2021 Formulary Kaiser Permanente a TRICARE® Prime Option
2021 Formulary Kaiser Permanente a TRICARE® Prime Option
To search for a specific medication or condition: • Press “Ctrl” or “CMD” and “F” on your keyboard at the same time. • In the search window that pops up, enter the text that you wish to search for and press “Enter”. • Press enter again to move to the next result. • You can also find an alphabetic list of medication starting on page 89.
For questions about specific drug costs, call us ta 1-877-904-0015. What is the Kaiser Permanente, a TRICARE® The drugs on this formulary are grouped into Prime Option Formulary? categories depending on the type of medical A formulary is a list of drugs determined to be condition that they are used to treat. For safe and effective for our members by our example, drugs used to treat a heart condition are Pharmacy and Therapeutics committee. Use of listed under the category, “Cardiovascular Drugs.” the formulary enables Kaiser Permanente to If you know what your drug is used for, simply provide optimal care to you and your family at look for the category name in the list. Then look reasonable costs. Kaiser Permanente continually under the category name for your drug. updates the formulary throughout the year based Alphabetical Listing on new medical evidence, considering the If you are not sure what category to look under, recommendations of appropriate physician you can look for the drug in the Index. The Index experts. Our physicians and pharmacists work provides an alphabetical list of all the drugs closely together to ensure that our formulary included in this document. Both brand-name meets your needs. drugs and generic drugs are listed in the Index. Does the formulary ever change? Look in the Index and find your drug. Next to the Yes, Kaiser Permanente periodically updates the drug, you will see the page number where you formulary based on new medical evidence, can find coverage information. Go to the page considering the recommendations of appropriate listed in the Index and find the name of your drug physician experts and notifies our doctors, on the list. pharmacists, and other clinicians about any What are generic drugs? changes. If a change in the formulary affects any Kaiser Permanente covers both brand-name drugs of your prescriptions, your doctor or pharmacist and generic drugs. will let you know. Generic drugs are produced and sold under their The enclosed formulary is effective as of chemical names after the patent of the brand September 9, 2021 and represents the most name drug expires. Although the price is lower, commonly prescribed medications. the quality and effectiveness of generic drugs is How do I use the Formulary? the same as brand name drugs. The Federal Food There is an easy way to find your drug within the and Drug Administration (FDA) requires that formulary: generic drugs contain the same active ingredients in the same amount as the brand name drug. To search for a specific medication or condition, Generic drugs are listed in lower-case italics (e.g., press the ‘CTRL’ key and the ‘F’ key on your amoxicillin) within the formulary. Brand-name keyboard at the same time. In the search window drugs are capitalized within the formulary (e.g., that pops up, enter the text you want to search FLOVENT). for and press ‘Enter.’ Press ‘Enter’ again to move to the next result. What are Formulary Brand name drugs?
