KAISER PERMANENTE OF GEORGIA MULTI-CHOICE FORMULARY

KAISER PERMANENTE OF GEORGIA MULTI-CHOICE FORMULARY This document includes Kaiser Permanente Georgia s Multi-Choice formulary as of October 3, 208 For an updated formulary, please visit our website at members.kp.org or call -888-865-583, Monday through Friday 7:00 a.m. to 7:00 p.m. TTY/TDD users should call -800-255-0056.

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 October 3, 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 -888-865-583, Monday through Friday 7:00 a.m. to 7:00 p.m. TTY/TDD users should call -800-255-0056. 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

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

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 -888-865-583, Monday through Friday 7:00 a.m. to 7:00 p.m. TTY/TDD users should call -800-255-0056 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 -888-865-583, Monday through Friday 7:00 a.m. to 7 p.m. TTY/TDD users should call -800-255-0056. 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

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

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 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

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 50 mg REYATAZ Preferred Brand QL atazanavir sulfate 200 mg, 300 mg REYATAZ QL 2 bictegravir & emtricitabine & tenofovir BIKTARVY Preferred Brand QL 3 boceprevir VICTRELIS Kaiser Permanente of Georgia Multi Choice Formulary 6

PA 3 daclatasvir DAKLINZA 2 darunavir & cobicistat PREZCOBIX 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 efavirenz 600 mg SUSTIVA QL 2 efavirenz, emtricitab & tenofovir ATRIPLA Preferred Brand QL 2 efavirenz 600 mg, lamivudine & tenofvir SYMFI Preferred Brand QL 3 efavirenz 400 mg, lamivudine & tenofvir SYMFI LO PA 3 elbasvir & grazoprevir ZEPATIER QL 3 elvitegravir, cobicistat, emtricitabine, & tenofovir STRIBILD QL 2 elvitegravir, cobicistat, emtricitabine, & tenofovir GENVOYA Preferred Brand QL 2 emtricitabine EMTRIVA Preferred Brand QL 2 emtricitabine & tenofovir TRUVADA Preferred Brand QL 2 emtricitabine & tenofovir DESCOVY Preferred Brand QL 3 emtricitabine, rilpivirine, & tenofovir COMPLERA QL 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, PA 3 glecaprevir & pibrentasvir MAVYRET QL 2 indinavir sulfate CRIXIVAN Preferred Brand 3 interferon alfacon- INFERGEN QL 3 lamivudine EPIVIR HBV QL lamivudine EPIVIR QL 2 Lamidudine & tenofovir CIMDUO Preferred Brand 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 Kaiser Permanente of Georgia Multi Choice Formulary 7

QL, PA 3 ombitasvir, paritaprevir, ritonavir, & dasabuvir VIEKIRA QL, PA 2 sofosbuvir, velpatasvir, voxilaprevir VOSEVI Preferred Brand 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 QL 2 raltegravir (600mg) ISENTRESS HD Preferred Brand ribavirin REBETOL QL 3 rilpivirine EDURANT QL rimantadine FLUMADINE QL ritonavir NORVIR 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 tenofovir 300 mg 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 3 abemaciclib VERZENIO 2 abiraterone ZYTIGA Preferred Brand 3 acalabrutinib CALQUENCE anastrozole ARIMIDEX 3 axitinib INLYTA 2 bexarotene TARGRETIN Preferred Brand bicalutamide CASODEX 3 bosutinib BOSULIF Kaiser Permanente of Georgia Multi Choice Formulary 8

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 3 enasidenib IDHIFA 2 enzalutamide XTANDI Preferred Brand 2 erlotinib TARCEVA Preferred Brand 2 estramustine EMCYT Preferred Brand 2 everolimus AFINITOR Preferred Brand exemestane AROMASIN flutamide EULEXIN hydroxyurea HYDREA 2 hydroxyurea DROXIA Preferred Brand 2 ibrutinib IMBRUVICA Preferred Brand 2 idelalisib ZYDELIG Preferred Brand imatinib mesylate GLEEVEC 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 niraparib ZEJULA 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 2 regorafenib STIVARGA Preferred Brand 3 ruxolitinib JAKAFI 2 sorafenib tosylate NEXAVAR Preferred Brand 2 sunitinib malate SUTENT Preferred Brand tamoxifen citrate NOLVADEX Kaiser Permanente of Georgia Multi Choice Formulary 9

temozolomide TEMODAR 2 thioguanine TABLOID Preferred Brand 2 topotecan HYCAMTIN Preferred Brand tretinoin VESANOID 2 trifluidine/tipiracil LONSURF Preferred Brand 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 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 Kaiser Permanente of Georgia Multi Choice Formulary 0

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 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 Kaiser Permanente of Georgia Multi Choice Formulary

3 apixaban ELIQUIS aspirin & dipyridamole AGGRENOX 3 betrixaban BEVYXXA 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 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 Kaiser Permanente of Georgia Multi Choice Formulary 2

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 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 Kaiser Permanente of Georgia Multi Choice Formulary 3

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 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 Kaiser Permanente of Georgia Multi Choice Formulary 4

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 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 Kaiser Permanente of Georgia Multi Choice Formulary 5

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 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 Kaiser Permanente of Georgia Multi Choice Formulary 6

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 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 Kaiser Permanente of Georgia Multi Choice Formulary 7

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 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 Kaiser Permanente of Georgia Multi Choice Formulary 8

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 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 Kaiser Permanente of Georgia Multi Choice Formulary 9

valproate sodium DEPAKENE valproic acid DEPAKENE PA 3 vigabatrin SABRIL zonisamide ZONEGRAN Antimigraine Agents almotriptan AXERT ergotamine & caffeine MIGERGOT 3 eletriptan RELPAX frovatriptan FROVA naratriptan AMERGE rizatriptan MAXALT rizatriptan orally disentigrating MAXALT MLT sumatriptan IMITREX zolmitriptan ZOMIG zolmitriptan orally disentigrating ZOMIG ZMT Antiparkinsonian Agents amantadine SYMMETREL PA 3 amantadine ER GOCOVRI benztropine COGENTIN bromocriptine PARLODEL 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 Kaiser Permanente of Georgia Multi Choice Formulary 20

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 3 zolpidem extended-release AMBIEN CR 3 zolpidem oral spray ZOLPIMIST Central Nervous System Agents Miscellaneous acamprosate CAMPRAL 3 atomoxetine STRATTERA PA 3 cannabidiol EPIDIOLEX 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 Kaiser Permanente of Georgia Multi Choice Formulary 2

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 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 Kaiser Permanente of Georgia Multi Choice Formulary 22

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 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 FLEX 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 Kaiser Permanente of Georgia Multi Choice Formulary 23

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 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, KLOR-CON 20 MEQ 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 Kaiser Permanente of Georgia Multi Choice Formulary 24

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 3 gatifloxacin (ophth) ZYMAXID gentamicin (ophth) GENTAK levofloxacin (ophth) QUIXIN 2 moxifloxacin (ophth) VIGAMOX 2 natamycin NATACYN Preferred Brand 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 Kaiser Permanente of Georgia Multi Choice Formulary 25

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 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 Kaiser Permanente of Georgia Multi Choice Formulary 26

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 House dust mite allergen extract ODACTRA 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 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 Kaiser Permanente of Georgia Multi Choice Formulary 27

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 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 Kaiser Permanente of Georgia Multi Choice Formulary 28

Only 75 mg/5 ml syrup Kaiser Permanente of Georgia Multi Choice Formulary cimetidine TAGAMET misoprostol CYTOTEC nizatidine AXID ranitidine ZANTAC 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 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 Kaiser Permanente of Georgia Multi Choice Formulary 29

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 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 Kaiser Permanente of Georgia Multi Choice Formulary 30

QL desogestrel & ethinyl estradiol (triphasic) CYCLESSA QL desogestrel & ethinyl estradiol (triphasic) VELIVET QL drospirenone & ethinyl estradiol GIANVI QL drospirenone & ethinyl estradiol OCELLA QL drospirenone & ethinyl estradiol YASMIN QL 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 LUTERA QL levonorgestrel & ethinyl estradiol LESSINA QL levonorgestrel & ethinyl estradiol PORTIA QL 3 levonorgestrel & ethinyl estradiol NORDETTE-28 QL levonorgestrel & ethinyl estradiol (9-day) INTROVALE QL 3 levonorgestrel & ethinyl estradiol (9-day) LOSEASONIQUE QL 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 Kaiser Permanente of Georgia Multi Choice Formulary 3

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 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 Kaiser Permanente of Georgia Multi Choice Formulary 32

QL norgestimate & ethinyl estradiol (triphasic) TRI-LO-SPRINTEC 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 3 empagliflozin JARDIANCE PA 3 empagliflozin & linagliptan GLYXAMBI PA 3 empagliflozin & metformin SYNJARDY PA 3 ertufliglozin STEGLATRO PA 3 ertugliflozin & metformin SEGLUROMET PA 3 ertugliflozin & sitagliptin STEGLUJAN 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 Kaiser Permanente of Georgia Multi Choice Formulary 33

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 3 linagliptin TRADJENTA 3 linagliptin & metformin JENTADUETO PA 3 liraglutide VICTOZA PA 3 lixisenatide ADLYXIN metformin GLUCOPHAGE metformin FORTAMET metformin GLUMETZA 3 metformin RIOMET 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 Kaiser Permanente of Georgia Multi Choice Formulary 34

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 All other strengths 3 estradiol vaginal VAGIFEM estradiol vaginal YUVAFEM estradiol vaginal ESTRACE 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 PA 3 abaloparatide TYMLOS calcitonin salmon FORTICAL calcitonin salmon MIACALCIN PA 3 teriparatide FORTEO Kaiser Permanente of Georgia Multi Choice Formulary 35

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 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 brodalumab SILIQ PA 3 c- esterase inhibitor HAEGARDA PA 3 canakinumab ILARIS Kaiser Permanente of Georgia Multi Choice Formulary 36

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 daflazacort EMFLAZA PA 3 dimethyl fumarate TECFIDERA PA 3 dupilumab DUPIXENT disulfiram ANTABUSE dutasteride AVODART dutasteride & tamsulosin JALYN PA 3 eliglustat CERDELGA PA 3 emicizumab-kxwh HEMLIBRA PA 3 erenumab-aooe AIMOVIG 2 etanercept ENBREL Preferred Brand etidronate DIDRONEL 3 everolimus ZORTRESS 3 febuxostat ULORIC PA 3 fingolimod GILENYA PA 3 guselkumab TREMFYA PA 3 glatiramer acetate COPAXONE glatiramer acetate GLATOPA 3 golimumab SIMPONI ibandronate BONIVA PA 3 icatibant FIRAZYR 3 immune globulin HYQVIA PA 3 Immune globulin HIZENTRA PA 3 interferon beta-a AVONEX 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 Kaiser Permanente of Georgia Multi Choice Formulary 37

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 PA 3 pegvaliase PALYNZIQ 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 sodium fluoride drops LURIDE DROPS 2 stannous fluoride GEL-KAM Preferred Brand tacrolimus PROGRAF PA 3 teriflunomide AUBAGIO 2 thalidomide THALOMID Preferred Brand 2 tocilizumab ACTEMRA Preferred Brand 2 tofacitinib XELJANZ Preferred PA 3 ustekinumab STELARA Respiratory Tract Agents Antitussives benzonatate TESSALON PERLES Kaiser Permanente of Georgia Multi Choice Formulary 38

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 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 PA 3 tezacaftor & ivacaftor SYMDEKO 2 tiotropium bromide and olodaterol STIOLTO RESPIMAT Preferred Brand Skin and Mucous Membrane Agents Kaiser Permanente of Georgia Multi Choice Formulary 39

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 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 Kaiser Permanente of Georgia Multi Choice Formulary 40

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 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 Kaiser Permanente of Georgia Multi Choice Formulary 4

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 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 Kaiser Permanente of Georgia Multi Choice Formulary 42

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 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 Kaiser Permanente of Georgia Multi Choice Formulary 43

doxercalciferol HECTOROL ergocalciferol DRISDOL niacin NIACOR paricalcitol ZEMPLAR 2 phytonadione MEPHYTON Preferred Brand Kaiser Permanente of Georgia Multi Choice Formulary 44

