APRI APTIOM... 9 APTIVUS... 8 ARALEN... 6 ARANELLE... 3 ARANESP... 2 ARAVA arformoterol... ARICEPT... 0 ARICEPT ODT... 0 ARIMIDEX... 8 aripiprazole... 2 ARIXTRA... armodafinil... 8 ARMOUR THYROID AROMASIN... 8 ARTANE ARTHROTEC... 6 artificial tear insert ASCENSIA BREEZE ASCENSIA TEST STRIPS asenapine... 2 ASENDIN... 2 ASMANEX Kaiser Permanente of Georgia Multi Choice Formulary 45

47 aspirin & dipyridamole... ASTELIN ASTEPRO ATACAND... 4 ATACAND HCT... 4 ATARAX atazanavir & cobicistat... 6 atazanavir sulfate... 6 ATELVIA atenolol... 5 atenolol & chlorthalidone... 5 ATIVAN atomoxetine... 2 atorvastatin... 2 atovaquone... 6 atovaquone & proguanil... 6 ATRIPLA... 7 atropine... 9, 27, 28 atropine sulfate... 9 ATROPINE SULFATE... 9 ATROVENT... 0 ATROVENTHFA... 0 AUBAGIO AUGMENTIN... 4 AUGMENTIN XR... 4 auranofin AURODEX AUSTEDO... 2 AUVI-Q... AVALIDE... 4 AVAPRO... 4 AVAR... 4 AVC AVELOX... 5 AVIANE AVINZA... 7 AVLOSULFON... 6 AVODART AVONEX... 36, 37 AXERT... 9 AXID AXIRON axitinib... 8 AYGESTIN AZASAN AZASITE azathioprine azelaic acid azelaic acid (acne) azelastine azelastine & fluticasone azelastine (ophth) Kaiser Permanente of Georgia Multi Choice Formulary AZELEX azelstine AZILECT azilsartan... 4 azithromycin... 4, 24 azithromycin (ophth) AZOPT AZOR... 3 AZULFIDINE... 5 B B & O SUPPRETTES... 7 bacitracin & polmyxin B (ophth) bacitracin (ophth) bacitracin, neomycin, polymyxin B & hydrocortisone (ophth) bacitracin, polymyxin, neomycin & hydrocortisone baclofen... 0 BACTRIM DS... 5 BACTROBAN BACTROBAN NASAL balsalazide BALZIVA... 3 BANZEL... 9 BARACLUDE... 7 BD INSULIN SYRINGE becaplermin beclomethasone dipropionate bedaquiline BELSOMRA benazepril... 2, 4 benazepril & hydrochlorothiazide... 4 BENEMID BENICAR... 4 BENICAR HCT... 4 BENTYL... 9 BENZACLIN BENZAMYCIN benzonatate benzoyl peroxide & erythromycin benzoyl peroxide & hydrocortisone benztropine... 9 bepotastine BEPREVE besilfoxacin BESIVANCE BETAGAN betamethasone dipropionate (topical) betamethasone dipropionate augmented betamethasone valerate BETAPACE... 6 Kaiser Permanente of Georgia Multi Choice Formulary 46

48 BETAPACE AF... 6 BETASERON BETASERON] betaxolol... 5, 27 betaxolol hcl bethanechol chloride... 0 BETIMOL BETOPTIC BETOPTIC S bexarotene... 8, 42 bexarotene (topical) BEYAZ BIAXIN... 4 BIAXIN XL... 4 bicalutamide... 8 BICITRA BIDIL... 5 bimatoprost bismuth subcitrate & metronidazole... 4 bisoprol & hydrochlorothiazide... 5 bisoprolol... 5 BLEPH BLEPHAMIDE BLOCADREN... 6 blood sugar diagnostic blood-glucose meter boceprevir... 6 BONIVA bosentan... 5 BOSULIF... 8 bosutinib... 8 BREO ELLIPTA BRETHINE... BREVICON... 3 brexpiprazole... 2 BRILINTA... brimonidine... 27, 42 brimonidine (topical) brimonidine tartrate BRINTELLIX brinzolamide bromfenac (ophth) bromocriptine... 9, 20 BROVANA... budesonide... 29, 38 budesonide & formoterol bumetanide BUMEX BUPHENYL buprenorphine... 6 buprenorphine & naloxone film... 6 buprenorphine transdermal... 6 Kaiser Permanente of Georgia Multi Choice Formulary buprenorphine& naloxone tablet... 6 bupropion... 2 bupropion extended-release... 2 bupropion hydrobromide... 2 bupropion sustained-release... 2 BUSPAR buspirone busulfan... 8 butalbital & acetaminophen... 6 butalbital, acetaminophen, & caffeine... 6 butalbital, acetaminophen, caffeine, & codeine... 6 butalbital, aspirin, & caffeine... 6 butalbital, aspirin, caffeine, & codeine... 6 butenafine butoconazole nitrate (vaginal) butorphanol tartrate... 6 BUTRANS... 6 BYDUREON... 32, 33 BYETTA BYSTOLIC... 5 C c- esterase inhibitor cabergoline CADUET... 2 CAFERGOT... 0 CALAN SR... 3 calcipotriene... 40, 42 calcipotriene & betamethasone calcitonin salmon calcitriol... 42, 43 calcitriol (topical) calcium acetate CAMILA... 3 CAMPRAL... 2 canagliflozin canagliflozin & metformin canakinumab CANASA candesartan... 4 candesartan & hydrochlorothiazide... 4 capecitabine... 8 CAPEX SHAMPOO CAPOTEN... 4 CAPOZIDE... 4 CAPRELSA... 9 captopril... 4 captopril & hydrochlorothiazide... 4 CARAC CARAFATE carbachol Kaiser Permanente of Georgia Multi Choice Formulary 47

49 CARBAGLU carbamazepine... 8 carbamazepine extended-release cap... 8 carbamazepine extended-release tab... 8 CARBATROL... 8 carbidopa carbidopa & levodopa carbidopa & levodopa extended release carbidopa, levodopa, & entacapone carbinoxamine maleate... 4 CARDENE... 3 CARDIZEM... 3 CARDIZEM CD... 3 CARDIZEM LA... 3 CARDURA... 2 carglumic acid cariprazine... 2 carisoprodol... 0, 6 carisoprodol, aspirin, & codeine... 6 carisoprodol/aspirin... 0 CARMOL... 4 CARMOL HC... 4 carteolol (ophth) CARTIA XT... 3 carvedilol... 5 carvedilol phosphate... 5 CASODEX... 8 CATAFLAM... 6 CATAPRES... 3 CATAPRES-TTS... 3 CECLOR... 4 CEDAX... 4 CEENU... 9 cefaclor... 4 cefadroxil... 4 cefdinir... 4 cefditoren... 4 cefixime... 4 cefpodoxime... 4 cefprozil... 4 ceftibuten... 4 CEFTIN... 4 cefuroxime axetil... 4 CEFZIL... 4 CELEBREX... 6 celecoxib... 6 CELEXA... 2 CELLCEPT CELONTIN... 9 CENESTIN cephalexin... 4 CERDELGA Kaiser Permanente of Georgia Multi Choice Formulary ceritinib... 8 cevimeline hcl... 0 CHANTIX... 0 CHEMET CHERATUSSIN AC chlorambucil... 8 chlordiazepoxide... 20, 2, 29 chlordiazepoxide & amitriptyline... 2 chlorhexidine (mouth-throat) chloroquine phosphate... 6 chlorothiazide chlorphenirmine, phenylephrine & pyrilamine... 4 chlorpromazine... 2 chlorpropamide CHLORPROPAMIDE chlorthalidone... 5, 23 chlorzoxazone... 0 CHOLBAM cholestyramine... 2 cholestyramine light... 2 cholic acid CHRONULAC CIBALITH-S ciclesonide ciclopirox cilostazol... CILOXAN cimetidine cinacalcet CIPRO... 4, 25 CIPRO HC CIPRODEX ciprofloxacin... 4, 24, 25 ciprofloxacin & dexamethasone (ophth) ciprofloxacin & hydrocortisone (otic) ciprofloxacin (ophth) ointment ciprofloxacin (ophth) solution citalopram... 2 citric acid, sodium citrate, & potassium citrate CLARAVIS clarithromycin... 4, 28 clarithromycin extended-release... 4 CLEOCIN... 4, 39 CLEOCIN HCL... 4 CLEOCIN PEDIATRIC... 4 CLEOCIN T clidinium & chlordiazepoxide CLIMARA DIS CLIMARA PRO CLINDAGEL clindamycin & benzoyl peroxide clindamycin & tretinoin Kaiser Permanente of Georgia Multi Choice Formulary 48