Medical Condition
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network 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 pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved. Kaiser Permanente, a TRICARE Prime Option Formulary 1 Formulary Brand name drugs are drugs that are those that are listed on the Kaiser Permanente, a produced and sold under the original TRICARE Prime Option drug formulary. Certain manufacturer’s name. diabetic supplies do not require a prescription but must still be listed in our formulary in order to be What are Non-Formulary Brand drugs? covered under the benefit. Non-Formulary Brand drugs are drugs that are Each prescription refill is provided on the same not included on the plan's list basis as the original prescription. Cost shares are of preferred prescription drugs. applied on a per prescription basis, for up to the Because all drug product strengths and package lesser of the dispensing amount listed in the sizes of a formulary drug will be included in your “Schedule of Benefits” or the standard plan’s benefits, just note the drug cost share prescription amount. coverage amount will be based on the specific The standard prescription amount for the tier of the formulary, check with your Kaiser following items is: Permanente pharmacist for clarification, if needed. • Migraine medications ― the smallest package How much will I pay for Covered Drugs? size commercially available • ― What you pay for covered drugs is determined by Ophthalmic and otic medications the the outpatient prescription drug benefit outlined smallest package size commercially available in your Evidence of Coverage. Kaiser Permanente, • Oral and nasal inhalers ― the smallest a TRICARE Prime Option plan has a three-tier standard package size open formulary benefit. Are there any other restrictions on coverage? Open formulary benefits have a generic cost Some covered drugs may have additional sharing requirement. This means that if you requirements or limits on coverage. These choose to fill a brand name drug when a generic is requirements and limits may include: available, then in addition to your standard cost share, you will also pay the difference in cost • Quantity Limits (QL): For certain drugs, Kaiser between the brand name and generic drug. Permanente limits the amount of the drug that will be covered. Generics drugs are those covered at the lowest cost share defined as Tier 1 coverage amount. • Age Restriction (Age): For certain drugs, Kaiser Formulary brand drugs are those brands which Permanente limits coverage based on a will be covered at your formulary brand cost designated age. share defined as Tier 2 coverage amount. Non- formulary brands drugs are covered at the non- • Prior Authorization (PA): For certain drugs, formulary cost share defined as Tier 3 coverage Kaiser Permanente requires review and amount. authorization prior to dispensing. Your Provider must obtain this review and Coverage for prescription drugs is limited to drugs authorization. The list of prescription drugs for which a prescription is required by law and Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network 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 pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved. Kaiser Permanente, a TRICARE Prime Option Formulary 2 requiring review and authorization is subject the formulary, check with your Kaiser Permanente to periodic review and modification by our pharmacist for clarification, if needed. Pharmacy and Therapeutics Committee. For