MULTI-CHOICE FORMULARY

Transcript

1 KAISER PERMANENTE OF GEORGIA MULTI-CHOICE FORMULARY This document includes Kaiser Permanente Georgia s Multi- Choice formulary as of October 23, For an updated formulary, please visit our website at members.kp.org or call , Monday through Friday 7:00 a.m. to 7:00 p.m. TTY/TDD users should call

2 What is the Kaiser Permanente MultiChoice Formulary? A formulary is a list of drugs determined to be safe and effective for our members by our Pharmacy and Therapeutics committee. Use of the formulary enables Kaiser Permanente to provide optimal care to you and your family at reasonable costs. Kaiser Permanente continually updates the formulary throughout the year based on new medical evidence, considering the recommendations of appropriate physician experts. Our physicians and pharmacists work closely together to ensure that our formulary meets your needs. This formulary is only for use at PPO Provider (Tier 2) and Non-Participating Provider (Tier 3) pharmacies. To see which medications are covered at a Select Provider (Tier 1) pharmacy, please reference the Kaiser Permanente HMO Formulary. Does the formulary ever change? Yes, Kaiser Permanente periodically updates the formulary based on new medical evidence, considering the recommendations of appropriate physician experts and notifies our doctors, pharmacists, and other clinicians about any changes. If a change in the formulary affects any of your prescriptions, your doctor or pharmacist will let you know. The enclosed formulary is current as of October 23, 2014 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 40. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to the drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug on the list. You may also use the search function on your computer to search this document for the medication by name. **All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary, check with your Kaiser Permanente pharmacist for Kaiser Permanente of Georgia Multi Choice Formulary 1

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

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

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

6 Restrictions Tier Name Brand Name Coverage Status 1 erythromycin base delayed-release ERY-TAB 1 erythromycin ethylsuccinate E.E.S. 3 erythromycin ethylsuccinate ERYPED 3 erythromycin sterate ERYTHROCIN 3 fidaxomicin DIFICID 3 gemifloxacin FACTIVE 1 gentamicin sulfate GARAMYCIN 1 levofloxacin LEVAQUIN 2 linezolid ZYVOX Preferred Brand 1 minocycline DYNACIN 1 minocycline MINOCIN 1 minocycline SOLODYN 1 moxifloxacin AVELOX 1 neomycin sulfate MYCIFRADIN 3 norfloxacin NOROXIN 1 penicillin v potassium PEN-VEE K 3 rifaximin XIFAXAN 1 sulfadiazine SULFADIAZINE 1 sulfamethoxazole & trimethoprim BACTRIM DS 1 sulfamethoxazole & trimethoprim SEPTRA 1 sulfasalazine AZULFIDINE 3 telithromycin KETEK 3 tetracycline TETRACYCLINE 3 tobramycin inhalation powder TOBI PODHALER 1 tobramycin inhalation solution TOBI 1 vancomycin hcl VANCOCIN HCL Antifungals QL 1 fluconazole DIFLUCAN 1 flucytosine ANCOBON 1 griseofulvin microsize GRIFULVIN V 1 griseofulvin ultramicrosize GRIS-PEG 1 itraconazole SPORANOX 2 itraconazole (solution) SPORANOX Preferred Brand 1 ketoconazole NIZORAL 1 nystatin MYCOSTATIN 3 posaconazole NOXAFIL 1 terbinafine LAMISIL 1 voriconazole VFEND Antimycobacterials 1 cycloserine SEROMYCIN 1 dapsone AVLOSULFON 1 ethambutol MYAMBUTOL 1 isoniazid NYDRAZID 1 pyrazinamide PYRAZINAMIDE 1 rifabutin MYCOBUTIN 1 rifampin RIFADIN 1 rifampin & isoniazid RIFAMATE Kaiser Permanente of Georgia Multi Choice Formulary 5

7 Restrictions Tier Name Brand Name Coverage Status 3 rifapentine PRIFTIN Antiprotozoals 1 atovaquone MEPRON 1 atovaquone & proguanil MALARONE 1 chloroquine phosphate ARALEN 1 hydroxychloroquine sulfate PLAQUENIL 1 mefloquine LARIAM 1 metronidazole FLAGYL 3 metronidazoleextended-release FLAGYL ER 3 nitazoxanide ALINIA 1 paromomycin sulfate HUMATIN 2 primaquine phosphate PRIMAQUINE Preferred Brand 2 pyrimethamine DARAPRIM Preferred Brand 1 quinine sulfate QUALAQUIN Antiviral QL 2 abacavir sulfate & lamivudine EPZICOM Preferred Brand QL 2 abacavir sulfate solution ZIAGEN Preferred Brand QL 1 abacavir sulfate tablet ZIAGEN QL 1 abacavir, lamivudine & zidovudine TRIZIVIR 1 acyclovir ZOVIRAX QL 1 adefovir dipivoxil HEPSERA QL 2 atazanavir sulfate REYATAZ Preferred Brand QL 3 boceprevir VICTRELIS QL 2 darunavir ethanolate PREZISTA Preferred Brand QL 2 delavirdine mesylate RESCRIPTOR Preferred Brand QL 1 didanosine VIDEX EC QL 2 didanosine solution VIDEX Preferred Brand 2 dolutegravir TIVICAY Preferred Brand QL 2 efavirenz SUSTIVA Preferred Brand QL 2 efavirenz, emtricitab & tenofovir ATRIPLA Preferred Brand QL 2 elvitegravir, cobicistat, emtricitabine, & tenofovir STRIBILD Preferred Brand QL 2 emtricitabine EMTRIVA Preferred Brand QL 2 emtricitabine & tenofovir TRUVADA Preferred Brand QL 2 emtricitabine, rilpivirine, & tenofovir COMPLERA Preferred Brand QL 2 enfuvirtide FUZEON Preferred Brand QL 1 entecavir BARACLUDE QL 2 etravirine INTELENCE Preferred Brand 1 famciclovir FAMVIR QL 2 fosamprenavir calcium LEXIVA Preferred Brand 1 ganciclovir CYTOVENE QL 2 indinavir sulfate CRIXIVAN Preferred Brand 3 interferon alfacon-1 INFERGEN QL 3 lamivudine EPIVIR HBV QL 1 lamivudine EPIVIR QL 1 lamivudine & zidovudine COMBIVIR QL 2 lopinavir & ritonavir KALETRA Preferred Brand Kaiser Permanente of Georgia Multi Choice Formulary 6

8 Restrictions Tier Name Brand Name Coverage Status QL 2 maraviroc SELZENTRY Preferred Brand QL 2 nelfinavir mesylate VIRACEPT Preferred Brand QL 1 nevirapine solution VIRAMUNE QL 1 nevirapine tablet VIRAMUNE QL 2 oseltamivir phosphate TAMIFLU Preferred Brand 3 palivizumab SYNAGIS QL 2 peginterferon alfa-2a PEGASYS Preferred Brand 2 peginterferon-alfa 2b PEG-INTRON Preferred Brand QL 2 raltegravir ISENTRESS Preferred Brand 1 ribavirin REBETOL QL 3 rilpivirine EDURANT QL 1 rimantadine FLUMADINE QL 2 ritonavir NORVIR Preferred Brand QL 2 saquinavir mesylate INVIRASE Preferred Brand QL 3 simeprevir OLYSIO QL 3 sofusbuvir SOVALDI QL 1 stavudine ZERIT QL 3 telaprevir INCIVEK QL 3 tenofovir VIREAD QL 2 tipranavir APTIVUS Preferred Brand 1 valacyclovir VALTREX 3 valganciclovir VALCYTE QL 2 zanamivir RELENZA Preferred Brand QL 1 zidovudine RETROVIR Urinary Antiinfectives 1 methenamine hippurate HIPREX 3 methenamine, sodium biphosphate, phenyl salicylate, methylene blue, URELLE and hyoscyamine 2 nitrofurantoin FURADANTIN Preferred Brand 1 nitrofurantoin macrocrystal MACRODANTIN 1 nitrofurantoin monohydrate MACROBID 1 trimethoprim PROLOPRIM Antineoplastic Agents Antineoplastic Agents 2 abiraterone ZYTIGA Preferred Brand 1 anastrozole ARIMIDEX 3 axitinib INLYTA 2 bexarotene TARGRETIN Preferred Brand 1 bicalutamide CASODEX 3 bosutinib BOSULIF 2 busulfan MYLERAN Preferred Brand 1 capecitabine XELODA 3 ceritinib ZYKADIA 2 chlorambucil LEUKERAN Preferred Brand 2 crizotinib XALKORI Preferred Brand 1 cyclophosphamide CYTOXAN Kaiser Permanente of Georgia Multi Choice Formulary 7