50 clindamycin hcl... 4 clindamycin palmitate... 4 clindamycin phosphate (topical) clindamyinc phosphate (vaginal) CLINORIL... 7 clobazam... 8 clobetasol propionate clobetasol propionate emollient clobetasol propionate emulsion CLOBEX clocortolone pivalate CLODERM clomipramine... 2 clonazepam... 8 clonidine... 3 clonidine extended-release... 3 clonidine transdermal... 3 clopidogrel... clorazepate clotrimazole clotrimazole & betametmethasone clozapine... 2 CLOZARIL... 2 codeine... 6, 38 CODEINE SULF... 6 COGENTIN... 9 COLAZAL COL-BENEMID colchicine... 24, 36 colchicine & probenecid COLCRYS colesevelam... 2 COLESTID... 2 colestipol... 2 collagenase COLYTE COMBIPATCH COMBIVENT RESPIMAT... COMBIVIR... 7 COMBUNOX... 7 COMPAZINE COMPLERA... 7 COMTAN CONCERTA... 8 CONDYLOX conjugated estrogens & bazedoxifene conjugated estrogens & medroxyprogesterone acetate COPAXONE CORDRAN COREG... 5 COREG CR... 5 Kaiser Permanente of Georgia Multi Choice Formulary CORGARD... 5 CORLANOR... 3 CORTEF CORTENEMA... 4 corticotropin CORTIFOAM... 4 cortisone acetate CORTISPORIN... 26, 40 CORTISPORIN-TC CORTONE ACETATE CORZIDE... 5 COSENTYX COSOPT COUMADIN... COVERA-HS... 3 COZAAR... 4 CREON CRESEMBA... 5 CRESTOR... 2 crisaborole CRIXIVAN... 7 crizotinib... 8 cromolyn sodium... 26, 38 cromolyn sodium (ophth) crotamiton CRYSELLE CUPRIMINE CUTIVATE... 4 CYCLESSA cyclobenzaprine... 0 cyclobenzaprine extended-release... 0 CYCLOCORT cyclophosphamide... 8 cycloserine... 6 CYCLOSET cyclosporine... 25, 36 cyclosporine (ophth) cyclosporine, modified CYMBALTA... 2 cyproheptadine... 4 CYSTAGON cysteamine cysteamine delayed-release cysteamine immediate-release CYTOMEL CYTOTEC CYTOVENE... 7 CYTOXAN... 8 CYTRA Kaiser Permanente of Georgia Multi Choice Formulary 49

51 D D.H.E dabigatran... daclatasvir... 6 daclizumab DAKLINZA... 6 dalfampridine DALIRESP DALMANE dalteparin... danazol DANOCRINE DANTRIUM... 0 dantrolene sodium... 0 dapagliflozin dapagliflozin & metformin dapsone... 6, 42 dapsone (topical) DARAPRIM... 6 darbepoetin alfa... 2 darifenacin darunavir & cobicistat... 6 darunavir ethanolate... 7 dasatinib... 8 DAYPRO... 7 DAYTRANA... 8 DDAVP DECADRON... 25, 29 DECLOMYCIN... 4 deferasirox deferiprone delavirdine mesylate... 7 DELESTROGEN DEMADEX demeclocycline... 4 DEMEROL... 7 DENAVIR DEPAKENE... 9 DEPAKOTE... 8, 9 DEPAKOTE ER... 9 DEPAKOTE SPRINKLE... 8 DEPEN DEPO-ESTRADIOL DEPO-TESTOSTERONE DERMA-SMOOTHE/FS OIL DERMATOP... 4 DERMOTIC DESCOVY... 7 desipramine... 2 desmopressin (non-refrigerated) desmopressin acetate Kaiser Permanente of Georgia Multi Choice Formulary DESOGEN desogestrel & ethinyl estradiol desogestrel & ethinyl estradiol (biphasic) desogestrel & ethinyl estradiol (triphasic) desonide DESOWEN desoximetasone DESOXYN... 8 desvenlafaxine... 2 desvenlafaxine base extended release... 2 desvenlafaxine succinate extended release... 2 DESYREL DETROL DETROL LA deutetrabenazine... 2 dexamethasone... 25, 26, 29 dexamethasone (ophth) solution dexamethasone (ophth) suspension DEXEDRINE... 8 dexmethylphenidate... 8 dexmethylphenidate extended-release... 8 dextroamphetamine sulfate... 8 dextroamphetamine sulfate extended-release... 8 dextromethorphan & quinidine... 2 DEXTROSTAT... 8 DIABETA DIAMOX... 26, 27 DIAMOX SEQUELS DIASTAT... 8 DIASTAT ACUDIAL... 8 diazepam... 8, 20 DIBENZYLINE... 0 dichlorphenamide diclofenac epolamine diclofenac potassium... 6 diclofenac sodium... 6, 25, 42 diclofenac sodium & misoprostol... 6 diclofenac sodium (actinic keratosis) diclofenac sodium (ophth) diclofenac sodium extended release... 6 dicloxacillin... 5 dicyclomine... 9 didanosine... 7 didanosine solution... 7 DIDRONEL difenoxin & atropine DIFFERIN DIFICID... 5 diflorasone diacetate DIFLUCAN... 5 diflunisal... 6 DIFLUNISAL... 6 Kaiser Permanente of Georgia Multi Choice Formulary 50

52 difluprednate digoxin... 3 dihydroergotamine mesylate... 0 DILANTIN... 9 DILAUDID... 6, 7 diltiazem... 3 diltiazem extended-release... 3 dimethyl fumarate DIOVAN... 5 DIOVAN HCT... 5 DIPENTUM diphenoxylate & atropine DIPROLENE DIPROSONE dipyridamole... DISALCID... 7 disopyramide... 3 disopyramide controlled-release... 3 disulfiram DITROPAN DITROPAN XL DIURIL divalproex sodium... 8, 9 divalproex sodium capsule... 8 divalproex sodium extended release... 9 DIVIGEL dofetilide... 3 dolasetron DOLOPHINE... 7 dolutegravir... 6, 7 donepezil... 0, 2 DONNATAL dornase alfa DORYX... 5 dorzolamide dorzolamide & timolol DOSTINEX DOVONEX doxazosin... 2 doxepin... 2, 4, 42 doxepin (antipuritic)... 4, 42 doxercalciferol doxycycline... 5, 42 doxycycline (rosacea) doxycycline hyclate... 5 doxycycline monohydrate... 5 DRISDOL DRITHOCREME HP... 4 DRITHO-SCALP... 4 dronabinol dronedarone... 3 drospirenone & estradiol Kaiser Permanente of Georgia Multi Choice Formulary drospirenone & ethinyl estradiol drospirenone & ethinyl estradiol w/ folate DROXIA... 9 droxidopa... DUAC DUAVEE DUETACT dulaglutide DULERA duloxetine... 2 DUONEB... dupilumab DUPIXENT DURAGESIC... 6 DUREZOL DURICEF... 4 dutasteride dutasteride & tamsulosin DYAZIDE DYMISTA DYNACIN... 5 DYNACIRC... 3 DYNACIRC CR... 3 DYNAPEN... 5 dyphylline DYRENIUM E E.E.S E.S.P... 5 econazole nitrate ecothiophate EDARBI... 4 EDECRIN EDLUAR edoxaban... EDURANT... 8 efavirenz... 7 efavirenz, emtricitab & tenofovir... 7 EFFEXOR EFFEXOR XR EFFIENT... efinaconazole... 5 EFUDEX ELAVIL... 2 elbasvir & grazoprevir... 7 ELDEPRYL ELESTAT ELESTRIN GEL eletriptan... 9 ELIDEL Kaiser Permanente of Georgia Multi Choice Formulary 5