more information • Step Therapy (ST): For certain drugs, Kaiser For more detailed information about your Kaiser Permanente requires the use of similar, Permanente, a TRICARE Prime Option prescription alternative medications prior to coverage. drug coverage, please review your Evidence of Coverage and other plan materials. You can find out if the drug has any additional requirements or limits by looking in the If you have questions about Kaiser Permanente, Restrictions Column on the formulary list. please call Member Services at 1-833-642-5973 or 770-291-4430, Monday through Friday 7:00 a.m. What if my drug is not on the Formulary? to 7 p.m. TTY/TDD users should call 1-800-255- Because all drug product strengths and package 0056. sizes of a formulary drug may not be included on Or visit kp.org/tricare.
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network 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 pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved. Kaiser Permanente, a TRICARE Prime Option Formulary 3 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Antihistamine Drugs Antihistamine Drugs
ST No 1 carbinoxamine maleate ARBINOXA Generic
No 1 cyproheptadine PERIACTIN Generic
chlorpheniramine, phenylephrine No 1 POLY HIST FORTE Generic & pyrilamine
No 1 promethazine & phenylephrine PHENERGAN VC Generic
QL No 1 promethazine PHENERGAN Generic Anti-infective Agents Anthelmintics No 2 albendazole ALBENZA Formulary Brand No 1 ivermectin STROMECTOL Generic
PA, QL No 1 ivermectin (topical) SOOLANTRA Generic
ST Yes 1 praziquantel BILTRICIDE Generic Anti-infectives, Miscellaneous bismuth subcitrate & Non-Formulary ST Yes 3 PYLERA metronidazole Brand
metronidazole, tetracycline & Non-Formulary Yes 3 HELIDAC bismuth subsalicylate Brand
Non-Formulary Yes 3 benznidazole benznidazole Brand Antibacterials
Non-Formulary PA No 3 amikacin liposomal inhalation ARIKAYCE Brand
No 1 amoxicillin AMOXIL Generic
amoxicillin & clavulanate No 1 AUGMENTIN Generic potassium
amoxicillin & clavulanate No 1 AUGMENTIN XR Generic potassium extended-release
Kaiser Permanente, a TRICARE Prime Option Formulary 4 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
No 1 ampicillin sodium AMPICILLIN Generic Yes 1 azithromycin ZITHROMAX Generic No 1 cefaclor CECLOR Generic No 1 cefadroxil DURICEF Generic No 1 cefdinir OMNICEF Generic ST Yes 1 cefditoren SPECTRACEF Generic Non-Formulary No 3 cefixime SUPRAX Brand No 1 cefixime solution SUPRAX Generic No 1 cefpodoxime VANTIN Generic No 1 cefprozil CEFZIL Generic No 1 cefuroxime axetil CEFTIN Generic No 1 cephalexin KEFLEX Generic No 1 ciprofloxacin CIPRO Generic No 1 clarithromycin BIAXIN Generic
No 1 clarithromycin extended-release BIAXIN XL Generic
No 1 clindamycin hcl CLEOCIN HCL Generic
No 1 clindamycin palmitate CLEOCIN PEDIATRIC Generic
Non-Formulary ST Yes 3 delafloxacin BEXDELA Brand No 1 demeclocycline DECLOMYCIN Generic No 1 dicloxacillin DYNAPEN Generic Non-Formulary Yes 3 doxycycline ORACEA Brand
Yes 1 doxycycline hyclate PERIOSTAT Generic
Non-Formulary ST Yes 3 doxycycline hyclate DORYX Brand
Yes 1 doxycycline monohydrate ADOXA Generic
Yes 1 doxycycline monohydrate MONODOX Generic
No 1 erythromycin & sulfisoxazole E.S.P Generic
QL No 1 erythromycin base ERYTHROMYCIN Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 5 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
erythromycin base delayed- QL No 1 ERY-TAB Generic release
QL No 1 erythromycin ethylsuccinate E.E.S. Generic
Non-Formulary No 3 erythromycin sterate ERYTHROCIN Brand