9 Restrictions Tier Name Brand Name Coverage Status 2 dasatinib SPRYCEL Preferred Brand 3 enzalutamide XTANDI 2 erlotinib TARCEVA Preferred Brand 2 estramustine EMCYT Preferred Brand 2 everolimus AFINITOR Preferred Brand 1 exemestane AROMASIN 1 flutamide EULEXIN 2 hydroxyurea DROXIA Preferred Brand 1 hydroxyurea HYDREA QRM 3 ibrutinib IMBRUVICA 2 imatinib mesylate GLEEVEC Preferred Brand 2 lapatinib TYKERB Preferred Brand 2 lenalidomide REVLIMID Preferred Brand 1 letrozole FEMARA 1 leuprolide acetate LUPRON 3 lomustine CEENU 2 melphalan ALKERAN Preferred Brand 1 mercaptopurine PURINETHOL 1 methotrexate sodium RHEUMATREX 3 methotrexate sodium TREXALL 2 mitotane LYSODREN Preferred Brand 2 nilotinib TASIGNA Preferred Brand 2 pazopanib VOTRIENT Preferred Brand QRM 3 pomalidomide POMALYST 3 ponatinib ICLUSIG 2 procarbazine MATULANE Preferred Brand 3 ruxolitinib JAKAFI 2 sorafenib tosylate NEXAVAR Preferred Brand 2 sunitinib malate SUTENT Preferred Brand 1 tamoxifen citrate NOLVADEX 1 temozolomide TEMODAR 2 thioguanine TABLOID Preferred Brand 2 topotecan HYCAMTIN Preferred Brand 1 tretinoin VESANOID 2 vandetanib CAPRELSA Preferred Brand 2 vemurafenib ZELBORAF Preferred Brand 2 vorinostat ZOLINZA Preferred Brand Autonomic Drugs Anticholinergic Agents 1 atropine sulfate ATROPINE SULFATE 1 dicyclomine BENTYL 1 glycopyrrolate ROBINUL 1 glycopyrrolate ROBINULFORTE 1 hyoscyamine sulfate LEVBID 1 hyoscyamine sulfate LEVSIN 1 hyoscyamine sulfate SYMAX 3 hyoscyamine sulfate SYMAX DUOTAB Kaiser Permanente of Georgia Multi Choice Formulary 8

10 Restrictions Tier Name Brand Name Coverage Status 1 ipratropium bromide ATROVENT 2 ipratropium bromide ATROVENTHFA Preferred Brand 1 methscopolamine PAMINE 1 propantheline bromide PRO-BANTHINE 2 tiotropium SPIRIVA Preferred Brand Autonomic Drugs, Miscellaneous 3 varenicline CHANTIX Parasympathomimetic (Cholinergic) Agents 1 bethanechol chloride URECHOLINE 1 cevimeline hcl EVOXAC 1 donepezil ARICEPT 1 donepezil ARICEPT ODT 1 galantamine hydrobromide RAZADYNE 1 galantamine hydrobromide RAZADYNEER 1 neostigmine bromide PROSTIGMIN 1 pilocarpine SALAGEN 2 pyridostigmine MESTION TIMESPAN Preferred Brand 1 pyridostigmine MESTION 1 rivastigmine tartrate EXELON 2 rivastigmine tartrate (solution) EXELON Preferred brand Skeletal Muscle Relaxants 1 baclofen LIORESAL 1 carisoprodol SOMA 1 carisoprodol/aspirin SOMA COMPOUND 1 chlorzoxazone PARAFON FORTE DSC 1 cyclobenzaprine FLEXERIL 3 cyclobenzaprine extended-release AMRIX 1 dantrolene sodium DANTRIUM 1 metaxalone SKELAXIN 1 methocarbamol ROBAXIN 1 orphenadrine citrate NORFLEX 1 orphenadrine, aspirin, & caffeine NORGESIC 1 tizanidine ZANAFLEX Sympatholytic (Adrenergic Blocking) Agents 1 alfuzosin hcl UROXATRAL 1 dihydroergotamine mesylate D.H.E.45 2 dihydroergotamine mesylate MIGRANAL Preferred Brand 1 ergoloid mesylates HYDERGINE 1 ergotamine & caffeine CAFERGOT 3 phenoxybenzamine DIBENZYLINE 3 silodosin RAPAFLO 1 tamsulosin hcl FLOMAX Sympathomimetic (Adrenergic) Agents 1 albuterol nebulizer solution ACCUNEB 2 albuterol sulfate PROAIR HFA Preferred Brand 3 albuterol sulfate PROVENTIL HFA 3 albuterol sulfate VENTOLIN HFA Kaiser Permanente of Georgia Multi Choice Formulary 9

11 Restrictions Tier Name Brand Name Coverage Status 2 albuterol sulfate & ipratropium COMBIVENT RESPIMAT Preferred Brand 1 albuterol sulfate & ipratropium DUONEB 1 albuterol sulfate tablet VOSPIRE ER 3 arformoterol BROVANA 1 epinephrine ADRENACLICK 3 epinephrine AUVI-Q 3 epinephrine EPIPEN 3 epinephrine EPIPEN JR 3 epinephrine TWINJECT 3 formoterol fumarate FORADIL 1 levalbuterol nebulizer solution XOPENEX NEBULIZER 3 levalbuterol tartrate XOPENEX HFA 1 midodrine hcl PROAMATINE 3 pirbuterol acetate MAXAIR AUTOHALER 2 salmeterol SEREVENT DISKUS Preferred Brand 1 terbutaline sulfate BRETHINE 3 umeclidinium & vilanterol ANORO ELLIPTA Blood Formation, Coagulation, and Thrombosis Coagulants and Anticoagulants 1 aminocaproic acid AMICAR 1 anagrelide AGRYLIN 3 apixaban ELIQUIS 2 aspirin & dipyridamole AGGRENOX Preferred Brand 1 cilostazol PLETAL 2 clopidogrel PLAVIX QL 3 dabigatran PRADAXA 3 dalteparin FRAGMIN 1 dipyridamole PERSANTINE 1 enoxaparin LOVENOX 1 fondaparinux ARIXTRA 1 heparin HEPARIN SODIUM 1 pentoxifylline TRENTAL QL 3 rivaroxaban XARELTO 3 ticagrelor BRILINTA 1 ticlopidine TICLID 1 warfarin COUMADIN Hematopoietic Agents 2 darbepoetin alfa ARANESP Preferred Brand QRM 3 eltrombopag PROMACTA 2 epoetin alfa PROCRIT Preferred Brand 3 epoetin alfa EPOGEN 2 filgrastim NEUPOGEN Preferred Brand 2 oprelvekin NEUMEGA Preferred Brand 3 pegfilgrastim NEULASTA 2 sargramostim LEUKINE Preferred Brand Cardiovascular Drugs α-adrenergic Blocking Agents Kaiser Permanente of Georgia Multi Choice Formulary 10