53 eliglustat ELIMITE ELIPHOS ELIQUIS... ELLA ELMIRON ELOCON... 4 eltrombopag... 2 eluxadoline elvitegravir, cobicistat, emtricitabine, & tenofovir... 7 EMADINE EMCYT... 8 emedastine EMEND EMLA... 4 empagliflozin... 32, 33 empagliflozin & linagliptan empagliflozin & metformin EMSAM emtricitabine... 7 emtricitabine & tenofovir... 7 emtricitabine, rilpivirine, & tenofovir... 7 EMTRIVA... 7 ENABLEX enalapril... 4 enalapril & hydrochlorothiazide... 4 ENBREL enfuvirtide... 7 ENJUVIA enoxaparin... entacapone entecavir... 7 ENTOCORT EC ENTRESTO... 3 ENULOSE enzalutamide... 8 EPANOVA... 2 EPCLUSA... 8 epinastine (ophth) epinephrine... EPIPEN... EPIPEN JR... EPIVIR... 7 EPIVIR HBV... 7 eplerenone... 4 epoetin alfa... 2 EPOGEN... 2 eprosartan... 4 eprosartan & hydrochlorothiazide... 4 EPZICOM... 6 EQUETRO... 8 ergocalciferol Kaiser Permanente of Georgia Multi Choice Formulary ergoloid mesylates... 0 ergotamine & caffeine... 0, 9 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... 2 eslicarbazepine... 9 estazolam esterified estrogens ESTRACE CREAM ESTRACE TAB ESTRADERM estradiol... 30, 3, 32, 34, 35 estradiol & levonorgestrel estradiol & norethindrone estradiol & norgestimate estradiol acetate estradiol acetate vaginal tablets estradiol cypionate estradiol gel estradiol transdermal estradiol vaginal... 34, 35 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... 3 eszopiclone etanercept ethacrynic acid ethambutol... 6 ethontoin... 9 ethosuximide... 9 Kaiser Permanente of Georgia Multi Choice Formulary 52

54 ethynodiol diacetate & ethinyl estradiol etidronate etodolac... 6 etonogestrel & ethinyl estradiol etravirine... 7 EUCRISA EULEXIN... 8 EURAX everolimus... 8, 36 EVISTA EVOCLIN evolocumab Evolocumab EVOTAZ... 6 EVOXAC... 0 EXALGO... 7 EXELDERM EXELON... 0 exemestane... 8 exenatide exenatide extended-release... 32, 33 EXFORGE... 3 EXFORGE HCT... 3 EXJADE EXTAVIA ezetimibe... 2 ezetimibe & simvastatin... 2 ezogaine... 9 F FACTIVE... 5 famciclovir... 7 FAMVIR... 7 FANAPT FARXIGA FAZACLO... 2 febuxostat felbamate... 9 FELBATOL... 9 FELDENE... 7 felodipine... 3 FEMARA... 9 FEMCON FE... 3 FEMHRT FEMRING FEMTRACE fenofibrate... 2 fenofibrate, micronized... 2 fenofibric acid... 2 fenoprofen calcium... 6 fentanyl film... 6 Kaiser Permanente of Georgia Multi Choice Formulary fentanyl intranasal... 6 fentanyl lozenge... 6 fentanyl sublingual... 6 fentanyl tablet... 6 fentanyl transdermal... 6 FENTORA... 6 FERRIPROX fesoterodine FETZIMA fidaxomicin... 5 filgrastim... 2 FINACEA fingolimod FIORICET... 6 FIORICET W/ CODEINE... 6 FIORINAL... 6 FIORINAL W/ CODEINE... 6 FIRAZYR FLAGYL... 6 FLAGYL ER... 6 FLAREX flavoxate FLAVOXATE flecainide... 3 FLECTOR FLEXERIL... 0 FLOMAX... FLORINEF ACETATE FLOVENT DISKUS AER FLOVENT HFA FLOXIN fluconazole... 5 flucytosine... 5 fludrocortisone FLUMADINE... 8 fluocinolone acetonide... 25, 40 fluocinolone acetonide (otic) fluocinonide fluocinonide emollient FLUORABON BASIC FLUORITAB fluorometholone (ophth) fluorometholone acetate FLUOROPLEX fluorouracil (topical) fluoxetine... 2, 22 fluoxymesterone fluphenazine flurandrenolide flurazepam flurbiprofen... 6, 25 flurbiprofen (ophth) Kaiser Permanente of Georgia Multi Choice Formulary 53

55 flutamide... 8 fluticasone & salmeterol fluticasone & salmeterol (00/50 mcg) fluticasone & salmeterol (250/50 mcg and 500/50 mcg) fluticasone & vilanterol fluticasone propionate... 38, 4 fluticasone propionate (topical)... 4 fluvastatin... 2 fluvastatin extended-release... 2 fluvoxamine FML FML FORTE FOCALIN... 8 FOCALIN XR... 8 fondaparinux... FORADIL... formoterol fumarate... FORTAMET FORTEO FORTESTA FORTICAL FOSAMAX FOSAMAX PLUS D fosamprenavir calcium... 7 fosinopril... 4 fosinopril & hydrochlorothiazide... 4 FOSRENOL FRAGMIN... FREESTYLE SYSTEM FREESTYLE TEST STRIPS FROVA... 9 frovatriptan... 9 FURADANTIN... 8 furosemide FUZEON... 7 FYCOMPA... 9 G gabapentin... 9 GABITRIL... 9 galantamine hydrobromide... 0 ganciclovir... 7, 24 ganciclovir (ophth) GARAMYCIN... 5, 39 GASTROCROM gatifloxacin (ophth) GATTEX GAVILYTE-C GEL-KAM gemfibrozil... 2 gemifloxacin... 5 Kaiser Permanente of Georgia Multi Choice Formulary GENERESS FE GENTAK gentamicin & prednisolone gentamicin (ophth) gentamicin sulfate... 5, 39 gentamicin sulfate (topical) GENTROPIN GENVOYA... 7 GEODON GIANVI GIAZO GILENYA glatiramer acetate GLATOPA GLEEVEC... 9 glimepiride... 33, 34 glipizide glipizide & metformin glipizide extended-release GLUCAGEN HYPOKIT glucagon GLUCAGON EMERGENCY KIT GLUCOPHAGE... 33, 34 GLUCOPHAGE XR GLUCOTROL GLUCOTROL XL GLUCOVANCE GLUMETZA glyburide glyburide & metformin glyburide micronized glycerol phenylbutyrate glycopyrrolate... 9, 38 glycopyrrolate & indacaterol glycopyrrolate inhalation pow... 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... 4, 2 guanfacine extended-release... 2 GYNAZOLE Kaiser Permanente of Georgia Multi Choice Formulary 54