Non-Formulary ST Yes 3 fidaxomicin DIFICID Brand No 1 gentamicin sulfate GARAMYCIN Generic Non-Formulary Yes 3 lefamulin XENLETA Brand No 1 levofloxacin LEVAQUIN Generic No 1 linezolid ZYVOX Generic Yes 1 minocycline DYNACIN Generic Yes 1 minocycline MINOCIN Generic ST Yes 1 minocycline SOLODYN Generic ST No 1 moxifloxacin AVELOX Generic No 1 neomycin sulfate MYCIFRADIN Generic Non-Formulary Yes 3 norfloxacin NOROXIN Brand
No 1 penicillin v potassium PEN-VK Generic
Non-Formulary ST Yes 3 omadacycline NUZYRA Brand
ST, QL (200 Non-Formulary Yes 3 rifaximin XIFAXAN mg only) Brand
No 1 sulfadiazine SULFADIAZINE Generic
Yes 1 sulfamethoxazole & trimethoprim BACTRIM DS Generic
Yes 1 sulfamethoxazole & trimethoprim SEPTRA Generic
No 1 sulfasalazine AZULFIDINE Generic Non-Formulary ST Yes 3 tedizolid SIVEXTRO Brand
Non-Formulary ST Yes 3 telithromycin KETEK Brand Yes 1 tetracycline TETRACYCLINE Generic Non-Formulary No 3 tobramycin inhalation powder TOBI PODHALER Brand
Kaiser Permanente, a TRICARE Prime Option Formulary 6 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
No 1 tobramycin inhalation solution TOBI Generic
No 1 Vancomycin capsule VANCOCIN Generic
Antifungals Non-Formulary PA, QL Yes 3 efinaconazole JUBLIA Brand QL No 1 fluconazole DIFLUCAN Generic No 1 flucytosine ANCOBON Generic
No 1 griseofulvin microsize GRIFULVIN V Generic
No 1 griseofulvin ultramicrosize GRIS-PEG Generic
Non-Formulary PA Yes 3 isavuconazonium CRESEMBA Brand No 1 itraconazole SPORANOX Generic No 1 ketoconazole NIZORAL Generic Non-Formulary No 3 luliconazole LUZU Brand No 1 nystatin MYCOSTATIN Generic Non-Formulary PA No 3 posaconazole NOXAFIL Brand
PA Yes 1 tavaborole KERYDIN Generic
No 1 terbinafine LAMISIL Generic
No 1 voriconazole tablet VFEND Generic
Non-Formulary ST No 3 voriconazole suspension VFEND Brand Antimycobacterials Yes 1 cycloserine SEROMYCIN Generic Yes 1 dapsone AVLOSULFON Generic Yes 1 ethambutol MYAMBUTOL Generic Non-Formulary ST Yes 3 ethionamide TRECATOR Brand Yes 1 isoniazid NYDRAZID Generic ST Yes 1 pretomanid PRETOMANID Generic Yes 1 pyrazinamide PYRAZINAMIDE Generic Yes 1 rifabutin MYCOBUTIN Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 7 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 rifampin RIFADIN Generic Non-Formulary Yes 3 rifapentine PRIFTIN Brand Antiprotozoals Non-Formulary ST Yes 3 artemether & lumefantrine COARTEM Brand No 1 atovaquone MEPRON Generic
ST No 1 atovaquone & proguanil MALARONE Generic
ST No 1 chloroquine phosphate ARALEN Generic
Yes 1 hydroxychloroquine sulfate PLAQUENIL Generic
ST No 1 mefloquine LARIAM Generic No 1 metronidazole FLAGYL Generic Non-Formulary No 3 metronidazole extended-release FLAGYL ER Brand
Non-Formulary PA Yes 3 miltefosine IMPAVIDO Brand
Yes 1 nitazoxanide ALINIA Generic
No 1 paromomycin sulfate HUMATIN Generic
Non-Formulary ST No 3 pentamidine NEBUPENT Brand
No 1 primaquine phosphate PRIMAQUINE Generic
PA No 1 pyrimethamine DARAPRIM Generic
ST No 1 quinine sulfate QUALAQUIN Generic Non-Formulary ST Yes 3 secnidazole SOLOSEC Brand Antiviral
QL Yes 1 abacavir sulfate & lamivudine EPZICOM Generic
QL No 2 abacavir sulfate solution ZIAGEN Formulary Brand
QL Yes 1 abacavir sulfate tablet ZIAGEN Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 8 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
abacavir, dolutegravir & Non-Formulary Yes 3 TRIUMEQ lamivudine Brand
abacavir, lamivudine & QL Yes 1 TRIZIVIR Generic zidovudine
Yes 1 acyclovir ZOVIRAX Generic QL,ST No 1 adefovir dipivoxil HEPSERA Generic Non-Formulary Yes 3 atazanavir & cobicistat EVOTAZ Brand