12 Restrictions Tier Name Brand Name Coverage Status 1 doxazosin CARDURA 1 prazosin MINIPRESS 1 terazosin HYTRIN Antilipemic Agents 1 atorvastatin LIPITOR 1 cholestyramine light QUESTRAN LIGHT 1 cholestyramine QUESTRAN 3 colesevelam WELCHOL 1 colestipol COLESTID 3 ezetimibe ZETIA 3 ezetimibe & simvastatin VYTORIN 1 fenofibrate LOFIBRA TAB 1 fenofibrate TRICOR 1 fenofibrate, micronized LOFIBRA CAP 1 fenofibric acid TRILIPIX 3 fluvastatin extended-release LESCOL XL 1 fluvastatin LESCOL 1 gemfibrozil LOPID QRM 3 lomitapide JUXTAPID 1 lovastatin MEVACOR 3 lovastatine extended-release ALTOPREV QRM 3 mipomersen sodium KYNAMRO 3 niacin NIASPAN 3 niacin & lovastatin ADVICOR 3 omega-3 acid ethyl esters LOVAZA 3 omega-3-carboxylic acid EPANOVA 3 pitavastatin LIVALO 1 pravastatin PRAVACHOL 3 rosuvastatin CRESTOR 1 simvastatin ZOCOR Calcium Channel Blocking Agents 1 amlodipine NORVASC 1 amlodipine & benazepril LOTREL 1 amlodipine & atorvastatin CADUET 3 amlodipine & olmesartan AZOR 3 amlodipine & valsartan EXFORGE 3 amlodipine, valsartan & hydrochlorothiazide EXFORGE HCT 3 amlodipine, olmesartan & hydrochlorothiazide TRIBENZOR 1 diltiazem extended-release CARDIZEM CD 1 diltiazem extended-release TIAZAC 1 diltiazem extended-release CARTIA XT 1 diltiazem extended-release CARDIZEM LA 1 diltiazem CARDIZEM 1 felodipine PLENDIL 1 isradipine DYNACIRC Kaiser Permanente of Georgia Multi Choice Formulary 11

13 Restrictions Tier Name Brand Name Coverage Status 3 isradipine DYNACIRC CR 1 nicardipine CARDENE 1 nifedipine PROCARDIA 1 nifedipine extended-release ADALAT CC 1 nifedipine extended-release PROCARDIA XL 1 nimodipine NIMOTOP 3 nisoldipine SULAR 1 Trandolapril & verapamil TARKA 1 verapamil sustained-release cap VERELAN 3 verapamil COVERA-HS 1 verapamil extended-release cap VERELAN PM 1 verapamil sustained-release cap CALAN SR 1 verapamil sustained-release tab ISOPTIN SR Cardiac Drugs 1 amiodarone PACERONE 1 digoxin LANOXIN 1 disopyramide NORPACE 2 disopyramide controlled-release NORPACE CR Preferred Brand 2 dofetilide TIKOSYN Preferred Brand 3 dronedarone MULTAQ 1 flecainide TAMBOCOR 1 mexiletine MEXITIL 1 propafenone RYTHMOL 3 propafenone RYTHMOL SR 1 quinidine gluconate QUINAGLUTE 1 quinidine QUINIDINE SULFATE QL 3 ranolazine RANEXA Hypotensive Agents 1 clonidine extended-release KAPVAY 1 clonidine CATAPRES 1 clonidine transdermal CATAPRES-TTS 1 guanfacine TENEX 1 hydralazine APRESOLINE 1 methyldopa ALDOMET 1 methyldopa & hydrochlorothiazide ALDORIL-25 1 minoxidil LONITEN 3 reserpine SERPASIL Renin-Angiotensin-Aldosterone System Inhibitors 3 aliskiren TEKTURNA 3 aliskiren, amlodipine & hydrochlorothiazide AMTURNIDE 3 aliskiren & amlodipine TEKAMLO 3 aliskiren & hydrochlorothiazide TEKTURNA HCT 3 aliskiren & valsartan VALTURNA 3 azilsartan EDARBI 1 benazepril LOTENSIN 1 benazepril & hydrochlorothiazide LOTENSIN HCT Kaiser Permanente of Georgia Multi Choice Formulary 12

14 Restrictions Tier Name Brand Name Coverage Status 1 candesartan ATACAND 1 candesartan & hydrochlorothiazide ATACAND HCT 1 captopril CAPOTEN 1 captopril & hydrochlorothiazide CAPOZIDE 1 enalapril VASOTEC 1 enalapril & hydrochlorothiazide VASERETIC 1 eplerenone INSPRA 3 eprosartan TEVETEN 3 eprosartan & hydrochlorothiazide TEVETEN 1 fosinopril MONOPRIL 1 fosinopril & hydrochlorothiazide MONOPRIL HCT 1 irbesartan AVAPRO 1 irbesartan & hydrochlorothiazide AVALIDE 1 lisinopril ZESTRIL 1 lisinopril & hydrochlorothiazide ZESTORETIC 1 losartan COZAAR 1 losartan & hydrochlorothiazide HYZAAR 1 moexipril UNIVASC 1 moexipril & hydrochlorothiazide UNIRETIC 3 olmesartan BENICAR 3 olmesartn & hydrochlorothiazide BENICAR HCT 1 perindopril ACEON 1 quinapril hcl ACCUPRIL 1 quinapril & hydrochlorothiazide ACCURETIC 1 ramipril ALTACE 1 spironolactone & hydrochlorothiazide ALDACTAZIDE 1 spironolactone ALDACTONE 1 telmisartan MICARDIS 1 telmisartan & hydrochlorothiazide MICARDIS HCT 1 trandolapril MAVIK 1 valsartan DIOVAN 1 valsartan & hydrochlorothiazide DIOVAN HCT Vasodilating Agents 2 ambrisentan LETAIRIS Preferred Brand 2 bosentan TRACLEER Preferred Brand 3 isosorbide dinitrate & hydralazine BIDIL 1 isosorbide dinitrate ISORDIL 1 isosorbide mononitrate IMDUR 2 macitentan OPSUMIT Preferred Brand 3 nitroglycerin aerosol NITROMIST 1 nitroglycerin solution NITROLINGUAL 2 nitroglycerin subligual NITROSTAT Preferred Brand 2 nitroglycerin topical ointment NITRO-BID Preferred Brand Excludes 0.8mg strength 1 nitroglycerin transdermal patch NITRO-DUR Kaiser Permanente of Georgia Multi Choice Formulary 13