56 GYNODIOL H HAEGARDA halcinonide... 4 HALCION HALDOL HALFLYTELY halobetasol propionate... 4 HALOG... 4 haloperidol HARVONI... 7 HARVONI... 7 HECTOROL HELIDAC... 4 heparin... HEPARIN SODIUM... HEPSERA... 6 HETLIOZ hexachlorophene HIPREX... 8 homatropine... 27, 38 HUMALOG HUMALOG MIX 50/ HUMALOG MIX 75/ HUMATIN... 6 HUMATROPE HUMIRA HUMULIN 50/ HUMULIN 70/ HUMULIN N HUMULIN R HYCAMTIN... 9 HYCODAN HYDERGINE... 0 hydralazine... 4, 5 HYDREA... 9 hydrochlorothiazide... 3, 4, 5, 23, 24 hydrocodone... 6, 7, 38 hydrocodone & acetaminophen... 7 hydrocodone & chlorpheniramine hydrocodone & homatropine hydrocodone & ibuprofen... 7 hydrocodone er... 7 hydrocortisone... 25, 26, 29, 39, 40, 4 hydrocortisone & acetic acid (otic) hydrocortisone & pramoxine... 4 hydrocortisone (intrarectal)... 4 hydrocortisone (rectal)... 4 hydrocortisone (topical)... 4 hydrocortisone acetate & urea... 4 Kaiser Permanente of Georgia Multi Choice Formulary hydrocortisone acetate (intrarectal)... 4 hydrocortisone butyrate... 4 hydrocortisone butyrate hydrophilic lipo base... 4 hydrocortisone probutate... 4 hydrocortisone valerate... 4 hydromorphone oral suspension... 6, 7 hydromorphone tablet... 7 hydroxychloroquine sulfate... 6 hydroxyurea... 9 hydroxyzine hcl hydroxyzine pamoate HYGROTON hyoscyamine sulfate... 9, 0 HYPERCARE... 4 HYPERSAL HYQVIA HYSINGLA ER... 7 HYTONE... 4 HYTRIN... 2 HYZAAR... 4 I ibandronate IBRANCE... 9 ibrutinib... 9 ibuprofen... 7 icatibant ICLUSIG... 9 ILARIS iloperidone imatinib mesylate... 9 IMBRUVICA... 9 IMDUR... 5 imipramine imipramine pamoate imiquimod IMITREX... 9 immune globulin IMPAVIDO... 6 IMURAN INCIVEK... 8 INCRUSE ELLIPTA... 0 indapamide INDERAL... 6 INDERAL LA... 6 INDERIDE... 5 indinavir sulfate... 7 INDOCIN... 7 indomethacin... 7 INFERGEN... 7 INFLAMASE FORTE Kaiser Permanente of Georgia Multi Choice Formulary 55

57 ingenol mebutate INGREZZA... 2 INLYTA... 8 INNOPRAN XL... 6 INSPRA... 4 insulin (oral inhalation) insulin aspart insulin aspart protamine & insulin aspart insulin degludec Insulin degludec/ liraglutide insulin degludec/insulin aspart insulin detemir insulin glargine insulin glargine,hum.rec.anlog Insulin glargine/ lixisenatide insulin glulisine insulin isophane insulin isophane & regular insulin insulin lispro insulin lispro protamine & insulin lispro insulin regular INTAL INTELENCE... 7 interferon alfacon interferon beta-a... 36, 37 interferon beta-b Interferon beta-b interferon gamma-b INTROVALE... 3 INTUNIV... 2 INVEGA INVIRASE... 8 INVOKAMET INVOKANA iodoquinol & hydrocortisone IOPIDINE ipratropium bromide... 0 irbesartan... 4 irbesartan & hydrochlorothiazide... 4 isavuconazonium... 5 ISENTRESS... 7 ISENTRESS HD... 7 isocarboxazid isoniazid... 6 ISOPTIN SR... 3 ISOPTO ATROPINE ISOPTO CARBACHOL ISOPTO CARPINE ISOPTO HOMATROPINE ISOPTO HYOSCINE ISORDIL... 5 isosorbide dinitrate... 5 Kaiser Permanente of Georgia Multi Choice Formulary isosorbide dinitrate & hydralazine... 5 isosorbide mononitrate... 5 isotretinoin isradipine... 3 ISTALOL itraconazole... 5 itraconazole (solution)... 5 Ivabradine... 3 ivacaftor ivermectin... 4 ixazomib... 9 ixekizumab J JAKAFI... 9 JALYN JANUMET JANUVIA JARDIANCE JENTADUETO JUBLIA... 5 JUNEL... 3, 32 JUNEL FE JUVISYNC JUXTAPID... 2 K KADIAN... 7 KALETRA... 7 KALYDECO KAON KAPVAY... 3 KARIVA KAZANO K-DUR KEFLEX... 4 KELNOR KENALOG... 4 KEPPRA... 9 KEPPRA XR... 9 KERLONE... 5 KERYDIN... 6 KETEK... 5 ketoconazole... 5, 39 ketoconazole (topical) ketoprofen... 7 KETOPROFEN... 7 ketorolac (ophth) ketorolac tablet... 7 KEVEYIS KINERET Kaiser Permanente of Georgia Multi Choice Formulary 56

58 KLARON KLONOPIN... 8 KLOR-CON 20 MEQ K-LYTE/CL KOMBIGLYZE XR KORLYM K-PHOS NEUTRAL K-PHOS ORIGINAL KRISTALOSE K-TAB KUVAN KWELL KYNAMRO... 2 KYTRIL L labetalol... 5 LAC-HYDRIN lacosamide... 9 LACRISERT lactic acid (ammonium lactate) LACTINOL lactulose LAMICTAL... 9 LAMICTAL XR... 9 LAMISIL... 6 lamivudine... 6, 7 lamivudine & zidovudine... 6, 7 lamotrigine... 9 lamotrigine extended-release... 9 LANOXIN... 3 lanreotide lanthanum carbonate LANTUS LANTUS, BASAGLAR lapatinib... 9 LARIAM... 6 LASIX LASTACAFT latanoprost LATUDA LAZANDA... 6 ledipasvir & sofosbuvir... 7 ledipasvir & sofosbuvir... 7 LEENA... 3 leflunomide lenalidomide... 9 lenvatinib... 9 LENVIMA... 9 LESCOL... 2 LESCOL XL... 2 Kaiser Permanente of Georgia Multi Choice Formulary lesinurad LESSINA LETAIRIS... 5 letrozole... 9 leucovorin LEUCOVORIN LEUKERAN... 8 LEUKINE... 2 leuprolide acetate... 9 levalbuterol nebulizer solution... levalbuterol tartrate... LEVAQUIN... 5 LEVATOL... 5 LEVBID... 9 LEVEMIR levetiracetam... 9 levetiracetam extended-release... 9 levobunolol LEVO-DROMORAN... 7 levofloxacin... 5, 24 levofloxacin (ophth) levomilnacipran levonorgestrel... 30, 3, 34 levonorgestrel & ethinyl estradiol... 30, 3 levonorgestrel & ethinyl estradiol (9-day)... 3 levonorgestrel & ethinyl estradiol (continuous)... 3 levonorgestrel & ethinyl estradiol (triphasic)... 3 LEVORA... 3 levorphanol... 7 LEVOTHROID levothyroxine LEVOXYL LEVSIN... 9 LEXAPRO... 2 LEXIVA... 7 LIALDA LIBRAX LIBRIUM LIDAMANTLE... 4 LIDEX LIDEX-E lidocaine... 27, 4 lidocaine & hydrocortisone... 4 lidocaine & prilocaine... 4 lidocaine (Jelly, oral solution)... 4 lidocaine (Jelly, topical)... 4 lidocaine (mouth-throat) lifitegrast LIMBITROL DS... 2 linaclotide linagliptin linagliptin & metformin Kaiser Permanente of Georgia Multi Choice Formulary 57

59 lindane linezolid... 5 LINZESS LIORESAL... 0 liothyronine liotrix LIPITOR... 2 liraglutide lisdexamfetamine... 8 lisinopril... 4 lisinopril & hydrochlorothiazide... 4 LITHIUM CARBONATE lithium carbonate capsule lithium carbonate extended release lithium citrate LITHOBID LIVALO... 2 lixisenatide LO LOESTRIN FE LO/OVRAL LOCOID... 4 LOCOID LIPOCREAM... 4 LODINE... 6 LODOSYN lodoxamide tromethamine LOESTRIN 24 FE LOESTRIN FE LOFIBRA CAP... 2 LOFIBRA TAB... 2 lomitapide... 2 LOMOTIL lomustine... 9 LONITEN... 4 LOPID... 2 lopinavir & ritonavir... 7 LOPRESSOR... 5 LOPRESSOR HCT... 5 LOPROX lorazepam losartan... 4 losartan & hydrochlorothiazide... 4 LOSEASONIQUE... 3 LOTEMAX LOTENSIN... 4 LOTENSIN HCT... 4 loteprednol loteprednol & tobramycin LOTREL... 2 LOTRISONE LOTRONEX lovastatin... 2 lovastatine extended-release... 2 Kaiser Permanente of Georgia Multi Choice Formulary LOVAZA... 2 LOVENOX... LOW-OGESTREL loxapine LOXITANE LOZOL lubiprostone LUDIOMIL LUFYLLIN luliconazole... 6 lumacaftor& ivacaftor LUMIGAN LUNESTA LUPRON... 9 lurasidone LURIDE CHEW LURIDE DROPS LUVOX LUXIQ LUZU... 6 LYPREL... 3 LYRICA... 9 LYSODREN... 9 M macitentan... 5 MACROBID... 8 MACRODANTIN... 8 mafenide acetate MALARONE... 6 malathion maprotiline maraviroc... 7 MARINOL MARPLAN MATULANE... 9 MAVIK... 5 MAXAIR AUTOHALER... MAXALT... 9 MAXALT MLT... 9 MAXIDEX MAXITROL MAXZIDE mechlorethamine... 9 mechlorethamine... 9 meclofenamate... 7 MECLOMEN... 7 MEDROL medroxyprogesterone acetate... 34, 35 mefenamic acid... 7 mefloquine... 6 Kaiser Permanente of Georgia Multi Choice Formulary 58