Index of Drugs Kaiser Permanente of Georgia Multi Choice Formulary 8 8-MOP... 43 A abacavir sulfate & lamivudine... 6 abacavir sulfate solution... 6 abacavir sulfate tablet... 6 abacavir, dolutegravir & lamivudine... 6 abacavir, lamivudine & zidovudine... 6 abaloparatide... 35 abatacept... 36 abemaciclib... 8 ABILIFY... 2 abiraterone... 8 ABSTRAL... 7 acalabrutinib... 8 acamprosate... 2 acarbose... 33 ACCOLATE... 39 ACCU-CHEK... 23 ACCU-CHEK TEST STRIPS... 23 ACCUNEB... ACCUPRIL... 5 ACCURETIC... 5 ACCUTANE... 43 acebutolol... 6 ACEON... 5 acetaminophen & codeine... 6 acetaminophen, caffeine, & dihydrocodine... 6 ACETASOL HC... 26 acetazolamide... 27 acetic acid... 26, 28 acetylcysteine... 36 acitretin... 42 ACLOVATE... 4 ACTEMRA... 38 ACTHAR... 36 ACTIGALL... 29 ACTIMMUNE... 37 ACTIQ... 7 ACTIVELLA... 35 ACTONEL... 38 ACTOPLUS MET... 34 ACTOS... 34 ACULAR... 26 ACULAR LS... 26 acyclovir... 6, 40 ACZONE... 43 ADALAT CC... 3 adalimumab... 36 adapalene... 42 ADCIRCA... 5 ADDERALL... 8 ADDERALL XR... 8 adefovir dipivoxil... 6 ADEMPAS... 5 ADLYXIN... 34 ADOXA... 5 ADRENACLICK... ADVAIR DISKUS... 39 ADVICOR... 3 AFINITOR... 9 aflcaftadine... 27 AFREZZA... 33 AGGRENOX... 2 AGRYLIN... AIMOBIG... 37 AIMOVIG... 37 AKNE-MYCIN... 40 AK-TRACIN... 25 AKYNZEO... 28 albendazole... 4 ALBENZA... 4 albiglutide... 33 albuterol nebulizer solution... albuterol sulfate... albuterol sulfate & ipratropium... albuterol sulfate tablet... alclometasone dipropionate... 4 ALDACTAZIDE... 5 ALDACTONE... 5 ALDARA... 43 ALDOMET... 4 ALDORIL-25... 4 alendronate... 36 alendronate & cholecalciferol... 36, 38 alfuzosin hcl... ALINIA... 6 alirocumab... 33 aliskiren... 4 aliskiren & amlodipine... 4 aliskiren & hydrochlorothiazide... 4 aliskiren & valsartan... 4 aliskiren, amlodipine & hydrochlorothiazide... 4 alitretinoin... 42 ALKERAN... 9 allopurinol... 36 Kaiser Permanente of Georgia Multi Choice Formulary 45

almotriptan... 20 ALOCRIL... 27 alogliptin... 33 alogliptin & metformin... 33 alogliptin & pioglitazone... 33 ALOMIDE... 27 ALORA... 35 alosetron... 28 ALPHAGAN... 27 ALPHAGAN P... 27 alprazolam... 20 alprazolam extended-release... 20 alprazolam orally disintegrating... 20 ALREX... 26 ALTABAX... 40 ALTACE... 5 ALTOPREV... 3 aluminum chloride hexahydrate... 42 ALVESCO... 39 amantadine... 20 amantadine ER... 20 AMARYL... 33 AMBIEN... 2 AMBIEN CR... 2 ambrisentan... 5 amcinonide... 4 AMERGE... 20 AMICAR... amiloride... 24 amiloride & hydrochlorothiazide... 24 aminocaproic acid... amiodarone... 4 AMITIZA... 29 amitriptyline... 2, 22 amitriptyline & perphenazine... 2 amlodipine... 3, 4 amlodipine & atorvastatin... 3 amlodipine & benazepril... 3 amlodipine & olmesartan... 3 amlodipine & valsartan... 3 amlodipine, olmesartan & hydrochlorothiazide... 3 amlodipine, valsartan & hydrochlorothiazide... 3 ammonium lactate... 42, 43 amoxapine... 2 amoxicillin... 2, 4, 28 amoxicillin & clavulanate potassium... 4 amoxicillin & clavulanate potassium extended-release... 4 amoxicillin, clarithromycin, & lansoprazole... 28 AMOXIL... 4 amphetamine & dextroamphetamine... 8 amphetamine & dextroamphetamine extended-release... 8 Kaiser Permanente of Georgia Multi Choice Formulary AMPICILLIN... 4 ampicillin sodium... 4 AMPYRA... 37 AMRIX... AMTURNIDE... 4 AMYTHYST... 3 ANAFRANIL... 22 anagrelide... anakinra... 36 ANALPRAM HC... 42 ANAPROX... 7 anastrozole... 8 ANCOBON... 5 ANDRODERM... 30 ANDROGEL... 30 ANDROID 0... 30 ANDROXY... 30 ANGELIQ... 35 ANORO ELLIPTA... ANSAID... 7 ANTABUSE... 37 anthralin... 42 antipyrine & benzocaine... 28 ANUSOL-HC... 4 ANZEMET... 28 APEXICON... 4 APIDRA... 34 apixaban... 2 APLENZIN... 22 apraclonidine... 28 apremilast... 36 aprepitant... 28 APRESOLINE... 4 APRI... 30 APTIOM... 9 APTIVUS... 8 ARALEN... 6 ARANELLE... 32 ARANESP... 2 ARAVA... 37 arformoterol... ARICEPT... 0 ARICEPT ODT... 0 ARIMIDEX... 8 aripiprazole... 2 ARIXTRA... 2 armodafinil... 8 ARMOUR THYROID... 36 AROMASIN... 9 ARTANE... 20 ARTHROTEC... 7 artificial tear insert... 28 Kaiser Permanente of Georgia Multi Choice Formulary 46

ASCENSIA BREEZE... 23 ASCENSIA TEST STRIPS... 23 asenapine... 2 ASENDIN... 2 ASMANEX... 39 aspirin & dipyridamole... 2 ASTELIN... 27 ASTEPRO... 27 ATACAND... 4 ATACAND HCT... 4 ATARAX... 2 atazanavir & cobicistat... 6 atazanavir sulfate... 6 atazanavir sulfate 50 mg... 6 atazanavir sulfate 200 mg, 300 mg... 6 ATELVIA... 38 atenolol... 6 atenolol & chlorthalidone... 6 ATIVAN... 2 atomoxetine... 2 atorvastatin... 2, 3 atovaquone... 6 atovaquone & proguanil... 6 ATRIPLA... 7 atropine... 0, 28 atropine sulfate... 0 ATROPINE SULFATE... 0 ATROVENT... 0 ATROVENTHFA... 0 AUBAGIO... 38 AUGMENTIN... 4 AUGMENTIN XR... 4 auranofin... 30 AURODEX... 28 AUSTEDO... 2 AUVI-Q... AVALIDE... 5 AVAPRO... 5 AVAR... 42 AVC... 4 AVELOX... 5 AVINZA... 7 AVLOSULFON... 6 AVODART... 37 AVONEX... 37 AXERT... 20 AXID... 29 AXIRON... 30 axitinib... 8 AYGESTIN... 36 AZASAN... 36 AZASITE... 25 Kaiser Permanente of Georgia Multi Choice Formulary azathioprine... 36 azelaic acid... 42 azelaic acid (acne)... 42 azelastine... 27 azelastine & fluticasone... 27 azelastine (ophth)... 27 AZELEX... 42 azelstine... 27 AZILECT... 20 azilsartan... 4 azithromycin... 4, 25 azithromycin (ophth)... 25 AZOPT... 27 AZOR... 3 AZULFIDINE... 5 B B & O SUPPRETTES... 8 bacitracin & polmyxin B (ophth)... 25 bacitracin (ophth)... 25 bacitracin, neomycin, polymyxin B & hydrocortisone (ophth)... 25 bacitracin, polymyxin, neomycin & hydrocortisone... 4 baclofen... 0 BACTRIM DS... 5 BACTROBAN... 40 BACTROBAN NASAL... 40 balsalazide... 28 BALZIVA... 3 BANZEL... 9 BARACLUDE... 7 BD INSULIN SYRINGE... 23 becaplermin... 42 beclomethasone dipropionate... 39 bedaquiline... 36 BELSOMRA... 2 benazepril... 3, 4 benazepril & hydrochlorothiazide... 4 BENEMID... 25 BENICAR... 5 BENICAR HCT... 5 BENTYL... 0 BENZACLIN... 40 BENZAMYCIN... 40 benzonatate... 38 benzoyl peroxide & erythromycin... 40 benzoyl peroxide & hydrocortisone... 4 benztropine... 20 bepotastine... 27 BEPREVE... 27 besilfoxacin... 25 Kaiser Permanente of Georgia Multi Choice Formulary 47

BESIVANCE... 25 BETAGAN... 27 betamethasone dipropionate (topical)... 4 betamethasone dipropionate augmented... 4 betamethasone valerate... 4 BETAPACE... 6 BETAPACE AF... 6 BETASERON... 37 BETASERON]... 37 betaxolol... 6, 27 betaxolol hcl... 27 bethanechol chloride... 0 BETIMOL... 27 BETOPTIC... 27 BETOPTIC S... 27 betrixaban... 2 BEVYXXA... 2 bexarotene... 8, 42 bexarotene (topical)... 42 BEYAZ... 3 BIAXIN... 4 BIAXIN XL... 4 bicalutamide... 8 BICITRA... 24 bictegravir & emtricitabine & tenofovir... 6 BIDIL... 5 BIKTARVY... 6 bimatoprost... 27 bismuth subcitrate & metronidazole... 4 bisoprol & hydrochlorothiazide... 6 bisoprolol... 6 BLEPH-0... 25 BLEPHAMIDE... 26 BLOCADREN... 6 blood sugar diagnostic... 23 blood-glucose meter... 23 boceprevir... 6 BONIVA... 37 bosentan... 5 BOSULIF... 8 bosutinib... 8 BREO ELLIPTA... 39 BRETHINE... BREVICON... 3 brexpiprazole... 22 BRILINTA... 2 brimonidine... 27, 42 brimonidine (topical)... 42 brimonidine tartrate... 27 BRINTELLIX... 23 brinzolamide... 27 brodalumab... 36 Kaiser Permanente of Georgia Multi Choice Formulary bromfenac (ophth)... 25 bromocriptine... 20 BROVANA... budesonide... 30, 39 budesonide & formoterol... 39 bumetanide... 24 BUMEX... 24 BUPHENYL... 24 buprenorphine... 6 buprenorphine & naloxone film... 6 buprenorphine transdermal... 6 buprenorphine& naloxone tablet... 6 bupropion... 22 bupropion extended-release... 22 bupropion hydrobromide... 22 bupropion sustained-release... 22 BUSPAR... 20 buspirone... 20 busulfan... 9 butalbital & acetaminophen... 6 butalbital, acetaminophen, & caffeine... 6 butalbital, acetaminophen, caffeine, & codeine... 6 butalbital, aspirin, & caffeine... 6 butalbital, aspirin, caffeine, & codeine... 6 butenafine... 40 butoconazole nitrate (vaginal)... 40 butorphanol tartrate... 6 BUTRANS... 6 BYDUREON... 33 BYETTA... 33 BYSTOLIC... 6 C c- esterase inhibitor... 36 cabergoline... 20 CADUET... 3 CAFERGOT... CALAN SR... 3 calcipotriene... 4, 42 calcipotriene & betamethasone... 4 calcitonin salmon... 35 calcitriol... 43 calcitriol (topical)... 43 calcium acetate... 24 CALQUENCE... 8 CAMILA... 3 CAMPRAL... 2 canagliflozin... 33 canagliflozin & metformin... 33 canakinumab... 36 CANASA... 28 Kaiser Permanente of Georgia Multi Choice Formulary 48