15 Restrictions Tier Name Brand Name Coverage Status Only 0.8mg strength 2 nitroglycerin transdermal patch NITRO-DUR Preferred Brand 1 papaverine PAVABID 3 riociguat ADEMPAS 1 sildenafil REVATIO 3 tadalafil ADCIRCA 3 treprostinil ORENITRAM 2 treprostinil REMODULIN Preferred Brand β-adrenergic Blocking Agents 1 acebutolol SECTRAL 1 atenolol TENORMIN 1 atenolol & chlorthalidone TENORETIC 1 betaxolol KERLONE 1 bisoprol & hydrochlorothiazide ZIAC 1 bisoprolol ZEBETA 1 carvedilol COREG 3 carvedilol phosphate COREG CR 1 labetalol TRANDATE 1 metoprol & hydrochlorothiazide LOPRESSOR HCT 1 metoprolol succinate TOPROL XL 1 metoprolol tartrate LOPRESSOR 1 nadolol CORGARD 1 nadolol & bendroflumethiazide CORZIDE 3 nebivolol BYSTOLIC 3 penbutolol LEVATOL 1 pindolol VISKEN 1 propranolol & hydrochlorothiazide INDERIDE 3 propranolol extended-release INNOPRAN XL 1 propranolol INDERAL 1 propranolol sustained-release INDERAL LA 1 sotalol BETAPACE 1 sotalol BETAPACE AF 1 timolol BLOCADREN Central Nervous System Agents Analgesics and Antipyretics 1 acetaminophen & codeine TYLENOL W/ CODEINE 1 acetaminophen, caffeine, & dihydrocodine PANLOR SS 1 buprenorphine SUBUTEX QL 1 buprenorphine& naloxone tablet SUBOXONE QL 3 buprenorphine & naloxone film SUBOXONE QL 3 buprenorphine transdermal BUTRANS 1 butalbital & acetaminophen PHRENILIN 3 butalbital & acetaminophen PHRENILIN FORTE 1 butalbital, acetaminophen, & caffeine FIORICET Kaiser Permanente of Georgia Multi Choice Formulary 14

16 Restrictions Tier Name Brand Name Coverage Status 1 butalbital, acetaminophen, caffeine, & codeine FIORICET W/ CODEINE 1 butalbital, aspirin, & caffeine FIORINAL 1 butalbital, aspirin, caffeine, & codeine FIORINAL W/ CODEINE 1 butorphanol tartrate STADOL 1 carisoprodol, aspirin, & codeine SOMA COMPOUND W/ CODEINE 3 celecoxib CELEBREX 1 codeine CODEINE SULF 1 diclofenac potassium CATAFLAM 1 diclofenac sodium VOLTAREN 1 diclofenac sodium PENNSAID 2 diclofenac sodium & misoprostol ARTHROTEC 1 diclofenac sodium extended release VOLTAREN XR 1 diflunisal DIFLUNISAL 1 etodolac LODINE 3 fenoprofen calcium NALFON 3 fentanyl film ONSOLIS 3 fentanyl intranasal LAZANDA 1 fentanyl lozenge ACTIQ 3 fentanyl sublingual ABSTRAL 3 fentanyl tablet FENTORA QL 1 fentanyl transdermal DURAGESIC 1 flurbiprofen ANSAID 3 hydrocodone ZOHYDRO ER 1 hydrocodone & acetaminophen NORCO 1 hydrocodone & ibuprofen VICOPROFEN 3 hydromorphone oral suspension DILAUDID 1 hydromorphone tablet DILAUDID 3 hydromorphone tablet EXALGO 1 ibuprofen MOTRIN 1 indomethacin INDOCIN 1 ketoprofen KETOPROFEN QL 1 ketorolac tablet TORADOL 1 levorphanol LEVO-DROMORAN 1 meclofenamate MECLOMEN QL 1 mefenamic acid PONSTEL 1 meloxicam MOBIC 1 meperidine tablet DEMEROL 1 methadone DOLOPHINE 2 morphine MORPHINE SULFATE Preferred Brand 1 morphine MSIR 3 morphine beads AVINZA 3 morphine extended-relase capsule KADIAN 1 morphine extended-release tablet MS CONTIN 1 nabumetone RELAFEN 1 nalbuphine NUBAIN Kaiser Permanente of Georgia Multi Choice Formulary 15

17 Restrictions Tier Name Brand Name Coverage Status 1 naproxen NAPROSYN 1 naproxen sodium ANAPROX 3 naproxen sodium NAPRELAN 1 opium & belladonna alkaloids B & O SUPPRETTES 3 opium tincture OPIUM 1 oxaprozin DAYPRO 1 oxycodone ROXICODONE 1 oxycodone & acetaminophen PERCOCET 2 oxycodone & acetaminophen ROXICET Preferred Brand 1 oxycodone & aspirin PERCODAN QL 3 oxycodone & ibuprofen COMBUNOX QL 3 oxycodone controlled-release OXYCONTIN 3 oxymorphone OPANA 3 oxymorphone extended-release OPANA ER 1 pentazocine & naloxone TALWIN NX 1 piroxicam FELDENE 1 salsalate DISALCID 1 sulindac CLINORIL QL 3 tapentadol NUCYNTA 1 tolmetin sodium TOLECTIN tramadol ULTRAM 1 tramadol & acetaminophen ULTRACET 1 tramadol extended-release ULTRAM ER Anorexigenic Agents and Respiratory and Cerebral Stimulants 1 amphetamine & dextroamphetamine ADDERALL 1 amphetamine & dextroamphetamine extended-release ADDERALL XR QL 3 armodafinil NUVIGIL QL 1 dexmethylphenidate FOCALIN 1 dexmethylphenidate extendedrelease FOCALIN XR QL 1 dextroamphetamine sulfate DEXTROSTAT QL 1 dextroamphetamine sulfate extended-release DEXEDRINE 3 lisdexamfetamine VYVANSE 1 methamphetamine DESOXYN 1 methylphenidate METHYLIN 1 methylphenidate RITALIN QL 1 methylphenidate extended-release METADATE ER QL 1 methylphenidate extended-release CONCERTA 1 methylphenidate extended-release METADATE CD QL 3 methylphenidate extended-release RITALIN LA QL 1 methylphenidate sustained release RITALIN SR QL 3 methylphenidate transdermal patch DAYTRANA QL 1 modafinil PROVIGIL Anticonvulsants 1 carbamazepine TEGRETOL Kaiser Permanente of Georgia Multi Choice Formulary 16

18 Restrictions Tier Name Brand Name Coverage Status 1 carbamazepine extended-release cap CARBATROL 3 carbamazepine extended-release cap EQUETRO 3 carbamazepine extended-release tab TEGRETOL XR 3 clobazam ONFI 1 clonazepam KLONOPIN 1 diazepam DIASTAT 2 diazepam DIASTAT ACUDIAL Preferred Brand 1 divalproex sodium DEPAKOTE 1 divalproex sodium capsule DEPAKOTE SPRINKLE 1 divalproex sodium extended release DEPAKOTE ER 3 eslicarbazepine APTIOM 3 ethontoin PEGANONE 1 ethosuximide ZARONTIN 3 ezogaine POTIGA 1 felbamate FELBATOL 1 gabapentin NEURONTIN QL 3 lacosamide VIMPAT 1 lamotrigine LAMICTAL 1 lamotrigine extended-release LAMICTAL XR 1 levetiracetam KEPPRA 1 levetiracetam extended-release KEPPRA XR 2 methsuximide CELONTIN Preferred Brand 1 oxcarbazepine TRILEPTAL 3 perampanel FYCOMPA 1 phenytoin sodium extended-release DILANTIN 1 phenytoin sodium extended-release PHENYTEK 1 phenytoin suspension DILANTIN 3 pregabalin LYRICA 1 primidone MYSOLINE 3 rufinamide BANZEL 1 tiagabine GABITRIL 1 topiramate capsule TOPAMAX SPRINKLE 1 topiramate tablet TOPAMAX 1 valproate sodium DEPAKENE 1 valproic acid DEPAKENE QRM 3 vigabatrin SABRIL 1 zonisamide ZONEGRAN Antimigraine Agents QL 3 almotriptan AXERT 1 ergotamine & caffeine MIGERGOT QL 3 eletriptan RELPAX QL 3 frovatriptan FROVA QL 1 naratriptan AMERGE QL 1 rizatriptan MAXALT QL 1 rizatriptan orally disentigrating MAXALT MLT QL 1 sumatriptan IMITREX QL 1 zolmitriptan ZOMIG Kaiser Permanente of Georgia Multi Choice Formulary 17