60 MEGACE megestrol acetate MELLARIL meloxicam... 7 melphalan... 9 memantine... 2 memantine er & donepezil... 2 M-END MAX D MENEST MENOSTAR MENTAX meperidine tablet... 7 MEPHYTON mepolizumab meprobamate MEPRON... 6 mercaptopurine... 9 mesalamine controlled-release mesalamine suppository mesalamine suspension mesalamine tablet mesna MESNEX MESTION... 0 MESTION TIMESPAN... 0 METADATE CD... 8 METADATE ER... 8 METAGLIP metaxalone... 0 metformin... 32, 33, 34 metformin extended-release methadone... 7 methamphetamine... 8 methazolamide methenamine hippurate... 8 methenamine, sodium biphosphate, phenyl salicylate, methylene blue, and hyoscyamine... 8, 37 METHERGINE methimazole METHITEST methocarbamol... 0 methotrexate... 9 methotrexate sodium... 9 methoxsalen methoxsalen, rapid methscopolamine... 0 methsuximide... 9 methyldopa... 4 methyldopa & hydrochlorothiazide... 4 methylergonovine maleate METHYLIN... 8 methylphenidate... 8 Kaiser Permanente of Georgia Multi Choice Formulary methylphenidate extended-release... 8 methylphenidate sustained release... 8 methylphenidate transdermal patch... 8 methylprednisolone methyltestosterone metipranolol metoclopramide metolazone metoprol & hydrochlorothiazide... 5 metoprolol succinate... 5 metoprolol tartrate... 5 metreleptin METROCREAM METROGEL METROGEL-VAGINAL METROLOTION metronidazole... 4, 6, 39 metronidazole (topical) metronidazole (vaginal) metronidazole, tetracycline & bismuth subsalicylate... 4 metronidazoleextended-release... 6 MEVACOR... 2 mexiletine... 3 MEXITIL... 3 MIACALCIN MICARDIS... 5 MICARDIS HCT... 5 miconazole nitrate & zinc oxide MICROGESTIN... 3, 32 MICROGESTIN FE MICROZIDE MIDAMOR midodrine hcl... MIFEPREX mifepristone... 34, 37 MIGERGOT... 9 miglitol miglustat MIGRANAL... 0 milnacipran... 2 miltefosine... 6 MILTOWN MINIPRESS... 2 MINOCIN... 5 minocycline... 5 minoxidil... 4 mipomersen sodium... 2 mirabegron MIRAPEX MIRAPEX ER mirtazapine MIRVASO Kaiser Permanente of Georgia Multi Choice Formulary 59

61 misoprostol... 6, 28 mitotane... 9 MOBIC... 7 modafinil... 8 MODICON... 3 MODURETIC moexipril... 4 moexipril & hydrochlorothiazide... 4 mometasone & formoterol mometasone furoate... 38, 4 MONODOX... 5 MONONESSA MONOPRIL... 4 MONOPRIL HCT... 4 montelukast morphine... 7 morphine beads... 7 morphine extended-relase capsule... 7 morphine extended-release tablet... 7 MORPHINE SULFATE... 7 MOTOFEN MOTRIN... 7 MOVIPREP moxifloxacin... 5, 24 moxifloxacin (ophth) MOZOBIL MS CONTIN... 7 MSIR... 7 MUCOMYST MULTAQ... 3 mupirocin mupirocin calcium MYALEPT MYAMBUTOL... 6 MYCELEX MYCIFRADIN... 5 MYCOBUTIN... 6 MYCOLOG II... 4 mycophenolate mofetil mycophenolate sodium MYCOSTATIN... 6 MYFORTIC MYLERAN... 8 MYRBETRIQ MYSOLINE... 9 N na sulfacetm/avobenzone/sulfur nabumetone... 7 nadolol... 5 nadolol & bendroflumethiazide... 5 Kaiser Permanente of Georgia Multi Choice Formulary nafarelin naftifine NAFTIN nalbuphine... 7 NALFON... 6 naloxone... 6, 7, 2 naloxone nasal spray... 2 naltrexone... 2 NAMENDA... 2 NAMZARIC... 2 NAPRELAN... 7 NAPROSYN... 7 naproxen... 7 naproxen sodium... 7 naratriptan... 9 NARCAN... 2 NARDIL NATACYN natamycin NATAZIA nateglinide NATPARA NATROBA NAVANE nebivolol... 5 NECON... 3 NECON 0/... 3 nedocromil sodium (ophth) nefazodone nelfinavir mesylate... 7 neomycin sulfate... 5 neomycin, bacitracin & polymyxin b (ophth) neomycin, colistin, hydrocortisone & thonzonium (otic).. 26 neomycin, polymycin b & gramicidin (ophth) neomycin, polymyxin B & dexamethasone (ophth) neomycin, polymyxin B & hydrocortisone (ophth)... 25, 26 neomycin, polymyxin B & hydrocortisone (otic) NEO-POLYCIN NEO-POLYCIN HC NEORAL NEOSPORIN neostigmine bromide... 0 nepafenac NEPTAZANE NESINA netupitant & palonosetron NEULASTA... 2 NEUMEGA... 2 NEUPOGEN... 2 NEUPRO NEURONTIN... 9 NEVANAC Kaiser Permanente of Georgia Multi Choice Formulary 60

62 nevirapine solution... 7 nevirapine tablet... 7 NEXAVAR... 9 niacin... 2, 43 niacin & lovastatin... 2 NIACOR NIASPAN... 2 nicardipine... 3 nifedipine... 3 nifedipine extended-release... 3 nilotinib... 9 nimodipine... 3 NIMOTOP... 3 NINLARO... 9 nintedanib NIRAVAM nisoldipine... 3 nitazoxanide... 6 nitisinone NITRO-BID... 5 NITRO-DUR... 5 nitrofurantoin... 8 nitrofurantoin macrocrystal... 8 nitrofurantoin monohydrate... 8 nitroglycerin aerosol... 5 nitroglycerin solution... 5 nitroglycerin subligual... 5 nitroglycerin topical ointment... 5 nitroglycerin transdermal patch... 5 NITROLINGUAL... 5 NITROMIST... 5 NITROSTAT... 5 nizatidine NIZORAL... 5, 39 NOLVADEX... 9 NORA-BE... 3 NORCO... 7 NORDETTE NORDITROPIN norelgestromin & ethinyl estradiol... 3 norethindrone... 3, 32, 34, 35 norethindrone & ethinyl estradiol... 3, 32 norethindrone & ethinyl estradiol (biphasic)... 3 norethindrone & ethinyl estradiol (triphasic)... 3 norethindrone & ethinyl estradiol w/ ferrous fumarate... 3, 32 norethindrone acetate... 32, 35 norethindrone acetate & ethinyl estradiol... 32, 35 norethindrone acetate & ethinyl estradiol w/ ferrous fumarate norethindrone acetate & ethinyl estradiol w/ ferrous fumarate (biphasic) Kaiser Permanente of Georgia Multi Choice Formulary norethindrone-mestranol NORFLEX... 0 norfloxacin... 5 NORGESIC... 0 norgestimate & ethinyl estradiol norgestimate & ethinyl estradiol (triphasic) norgestrel & ethinyl estradiol NORINYL NORINYL NOROXIN... 5 NORPACE... 3 NORPACE CR... 3 NORPRAMIN... 2 NOR-QD... 3 NORTHERA... NORTREL... 3 NORTREL / NORTREL 7/7/ nortriptyline NORVASC... 2 NORVIR... 8 NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG MIX 70/ NOXAFIL... 6 NUBAIN... 7 NUCALA NUCYNTA... 7 NUEDEXTA... 2 NULYTELY NUPLAZID NUTROPIN AQ NUVARING NUVIGIL... 8 NYDRAZID... 6 nystatin... 6, 40, 4 NYSTATIN nystatin & triamcinolone... 4 nystatin (topical) O OCELLA octreotide acetate OCUFEN OCUFLOX OCUPRESS ODEFSEY... 7 OFEV ofloxacin (ophth) Kaiser Permanente of Georgia Multi Choice Formulary 6