candesartan... 4 candesartan & hydrochlorothiazide... 4 cannabidiol... 2 capecitabine... 9 CAPEX SHAMPOO... 4 CAPOTEN... 4 CAPOZIDE... 4 CAPRELSA... 0 captopril... 4 captopril & hydrochlorothiazide... 4 CARAC... 43 CARAFATE... 29 carbachol... 27 CARBAGLU... 24 carbamazepine... 9 carbamazepine extended-release cap... 9 carbamazepine extended-release tab... 9 CARBATROL... 9 carbidopa... 20 carbidopa & levodopa... 20 carbidopa & levodopa extended release... 20 carbidopa, levodopa, & entacapone... 20 carbinoxamine maleate... 4 CARDENE... 3 CARDIZEM... 3 CARDIZEM CD... 3 CARDIZEM LA... 3 CARDURA... 2 carglumic acid... 24 cariprazine... 22 carisoprodol... 0, 6 carisoprodol, aspirin, & codeine... 6 carisoprodol/aspirin... 0 CARMOL... 4, 42 CARMOL HC... 4 carteolol (ophth)... 27 CARTIA XT... 3 carvedilol... 6 carvedilol phosphate... 6 CASODEX... 8 CATAFLAM... 7 CATAPRES... 4 CATAPRES-TTS... 4 CECLOR... 4 CEDAX... 4 CEENU... 9 cefaclor... 4 cefadroxil... 4 cefdinir... 4 cefditoren... 4 cefixime... 4 cefpodoxime... 4 Kaiser Permanente of Georgia Multi Choice Formulary cefprozil... 4 ceftibuten... 4 CEFTIN... 4 cefuroxime axetil... 4 CEFZIL... 4 CELEBREX... 7 celecoxib... 7 CELEXA... 22 CELLCEPT... 38 CELONTIN... 9 CENESTIN... 35 cephalexin... 4 CERDELGA... 37 ceritinib... 9 cevimeline hcl... 0 CHANTIX... 0 CHEMET... 30 CHERATUSSIN AC... 39 chlorambucil... 9 chlordiazepoxide... 2, 22, 29 chlordiazepoxide & amitriptyline... 22 chlorhexidine (mouth-throat)... 25 chloroquine phosphate... 6 chlorothiazide... 24 chlorphenirmine, phenylephrine & pyrilamine... 4 chlorpromazine... 22 chlorpropamide... 33 CHLORPROPAMIDE... 33 chlorthalidone... 6, 24 chlorzoxazone... CHOLBAM... 37 cholestyramine... 2 cholestyramine light... 2 cholic acid... 37 CHRONULAC... 24 CIBALITH-S... 22 ciclesonide... 39 ciclopirox... 40 cilostazol... 2 CILOXAN... 25 CIMDUO... 7 cimetidine... 29 cinacalcet... 37 CIPRO... 4, 26 CIPRO HC... 26 CIPRODEX... 25 ciprofloxacin... 4, 25, 26 ciprofloxacin & dexamethasone (ophth)... 25 ciprofloxacin & hydrocortisone (otic)... 26 ciprofloxacin (ophth) ointment... 25 ciprofloxacin (ophth) solution... 25 citalopram... 22 Kaiser Permanente of Georgia Multi Choice Formulary 49

citric acid, sodium citrate, & potassium citrate... 23 CLARAVIS... 43 clarithromycin... 4, 28 clarithromycin extended-release... 4 CLEOCIN... 4, 40 CLEOCIN HCL... 4 CLEOCIN PEDIATRIC... 4 CLEOCIN T... 40 clidinium & chlordiazepoxide... 29 CLIMARA DIS... 35 CLIMARA PRO... 35 CLINDAGEL... 40 clindamycin & benzoyl peroxide... 40 clindamycin & tretinoin... 43 clindamycin hcl... 4 clindamycin palmitate... 4 clindamycin phosphate (topical)... 40 clindamyinc phosphate (vaginal)... 40 CLINORIL... 8 clobazam... 9 clobetasol propionate... 4 clobetasol propionate emollient... 4 clobetasol propionate emulsion... 4 CLOBEX... 4 clocortolone pivalate... 4 CLODERM... 4 clomipramine... 22 clonazepam... 9 clonidine... 4 clonidine extended-release... 4 clonidine transdermal... 4 clopidogrel... 2 clorazepate... 2 clotrimazole... 40 clotrimazole & betametmethasone... 40 clozapine... 22 CLOZARIL... 22 codeine... 6, 7, 39 CODEINE SULF... 7 COGENTIN... 20 COLAZAL... 28 COL-BENEMID... 25 colchicine... 25, 37 colchicine & probenecid... 25 COLCRYS... 37 colesevelam... 2 COLESTID... 2 colestipol... 2 collagenase... 43 COLYTE... 29 COMBIPATCH... 35 COMBIVENT RESPIMAT... Kaiser Permanente of Georgia Multi Choice Formulary COMBIVIR... 7 COMBUNOX... 8 COMPAZINE... 28 COMPLERA... 7 COMTAN... 20 CONCERTA... 8 CONDYLOX... 43 conjugated estrogens & bazedoxifene... 34 conjugated estrogens & medroxyprogesterone acetate... 34, 35 COPAXONE... 37 CORDRAN... 4 COREG... 6 COREG CR... 6 CORGARD... 6 CORLANOR... 4 CORTEF... 30 CORTENEMA... 4 corticotropin... 36 CORTIFOAM... 4 cortisone acetate... 30 CORTISPORIN... 26, 4 CORTISPORIN-TC... 26 CORTONE ACETATE... 30 CORZIDE... 6 COSENTYX... 38 COSOPT... 27 COUMADIN... 2 COVERA-HS... 3 COZAAR... 5 CREON... 29 CRESEMBA... 5 CRESTOR... 3 crisaborole... 4 CRIXIVAN... 7 crizotinib... 9 cromolyn sodium... 27, 39 cromolyn sodium (ophth)... 27 crotamiton... 40 CRYSELLE... 32 CUPRIMINE... 30 CUTIVATE... 4 CYCLESSA... 3 cyclobenzaprine... cyclobenzaprine extended-release... CYCLOCORT... 4 cyclophosphamide... 9 cycloserine... 6 CYCLOSET... 20 cyclosporine... 26, 37 cyclosporine (ophth)... 26 cyclosporine, modified... 37 Kaiser Permanente of Georgia Multi Choice Formulary 50

CYMBALTA... 22 cyproheptadine... 4 CYSTAGON... 37 cysteamine... 37 cysteamine delayed-release... 37 cysteamine immediate-release... 37 CYTOMEL... 36 CYTOTEC... 29 CYTOVENE... 7 CYTOXAN... 9 CYTRA-3... 23 D D.H.E.45... dabigatran... 2 daclatasvir... 7 daclizumab... 37 daflazacort... 37 DAKLINZA... 7 dalfampridine... 37 DALIRESP... 39 DALMANE... 2 dalteparin... 2 danazol... 30 DANOCRINE... 30 DANTRIUM... dantrolene sodium... dapagliflozin... 33 dapagliflozin & metformin... 33 dapsone... 6, 43 dapsone (topical)... 43 DARAPRIM... 6 darbepoetin alfa... 2 darifenacin... 43 darunavir & cobicistat... 7 darunavir ethanolate... 7 dasatinib... 9 DAYPRO... 8 DAYTRANA... 9 DDAVP... 36 DECADRON... 26, 30 DECLOMYCIN... 4 deferasirox... 30 deferiprone... 30 delavirdine mesylate... 7 DELESTROGEN... 3 DEMADEX... 24 demeclocycline... 4 DEMEROL... 7 DENAVIR... 40 DEPAKENE... 20 Kaiser Permanente of Georgia Multi Choice Formulary DEPAKOTE... 9 DEPAKOTE ER... 9 DEPAKOTE SPRINKLE... 9 DEPEN... 30 DEPO-ESTRADIOL... 3 DEPO-TESTOSTERONE... 30 DERMA-SMOOTHE/FS OIL... 4 DERMATOP... 42 DERMOTIC... 26 DESCOVY... 7 desipramine... 22 desmopressin (non-refrigerated)... 36 desmopressin acetate... 36 DESOGEN... 30 desogestrel & ethinyl estradiol... 30, 3 desogestrel & ethinyl estradiol (biphasic)... 30 desogestrel & ethinyl estradiol (triphasic)... 3 desonide... 4 DESOWEN... 4 desoximetasone... 4 DESOXYN... 8 desvenlafaxine... 22 desvenlafaxine base extended release... 22 desvenlafaxine succinate extended release... 22 DESYREL... 23 DETROL... 43 DETROL LA... 43 deutetrabenazine... 2 dexamethasone... 25, 26, 30 dexamethasone (ophth) solution... 26 dexamethasone (ophth) suspension... 26 DEXEDRINE... 8 dexmethylphenidate... 8 dexmethylphenidate extended-release... 8 dextroamphetamine sulfate... 8 dextroamphetamine sulfate extended-release... 8 dextromethorphan & quinidine... 2 DEXTROSTAT... 8 DIABETA... 33 DIAMOX... 27 DIAMOX SEQUELS... 27 DIASTAT... 9 DIASTAT ACUDIAL... 9 diazepam... 9, 2 DIBENZYLINE... dichlorphenamide... 37 diclofenac epolamine... 43 diclofenac potassium... 7 diclofenac sodium... 7, 26, 43 diclofenac sodium & misoprostol... 7 diclofenac sodium (actinic keratosis)... 43 diclofenac sodium (ophth)... 26 Kaiser Permanente of Georgia Multi Choice Formulary 5

diclofenac sodium extended release... 7 dicloxacillin... 5 dicyclomine... 0 didanosine... 7 didanosine solution... 7 DIDRONEL... 37 difenoxin & atropine... 28 DIFFERIN... 42 DIFICID... 5 diflorasone diacetate... 4 DIFLUCAN... 5 diflunisal... 7 DIFLUNISAL... 7 difluprednate... 26 digoxin... 4 dihydroergotamine mesylate... DILANTIN... 9 DILAUDID... 7 diltiazem... 3 diltiazem extended-release... 3 dimethyl fumarate... 37 DIOVAN... 5 DIOVAN HCT... 5 DIPENTUM... 28 diphenoxylate & atropine... 28 DIPROLENE... 4 DIPROSONE... 4 dipyridamole... 2 DISALCID... 8 disopyramide... 4 disopyramide controlled-release... 4 disulfiram... 37 DITROPAN... 43 DITROPAN XL... 43 DIURIL... 24 divalproex sodium... 9 divalproex sodium capsule... 9 divalproex sodium extended release... 9 DIVIGEL... 35 dofetilide... 4 dolasetron... 28 DOLOPHINE... 7 dolutegravir... 6, 7 donepezil... 0, 2 DONNATAL... 29 dornase alfa... 25 DORYX... 5 dorzolamide... 27 dorzolamide & timolol... 27 DOSTINEX... 20 DOVONEX... 42 doxazosin... 2 Kaiser Permanente of Georgia Multi Choice Formulary doxepin... 22, 42, 43 doxepin (antipuritic)... 42, 43 doxercalciferol... 44 doxycycline... 5, 43 doxycycline (rosacea)... 43 doxycycline hyclate... 5 doxycycline monohydrate... 5 DRISDOL... 44 DRITHOCREME HP... 42 DRITHO-SCALP... 42 dronabinol... 28 dronedarone... 4 drospirenone & estradiol... 35 drospirenone & ethinyl estradiol... 3 drospirenone & ethinyl estradiol w/ folate... 3 DROXIA... 9 droxidopa... DUAC... 40 DUAVEE... 34 DUETACT... 34 dulaglutide... 33 DULERA... 39 duloxetine... 22 DUONEB... dupilumab... 37 DUPIXENT... 37 DURAGESIC... 7 DUREZOL... 26 DURICEF... 4 dutasteride... 37 dutasteride & tamsulosin... 37 DYAZIDE... 24 DYMISTA... 27 DYNACIN... 5 DYNACIRC... 3 DYNACIRC CR... 3 DYNAPEN... 5 dyphylline... 43 DYRENIUM... 24 E E.E.S.... 5 E.S.P... 5 econazole nitrate... 40 ecothiophate... 27 EDARBI... 4 EDECRIN... 24 EDLUAR... 2 edoxaban... 2 EDURANT... 8 efavirenz... 7 Kaiser Permanente of Georgia Multi Choice Formulary 52