19 Restrictions Tier Name Brand Name Coverage Status QL 1 zolmitriptan orally disentigrating ZOMIG ZMT Antiparkinsonian Agents 1 amantadine SYMMETREL 1 benztropine COGENTIN 1 bromocriptine PARLODEL 3 bromocriptine CYCLOSET 1 cabergoline DOSTINEX 3 carbidopa LODOSYN 1 carbidopa & levodopa SINEMET 3 carbidopa & levodopa PARCOPA 1 carbidopa & levodopa extended release SINEMET CR 2 carbidopa, levodopa, & entacapone STALEVO Preferred Brand 1 entacapone COMTAN 1 pramipexole MIRAPEX 3 pramipexole extended-release MIRAPEX ER 3 rasagiline AZILECT 1 ropinirole REQUIP 1 ropinirole extended-release REQUIP XL 3 rotigotine NEUPRO 1 selegiline ELDEPRYL 3 selegiline ZELAPAR 3 selegiline transdermal EMSAM 2 tolcapone TASMAR Preferred Brand 1 trihexyphenidyl ARTANE Anxiolytics, Sedatives, and Hypnotics 1 alprazolam XANAX 1 alprazolam extended-release XANAX XR 3 alprazolam orally disintegrating NIRAVAM 1 buspirone BUSPAR 1 chlordiazepoxide LIBRIUM 1 clorazepate TRANXENE 1 diazepam VALIUM 1 estazolam PROSOM 1 eszopiclone LUNESTA 1 flurazepam DALMANE 1 hydroxyzine hcl ATARAX 1 hydroxyzine pamoate VISTARIL 1 lorazepam ATIVAN 1 meprobamate MILTOWN 1 oxazepam SERAX 1 phenobarbital PHENOBARBITAL 3 ramelteon ROZEREM 1 temazepam RESTORIL 1 triazolam HALCION 1 zaleplon SONATA 3 zolipdem sublingual EDLUAR Kaiser Permanente of Georgia Multi Choice Formulary 18

20 Restrictions Tier Name Brand Name Coverage Status 1 zolpidem AMBIEN 1 zolpidem extended-release AMBIEN CR 3 zolpidem oral spray ZOLPIMIST Central Nervous System Agents Miscellaneous 1 acamprosate CAMPRAL 3 atomoxetine STRATTERA 3 dextromethorphan & quinidine NUEDEXTA 3 guanfacine extended-release INTUNIV 2 memantine NAMENDA Preferred Brand QL 3 milnacipran SAVELLA 1 riluzole RILUTEK 3 sodium oxybate XYREM QRM 3 tetrabenazine XENAZINE Opioid Antagonists 1 naloxone NARCAN 1 naltrexone REVIA Psychotherapeutic Agents 1 amitriptyline ELAVIL 1 amitriptyline & perphenazine TRIAVIL 1 amoxapine ASENDIN 2 aripiprazole ABILIFY Preferred Brand 3 asenapine SAPHRIS 1 bupropion WELLBUTRIN 1 bupropion extended-release WELLBUTRIN XL 3 bupropion hydrobromide APLENZIN 1 bupropion sustained-release WELLBUTRIN SR 1 chlordiazepoxide & amitriptyline LIMBITROL DS 1 chlorpromazine THORAZINE 1 citalopram CELEXA 1 clomipramine ANAFRANIL 1 clozapine CLOZARIL 3 clozapine FAZACLO 1 desipramine NORPRAMIN 1 desvenlafaxine base extended release PRISTIQ 1 doxepin SINEQUAN 1 duloxetine CYMBALTA 1 escitalopram LEXAPRO 1 fluoxetine PROZAC 3 fluoxetine PROZAC WEEKLY 3 fluoxetine SARAFEM 1 fluphenazine PROLIXIN 1 fluvoxamine LUVOX 1 haloperidol HALDOL 3 iloperidone FANAPT 1 imipramine TOFRANIL 1 imipramine pamoate TOFRANIL-PM Kaiser Permanente of Georgia Multi Choice Formulary 19

21 Restrictions Tier Name Brand Name Coverage Status 3 isocarboxazid MARPLAN 3 levomilnacipran FETZIMA 1 lithium carbonate capsule LITHIUM CARBONATE 1 lithium carbonate extended release LITHOBID 1 lithium citrate CIBALITH-S 1 loxapine LOXITANE 3 lurasidone LATUDA 1 maprotiline LUDIOMIL 1 mirtazapine REMERON 1 nefazodone SERZONE 1 nortriptyline PAMELOR 1 olanzapine ZYPREXA 1 olanzapine & fluoxetine hcl SYMBYAX 1 olanzapine orally disintegrating ZYPREXA ZYDIS 3 paliperidone INVEGA 1 paroxetine PAXIL 3 paroxetine extended-release PAXIL CR 3 paroxetine mesylate PEXEVA 1 perphenazine TRILAFON 1 phenelzine NARDIL 3 pimozide ORAP 3 protriptyline VIVACTIL 1 quetiapine SEROQUEL 3 quetiapine extended-release SEROQUEL XR 1 risperidone RISPERDAL 3 risperidone orally disintegrating RISPERDALM-TAB 1 sertraline ZOLOFT 1 thioridazine MELLARIL 1 thiothixene NAVANE 1 tranylcypromine sulfate PARNATE 1 trazodone DESYREL 3 trazodone extended-release OLEPTRO 1 trifluoperazine STELAZINE 3 trimipramine SURMONTIL 1 venlafaxine EFFEXOR 1 venlafaxine extended-release EFFEXOR XR QL 3 vilazodone VIIBRYD 3 vortioxetine BRINTELLIX 1 ziprasidone GEODON Diabetic Supplies Diabetic Supplies QL 3 blood sugar diagnostic ONE TOUCH ULTRA TEST STRIPS QL 1 blood sugar diagnostic ONE TOUCH VERIO TEST STRIPS Preferred Brand QL 3 blood sugar diagnostic ACCU-CHEK TEST STRIPS QL 3 blood sugar diagnostic ASCENSIA TEST STRIPS Kaiser Permanente of Georgia Multi Choice Formulary 20

22 Restrictions Tier Name Brand Name Coverage Status QL 3 blood sugar diagnostic FREESTYLE TEST STRIPS QL 3 blood sugar diagnostic PRODIGY TEST STRIPS QL 3 blood-glucose meter ONE TOUCH ULTRA 2 QL 1 blood-glucose meter ONE TOUCH VERIO IQ Preferred Brand QL 3 blood-glucose meter ACCU-CHEK QL 3 blood-glucose meter ASCENSIA BREEZE QL 3 blood-glucose meter FREESTYLE SYSTEM QL 3 blood-glucose meter ONE TOUCH ULTRA SMART QL 3 blood-glucose meter ONE TOUCH ULTRAMINI QL 3 blood-glucose meter PRODIGY QL 1 syringe with needle,disposable BD INSULIN SYRINGE Electrolytic, Caloric and Water Balance Acidifying and Alkalinizing Agents 3 citric acid, sodium citrate, & potassium citrate CYTRA-3 1 potassium citrate UROCIT-K 2 potassium citrate & citric acid POLYCITRA-K Preferred Brand 3 sodium citrate & citric acid BICITRA Ammonia Detoxicants 3 carglumic acid CARBAGLU QRM 3 glycerol phenylbutyrate RAVICTI 3 sodium phenylbutyrate BUPHENYL 3 lactulose CHRONULAC 1 lactulose ENULOSE 3 lactulose KRISTALOSE Diuretics 1 amiloride MIDAMOR 1 amiloride & hydrochlorothiazide MODURETIC 1 bumetanide BUMEX 1 chlorothiazide DIURIL 1 chlorthalidone HYGROTON 3 ethacrynic acid EDECRIN 1 furosemide LASIX 1 hydrochlorothiazide MICROZIDE 1 indapamide LOZOL 1 metolazone ZAROXOLYN QL 3 tolvaptan SAMSCA 1 torsemide DEMADEX 3 triamterene DYRENIUM 1 triamterene & hydrochlorothiazide DYAZIDE 1 triamterene & hydrochlorothiazide MAXZIDE Ion-Removing Agnets 1 sevelamer carbonate RENVELA 2 sodium polystyrene sulfonate SPS Preferred Brand 3 sucroferric oxyhydroxide VELPHORO 3 lanthanum carbonate FOSRENOL Kaiser Permanente of Georgia Multi Choice Formulary 21