63 ofloxacin (otic) OGESTREL olanzapine olanzapine & fluoxetine hcl olanzapine orally disintegrating OLEPTRO olmesartan... 3, 4 olmesartn & hydrochlorothiazide... 4 olodaterol..., 39 olopatadine olopatadine (nasal) olopatadine (ophth) olsalazine OLUX-E OLYSIO... 8 omalizumab ombitasvir, paritaprevir & ritonavir... 7 ombitasvir, paritaprevir, ritonavir, & dasabuvir... 7 omega-3 acid ethyl esters... 2 omega-3-carboxylic acid... 2 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... 8 ONGLYZA ONSOLIS... 6 OPANA... 7 OPANA ER... 7 OPIUM... 7 opium & belladonna alkaloids... 7 opium tincture... 7 oprelvekin... 2 OPSUMIT... 5 OPTHETIC OPTICROM OPTIPRANOLOL OPTIVAR ORACEA... 5, 42 ORALAIR ORALAIR ORAP ORAPRED ORAPRED ODT ORENCIA Kaiser Permanente of Georgia Multi Choice Formulary ORENITRAM... 5 ORFADIN ORINASE ORKAMBI orphenadrine citrate... 0 orphenadrine, aspirin, & caffeine... 0 ORTHO EVRA... 3 ORTHO TRI-CYCLEN ORTHO TRI-CYCLEN LO ORTHO-CEPT ORTHO-CYCLEN ORTHO-EST ORTHO-NOVUM... 3, 32 oseltamivir phosphate... 7 OSENI OSMOPREP ospemifene OSPHENA OTEZLA OTREXUP... 9 OVCON OVCON OVIDE OXANDRIN oxandrolone oxaprozin... 7 oxazepam oxcarbazepine... 9 oxiconazole nitrate OXISTAT OXSORALEN-ULTRA oxybutynin... 42, 43 oxybutynin extended-release oxybutynin transdermal oxycodone... 7 oxycodone & acetaminophen... 7 oxycodone & acetaminophen er... 7 oxycodone & aspirin... 7 oxycodone & ibuprofen... 7 oxycodone controlled-release... 7 OXYCONTIN... 7 oxymorphone... 7 oxymorphone extended-release... 7 OXYTROL P PACERONE... 3 palbociclib... 9 PALGIC... 4 paliperidone palivizumab... 7 Kaiser Permanente of Georgia Multi Choice Formulary 62

64 PAMELOR PAMINE... 0 PANCREAZE pancrelipase (lipase-protease-amylase) PANDEL... 4 PANLOR SS... 6 PANRETIN papaverine... 5 PARAFON FORTE DSC... 0 parathyroid hormone PARCOPA paregoric PAREGORIC paricalcitol PARLODEL... 9 PARNATE paromomycin sulfate... 6 paroxetine paroxetine extended-release paroxetine mesylate pasireotide PATADAY PATANASE PATANOL patiromer PAVABID... 5 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... 9 PEGASYS... 7 pegfilgrastim... 2 peginterferon alfa-2a... 7 peginterferon-alfa 2b... 7 PEG-INTRON... 7 pegvisomant penbutolol... 5 penciclovir penicillamine penicillin v potassium... 5 PENLAC PENNSAID... 6 PENTASA pentazocine & naloxone... 7 pentosan polysulfate sodium pentoxifylline... PEN-VEE K... 5 Kaiser Permanente of Georgia Multi Choice Formulary perampanel... 9 PERCOCET... 7 PERCODAN... 7 PERIACTIN... 4 PERIDEX perindopril... 4 PERIOSTAT... 5 permethrin perphenazine... 2, 22 PERSANTINE... PERTZYE PEXEVA phenelzine PHENERGAN... 4, 38 PHENERGAN VC... 4, 38 PHENERGAN VC W/CODEINE PHENERGAN W/ CODEINE phenobarbital... 20, 29 PHENOBARBITAL phenobarbital and belladonna alkaloids phenoxybenzamine... 0 PHENYTEK... 9 phenytoin sodium extended-release... 9 phenytoin suspension... 9 PHISOHEX PHOSLO PHOSLYRA PHOSPHA PHOSPHOLINE IODIDE PHRENILIN... 6 PHRENILIN FORTE... 6 phytonadione PICATO pilocarpine... 0, 27 pilocarpine gel PILOPINE HS pimavanserin pimecrolimus pimozide pindolol... 5 pioglitazone... 32, 34 pioglitazone & glimepiride pioglitazone & metformin pirbuterol acetate... pirfenidone piroxicam... 7 pitavastatin... 2 PLAN B PLAQUENIL... 6 PLAVIX... PLEGRIDY PLENDIL... 3 Kaiser Permanente of Georgia Multi Choice Formulary 63

65 plerixafor PLETAL... PLEXION... 4 PLEXION SCT... 4 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... 7 posaconazole... 6 potassium bicarbonate & potassium chloride potassium chloride potassium chrloide powder potassium citrate potassium citrate & citric acid potassium gluconate potassium phosphate potassium phosphate, monobasic POTIGA... 9 PRADAXA... PRALUENT pramipexole pramipexole extended-release pramlintide acetate PRAMOSONE... 4 PRAMOSONE-E... 4 pramoxine... 4 PRANDIMET PRANDIN prasugrel... PRAVACHOL... 2 pravastatin... 2 prazosin... 2 PRECOSE PRED FORTE PRED MILD PRED-G prednicarbate... 4 PREDNISOL prednisolone... 25, 26, 29, 30 PREDNISOLONE prednisolone acetate... 26, 29 prednisolone acetate (ophth) prednisolone sodium phosphate... 26, 29, 30 Kaiser Permanente of Georgia Multi Choice Formulary prednisolone sodium phosphate (ophth) prednisone PREDNISONE PREFEST pregabalin... 9 PRELONE PREMARIN PREMARIN CREAM PREMPHASE PREMPRO PREVIDENT PREVIDENT 5000 PLUS PREVPAC PREZCOBIX... 6 PREZISTA... 7 PRIFTIN... 6 PRIMAQUINE... 6 primaquine phosphate... 6 primidone... 9 PRISTIQ... 2 PROAIR HFA... PROAMATINE... PRO-BANTHINE... 0 probenecid procarbazine... 9 PROCARDIA... 3 PROCARDIA XL... 3 prochlorperazine PROCRIT... 2 PROCTOCORT... 4 PROCTOFOAM... 4 PROCTOFOAM-HC... 4 PROCYSBI PRODIGY PRODIGY TEST STRIPS progesterone, micronized PROGRAF PROLIXIN PROLOPRIM... 8 PROMACTA... 2 promethazine... 4, 38 promethazine & codeine promethazine & dextromethorphan promethazine & phenylephrine... 4 promethazine, phenylephrine & codeine PROMETHAZINE-DM PROMETRIUM propafenone... 3 propantheline bromide... 0 proparacaine propranolol... 5, 6 propranolol & hydrochlorothiazide... 5 Kaiser Permanente of Georgia Multi Choice Formulary 64