efavirenz 400 mg, lamivudine & tenofvir... 7 efavirenz 600 mg... 7 efavirenz 600 mg, lamivudine & tenofvir... 7 efavirenz, emtricitab & tenofovir... 7 EFFEXOR... 23 EFFEXOR XR... 23 EFFIENT... 2 efinaconazole... 5 EFUDEX... 43 ELAVIL... 2 elbasvir & grazoprevir... 7 ELDEPRYL... 20 ELESTAT... 27 ELESTRIN GEL... 35 eletriptan... 20 ELIDEL... 43 eliglustat... 37 ELIMITE... 40 ELIPHOS... 24 ELIQUIS... 2 ELLA... 33 ELMIRON... 38 ELOCON... 42 eltrombopag... 2 eluxadoline... 28 elvitegravir, cobicistat, emtricitabine, & tenofovir... 7 EMADINE... 27 EMCYT... 9 emedastine... 27 EMEND... 28 EMFLAZA... 37 emicizumab-kxwh... 37 EMLA... 42 empagliflozin... 33 empagliflozin & linagliptan... 33 empagliflozin & metformin... 33 EMSAM... 20 emtricitabine... 6, 7 emtricitabine & tenofovir... 6, 7 emtricitabine, rilpivirine, & tenofovir... 7 EMTRIVA... 7 ENABLEX... 43 enalapril... 4 enalapril & hydrochlorothiazide... 4 enasidenib... 9 Enasidenib... 9 ENBREL... 37 enfuvirtide... 7 ENJUVIA... 35 enoxaparin... 2 entacapone... 20 entecavir... 7 ENTOCORT EC... 30 Kaiser Permanente of Georgia Multi Choice Formulary ENTRESTO... 4 ENULOSE... 24 enzalutamide... 9 EPANOVA... 3 EPCLUSA... 8 EPIDIOLEX... 2 epinastine (ophth)... 27 epinephrine... EPIPEN... EPIPEN JR... EPIVIR... 7 EPIVIR HBV... 7 eplerenone... 4 epoetin alfa... 2 EPOGEN... 2 eprosartan... 4 eprosartan & hydrochlorothiazide... 4 EPZICOM... 6 EQUETRO... 9 erenumab-aooe... 37 ergocalciferol... 44 ergoloid mesylates... ergotamine & caffeine..., 20 erlotinib... 9 ERTACZO... 40 ertufliglozin... 33 ertugliflozin & metformin... 33 ertugliflozin & sitagliptin... 33 ERYGEL... 40 ERYPED... 5 ERY-TAB... 5 ERYTHROCIN... 5 ERYTHROMYCIN... 5 erythromycin & sulfisoxazole... 5 erythromycin (acne acid)... 40 erythromycin (ophth)... 25 erythromycin base... 5 erythromycin base delayed-release... 5 erythromycin ethylsuccinate... 5 erythromycin sterate... 5 ESBRIET... 39 escitalopram... 22 eslicarbazepine... 9 estazolam... 2 esterified estrogens... 35 ESTRACE... 35 ESTRACE CREAM... 35 ESTRACE TAB... 35 ESTRADERM... 35 estradiol... 30, 3, 32, 33, 35 estradiol & levonorgestrel... 35 estradiol & norethindrone... 35 Kaiser Permanente of Georgia Multi Choice Formulary 53

estradiol & norgestimate... 35 estradiol acetate... 35 estradiol acetate vaginal tablets... 35 estradiol cypionate... 3 estradiol gel... 35 estradiol transdermal... 35 estradiol vaginal... 35 estradiol valerate... 3 estradiol valerate & dienogest... 3 estramustine... 9 ESTRATEST... 35 ESTRING... 35 estrogen,ester/me-testosterone... 35 estrogens, conjugated... 35 estrogens, conjugated synthetic a... 35 estrogens, conjugated synthetic b... 35 estrogens, conjugated vaginal... 35 estropipate... 35 ESTROSTEP FE... 32 eszopiclone... 2 etanercept... 37 ethacrynic acid... 24 ethambutol... 6 ethontoin... 9 ethosuximide... 9 ethynodiol diacetate & ethinyl estradiol... 3 etidronate... 37 etodolac... 7 etonogestrel & ethinyl estradiol... 3 etravirine... 7 EUCRISA... 4 EULEXIN... 9 EURAX... 40 everolimus... 9, 37 EVISTA... 35 EVOCLIN... 40 evolocumab... 33 Evolocumab... 33 EVOTAZ... 6 EVOXAC... 0 EXALGO... 7 EXELDERM... 4 EXELON... 0 exemestane... 9 exenatide... 33 exenatide extended-release... 33 EXFORGE... 3 EXFORGE HCT... 3 EXJADE... 30 EXTAVIA... 37 ezetimibe... 2 ezetimibe & simvastatin... 2 Kaiser Permanente of Georgia Multi Choice Formulary ezogaine... 9 F FACTIVE... 5 famciclovir... 7 FAMVIR... 7 FANAPT... 22 FARXIGA... 33 FAZACLO... 22 febuxostat... 37 felbamate... 9 FELBATOL... 9 FELDENE... 8 felodipine... 3 FEMARA... 9 FEMCON FE... 32 FEMHRT... 35 FEMRING... 35 FEMTRACE... 35 fenofibrate... 2 fenofibrate, micronized... 2 fenofibric acid... 2 fenoprofen calcium... 7 fentanyl film... 7 fentanyl intranasal... 7 fentanyl lozenge... 7 fentanyl sublingual... 7 fentanyl tablet... 7 fentanyl transdermal... 7 FENTORA... 7 FERRIPROX... 30 fesoterodine... 43 FETZIMA... 22 fidaxomicin... 5 filgrastim... 2 FINACEA... 42 fingolimod... 37 FIORICET... 6 FIORICET W/ CODEINE... 6 FIORINAL... 6 FIORINAL W/ CODEINE... 6 FIRAZYR... 37 FLAGYL... 6 FLAGYL ER... 6 FLAREX... 26 flavoxate... 43 FLAVOXATE... 43 flecainide... 4 FLECTOR... 43 FLEXERIL... FLOMAX... Kaiser Permanente of Georgia Multi Choice Formulary 54

FLORINEF ACETATE... 30 FLOVENT DISKUS AER... 39 FLOVENT HFA... 39 FLOXIN... 25 fluconazole... 5 flucytosine... 5 fludrocortisone... 30 FLUMADINE... 8 fluocinolone acetonide... 26, 4 fluocinolone acetonide (otic)... 26 fluocinonide... 4 fluocinonide emollient... 4 FLUORABON BASIC... 38 FLUORITAB... 38 fluorometholone (ophth)... 26 fluorometholone acetate... 26 FLUOROPLEX... 43 fluorouracil (topical)... 43 fluoxetine... 22 fluoxymesterone... 30 fluphenazine... 22 flurandrenolide... 4 flurazepam... 2 flurbiprofen... 7, 26 flurbiprofen (ophth)... 26 flutamide... 9 fluticasone & salmeterol... 39 fluticasone & salmeterol (00/50 mcg)... 39 fluticasone & salmeterol (250/50 mcg and 500/50 mcg)... 39 fluticasone & vilanterol... 39 fluticasone propionate... 39, 4 fluticasone propionate (topical)... 4 fluvastatin... 3 fluvastatin extended-release... 3 fluvoxamine... 22 FML... 26 FML FORTE... 26 FOCALIN... 8 FOCALIN XR... 8 fondaparinux... 2 FORADIL... formoterol fumarate... FORTAMET... 34 FORTEO... 35 FORTESTA... 30 FORTICAL... 35 FOSAMAX... 36 FOSAMAX PLUS D... 36 fosamprenavir calcium... 7 fosinopril... 5 fosinopril & hydrochlorothiazide... 5 FOSRENOL... 24 Kaiser Permanente of Georgia Multi Choice Formulary FRAGMIN... 2 FREESTYLE SYSTEM... 23 FREESTYLE TEST STRIPS... 23 FROVA... 20 frovatriptan... 20 FURADANTIN... 8 furosemide... 24 FUZEON... 7 FYCOMPA... 9 G gabapentin... 9 GABITRIL... 9 galantamine hydrobromide... 0 ganciclovir... 7, 25 ganciclovir (ophth)... 25 GARAMYCIN... 5, 40 GASTROCROM... 39 gatifloxacin (ophth)... 25 GATTEX... 29 GAVILYTE-C... 29 GEL-KAM... 38 gemfibrozil... 3 gemifloxacin... 5 GENERESS FE... 32 GENTAK... 25 gentamicin & prednisolone... 26 gentamicin (ophth)... 25 gentamicin sulfate... 5, 40 gentamicin sulfate (topical)... 40 GENTROPIN... 36 GENVOYA... 7 GEODON... 23 GIANVI... 3 GIAZO... 28 GILENYA... 37 glatiramer acetate... 37 GLATOPA... 37 glecaprevir & pibrentasvir... 7 GLEEVEC... 9 glimepiride... 33, 34 glipizide... 33 glipizide & metformin... 33 glipizide extended-release... 33 GLUCAGEN HYPOKIT... 33 glucagon... 33 GLUCAGON EMERGENCY KIT... 33 GLUCOPHAGE... 34 GLUCOPHAGE XR... 34 GLUCOTROL... 33 GLUCOTROL XL... 33 Kaiser Permanente of Georgia Multi Choice Formulary 55

GLUCOVANCE... 33 GLUMETZA... 34 glyburide... 33 glyburide & metformin... 33 glyburide micronized... 33 glycerol phenylbutyrate... 24 glycopyrrolate... 0, 39 glycopyrrolate & indacaterol... 39 glycopyrrolate inhalation pow... 0 GLYNASE... 33 GLYSET... 34 GLYXAMBI... 33 GOCOVRI... 20 golimumab... 37 GOLYTELY... 29 granisetron... 28 grass pollen allergen extract (5 glass extract)... 27 GRASTEK... 27 GRASTEK... 27 GRIFULVIN V... 5 griseofulvin microsize... 5 griseofulvin ultramicrosize... 5 GRIS-PEG... 5 guaifenesin & codeine... 39 guanfacine... 4, 2 guanfacine extended-release... 2 guselkumab... 37 GYNAZOLE-... 40 GYNODIOL... 35 H HAEGARDA... 36 halcinonide... 4 HALCION... 2 HALDOL... 22 HALFLYTELY... 29 halobetasol propionate... 4 HALOG... 4 haloperidol... 22 HARVONI... 7 HARVONI... 7 HECTOROL... 44 HELIDAC... 4 HEMLIBRA... 37 heparin... 2 HEPARIN SODIUM... 2 HEPSERA... 6 HETLIOZ... 2 hexachlorophene... 40 HIPREX... 8 HIZENTRA... 37 homatropine... 28, 39 Kaiser Permanente of Georgia Multi Choice Formulary House dust mite allergen extract... 27 HUMALOG... 34 HUMALOG MIX 50/50... 34 HUMALOG MIX 75/25... 34 HUMATIN... 6 HUMATROPE... 36 HUMIRA... 36 HUMULIN 50/50... 34 HUMULIN 70/30... 34 HUMULIN N... 34 HUMULIN R... 34 HYCAMTIN... 0 HYCODAN... 39 HYDERGINE... hydralazine... 4, 5 HYDREA... 9 hydrochlorothiazide... 3, 4, 5, 6, 24 hydrocodone... 7, 39 hydrocodone & acetaminophen... 7 hydrocodone & chlorpheniramine... 39 hydrocodone & homatropine... 39 hydrocodone & ibuprofen... 7 hydrocodone er... 7 hydrocortisone...25, 26, 30, 40, 4, 42 hydrocortisone & acetic acid (otic)... 26 hydrocortisone & pramoxine... 42 hydrocortisone (intrarectal)... 4 hydrocortisone (rectal)... 4 hydrocortisone (topical)... 4 hydrocortisone acetate & urea... 4 hydrocortisone acetate (intrarectal)... 4 hydrocortisone butyrate... 42 hydrocortisone butyrate hydrophilic lipo base... 42 hydrocortisone probutate... 42 hydrocortisone valerate... 42 hydromorphone oral suspension... 7 hydromorphone tablet... 7 hydroxychloroquine sulfate... 6 hydroxyurea... 9 hydroxyzine hcl... 2 hydroxyzine pamoate... 2 HYGROTON... 24 hyoscyamine sulfate... 0 HYPERCARE... 42 HYPERSAL... 39 HYQVIA... 37 HYSINGLA ER... 7 HYTONE... 4 HYTRIN... 2 HYZAAR... 5 Kaiser Permanente of Georgia Multi Choice Formulary 56