23 Restrictions Tier Name Brand Name Coverage Status 3 sevelamer hcl RENAGEL Replacement Products 2 calcium acetate ELIPHOS Preferred Brand 1 calcium acetate PHOSLO 2 calcium acetate PHOSLYRA Preferred Brand 1 potassium bicarbonate & potassium chloride K-LYTE/CL 1 potassium chloride K-DUR 1 potassium chloride K-TAB 2 potassium chrloide powder KLOR-CON 20 MEQ Preferred Brand 1 potassium gluconate KAON 2 potassium phosphate PHOSPHA Preferred Brand 3 potassium phosphate, monobasic K-PHOS NEUTRAL 2 potassium phosphate, monobasic K-PHOS ORIGINAL Preferred Brand Uricosuric Agents 1 colchicine & probenecid COL-BENEMID 1 probenecid BENEMID Enzymes Enzymes 2 dornase alfa PULMOZYME Preferred Brand Eye, Ear, Nose and Throat (EENT) Anti-infectives 3 azithromycin (ophth) AZASITE 1 bacitracin & polmyxin B (ophth) POLYSPORIN 1 bacitracin (ophth) AK-TRACIN 3 besilfoxacin BESIVANCE 1 chlorhexidine (mouth-throat) PERIDEX 3 ciprofloxacin (ophth) ointment CILOXAN 1 ciprofloxacin (ophth) solution CILOXAN 1 erythromycin (ophth) ROMYCIN 3 ganciclovir (ophth) ZIRGAN 2 gatifloxacin (ophth) ZYMAXID Preferred Brand 1 gentamicin (ophth) GENTAK 1 levofloxacin (ophth) QUIXIN 3 moxifloxacin (ophth) VIGAMOX 2 natamycin NATACYN Preferred Brand 1 neomycin, bacitracin & polymyxin b (ophth) NEO-POLYCIN 1 neomycin, polymycin b & gramicidin (ophth) NEOSPORIN 1 ofloxacin (ophth) OCUFLOX 1 ofloxacin (otic) FLOXIN 1 polymyxin b & trimethoprim (ophth) POLYTRIM 1 sulfacetamide sodium (ophth) ointment SULFAC 1 sulfacetamide sodium (ophth) solution BLEPH-10 Kaiser Permanente of Georgia Multi Choice Formulary 22

24 Restrictions Tier Name Brand Name Coverage Status 2 tobramycin sulfate (ophth) ointment TOBREX Preferred Brand 1 tobramycin sulfate (ophth) solution TOBREX 1 trifluridine VIROPTIC Anti-Inflammatory Agents 1 bacitracin, neomycin, polymyxin B & hydrocortisone (ophth) NEO-POLYCIN HC 3 beclomethasone dipropionate (nasal) QNASL 3 beclomethasone dipropionate monohydrate (nasal) BECONASE AQ 3 bromfenac (ophth) XIBROM 1 budesonide (nasal) RHINOCORT AQUA 3 ciclesonide (nasal) OMNARIS 2 ciprofloxacin & dexamethasone (ophth) CIPRODEX Preferred Brand 3 ciprofloxacin & hydrocortisone (otic) CIPRO HC 2 cyclosporine (ophth) RESTASIS Preferred Brand 1 dexamethasone (ophth) solution DECADRON 2 dexamethasone (ophth) suspension MAXIDEX Preferred Brand 1 diclofenac sodium (ophth) VOLTAREN 3 difluprednate DUREZOL 3 fluocinolone acetonide (otic) DERMOTIC 1 fluorometholone (ophth) FML 3 fluorometholone (ophth) FML FORTE 2 fluorometholone acetate FLAREX Preferred Brand 1 flurbiprofen (ophth) OCUFEN 3 fluticasone furoate VERAMYST 2 gentamicin & prednisolone PRED-G Preferred Brand 1 hydrocortisone & acetic acid (otic) ACETASOL HC 1 ketorolac (ophth) ACULAR 1 ketorolac (ophth) ACULAR LS 3 loteprednol ALREX 3 loteprednol LOTEMAX 3 loteprednol & tobramycin ZYLET 3 mometasone (nasal) NASONEX 2 neomycin, colistin, hydrocortisone & thonzonium (otic) CORTISPORIN-TC Preferred Brand 1 neomycin, polymyxin B & dexamethasone (ophth) MAXITROL 1 neomycin, polymyxin B & hydrocortisone (ophth) CORTISPORIN 1 neomycin, polymyxin B & hydrocortisone (otic) CORTISPORIN 3 nepafenac NEVANAC 1 prednisolone acetate (ophth) OMNIPRED 1 prednisolone acetate (ophth) PRED FORTE 2 prednisolone acetate (ophth) PRED MILD Preferred Brand Kaiser Permanente of Georgia Multi Choice Formulary 23

25 Restrictions Tier Name Brand Name Coverage Status 3 prednisolone sodium phosphate (ophth) INFLAMASE FORTE 1 prednisolone sodium phosphate (ophth) PREDNISOL 3 rimexolone VEXOL 1 sulfacetamide sodium & prednisolone BLEPHAMIDE 2 tobramycin & dexamethasone ointment TOBRADEX Preferred Brand 1 tobramycin & dexamethasone suspension TOBRADEX 3 triamcinolone acetonide (nasal) NASACORT AQ Antiallergic Agents 3 aflcaftadine LASTACAFT 1 azelastine ASTELIN 3 azelastine & fluticasone DYMISTA 1 azelastine (ophth) OPTIVAR 1 azelastine ASTEPRO 3 bepotastine BEPREVE 1 cromolyn sodium (ophth) OPTICROM 3 emedastine EMADINE 1 epinastine (ophth) ELESTAT 3 lodoxamide tromethamine ALOMIDE 3 nedocromil sodium (ophth) ALOCRIL 3 olopatadine PATADAY 3 olopatadine (nasal) PATANASE 3 olopatadine (ophth) PATANOL Antiglaucoma Agents 1 acetazolamide DIAMOX 1 acetazolamide DIAMOX SEQUELS 1 betaxolol hcl BETOPTIC 2 betaxolol hcl BETOPTIC S Preferred Brand 3 bimatoprost LUMIGAN 1 brimonidine ALPHAGAN 1 brimonidine tartrate ALPHAGAN P 3 brinzolamide AZOPT 2 carbachol ISOPTO CARBACHOL Preferred Brand 1 carteolol (ophth) OCUPRESS 1 dorzolamide TRUSOPT 1 dorzolamide & timolol COSOPT 2 ecothiophate PHOSPHOLINE IODIDE Preferred Brand 1 latanoprost XALATAN 1 levobunolol BETAGAN 1 methazolamide NEPTAZANE 1 metipranolol OPTIPRANOLOL 1 pilocarpine ISOPTO CARPINE 3 pilocarpine gel PILOPINE HS Kaiser Permanente of Georgia Multi Choice Formulary 24