66 propranolol extended-release... 6 propranolol sustained-release... 6 propylthiouracil PROPYLTHIOURACIL PROSOM PROSTIGMIN... 0 PROTOPIC protriptyline PROVENTIL HFA... PROVERA PROVIGIL... 8 PROZAC... 2 PROZAC WEEKLY... 2 PRUDOXIN pseudoephedrine, brompheniramine & codeine PSORIATEC... 4 PULMICORT FLEXHALER PULMICORT RESPULES PULMOZYME PURINETHOL... 9 PYLERA... 4 pyrazinamide... 6 PYRAZINAMIDE... 6 pyridostigmine... 0 pyrimethamine... 6 Q QUALAQUIN... 6 QUESTRAN... 2 QUESTRAN LIGHT... 2 quetiapine quetiapine extended-release QUINAGLUTE... 3 quinapril & hydrochlorothiazide... 4 quinapril hcl... 4 quinidine... 3, 2 quinidine gluconate... 3 QUINIDINE SULFATE... 3 quinine sulfate... 6 QUIXIN QVAR R RAGWITEK RAGWITEK raloxifene hcl raltegravir... 7 raltegravir (600mg)... 7 ramelteon ramipril... 4 RANEXA... 3 Kaiser Permanente of Georgia Multi Choice Formulary ranitidine ranolazine... 3 RAPAFLO... 0 RAPAMUNE rasagiline RASUVO... 9 RAVICTI RAYOS RAZADYNE... 0 RAZADYNEER... 0 REBETOL... 7 REBIF REBIF REBIDOSE RECLIPSEN REGLAN REGRANEX RELAFEN... 7 RELENZA... 8 RELPAX... 9 REMERON REMODULIN... 5 RENAGEL RENVELA repaglinide repaglinide & metformin REPATHA REQUIP REQUIP XL RESCRIPTOR... 7 RESCULA reserpine... 4 RESTASIS RESTORIL retapamulin RETIN-A... 4 RETIN-A MICRO... 4 RETROVIR... 8 REVATIO... 5 REVIA... 2 REVLIMID... 9 REXULTI... 2 REYATAZ... 6 RHEUMATREX... 9 ribavirin... 7 RIDAURA rifabutin... 6 RIFADIN... 6 RIFAMATE... 6 rifampin... 6 rifampin & isoniazid... 6 rifapentine... 6 rifaximin... 5 Kaiser Permanente of Georgia Multi Choice Formulary 65

67 rilpivirine... 7, 8 RILUTEK... 2 riluzole... 2 rimantadine... 8 rimexolone riociguat... 5 RIOMET risedronate sodium RISPERDAL RISPERDALM-TAB risperidone risperidone orally disintegrating RITALIN... 8 RITALIN LA... 8 RITALIN SR... 8 ritonavir... 7, 8 rivaroxaban... rivastigmine tartrate... 0 rivastigmine tartrate (solution)... 0 rizatriptan... 9 rizatriptan orally disentigrating... 9 ROBAXIN... 0 ROBINUL... 9 ROBINULFORTE... 9 ROCALTROL roflumilast rolapitant ROMYCIN ropinirole ropinirole extended-release ROSAC ROSULA... 4 rosuvastatin... 2 rotigotine ROWASA ROXICET... 7 ROXICODONE... 7 ROZEREM rufinamide... 9 ruxolitinib... 9 RYTHMOL... 3 RYTHMOL SR... 3 RYZODEG 70/ S SABRIL... 9 sacubitril & valsartan... 3 SAFYRAL SAIZEN SALAGEN... 0 salmeterol... 38, 39 Kaiser Permanente of Georgia Multi Choice Formulary salsalate... 7 SAMSCA SANCTURA SANCTURA XR SANCUSO SANDIMMUNE SANDOSTATIN SANTYL SAPHRIS... 2 sapropterin dihydrochlorid saquinavir mesylate... 8 SARAFEM... 2 sargramostim... 2 SAVAYSA... SAVELLA... 2 saxagliptin saxagliptin & metformin extended-release scopolamine (ophth) scopolamine hydrobromide SEASONALE... 3 SEASONIQUE... 3 SEB-PREV SECTRAL... 5 secukinumab SEEBRI NEOHALER... 9 selegiline selegiline transdermal selenium sulfide SELSEB SELSUN RX SELZENTRY... 7 SENSIPAR SEPTRA... 5 SERAX SEREVENT DISKUS SEROMYCIN... 6 SEROQUEL SEROQUEL XR SEROSTIM SERPASIL... 4 sertaconazole nitrate sertraline SERZONE sevelamer carbonate sevelamer hcl short ragweed pollen allergen extract short ragweed pollen allergen extract SIGNIFOR sildenafil... 5 silodosin... 0 SILVADENE silver sulfadiazine Kaiser Permanente of Georgia Multi Choice Formulary 66

68 simeprevir... 8 SIMPONI simvastatin... 2, 34 sinecatechins SINEMET SINEMET CR SINEQUAN... 2 SINGULAIR sirolimus SIRTURO sitagliptin & metformin sitagliptin & simvastatin sitagliptin phosphate SIVEXTRO... 5 SKELAXIN... 0 sodium chloride sodium citrate & citric acid sodium fluoride... 37, 38 sodium fluoride (dental) sodium fluoride drops sodium oxybate... 2 sodium phenylbutyrate sodium phosphates sodium polystyrene sulfonate sofosbuvir... 7, 8 sofosbuvir & velpatasvir... 8 sofusbuvir... 8 SOLARAZE solifenacin SOLIQUA SOLODYN... 5 SOMA... 0, 6 SOMA COMPOUND... 0, 6 SOMA COMPOUND W/ CODEINE... 6 somatropin SOMATULINE DEPOT SOMAVERT SONATA SOOLANTRA... 4 sorafenib tosylate... 9 SORIATANE... 4 SORILUX sotalol... 6 SOVALDI... 8 SPECTAZOLE SPECTRACEF... 4 spinosad SPIRIVA... 0 SPIRIVA RESPIMAT... 0 SPIRIVA RESPIMAT... 0 SPIRIVA RESPIMAT... 0 spironolactone... 4 Kaiser Permanente of Georgia Multi Choice Formulary spironolactone & hydrochlorothiazide... 4 SPORANOX... 5 SPRINTEC SPRYCEL... 8 SPS STADOL... 6 STALEVO stannous fluoride STARLIX stavudine... 8 STELARA STELAZINE STIMATE STIOLTO RESPIMAT STRATTERA... 2 STRIBILD... 7 STRIVERDI RESPIMAT... STROMECTOL... 4 SUBOXONE... 6 SUBUTEX... 6 succimer sucralfate sucralfate suspension sucralfate tablets sucroferric oxyhydroxide SULAR... 3 sulconazole nitrate SULFAC sulfacetamide sodium & prednisolone sulfacetamide sodium & sulfur... 4 sulfacetamide sodium (acne) sulfacetamide sodium (ophth) ointment sulfacetamide sodium (ophth) solution sulfadiazine... 5, 40 SULFADIAZINE... 5 sulfamethoxazole & trimethoprim... 5 SULFAMYLON sulfanilamide sulfasalazine... 5 sulindac... 7 sumatriptan... 9 sunitinib malate... 9 SUPRAX... 4 SURMONTIL SUSTIVA... 7 SUTENT... 9 suvorexant SYMAX... 9, 0 SYMAX DUOTAB... 0 SYMBICORT SYMBYAX SYMLIN Kaiser Permanente of Georgia Multi Choice Formulary 67