I ibandronate... 37 IBRANCE... 9 ibrutinib... 9 ibuprofen... 7, 8 icatibant... 37 ICLUSIG... 9 idelalisib... 9 IDHIFA... 9 ILARIS... 36 iloperidone... 22 imatinib mesylate... 9 IMBRUVICA... 9 IMDUR... 5 imipramine... 22 imipramine pamoate... 22 imiquimod... 43 IMITREX... 20 immune globulin... 37 Immune globulin... 37 IMPAVIDO... 6 IMURAN... 36 INCIVEK... 8 INCRUSE ELLIPTA... 0 indapamide... 24 INDERAL... 6 INDERAL LA... 6 INDERIDE... 6 indinavir sulfate... 7 INDOCIN... 7 indomethacin... 7 INFERGEN... 7 INFLAMASE FORTE... 26 ingenol mebutate... 43 INGREZZA... 2 INLYTA... 8 INNOPRAN XL... 6 INSPRA... 4 insulin (oral inhalation)... 33 insulin aspart... 33 insulin aspart protamine & insulin aspart... 33 insulin degludec... 33 Insulin degludec/ liraglutide... 34 insulin degludec/insulin aspart... 33 insulin detemir... 34 insulin glargine... 34 insulin glargine,hum.rec.anlog... 34 Insulin glargine/ lixisenatide... 34 insulin glulisine... 34 insulin isophane... 34 insulin isophane & regular insulin... 34 insulin lispro... 34 Kaiser Permanente of Georgia Multi Choice Formulary insulin lispro protamine & insulin lispro... 34 insulin regular... 34 INTAL... 39 INTELENCE... 7 interferon alfacon-... 7 interferon beta-a... 37 interferon beta-b... 37 Interferon beta-b... 37 interferon gamma-b... 37 INTROVALE... 3 INTUNIV... 2 INVEGA... 22 INVIRASE... 8 INVOKAMET... 33 INVOKANA... 33 iodoquinol & hydrocortisone... 40 IOPIDINE... 28 ipratropium bromide... 0 irbesartan... 5 irbesartan & hydrochlorothiazide... 5 isavuconazonium... 5 ISENTRESS... 8 ISENTRESS HD... 8 isocarboxazid... 22 isoniazid... 6 ISOPTIN SR... 3 ISOPTO ATROPINE... 28 ISOPTO CARBACHOL... 27 ISOPTO CARPINE... 27 ISOPTO HOMATROPINE... 28 ISOPTO HYOSCINE... 28 ISORDIL... 5 isosorbide dinitrate... 5 isosorbide dinitrate & hydralazine... 5 isosorbide mononitrate... 5 isotretinoin... 43 isradipine... 3 ISTALOL... 27 itraconazole... 5 itraconazole (solution)... 5 Ivabradine... 4 ivacaftor... 39 ivermectin... 4 ixazomib... 9 ixekizumab... 37 J JAKAFI... 9 JALYN... 37 JANUMET... 34 JANUVIA... 34 Kaiser Permanente of Georgia Multi Choice Formulary 57

JARDIANCE... 33 JENTADUETO... 34 JUBLIA... 5 JUNEL... 32 JUNEL FE... 32 JUVISYNC... 34 JUXTAPID... 3 K KADIAN... 7 KALETRA... 7 KALYDECO... 39 KAON... 24 KAPVAY... 4 KARIVA... 30 KAZANO... 33 K-DUR... 24 KEFLEX... 4 KELNOR... 3 KENALOG... 42 KEPPRA... 9 KEPPRA XR... 9 KERLONE... 6 KERYDIN... 6 KETEK... 5 ketoconazole... 5, 40 ketoconazole (topical)... 40 ketoprofen... 7 KETOPROFEN... 7 ketorolac (ophth)... 26 ketorolac tablet... 7 KEVEYIS... 37 KINERET... 36 KLARON... 4 KLONOPIN... 9 KLOR-CON 20 MEQ... 24 K-LYTE/CL... 24 KOMBIGLYZE XR... 34 KORLYM... 34 K-PHOS NEUTRAL... 24 K-PHOS ORIGINAL... 24 KRISTALOSE... 24 K-TAB... 24 K-TAB, KLOR-CON 20 MEQ... 24 KUVAN... 38 KWELL... 40 KYNAMRO... 3 KYTRIL... 28 L labetalol... 6 Kaiser Permanente of Georgia Multi Choice Formulary LAC-HYDRIN... 42 lacosamide... 9 LACRISERT... 28 lactic acid (ammonium lactate)... 43 LACTINOL... 43 lactulose... 24 LAMICTAL... 9 LAMICTAL XR... 9 Lamidudine & tenofovir... 7 LAMISIL... 6 lamivudine... 6, 7 lamivudine & zidovudine... 6, 7 lamotrigine... 9 lamotrigine extended-release... 9 LANOXIN... 4 lanreotide... 37 lanthanum carbonate... 24 LANTUS... 34 LANTUS, BASAGLAR... 34 lapatinib... 9 LARIAM... 6 LASIX... 24 LASTACAFT... 27 latanoprost... 27 LATUDA... 22 LAZANDA... 7 ledipasvir & sofosbuvir... 7 ledipasvir & sofosbuvir... 7 LEENA... 32 leflunomide... 37 lenalidomide... 9 lenvatinib... 9 LENVIMA... 9 LESCOL... 3 LESCOL XL... 3 lesinurad... 37 LESSINA... 3 LETAIRIS... 5 letrozole... 9 leucovorin... 37 LEUCOVORIN... 37 LEUKERAN... 9 LEUKINE... 2 leuprolide acetate... 9 levalbuterol nebulizer solution... levalbuterol tartrate... LEVAQUIN... 5 LEVATOL... 6 LEVBID... 0 LEVEMIR... 34 levetiracetam... 9 levetiracetam extended-release... 9 Kaiser Permanente of Georgia Multi Choice Formulary 58

levobunolol... 27 LEVO-DROMORAN... 7 levofloxacin... 5, 25 levofloxacin (ophth)... 25 levomilnacipran... 22 levonorgestrel... 3, 35 levonorgestrel & ethinyl estradiol... 3 levonorgestrel & ethinyl estradiol (9-day)... 3 levonorgestrel & ethinyl estradiol (continuous)... 3 levonorgestrel & ethinyl estradiol (triphasic)... 3 levorphanol... 7 LEVOTHROID... 36 levothyroxine... 36 LEVOXYL... 36 LEVSIN... 0 LEXAPRO... 22 LEXIVA... 7 LIALDA... 28 LIBRAX... 29 LIBRIUM... 2 LIDAMANTLE... 42 LIDEX... 4 LIDEX-E... 4 lidocaine... 28, 42 lidocaine & hydrocortisone... 42 lidocaine & prilocaine... 42 lidocaine (Jelly, oral solution)... 42 lidocaine (Jelly, topical)... 42 lidocaine (mouth-throat)... 28 lifitegrast... 26 LIMBITROL DS... 22 linaclotide... 29 linagliptin... 34 linagliptin & metformin... 34 lindane... 40 linezolid... 5 LINZESS... 29 LIORESAL... 0 liothyronine... 36 liotrix... 36 LIPITOR... 2 liraglutide... 34 lisdexamfetamine... 8 lisinopril... 5 lisinopril & hydrochlorothiazide... 5 LITHIUM CARBONATE... 22 lithium carbonate capsule... 22 lithium carbonate extended release... 22 lithium citrate... 22 LITHOBID... 22 LIVALO... 3 lixisenatide... 34 Kaiser Permanente of Georgia Multi Choice Formulary LO LOESTRIN FE... 32 LO/OVRAL-28... 33 LOCOID... 42 LOCOID LIPOCREAM... 42 LODINE... 7 LODOSYN... 20 lodoxamide tromethamine... 27 LOESTRIN 24 FE... 32 LOESTRIN FE... 32 LOFIBRA CAP... 2 LOFIBRA TAB... 2 lomitapide... 3 LOMOTIL... 28 lomustine... 9 LONITEN... 4 LONSURF... 0 LOPID... 3 lopinavir & ritonavir... 7 LOPRESSOR... 6 LOPRESSOR HCT... 6 LOPROX... 40 lorazepam... 2 losartan... 5 losartan & hydrochlorothiazide... 5 LOSEASONIQUE... 3 LOTEMAX... 26 LOTENSIN... 4 LOTENSIN HCT... 4 loteprednol... 26 loteprednol & tobramycin... 26 LOTREL... 3 LOTRISONE... 40 LOTRONEX... 28 lovastatin... 3 lovastatine extended-release... 3 LOVAZA... 3 LOVENOX... 2 LOW-OGESTREL... 33 loxapine... 22 LOXITANE... 22 LOZOL... 24 lubiprostone... 29 LUDIOMIL... 22 LUFYLLIN... 43 luliconazole... 6 lumacaftor& ivacaftor... 39 LUMIGAN... 27 LUNESTA... 2 LUPRON... 9 lurasidone... 22 LURIDE CHEW... 38 LURIDE DROPS... 38 Kaiser Permanente of Georgia Multi Choice Formulary 59

LUTERA... 3 LUVOX... 22 LUXIQ... 4 LUZU... 6 LYPREL... 3 LYRICA... 9 LYSODREN... 9 M macitentan... 5 MACROBID... 8 MACRODANTIN... 8 mafenide acetate... 40 MALARONE... 6 malathion... 40 maprotiline... 22 maraviroc... 7 MARINOL... 28 MARPLAN... 22 MATULANE... 9 MAVIK... 5 MAVYRET... 7 MAXAIR AUTOHALER... MAXALT... 20 MAXALT MLT... 20 MAXIDEX... 26 MAXITROL... 26 MAXZIDE... 24 mechlorethamine... 9 mechlorethamine... 9 meclofenamate... 7 MECLOMEN... 7 MEDROL... 30 medroxyprogesterone acetate... 34, 35, 36 mefenamic acid... 7 mefloquine... 6 MEGACE... 36 megestrol acetate... 36 MELLARIL... 23 meloxicam... 7 melphalan... 9 memantine... 2 memantine er & donepezil... 2 M-END MAX D... 39 MENEST... 35 MENOSTAR... 35 MENTAX... 40 meperidine tablet... 7 MEPHYTON... 44 mepolizumab... 39 meprobamate... 2 Kaiser Permanente of Georgia Multi Choice Formulary MEPRON... 6 mercaptopurine... 9 mesalamine controlled-release... 28 mesalamine suppository... 28 mesalamine suspension... 28 mesalamine tablet... 28 mesna... 37 MESNEX... 37 MESTION... 0 MESTION TIMESPAN... 0 METADATE CD... 8 METADATE ER... 8 METAGLIP... 33 metaxalone... metformin... 33, 34 metformin extended-release... 34 methadone... 7 methamphetamine... 8 methazolamide... 27 methenamine hippurate... 8 methenamine, sodium biphosphate, phenyl salicylate, methylene blue, and hyoscyamine... 8, 38 METHERGINE... 38 methimazole... 36 METHITEST... 30 methocarbamol... methotrexate... 9 methotrexate sodium... 9 methoxsalen... 43 methoxsalen, rapid... 43 methscopolamine... 0 methsuximide... 9 methyldopa... 4 methyldopa & hydrochlorothiazide... 4 methylergonovine maleate... 38 METHYLIN... 8 methylphenidate... 8, 9 methylphenidate extended-release... 8 methylphenidate sustained release... 9 methylphenidate transdermal patch... 9 methylprednisolone... 30 methyltestosterone... 30 metipranolol... 27 metoclopramide... 29 metolazone... 24 metoprol & hydrochlorothiazide... 6 metoprolol succinate... 6 metoprolol tartrate... 6 metreleptin... 38 METROCREAM... 40 METROGEL... 40 METROGEL-VAGINAL... 40 Kaiser Permanente of Georgia Multi Choice Formulary 60