26 Restrictions Tier Name Brand Name Coverage Status 3 timolol BETIMOL 3 timolol ISTALOL 1 timolol TIMOPTIC 3 timolol TIMOPTIC-XE 3 travoprost TRAVATAN Z 3 unoprostone isopropyl RESCULA EENT Drugs, Miscellaneous 1 acetic acid VOSOL 2 apraclonidine IOPIDINE Preferred Brand 3 artificial tear insert LACRISERT Local Anesthetics 1 antipyrine & benzocaine AURODEX 1 lidocaine (mouth-throat) XYLOCAINE VISCOUS 1 proparacaine OPTHETIC Mydriatics 1 atropine ISOPTO ATROPINE 2 homatropine ISOPTO HOMATROPINE Preferred Brand 2 scopolamine (ophth) ISOPTO HYOSCINE Preferred Brand Vasoconstrictors 1 tetrahydrozoline TYZINE Gastrointestinal Drugs Anti-inflammatory Agents 3 alosetron LOTRONEX 1 balsalazide COLAZAL 3 balsalazide GIAZO 2 mesalamine controlled-release PENTASA Preferred Brand 2 mesalamine suppository CANASA Preferred Brand 1 mesalamine suspension ROWASA 2 mesalamine tablet LIALDA Preferred Brand 3 olsalazine DIPENTUM Antidiarrhea Agents 3 difenoxin & atropine MOTOFEN 1 diphenoxylate & atropine LOMOTIL 3 paregoric PAREGORIC Antiemetics 2 aprepitant EMEND Preferred Brand 3 dolasetron ANZEMET 1 dronabinol MARINOL 3 granisetron KYTRIL 3 granisetron SANCUSO 1 ondansetron ZOFRAN 1 ondansetron (orally disentigrating) ZOFRAN ODT QL 1 prochlorperazine COMPAZINE 3 scopolamine hydrobromide TRANSDERM-SCOP 1 trimethobenzamide TIGAN Antiulcer Agents and Acid Suppressants Kaiser Permanente of Georgia Multi Choice Formulary 25

27 Restrictions Tier Name Brand Name Coverage Status 3 amoxicillin, clarithromycin, & lansoprazole PREVPAC 1 cimetidine TAGAMET 1 misoprostol CYTOTEC 1 nizatidine AXID Only 75 mg/5 ml 1 ranitidine ZANTAC syrup 1 sucralfate CARAFATE Cathartics and Laxatives 3 polyethylene glycol-electrolyte solution HALFLYTELY 3 polyethylene glycol-electrolyte solution MOVIPREP 1 polyethylene glycol-electrolyte solution COLYTE 1 polyethylene glycol-electrolyte solution GOLYTELY 1 polyethylene glycol-electrolyte solution GAVILYTE-C 1 polyethylene glycol-electrolyte solution NULYTELY 3 sodium phosphates OSMOPREP 3 sodium phosphates VISICOL Digestants 3 pancrelipase (lipase-proteaseamylase) CREON 2 pancrelipase (lipase-proteaseamylase) ZENPEP Preferred Brand 2 pancrelipase (lipase-proteaseamylase) PANCREAZE Preferred Brand 3 pancrelipase (lipase-proteaseamylase) VIOKACE 3 pancrelipase (lipase-proteaseamylase) PERTZYE GI Drugs, Miscellaneous 1 clidinium & chlordiazepoxide LIBRAX 3 linaclotide LINZESS 3 lubiprostone AMITIZA 1 metoclopramide REGLAN 3 phenobarbital and belladonna alkaloids DONNATAL 3 teduglutide GATTEX 1 ursodiol ACTIGALL 1 ursodiol URSO 1 ursodiol URSO FORTE Gold Compounds Kaiser Permanente of Georgia Multi Choice Formulary 26

28 Restrictions Tier Name Brand Name Coverage Status Gold Compounds 2 auranofin RIDAURA Preferred Brand Heavy Metal Antagonists Heavy Metal Antagonists 2 deferasirox EXJADE Preferred Brand 3 deferiprone FERRIPROX 2 penicillamine CUPRIMINE Preferred Brand 2 penicillamine DEPEN Preferred Brand 3 succimer CHEMET 3 trientine SYPRINE Hormones and Synthetic Substitutes Adrenals 1 budesonide ENTOCORT EC 3 budesonide UCERIS 1 cortisone acetate CORTONE ACETATE 1 dexamethasone DECADRON 1 fludrocortisone FLORINEF ACETATE 1 hydrocortisone CORTEF 1 methylprednisolone MEDROL 1 prednisolone PRELONE 1 prednisolone acetate PREDNISOLONE 1 prednisolone sodium phosphate ORAPRED 3 prednisolone sodium phosphate ORAPRED ODT 1 prednisolone sodium phosphate PEDIAPRED 1 prednisone PREDNISONE 3 prednisone RAYOS Androgens 1 danazol DANOCRINE 2 fluoxymesterone ANDROXY Preferred Brand 2 methyltestosterone ANDROID 10 Preferred Brand 3 methyltestosterone METHITEST 2 methyltestosterone TESTRED Preferred Brand 1 oxandrolone OXANDRIN 2 testosterone ANDRODERM Preferred Brand 3 testosterone AXIRON 3 testosterone ANDROGEL 3 testosterone TESTIM 3 testosterone FORTESTA 1 testosterone cypionate DEPO-TESTOSTERONE Contraceptives QL 1 desogestrel & ethinyl estradiol APRI QL 3 desogestrel & ethinyl estradiol DESOGEN QL 3 desogestrel & ethinyl estradiol ORTHO-CEPT QL 1 desogestrel & ethinyl estradiol RECLIPSEN QL 1 desogestrel & ethinyl estradiol (biphasic) KARIVA Kaiser Permanente of Georgia Multi Choice Formulary 27

29 Restrictions Tier Name Brand Name Coverage Status QL 1 desogestrel & ethinyl estradiol (triphasic) CYCLESSA QL 1 desogestrel & ethinyl estradiol (triphasic) VELIVET QL 1 drospirenone & ethinyl estradiol GIANVI QL 1 drospirenone & ethinyl estradiol OCELLA QL 3 drospirenone & ethinyl estradiol YASMIN Non-PReferred QL 3 drospirenone & ethinyl estradiol YAZ QL 3 drospirenone & ethinyl estradiol w/ folate BEYAZ QL 3 drospirenone & ethinyl estradiol w/ folate SAFYRAL QL 3 estradiol valerate & dienogest NATAZIA QL 1 ethynodiol diacetate & ethinyl estradiol KELNOR QL 1 ethynodiol diacetate & ethinyl estradiol ZOVIA QL 3 etonogestrel & ethinyl estradiol NUVARING AGE 1 levonorgestrel PLAN B QL 1 levonorgestrel & ethinyl estradiol AVIANE QL 1 levonorgestrel & ethinyl estradiol LESSINA QL 1 levonorgestrel & ethinyl estradiol LEVORA QL 3 levonorgestrel & ethinyl estradiol NORDETTE-28 QL 1 levonorgestrel & ethinyl estradiol (91- day) INTROVALE QL 3 levonorgestrel & ethinyl estradiol (91- day) LOSEASONIQUE QL 3 levonorgestrel & ethinyl estradiol (91- day) SEASONALE QL 3 levonorgestrel & ethinyl estradiol (91- day) SEASONIQUE QL 1 levonorgestrel & ethinyl estradiol (continuous) AMYTHYST QL 3 levonorgestrel & ethinyl estradiol (continuous) LYPREL QL 1 levonorgestrel & ethinyl estradiol (triphasic) TRIVORA QL 3 norelgestromin & ethinyl estradiol ORTHO EVRA QL 1 norelgestromin & ethinyl estradiol XULANE QL 1 norethindrone CAMILA QL 1 norethindrone NORA-BE QL 3 norethindrone NOR-QD QL 1 norethindrone & ethinyl estradiol BALZIVA QL 3 norethindrone & ethinyl estradiol BREVICON QL 1 norethindrone & ethinyl estradiol JUNEL QL 1 norethindrone & ethinyl estradiol MICROGESTIN QL 3 norethindrone & ethinyl estradiol MODICON Kaiser Permanente of Georgia Multi Choice Formulary 28