69 SYMMETREL... 9 SYNAGIS... 7 SYNALAR SYNAREL SYNJARDY SYNTHROID SYPRINE syringe with needle,disposable T TABLOID... 9 TACLONEX tacrolimus... 38, 42 tacrolimus (topical) tadalafil... 5 TAGAMET TALTZ TALWIN NX... 7 TAMBOCOR... 3 TAMIFLU... 7 tamoxifen citrate... 9 tamsulosin hcl... TANZEUM TAPAZOLE tapentadol... 7 TARCEVA... 8 TARGRETIN... 8, 42 TARKA... 3 TASIGNA... 9 tasimelteon TASMAR tavaborole... 6 tazarotene TAZORAC TECFIDERA TECHNIVIE... 7 tedizolid... 5 teduglutide TEGRETOL... 8 TEGRETOL XR... 8 TEKAMLO... 4 TEKTURNA... 4 TEKTURNA HCT... 4 telaprevir... 8 telithromycin... 5 telmisartan... 5 telmisartan & hydrochlorothiazide... 5 temazepam TEMODAR... 9 TEMOVATE TEMOVATE E Kaiser Permanente of Georgia Multi Choice Formulary temozolomide... 9 TENEX... 4 tenofovir... 7, 8 TENORETIC... 5 TENORMIN... 5 TERAZOL TERAZOL terazosin... 2 terbinafine... 6 terbutaline sulfate... terconazole terconazole (vaginal) teriflunomide teriparatide TESSALON PERLES TESTIM testosterone... 30, 35 testosterone cypionate TESTRED tetrabenazine... 2 tetracycline... 4, 5 TETRACYCLINE... 5 tetrahydrozoline TEVETEN... 4 thalidomide THALOMID theophylline thioguanine... 9 thioridazine thiothixene THORAZINE... 2 thyroid THYROLAR tiagabine... 9 TIAZAC... 3 ticagrelor... TICLID... ticlopidine... TIGAN TIKOSYN... 3 TILIA timolol... 6, 27 TIMOPTIC TIMOPTIC-XE timothy grass pollen allergen extract timothy grass pollen allergen extract tiotropium... 0, 39 tiotropium bromide and olodaterol tipranavir... 8 TIROSINT TIVICAY... 7 tizanidine... 0 Kaiser Permanente of Georgia Multi Choice Formulary 68

70 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... 7 tolterodine tolterodine extended-release tolvaptan TOPAMAX... 9 TOPAMAX SPRINKLE... 9 TOPICORT topiramate capsule... 9 topiramate tablet... 9 topotecan... 9 TOPROL XL... 5 TORADOL... 7 torsemide TOVIAZ TRACLEER... 5 TRADJENTA tramadol... 7, 8 tramadol & acetaminophen... 8 tramadol extended-release... 8 TRANDATE... 5 trandolapril... 3, 5 trandolapril & verapamil... 3 TRANSDERM-SCOP TRANXENE tranylcypromine sulfate TRAVATAN Z travoprost trazodone trazodone extended-release TRENTAL... treprostinil... 5 TRESIBA Kaiser Permanente of Georgia Multi Choice Formulary tretinoin... 9, 4, 42 tretinoin microspheres... 4 TREXALL... 9 triamcinolone acetonide (topical)... 4 triamterene triamterene & hydrochlorothiazide TRIAVIL... 2 triazolam TRIBENZOR... 3 TRICOR... 2 trientine trifluoperazine trifluridine trihexyphenidyl TRILAFON TRILEPTAL... 9 TRILIPIX... 2 trimethobenzamide trimethoprim... 5, 8, 25 trimipramine TRINESSA TRI-NORINYL... 3 TRI-SPRINTEC TRIUMEQ... 6 TRI-VI-FLOR TRI-VI-FLOR W/IRON TRIVORA... 3 TRIZIVIR... 6 trospium trospium extended-release TRULICITY TRUSOPT TRUVADA... 7 TUSSIONEX TWINJECT... TYKERB... 9 TYLENOL W/ CODEINE... 6 TYZINE U UCERIS ulipristal ULORIC ULTRACET... 8 ULTRAM... 7, 8 ULTRAM ER... 8 ULTRAVATE... 4 umeclidinium... 0, umeclidinium & vilanterol... UNIPHYL UNIRETIC... 4 Kaiser Permanente of Georgia Multi Choice Formulary 69

71 UNITHROID UNIVASC... 4 unoprostone isopropyl urea... 4 URECHOLINE... 0 URELLE... 8 UROCIT-K URO-MP UROXATRAL... 0 URSO URSO FORTE ursodiol ustekinumab UTIBRON NEOHALER V VAGIFEM... 34, 35 valacyclovir... 8 valbenazine... 2 VALCHLOR... 9 VALCHLOR... 9 VALCYTE... 8 valganciclovir... 8 VALISONE VALIUM valproate sodium... 9 valproic acid... 9 valsartan... 3, 4, 5 valsartan & hydrochlorothiazide... 3, 5 VALTREX... 8 VALTURNA... 4 VANCOCIN HCL... 5 vancomycin hcl... 5 vandetanib... 9 VANOS VANOXIDE-HC VANTIN... 4 varenicline... 0 VARUBI VASERETIC... 4 VASOTEC... 4 VECTICAL VELIVET VELPHORO VELTASSA VELTIN vemurafenib... 9 venlafaxine venlafaxine extended-release VENTOLIN HFA... verapamil... 3 Kaiser Permanente of Georgia Multi Choice Formulary verapamil extended-release cap... 3 verapamil sustained-release cap... 3 verapamil sustained-release tab... 3 VEREGEN VERELAN... 3 VERELAN PM... 3 VESANOID... 9 VESICARE VEXOL VFEND... 6 VIBERZI VICOPROFEN... 7 VICTOZA VICTRELIS... 6 VIDEX... 7 VIDEX EC... 7 VIEKIRA... 7 vigabatrin... 9 VIGAMOX VIIBRYD vilazodone VIMPAT... 9 VIOKACE VIRACEPT... 7 VIRAMUNE... 7 VIREAD... 8 VIROPTIC VISICOL VISKEN... 5 VISTARIL VIVACTIL VIVELLE-DOT VOLTAREN... 6, 25, 42 VOLTAREN GEL VOLTAREN XR... 6 vorapaxar... voriconazole... 6 vorinostat... 9 vortioxetine VOSOL VOSPIRE ER... VOTRIENT... 9 VRAYLAR... 2 VUSION VYTONE VYTORIN... 2 VYVANSE... 8 W warfarin... WELCHOL... 2 Kaiser Permanente of Georgia Multi Choice Formulary 70

72 WELLBUTRIN... 2 WELLBUTRIN SR... 2 WELLBUTRIN XL... 2 WESTCORT... 4 X XALATAN XALKORI... 8 XANAX XANAX XR XARELTO... XARTEMIS XR... 7 XELJANZ XELODA... 8 XENAZINE... 2 XIBROM XIFAXAN... 5 XIGDUO XR XIIDRA XOLAIR XOPENEX HFA... XOPENEX NEBULIZER... XTANDI... 8 XULANE... 3 XULTOPHY XYLOCAINE... 27, 4 XYLOCAINE VISCOUS XYREM... 2 Y YASMIN YAZ YUVAFEM Z zafirlukast zaleplon ZANAFLEX... 0 zanamivir... 8 ZANTAC ZARONTIN... 9 ZAROXOLYN ZARXIO... 2 ZAVESCA ZEBETA... 5 ZELAPAR ZELBORAF... 9 Kaiser Permanente of Georgia Multi Choice Formulary ZEMPLAR ZENPEP ZEPATIER... 7 ZERIT... 8 ZESTORETIC... 4 ZESTRIL... 4 ZETIA... 2 ZIAC... 5 ZIAGEN... 6 ZIANA zidovudine... 6, 7, 8 zileuton ZINBRYTA ziprasidone ZIRGAN ZITHROMAX... 4 ZOCOR... 2 ZOFRAN ZOFRAN ODT ZOHYDRO ER... 6, 7 ZOLINZA... 9 zolipdem sublingual zolmitriptan... 9 zolmitriptan orally disentigrating... 9 ZOLOFT zolpidem... 20, 2 zolpidem extended-release... 2 zolpidem oral spray... 2 ZOLPIMIST... 2 ZOMIG... 9 ZOMIG ZMT... 9 ZONALON... 4 ZONEGRAN... 9 zonisamide... 9 ZONTIVITY... ZORBTIVE ZORTRESS ZOVIA ZOVIRAX... 6, 39 ZURAMPIC ZYCLARA ZYFLO ZYKADIA... 8 ZYLET ZYLOPRIM ZYMAXID ZYPREXA ZYPREXA ZYDIS ZYTIGA... 8 ZYVOX... 5 Kaiser Permanente of Georgia Multi Choice Formulary 7

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74 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: -(888) , (TTY) 7 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: - (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 2020, , (TDD). Complaint forms are available at Kaiser Permanente of Georgia Multi Choice Formulary 73

75 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., 20 E. Jefferson St., Rockville, MD Kaiser Foundation Health Plan of the Northwest, 500 NE Multnomah St., Suite 00, Portland, OR Kaiser Permanente of Georgia Multi Choice Formulary 74

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