METROLOTION... 40 metronidazole... 4, 6, 40 metronidazole (topical)... 40 metronidazole (vaginal)... 40 metronidazole, tetracycline & bismuth subsalicylate... 4 metronidazoleextended-release... 6 MEVACOR... 3 mexiletine... 4 MEXITIL... 4 MIACALCIN... 35 MICARDIS... 5 MICARDIS HCT... 5 miconazole nitrate & zinc oxide... 40 MICROGESTIN... 32 MICROGESTIN FE... 32 MICROZIDE... 24 MIDAMOR... 24 midodrine hcl... MIFEPREX... 38 mifepristone... 34, 38 MIGERGOT... 20 miglitol... 34 miglustat... 38 MIGRANAL... milnacipran... 2 miltefosine... 6 MILTOWN... 2 MINIPRESS... 2 MINOCIN... 5 minocycline... 5 minoxidil... 4 mipomersen sodium... 3 mirabegron... 43 MIRAPEX... 20 MIRAPEX ER... 20 mirtazapine... 22 MIRVASO... 42 misoprostol... 7, 29 mitotane... 9 MOBIC... 7 modafinil... 9 MODICON... 32 MODURETIC... 24 moexipril... 5 moexipril & hydrochlorothiazide... 5 mometasone & formoterol... 39 mometasone furoate... 39, 42 MONODOX... 5 MONONESSA... 32 MONOPRIL... 5 MONOPRIL HCT... 5 montelukast... 39 Kaiser Permanente of Georgia Multi Choice Formulary morphine... 7 morphine beads... 7 morphine extended-relase capsule... 7 morphine extended-release tablet... 7 MORPHINE SULFATE... 7 MOTOFEN... 28 MOTRIN... 7 MOVIPREP... 29 moxifloxacin... 5, 25 moxifloxacin (ophth)... 25 MOZOBIL... 38 MS CONTIN... 7 MSIR... 7 MUCOMYST-0... 36 MULTAQ... 4 mupirocin... 40 mupirocin calcium... 40 MYALEPT... 38 MYAMBUTOL... 6 MYCELEX... 40 MYCIFRADIN... 5 MYCOBUTIN... 6 MYCOLOG II... 42 mycophenolate mofetil... 38 mycophenolate sodium... 38 MYCOSTATIN... 6 MYFORTIC... 38 MYLERAN... 9 MYRBETRIQ... 43 MYSOLINE... 9 N na sulfacetm/avobenzone/sulfur... 40 nabumetone... 7 nadolol... 6 nadolol & bendroflumethiazide... 6 nafarelin... 35 naftifine... 40 NAFTIN... 40 nalbuphine... 7 NALFON... 7 naloxone... 6, 8, 2 naloxone nasal spray... 2 naltrexone... 2 NAMENDA... 2 NAMZARIC... 2 NAPRELAN... 7 NAPROSYN... 7 naproxen... 7 naproxen sodium... 7 naratriptan... 20 Kaiser Permanente of Georgia Multi Choice Formulary 6

NARCAN... 2 NARDIL... 23 NATACYN... 25 natamycin... 25 NATAZIA... 3 nateglinide... 34 NATPARA... 38 NATROBA... 40 NAVANE... 23 nebivolol... 6 NECON... 32 NECON 0/... 32 nedocromil sodium (ophth)... 27 nefazodone... 22 nelfinavir mesylate... 7 neomycin sulfate... 5 neomycin, bacitracin & polymyxin b (ophth)... 25 neomycin, colistin, hydrocortisone & thonzonium (otic).. 26 neomycin, polymycin b & gramicidin (ophth)... 25 neomycin, polymyxin B & dexamethasone (ophth)... 26 neomycin, polymyxin B & hydrocortisone (ophth)... 25, 26 neomycin, polymyxin B & hydrocortisone (otic)... 26 NEO-POLYCIN... 25 NEO-POLYCIN HC... 25 NEORAL... 37 NEOSPORIN... 25 neostigmine bromide... 0 nepafenac... 26 NEPTAZANE... 27 NESINA... 33 netupitant & palonosetron... 28 NEULASTA... 2 NEUMEGA... 2 NEUPOGEN... 2 NEUPRO... 20 NEURONTIN... 9 NEVANAC... 26 nevirapine solution... 7 nevirapine tablet... 7 NEXAVAR... 9 niacin... 3, 44 niacin & lovastatin... 3 NIACOR... 44 NIASPAN... 3 nicardipine... 3 nifedipine... 3 nifedipine extended-release... 3 nilotinib... 9 nimodipine... 3 NIMOTOP... 3 NINLARO... 9 nintedanib... 39 Kaiser Permanente of Georgia Multi Choice Formulary niraparib... 9 NIRAVAM... 20 nisoldipine... 3 nitazoxanide... 6 nitisinone... 38 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... 29 NIZORAL... 5, 40 NOLVADEX... 9 NORA-BE... 3 NORCO... 7 NORDETTE-28... 3 NORDITROPIN... 36 norelgestromin & ethinyl estradiol... 3 norethindrone... 3, 32, 35, 36 norethindrone & ethinyl estradiol... 3, 32 norethindrone & ethinyl estradiol (biphasic)... 32 norethindrone & ethinyl estradiol (triphasic)... 32 norethindrone & ethinyl estradiol w/ ferrous fumarate... 32 norethindrone acetate... 32, 35, 36 norethindrone acetate & ethinyl estradiol... 32, 35 norethindrone acetate & ethinyl estradiol w/ ferrous fumarate... 32 norethindrone acetate & ethinyl estradiol w/ ferrous fumarate (biphasic)... 32 norethindrone-mestranol... 32 NORFLEX... norfloxacin... 5 NORGESIC... norgestimate & ethinyl estradiol... 32, 33 norgestimate & ethinyl estradiol (triphasic)... 32, 33 norgestrel & ethinyl estradiol... 33 NORINYL +35... 32 NORINYL +50... 32 NOROXIN... 5 NORPACE... 4 NORPACE CR... 4 NORPRAMIN... 22 NOR-QD... 3 NORTHERA... Kaiser Permanente of Georgia Multi Choice Formulary 62

NORTREL... 32 NORTREL /35... 32 NORTREL 7/7/7... 32 nortriptyline... 22 NORVASC... 3 NORVIR... 8 NOVOLIN 70/30... 34 NOVOLIN N... 34 NOVOLIN R... 34 NOVOLOG... 33 NOVOLOG MIX 70/30... 33 NOXAFIL... 6 NUBAIN... 7 NUCALA... 39 NUCYNTA... 8 NUEDEXTA... 2 NULYTELY... 29 NUPLAZID... 23 NUTROPIN AQ... 36 NUVARING... 3 NUVIGIL... 8 NYDRAZID... 6 nystatin... 6, 40, 42 NYSTATIN... 40 nystatin & triamcinolone... 42 nystatin (topical)... 40 O OCELLA... 3 octreotide acetate... 38 OCUFEN... 26 OCUFLOX... 25 OCUPRESS... 27 ODACTRA... 27 ODEFSEY... 7 OFEV... 39 ofloxacin (ophth)... 25 ofloxacin (otic)... 25 OGESTREL... 33 olanzapine... 22 olanzapine & fluoxetine hcl... 22 olanzapine orally disintegrating... 22 OLEPTRO... 23 olmesartan... 3, 5 olmesartn & hydrochlorothiazide... 5 olodaterol..., 39 olopatadine... 27 olopatadine (nasal)... 27 olopatadine (ophth)... 27 olsalazine... 28 OLUX-E... 4 Kaiser Permanente of Georgia Multi Choice Formulary OLYSIO... 8 omalizumab... 39 ombitasvir, paritaprevir & ritonavir... 7 ombitasvir, paritaprevir, ritonavir, & dasabuvir... 8 omega-3 acid ethyl esters... 3 omega-3-carboxylic acid... 3 OMNICEF... 4 OMNIPRED... 26 OMNITROPE... 36 ondansetron... 28 ondansetron (orally disentigrating)... 28 ONE TOUCH ULTRA 2... 23 ONE TOUCH ULTRA SMART... 23 ONE TOUCH ULTRA TEST STRIPS... 23 ONE TOUCH ULTRAMINI... 23 ONE TOUCH VERIO FLEX... 23 ONE TOUCH VERIO TEST STRIPS... 23 ONFI... 9 ONGLYZA... 34 ONSOLIS... 7 OPANA... 8 OPANA ER... 8 OPIUM... 8 opium & belladonna alkaloids... 8 opium tincture... 8 oprelvekin... 2 OPSUMIT... 5 OPTHETIC... 28 OPTICROM... 27 OPTIPRANOLOL... 27 OPTIVAR... 27 ORACEA... 5, 43 ORALAIR... 27 ORALAIR... 27 ORAP... 23 ORAPRED... 30 ORAPRED ODT... 30 ORENCIA... 36 ORENITRAM... 5 ORFADIN... 38 ORINASE... 34 ORKAMBI... 39 orphenadrine citrate... orphenadrine, aspirin, & caffeine... ORTHO EVRA... 3 ORTHO TRI-CYCLEN... 32 ORTHO-CEPT... 30 ORTHO-CYCLEN... 32 ORTHO-EST... 35 ORTHO-NOVUM... 32 oseltamivir phosphate... 8 OSENI... 33 Kaiser Permanente of Georgia Multi Choice Formulary 63

OSMOPREP... 29 ospemifene... 35 OSPHENA... 35 OTEZLA... 36 OTREXUP... 9 OVCON-35... 32 OVCON-50... 32 OVIDE... 40 OXANDRIN... 30 oxandrolone... 30 oxaprozin... 8 oxazepam... 2 oxcarbazepine... 9 oxiconazole nitrate... 40 OXISTAT... 40 OXSORALEN-ULTRA... 43 oxybutynin... 43 oxybutynin extended-release... 43 oxybutynin transdermal... 43 oxycodone... 8 oxycodone & acetaminophen... 8 oxycodone & acetaminophen er... 8 oxycodone & aspirin... 8 oxycodone & ibuprofen... 8 oxycodone controlled-release... 8 OXYCONTIN... 8 oxymorphone... 8 oxymorphone extended-release... 8 OXYTROL... 43 P PACERONE... 4 palbociclib... 9 PALGIC... 4 paliperidone... 22 palivizumab... 8 PALYNZIQ... 38 PAMELOR... 22 PAMINE... 0 PANCREAZE... 29 pancrelipase (lipase-protease-amylase)... 29 PANDEL... 42 PANLOR SS... 6 PANRETIN... 42 papaverine... 5 PARAFON FORTE DSC... parathyroid hormone... 38 PARCOPA... 20 paregoric... 28 PAREGORIC... 28 paricalcitol... 44 Kaiser Permanente of Georgia Multi Choice Formulary PARLODEL... 20 PARNATE... 23 paromomycin sulfate... 6 paroxetine... 22 paroxetine extended-release... 22 paroxetine mesylate... 22 pasireotide... 38 PATADAY... 27 PATANASE... 27 PATANOL... 27 patiromer... 24 PAVABID... 5 PAXIL... 22 PAXIL CR... 22 pazopanib... 9 PEDIAPRED... 30 pediatric multivitamins w/ fluoride... 38 pediatric multivitamins w/ fluoride & iron... 38 pediatric vitamins a, c, & d, w/ fluoride... 38 pediatric vitamins a, c, & d, w/ fluoride & iron... 38 PEGANONE... 9 PEGASYS... 8 pegfilgrastim... 2 peginterferon alfa-2a... 8 peginterferon-alfa 2b... 8 PEG-INTRON... 8 pegvaliase... 38 pegvisomant... 36 penbutolol... 6 penciclovir... 40 penicillamine... 30 penicillin v potassium... 5 PENLAC... 40 PENNSAID... 7 PENTASA... 28 pentazocine & naloxone... 8 pentosan polysulfate sodium... 38 pentoxifylline... 2 PEN-VEE K... 5 perampanel... 9 PERCOCET... 8 PERCODAN... 8 PERIACTIN... 4 PERIDEX... 25 perindopril... 5 PERIOSTAT... 5 permethrin... 40 perphenazine... 2, 22 PERSANTINE... 2 PERTZYE... 29 PEXEVA... 22 phenelzine... 23 Kaiser Permanente of Georgia Multi Choice Formulary 64