30 Restrictions Tier Name Brand Name Coverage Status QL 1 norethindrone & ethinyl estradiol NECON QL 3 norethindrone & ethinyl estradiol NORINYL 1+35 QL 1 norethindrone & ethinyl estradiol NORTREL QL 1 norethindrone & ethinyl estradiol OVCON-35 QL 3 norethindrone & ethinyl estradiol OVCON-50 QL 1 norethindrone & ethinyl estradiol (biphasic) NECON 10/11 QL 1 norethindrone & ethinyl estradiol (triphasic) LEENA QL 1 norethindrone & ethinyl estradiol (triphasic) NORTREL 7/7/7 QL 3 norethindrone & ethinyl estradiol (triphasic) ORTHO-NOVUM QL 3 norethindrone & ethinyl estradiol (triphasic) TRI-NORINYL QL 3 norethindrone & ethinyl estradiol w/ ferrous fumarate ESTROSTEP FE QL 3 norethindrone & ethinyl estradiol w/ ferrous fumarate FEMCON FE QL 3 norethindrone & ethinyl estradiol w/ ferrous fumarate JUNEL FE QL 1 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 1 norethindrone acetate & ethinyl estradiol w/ ferrous fumarate TILIA QL 3 norethindrone acetate & ethinyl estradiol w/ ferrous fumarate LO LOESTRIN FE (biphasic) QL 3 norethindrone-mestranol NORINYL 1+50 QL 3 norethindrone-mestranol ORTHO-NOVUM QL 1 norgestimate & ethinyl estradiol CRYSELLE QL 1 norgestimate & ethinyl estradiol MONONESSA QL 3 norgestimate & ethinyl estradiol ORTHO-CYCLEN QL 1 norgestimate & ethinyl estradiol SPRINTEC QL 1 norgestimate & ethinyl estradiol TRINESSA QL 3 norgestimate & ethinyl estradiol (triphasic) ORTHO TRI-CYCLEN QL 3 norgestimate & ethinyl estradiol (triphasic) ORTHO TRI-CYCLEN LO QL 1 norgestimate & ethinyl estradiol (triphasic) TRI-SPRINTEC QL 3 norgestrel & ethinyl estradiol LO/OVRAL-28 QL 1 norgestrel & ethinyl estradiol LOW-OGESTREL Kaiser Permanente of Georgia Multi Choice Formulary 29

31 Restrictions Tier Name Brand Name Coverage Status QL 1 norgestrel & ethinyl estradiol OGESTREL 2 ulipristal ELLA Preferred Brand Diabetic Agents 1 acarbose PRECOSE QRM 3 alogliptin NESINA QRM 3 alogliptin & metformin KAZANO QRM 3 alogliptin & pioglitazone OSENI QRM 3 canagliflozin INVOKANA 1 chlorpropamide CHLORPROPAMIDE QRM 3 exenatide BYETTA QRM 3 exenatide extended-release BYDUREON QRM 3 dapagliflozin FARXIGA 1 glimepiride AMARYL 1 glipizide GLUCOTROL 1 glipizide & metformin METAGLIP 1 glipizide extended-release GLUCOTROL XL 2 glucagon GLUCAGON EMERGENCY KIT Preferred Brand 3 glucagon GLUCAGEN HYPOKIT 1 glyburide DIABETA 1 glyburide & metformin GLUCOVANCE 1 glyburide micronized GLYNASE 3 insulin aspart NOVOLOG 3 insulin aspart protamine & insulin aspart NOVOLOG MIX 70/30 3 insulin detemir LEVEMIR 3 insulin glargine,hum.rec.anlog LANTUS 3 insulin glulisine APIDRA 3 insulin isophane NOVOLIN N 2 insulin isophane HUMULIN N Preferred Brand 3 insulin isophane & regular insulin NOVOLIN 70/30 3 insulin isophane & regular insulin HUMULIN 50/50 2 insulin isophane & regular insulin HUMULIN 70/30 Preferred Brand 3 insulin lispro HUMALOG 3 insulin lispro protamine & insulin lispro HUMALOG MIX 50/50 3 insulin lispro protamine & insulin lispro HUMALOG MIX 75/25 3 insulin regular NOVOLIN R 2 insulin regular HUMULIN R Preferred Brand QRM 3 linagliptin TRADJENTA QRM 3 linagliptin & metformin JENTADUETO QRM 3 liraglutide VICTOZA 1 metformin GLUCOPHAGE 3 metformin FORTAMET 3 metformin GLUMETZA 3 metformin RIOMET Kaiser Permanente of Georgia Multi Choice Formulary 30

32 Restrictions Tier Name Brand Name Coverage Status 1 metformin extended-release GLUCOPHAGE XR QRM 3 mifepristone KORLYM 3 miglitol GLYSET 1 nateglinide STARLIX 1 pioglitazone ACTOS 3 pioglitazone & glimepiride DUETACT 3 pioglitazone & metformin ACTOPLUS MET QRM 3 pramlintide acetate SYMLIN 1 repaglinide PRANDIN 3 repaglinide & metformin PRANDIMET QRM 3 saxagliptin ONGLYZA QRM 3 Saxagliptin & metformin extendedrelease KOMBIGLYZE XR QRM 3 sitagliptin & metformin JANUMET QRM 3 sitagliptin & simvastatin JUVISYNC QRM 3 sitagliptin phosphate JANUVIA 1 tolazamide TOLINASE 1 tolbutamide ORINASE Estrogens and Antiestrogens 3 conjugated estrogens & bazedoxifene DUAVEE 3 conjugated estrogens & medroxyprogesterone acetate PREMPHASE 3 conjugated estrogens & PREMPRO Only 10mg strength medroxyprogesterone acetate 3 drospirenone & estradiol ANGELIQ 3 esterified estrogens MENEST 1 estradiol ESTRACE TAB 1 estradiol GYNODIOL 3 estradiol & levonorgestrel CLIMARA PRO 1 estradiol & norethindrone ACTIVELLA 3 estradiol & norethindrone COMBIPATCH 3 estradiol & norgestimate PREFEST 3 estradiol acetate FEMTRACE 3 estradiol acetate vaginal tablets FEMRING 3 estradiol gel DIVIGEL 3 estradiol gel ELESTRIN GEL 3 estradiol transdermal ALORA 1 estradiol transdermal CLIMARA DIS 3 estradiol transdermal ESTRADERM 3 estradiol transdermal MENOSTAR 3 estradiol transdermal VIVELLE-DOT 1 estradiol vaginal ESTRACE CREAM 2 estradiol vaginal ESTRING Preferred Brand 2 estradiol vaginal VAGIFEM Preferred Brand Kaiser Permanente of Georgia Multi Choice Formulary 31