PHENERGAN... 4, 39 PHENERGAN VC... 4, 39 PHENERGAN VC W/CODEINE... 39 PHENERGAN W/ CODEINE... 39 phenobarbital... 2, 29 PHENOBARBITAL... 2 phenobarbital and belladonna alkaloids... 29 phenoxybenzamine... PHENYTEK... 9 phenytoin sodium extended-release... 9 phenytoin suspension... 9 PHISOHEX... 40 PHOSLO... 24 PHOSLYRA... 24 PHOSPHA... 24 PHOSPHOLINE IODIDE... 27 PHRENILIN... 6 PHRENILIN FORTE... 6 phytonadione... 44 PICATO... 43 pilocarpine... 0, 27 pilocarpine gel... 27 PILOPINE HS... 27 pimavanserin... 23 pimecrolimus... 43 pimozide... 23 pindolol... 6 pioglitazone... 33, 34 pioglitazone & glimepiride... 34 pioglitazone & metformin... 34 pirbuterol acetate... pirfenidone... 39 piroxicam... 8 pitavastatin... 3 PLAN B... 3 PLAQUENIL... 6 PLAVIX... 2 PLEGRIDY... 37 PLENDIL... 3 plerixafor... 38 PLETAL... 2 PLEXION... 42 PLEXION SCT... 42 podofilox... 43 POLY HIST FORTE... 4 POLYCITRA-K... 24 polyethylene glycol-electrolyte solution... 29 polymyxin b & trimethoprim (ophth)... 25 POLYSPORIN... 25 POLYTRIM... 25 POLY-VI-FLOR... 38 POLY-VI-FLOR W/IRON... 38 Kaiser Permanente of Georgia Multi Choice Formulary pomalidomide... 9 POMALYST... 9 ponatinib... 9 PONSTEL... 7 PORTIA... 3 posaconazole... 6 potassium bicarbonate & potassium chloride... 24 potassium chloride... 24 potassium chrloide powder... 24 potassium citrate... 23, 24 potassium citrate & citric acid... 24 potassium gluconate... 24 potassium phosphate... 24 potassium phosphate, monobasic... 24 POTIGA... 9 PRADAXA... 2 PRALUENT... 33 pramipexole... 20 pramipexole extended-release... 20 pramlintide acetate... 34 PRAMOSONE... 42 PRAMOSONE-E... 42 pramoxine... 42 PRANDIMET... 34 PRANDIN... 34 prasugrel... 2 PRAVACHOL... 3 pravastatin... 3 prazosin... 2 PRECOSE... 33 PRED FORTE... 26 PRED MILD... 26 PRED-G... 26 prednicarbate... 42 PREDNISOL... 26 prednisolone... 26, 30 PREDNISOLONE... 30 prednisolone acetate... 26, 30 prednisolone acetate (ophth)... 26 prednisolone sodium phosphate... 26, 30 prednisolone sodium phosphate (ophth)... 26 prednisone... 30 PREDNISONE... 30 PREFEST... 35 pregabalin... 9 PRELONE... 30 PREMARIN... 35 PREMARIN CREAM... 35 PREMPHASE... 34, 35 PREMPRO... 35 PREVIDENT... 38 PREVIDENT 5000 PLUS... 38 Kaiser Permanente of Georgia Multi Choice Formulary 65

PREVPAC... 28 PREZCOBIX... 7 PREZISTA... 7 PRIFTIN... 6 PRIMAQUINE... 6 primaquine phosphate... 6 primidone... 9 PRISTIQ... 22 PROAIR HFA... PROAMATINE... PRO-BANTHINE... 0 probenecid... 25 procarbazine... 9 PROCARDIA... 3 PROCARDIA XL... 3 prochlorperazine... 28 PROCRIT... 2 PROCTOCORT... 4 PROCTOFOAM... 42 PROCTOFOAM-HC... 42 PROCYSBI... 37 PRODIGY... 23 PRODIGY TEST STRIPS... 23 progesterone, micronized... 36 PROGRAF... 38 PROLIXIN... 22 PROLOPRIM... 8 PROMACTA... 2 promethazine... 4, 39 promethazine & codeine... 39 promethazine & dextromethorphan... 39 promethazine & phenylephrine... 4 promethazine, phenylephrine & codeine... 39 PROMETHAZINE-DM... 39 PROMETRIUM... 36 propafenone... 4 propantheline bromide... 0 proparacaine... 28 propranolol... 6 propranolol & hydrochlorothiazide... 6 propranolol extended-release... 6 propranolol sustained-release... 6 propylthiouracil... 36 PROPYLTHIOURACIL... 36 PROSOM... 2 PROSTIGMIN... 0 PROTOPIC... 43 protriptyline... 23 PROVENTIL HFA... PROVERA... 36 PROVIGIL... 9 PROZAC... 22 Kaiser Permanente of Georgia Multi Choice Formulary PROZAC WEEKLY... 22 PRUDOXIN... 43 pseudoephedrine, brompheniramine & codeine... 39 PSORIATEC... 42 PULMICORT FLEXHALER... 39 PULMICORT RESPULES... 39 PULMOZYME... 25 PURINETHOL... 9 PYLERA... 4 pyrazinamide... 6 PYRAZINAMIDE... 6 pyridostigmine... 0 pyrimethamine... 6 Q QUALAQUIN... 6 QUESTRAN... 2 QUESTRAN LIGHT... 2 quetiapine... 23 quetiapine extended-release... 23 QUINAGLUTE... 4 quinapril & hydrochlorothiazide... 5 quinapril hcl... 5 quinidine... 4, 2 quinidine gluconate... 4 QUINIDINE SULFATE... 4 quinine sulfate... 6 QUIXIN... 25 QVAR... 39 R RAGWITEK... 27 RAGWITEK... 27 raloxifene hcl... 35 raltegravir... 8 raltegravir (600mg)... 8 ramelteon... 2 ramipril... 5 RANEXA... 4 ranitidine... 29 ranolazine... 4 RAPAFLO... RAPAMUNE... 38 rasagiline... 20 RASUVO... 9 RAVICTI... 24 RAYOS... 30 RAZADYNE... 0 RAZADYNEER... 0 REBETOL... 8 REBIF... 37 Kaiser Permanente of Georgia Multi Choice Formulary 66

REBIF REBIDOSE... 37 RECLIPSEN... 30 REGLAN... 29 regorafenib... 9 REGRANEX... 42 RELAFEN... 7 RELENZA... 8 RELPAX... 20 REMERON... 22 REMODULIN... 5 RENAGEL... 24 RENVELA... 24 repaglinide... 34 repaglinide & metformin... 34 REPATHA... 33 REQUIP... 20 REQUIP XL... 20 RESCRIPTOR... 7 RESCULA... 28 reserpine... 4 RESTASIS... 26 RESTORIL... 2 retapamulin... 40 RETIN-A... 42 RETIN-A MICRO... 42 RETROVIR... 8 REVATIO... 5 REVIA... 2 REVLIMID... 9 REXULTI... 22 REYATAZ... 6 RHEUMATREX... 9 ribavirin... 8 RIDAURA... 30 rifabutin... 6 RIFADIN... 6 RIFAMATE... 6 rifampin... 6 rifampin & isoniazid... 6 rifapentine... 6 rifaximin... 5 rilpivirine... 7, 8 RILUTEK... 2 riluzole... 2 rimantadine... 8 rimexolone... 26 riociguat... 5 RIOMET... 34 risedronate sodium... 38 RISPERDAL... 23 RISPERDALM-TAB... 23 risperidone... 23 Kaiser Permanente of Georgia Multi Choice Formulary risperidone orally disintegrating... 23 RITALIN... 8, 9 RITALIN LA... 8 RITALIN SR... 9 ritonavir... 7, 8 rivaroxaban... 2 rivastigmine tartrate... 0 rivastigmine tartrate (solution)... 0 rizatriptan... 20 rizatriptan orally disentigrating... 20 ROBAXIN... ROBINUL... 0 ROBINULFORTE... 0 ROCALTROL... 43 roflumilast... 39 rolapitant... 28 ROMYCIN... 25 ropinirole... 20 ropinirole extended-release... 20 ROSAC... 40 ROSULA... 42 rosuvastatin... 3 rotigotine... 20 ROWASA... 28 ROXICET... 8 ROXICODONE... 8 ROZEREM... 2 rufinamide... 9 ruxolitinib... 9 RYTHMOL... 4 RYTHMOL SR... 4 RYZODEG 70/30... 33 S SABRIL... 20 sacubitril & valsartan... 4 SAFYRAL... 3 SAIZEN... 36 SALAGEN... 0 salmeterol... 39 salsalate... 8 SAMSCA... 24 SANCTURA... 43 SANCTURA XR... 43 SANCUSO... 28 SANDIMMUNE... 37 SANDOSTATIN... 38 SANTYL... 43 SAPHRIS... 2 sapropterin dihydrochlorid... 38 saquinavir mesylate... 8 Kaiser Permanente of Georgia Multi Choice Formulary 67

SARAFEM... 22 sargramostim... 2 SAVAYSA... 2 SAVELLA... 2 saxagliptin... 34 saxagliptin & metformin extended-release... 34 scopolamine (ophth)... 28 scopolamine hydrobromide... 28 SEASONALE... 3 SEASONIQUE... 3 SEB-PREV... 4 SECTRAL... 6 secukinumab... 38 SEEBRI NEOHALER... 0 SEGLUROMET... 33 selegiline... 20 selegiline transdermal... 20 selenium sulfide... 40 SELSEB... 40 SELSUN RX... 40 SELZENTRY... 7 SENSIPAR... 37 SEPTRA... 5 SERAX... 2 SEREVENT DISKUS... 39 SEROMYCIN... 6 SEROQUEL... 23 SEROQUEL XR... 23 SEROSTIM... 36 SERPASIL... 4 sertaconazole nitrate... 40 sertraline... 23 SERZONE... 22 sevelamer carbonate... 24 sevelamer hcl... 24 short ragweed pollen allergen extract... 27 short ragweed pollen allergen extract... 27 SIGNIFOR... 38 sildenafil... 5 SILIQ... 36 silodosin... SILVADENE... 40 silver sulfadiazine... 40 simeprevir... 8 SIMPONI... 37 simvastatin... 2, 3, 34 sinecatechins... 43 SINEMET... 20 SINEMET CR... 20 SINEQUAN... 22 SINGULAIR... 39 sirolimus... 38 Kaiser Permanente of Georgia Multi Choice Formulary SIRTURO... 36 sitagliptin & metformin... 34 sitagliptin & simvastatin... 34 sitagliptin phosphate... 34 SIVEXTRO... 5 SKELAXIN... sodium chloride... 39 sodium citrate & citric acid... 24 sodium fluoride... 38 sodium fluoride (dental)... 38 sodium fluoride drops... 38 sodium oxybate... 2 sodium phenylbutyrate... 24 sodium phosphates... 29 sodium polystyrene sulfonate... 24 sofosbuvir... 7, 8 sofosbuvir & velpatasvir... 8 sofosbuvir, velpatasvir, voxilaprevir... 8 sofusbuvir... 8 SOLARAZE... 43 solifenacin... 43 SOLIQUA... 34 SOLODYN... 5 SOMA... 0, 6 SOMA COMPOUND... 0, 6 SOMA COMPOUND W/ CODEINE... 6 somatropin... 36 SOMATULINE DEPOT... 37 SOMAVERT... 36 SONATA... 2 SOOLANTRA... 4 sorafenib tosylate... 9 SORIATANE... 42 SORILUX... 42 sotalol... 6 SOVALDI... 8 SPECTAZOLE... 40 SPECTRACEF... 4 spinosad... 40 SPIRIVA... 0 SPIRIVA RESPIMAT... 0 SPIRIVA RESPIMAT... 0 SPIRIVA RESPIMAT... 0 spironolactone... 5 spironolactone & hydrochlorothiazide... 5 SPORANOX... 5 SPRINTEC... 32, 33 SPRYCEL... 9 SPS... 24 STADOL... 6 STALEVO... 20 stannous fluoride... 38 Kaiser Permanente of Georgia Multi Choice Formulary 68

STARLIX... 34 stavudine... 8 STEGLATRO... 33 STEGLUJAN... 33 STELARA... 38 STELAZINE... 23 STIMATE... 36 STIOLTO RESPIMAT... 39 STIVARGA... 9 STRATTERA... 2 STRIBILD... 7 STRIVERDI RESPIMAT... STROMECTOL... 4 SUBOXONE... 6 SUBUTEX... 6 succimer... 30 sucralfate... 29 sucralfate suspension... 29 sucralfate tablets... 29 sucroferric oxyhydroxide... 24 SULAR... 3 sulconazole nitrate... 4 SULFAC... 25 sulfacetamide sodium & prednisolone... 26 sulfacetamide sodium & sulfur... 42 sulfacetamide sodium (acne)... 4 sulfacetamide sodium (ophth) ointment... 25 sulfacetamide sodium (ophth) solution... 25 sulfadiazine... 5, 40 SULFADIAZINE... 5 sulfamethoxazole & trimethoprim... 5 SULFAMYLON... 40 sulfanilamide... 4 sulfasalazine... 5 sulindac... 8 sumatriptan... 20 sunitinib malate... 9 SUPRAX... 4 SURMONTIL... 23 SUSTIVA... 7 SUTENT... 9 suvorexant... 2 SYMAX... 0 SYMAX DUOTAB... 0 SYMBICORT... 39 SYMBYAX... 22 SYMDEKO... 39 SYMFI... 7 SYMFI LO... 7 SYMLIN... 34 SYMMETREL... 20 SYNAGIS... 8 Kaiser Permanente of Georgia Multi Choice Formulary SYNALAR... 4 SYNAREL... 35 SYNJARDY... 33 SYNTHROID... 36 SYPRINE... 30 syringe with needle,disposable... 23 T TABLOID... 0 TACLONEX... 4 tacrolimus... 38, 43 tacrolimus (topical)... 43 tadalafil... 5 TAGAMET... 29 TALTZ... 37 TALWIN NX... 8 TAMBOCOR... 4 TAMIFLU... 8 tamoxifen citrate... 9 tamsulosin hcl... TANZEUM... 33 TAPAZOLE... 36 tapentadol... 8 TARCEVA... 9 TARGRETIN... 8, 42 TARKA... 3 TASIGNA... 9 tasimelteon... 2 TASMAR... 20 tavaborole... 6 tazarotene... 43 TAZORAC... 43 TECFIDERA... 37 TECHNIVIE... 7 tedizolid... 5 teduglutide... 29 TEGRETOL... 9 TEGRETOL XR... 9 TEKAMLO... 4 TEKTURNA... 4 TEKTURNA HCT... 4 telaprevir... 8 telithromycin... 5 telmisartan... 5 telmisartan & hydrochlorothiazide... 5 temazepam... 2 TEMODAR... 0 TEMOVATE... 4 TEMOVATE E... 4 temozolomide... 0 TENEX... 4 Kaiser Permanente of Georgia Multi Choice Formulary 69

tenofovir... 6, 7, 8 tenofovir 300 mg... 8 TENORETIC... 6 TENORMIN... 6 TERAZOL 3... 4 TERAZOL 7... 4 terazosin... 2 terbinafine... 6 terbutaline sulfate... terconazole... 4 terconazole (vaginal)... 4 teriflunomide... 38 teriparatide... 35 TESSALON PERLES... 38 TESTIM... 30 testosterone... 30, 35 testosterone cypionate... 30 TESTRED... 30 tetrabenazine... 2 tetracycline... 4, 5 TETRACYCLINE... 5 tetrahydrozoline... 28 TEVETEN... 4 tezacaftor & ivacaftor... 39 thalidomide... 38 THALOMID... 38 theophylline... 43 thioguanine... 0 thioridazine... 23 thiothixene... 23 THORAZINE... 22 thyroid... 36 THYROLAR... 36 tiagabine... 9 TIAZAC... 3 ticagrelor... 2 TICLID... 2 ticlopidine... 2 TIGAN... 28 TIKOSYN... 4 TILIA... 32 timolol... 6, 27 TIMOPTIC... 27 TIMOPTIC-XE... 27 timothy grass pollen allergen extract... 27 timothy grass pollen allergen extract... 27 tiotropium... 0, 39 tiotropium bromide and olodaterol... 39 tipranavir... 8 TIROSINT... 36 TIVICAY... 7 tizanidine... Kaiser Permanente of Georgia Multi Choice Formulary TOBI... 5 TOBI Podhaler... 5 TOBI PODHALER... 5 TOBRADEX... 26 tobramycin & dexamethasone ointment... 26 tobramycin & dexamethasone suspension... 26 tobramycin inhalation powder... 5 tobramycin inhalation solution... 5 tobramycin sulfate (ophth) ointment... 25 tobramycin sulfate (ophth) solution... 25 TOBREX... 25 tocilizumab... 38 tofacitinib... 38 TOFRANIL... 22 TOFRANIL-PM... 22 tolazamide... 34 tolbutamide... 34 tolcapone... 20 TOLECTIN 600... 8 TOLINASE... 34 tolmetin sodium... 8 tolterodine... 43 tolterodine extended-release... 43 tolvaptan... 24 TOPAMAX... 9 TOPAMAX SPRINKLE... 9 TOPICORT... 4 topiramate capsule... 9 topiramate tablet... 9 topotecan... 0 TOPROL XL... 6 TORADOL... 7 torsemide... 24 TOVIAZ... 43 TRACLEER... 5 TRADJENTA... 34 tramadol... 8 tramadol & acetaminophen... 8 tramadol extended-release... 8 TRANDATE... 6 trandolapril... 3, 5 trandolapril & verapamil... 3 TRANSDERM-SCOP... 28 TRANXENE... 2 tranylcypromine sulfate... 23 TRAVATAN Z... 27 travoprost... 27 trazodone... 23 trazodone extended-release... 23 TREMFYA... 37 TRENTAL... 2 treprostinil... 5 Kaiser Permanente of Georgia Multi Choice Formulary 70

TRESIBA... 33 tretinoin... 0, 42, 43 tretinoin microspheres... 42 TREXALL... 9 triamcinolone acetonide (topical)... 42 triamterene... 24 triamterene & hydrochlorothiazide... 24 TRIAVIL... 2 triazolam... 2 TRIBENZOR... 3 TRICOR... 2 trientine... 30 trifluidine/tipiracil... 0 trifluoperazine... 23 trifluridine... 25 trihexyphenidyl... 20 TRILAFON... 22 TRILEPTAL... 9 TRILIPIX... 2 TRI-LO-SPRINTEC... 33 trimethobenzamide... 28 trimethoprim... 5, 8, 25 trimipramine... 23 TRINESSA... 32 TRI-NORINYL... 32 TRI-SPRINTEC... 33 TRIUMEQ... 6 TRI-VI-FLOR... 38 TRI-VI-FLOR W/IRON... 38 TRIVORA... 3 TRIZIVIR... 6 trospium... 43 trospium extended-release... 43 TRULICITY... 33 TRUSOPT... 27 TRUVADA... 7 TUSSIONEX... 39 TWINJECT... TYKERB... 9 TYLENOL W/ CODEINE... 6 TYMLOS... 35 TYZINE... 28 U UCERIS... 30 ulipristal... 33 ULORIC... 37 ULTRACET... 8 ULTRAM... 8 ULTRAM ER... 8 ULTRAVATE... 4 Kaiser Permanente of Georgia Multi Choice Formulary umeclidinium... 0, umeclidinium & vilanterol... UNIPHYL... 43 UNIRETIC... 5 UNITHROID... 36 UNIVASC... 5 unoprostone isopropyl... 28 urea... 4, 42 URECHOLINE... 0 URELLE... 8 UROCIT-K... 23 URO-MP... 38 UROXATRAL... URSO... 29 URSO FORTE... 29 ursodiol... 29 ustekinumab... 38 UTIBRON NEOHALER... 39 V VAGIFEM... 35 valacyclovir... 8 valbenazine... 2 VALCHLOR... 9 VALCHLOR... 9 VALCYTE... 8 valganciclovir... 8 VALISONE... 4 VALIUM... 2 valproate sodium... 20 valproic acid... 20 valsartan... 3, 4, 5 valsartan & hydrochlorothiazide... 3, 5 VALTREX... 8 VALTURNA... 4 VANCOCIN HCL... 5 vancomycin hcl... 5 vandetanib... 0 VANOS... 4 VANOXIDE-HC... 4 VANTIN... 4 varenicline... 0 VARUBI... 28 VASERETIC... 4 VASOTEC... 4 VECTICAL... 43 VELIVET... 3 VELPHORO... 24 VELTASSA... 24 VELTIN... 43 vemurafenib... 0 Kaiser Permanente of Georgia Multi Choice Formulary 7

venlafaxine... 23 venlafaxine extended-release... 23 VENTOLIN HFA... verapamil... 3 verapamil extended-release cap... 3 verapamil sustained-release cap... 3 verapamil sustained-release tab... 3 VEREGEN... 43 VERELAN... 3 VERELAN PM... 3 VERZENIO... 8 VESANOID... 0 VESICARE... 43 VEXOL... 26 VFEND... 6 VIBERZI... 28 VICOPROFEN... 7 VICTOZA... 34 VICTRELIS... 6 VIDEX... 7 VIDEX EC... 7 VIEKIRA... 8 vigabatrin... 20 VIGAMOX... 25 VIIBRYD... 23 vilazodone... 23 VIMPAT... 9 VIOKACE... 29 VIRACEPT... 7 VIRAMUNE... 7 VIREAD... 8 VIROPTIC... 25 VISICOL... 29 VISKEN... 6 VISTARIL... 2 VIVACTIL... 23 VIVELLE-DOT... 35 VOLTAREN... 7, 26, 43 VOLTAREN GEL... 43 VOLTAREN XR... 7 vorapaxar... 2 voriconazole... 6 vorinostat... 0 vortioxetine... 23 VOSEVI... 8 VOSOL... 28 VOSPIRE ER... VOTRIENT... 9 VRAYLAR... 22 VUSION... 40 VYTONE... 40 VYTORIN... 2 Kaiser Permanente of Georgia Multi Choice Formulary VYVANSE... 8 W warfarin... 2 WELCHOL... 2 WELLBUTRIN... 22 WELLBUTRIN SR... 22 WELLBUTRIN XL... 22 WESTCORT... 42 X XALATAN... 27 XALKORI... 9 XANAX... 20 XANAX XR... 20 XARELTO... 2 XARTEMIS XR... 8 XELJANZ... 38 XELODA... 9 XENAZINE... 2 XIBROM... 25 XIFAXAN... 5 XIGDUO XR... 33 XIIDRA... 26 XOLAIR... 39 XOPENEX HFA... XOPENEX NEBULIZER... XTANDI... 9 XULANE... 3 XULTOPHY... 34 XYLOCAINE... 28, 42 XYLOCAINE VISCOUS... 28 XYREM... 2 Y YASMIN... 3 YAZ... 3 YUVAFEM... 35 Z zafirlukast... 39 zaleplon... 2 ZANAFLEX... zanamivir... 8 ZANTAC... 29 ZARONTIN... 9 ZAROXOLYN... 24 ZARXIO... 2 ZAVESCA... 38 Kaiser Permanente of Georgia Multi Choice Formulary 72

ZEBETA... 6 ZEJULA... 9 ZELAPAR... 20 ZELBORAF... 0 ZEMPLAR... 44 ZENPEP... 29 ZEPATIER... 7 ZERIT... 8 ZESTORETIC... 5 ZESTRIL... 5 ZETIA... 2 ZIAC... 6 ZIAGEN... 6 ZIANA... 43 zidovudine... 6, 7, 8 zileuton... 39 ZINBRYTA... 37 ziprasidone... 23 ZIRGAN... 25 ZITHROMAX... 4 ZOCOR... 3 ZOFRAN... 28 ZOFRAN ODT... 28 ZOHYDRO ER... 7 ZOLINZA... 0 zolipdem sublingual... 2 zolmitriptan... 20 zolmitriptan orally disentigrating... 20 Kaiser Permanente of Georgia Multi Choice Formulary ZOLOFT... 23 zolpidem... 2 zolpidem extended-release... 2 zolpidem oral spray... 2 ZOLPIMIST... 2 ZOMIG... 20 ZOMIG ZMT... 20 ZONALON... 42 ZONEGRAN... 20 zonisamide... 20 ZONTIVITY... 2 ZORBTIVE... 36 ZORTRESS... 37 ZOVIA... 3 ZOVIRAX... 6, 40 ZURAMPIC... 37 ZYCLARA... 43 ZYDELIG... 9 ZYFLO... 39 ZYKADIA... 9 ZYLET... 26 ZYLOPRIM... 36 ZYMAXID... 25 ZYPREXA... 22 ZYPREXA ZYDIS... 22 ZYTIGA... 8 ZYVOX... 5 Kaiser Permanente of Georgia Multi Choice Formulary 73

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) 865-583, (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 30305-736, telephone number: - (888) 865-583. 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 https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 2020, 800 368 09, 800 537 7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Kaiser Permanente of Georgia Multi Choice Formulary 74

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, 404-364-7000 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., in Maryland, Virginia, and Washington, D.C., 20 E. Jefferson St., Rockville, MD 20852 Kaiser Foundation Health Plan of the Northwest, 500 NE Multnomah St., Suite 00, Portland, OR 97232. Kaiser Permanente of Georgia Multi Choice Formulary 75

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