QL Yes 2 atazanavir sulfate 150 mg REYATAZ Formulary Brand
atazanavir sulfate 200 mg, 300 QL Yes 1 REYATAZ Generic mg
bictegravir & emtricitabine & QL Yes 2 BIKTARVY Formulary Brand tenofovir
Non-Formulary QL Yes 3 boceprevir VICTRELIS Brand
Non-Formulary PA Yes 3 daclatasvir DAKLINZA Brand
Yes 2 darunavir & cobicistat PREZCOBIX Formulary Brand
QL Yes 2 darunavir ethanolate PREZISTA Formulary Brand
QL Yes 2 darunavir/cobicistat/FTC/tenofovir SYMTUZA Formulary Brand
QL Yes 2 delavirdine mesylate RESCRIPTOR Formulary Brand
QL Yes 1 didanosine VIDEX EC Generic
QL Yes 2 didanosine solution VIDEX Formulary Brand
Yes 2 dolutegravir TIVICAY Formulary Brand Non-Formulary QL Yes 3 dolutegravir & rilpivirine JULUCA Brand
QL Yes 2 dolutegravir & lamivudine DOVATO Formulary Brand
Non-Formulary Yes 3 doravirine PIFELTRO Brand
Kaiser Permanente, a TRICARE Prime Option Formulary 9 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Non-Formulary QL Yes 3 doravirine, lamivudine, tenofovir DELSTRIGO Brand
QL Yes 1 efavirenz 600 mg SUSTIVA Generic
efavirenz, emtricitabine & QL Yes 1 ATRIPLA Generic tenofovir
efavirenz 600 mg, lamivudine & QL Yes 1 SYMFI Generic tenofvir
efavirenz 400 mg, lamivudine & QL Yes 1 SYMFI LO Generic tenofvir
Non-Formulary PA Yes 3 elbasvir & grazoprevir ZEPATIER Brand
elvitegravir, cobicistat, Non-Formulary QL Yes 3 STRIBILD emtricitabine, & tenofovir Brand
elvitegravir, cobicistat, QL Yes 2 GENVOYA Formulary Brand emtricitabine, & tenofovir
QL Yes 1 emtricitabine EMTRIVA Generic
QL Yes 1 emtricitabine & tenofovir TRUVADA Generic
QL Yes 2 emtricitabine & tenofovir DESCOVY Formulary Brand
emtricitabine, rilpivirine, & Non-Formulary QL Yes 3 COMPLERA tenofovir Brand
emtricitabine, rilpivirine, & QL Yes 2 ODEFSEY Formulary Brand tenofovir
QL Yes 2 enfuvirtide FUZEON Formulary Brand QL Yes 1 entecavir BARACLUDE Generic QL Yes 1 etravirine INTELENCE Generic ST Yes 1 famciclovir FAMVIR Generic
QL Yes 2 fosamprenavir calcium LEXIVA Formulary Brand
Kaiser Permanente, a TRICARE Prime Option Formulary 10 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Non-Formulary No 3 fostemsavir RUKOBIA Brand Yes 1 ganciclovir CYTOVENE Generic Non-Formulary PA, QL Yes 3 glecaprevir & pibrentasvir MAVYRET Brand QL Yes 2 indinavir sulfate CRIXIVAN Formulary Brand Non-Formulary Yes 3 interferon alfacon-1 INFERGEN Brand
Non-Formulary QL, ST Yes 3 lamivudine EPIVIR HBV Brand QL Yes 1 lamivudine EPIVIR Generic
QL Yes 2 Lamivudine & tenofovir CIMDUO Formulary Brand
QL Yes 1 lamivudine & zidovudine COMBIVIR Generic
Non-Formulary ST Yes 3 letermovir PREVYMIS Brand
Non-Formulary PA, QL No 3 ledipasvir & sofosbuvir HARVONI Brand
QL Yes 1 lopinavir & ritonavir KALETRA Generic
QL Yes 2 maraviroc SELZENTRY Formulary Brand
QL Yes 2 nelfinavir mesylate VIRACEPT Formulary Brand
QL Yes 1 nevirapine solution VIRAMUNE Generic
QL Yes 1 nevirapine tablet VIRAMUNE Generic
Non-Formulary PA Yes 3 ombitasvir, paritaprevir & ritonavir TECHNIVIE Brand
ombitasvir, paritaprevir, ritonavir, Non-Formulary PA, QL Yes 3 VIEKIRA & dasabuvir Brand
sofosbuvir, velpatasvir, PA, QL No 2 VOSEVI Formulary Brand voxilaprevir
QL Yes 1 oseltamivir phosphate TAMIFLU Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 11 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Non-Formulary Yes 3 palivizumab SYNAGIS Brand
QL Yes 2 peginterferon alfa-2a PEGASYS Formulary Brand
Yes 2 peginterferon-alfa 2b PEG-INTRON Formulary Brand
QL Yes 2 raltegravir ISENTRESS Formulary Brand
QL Yes 2 raltegravir (600mg) ISENTRESS HD Formulary Brand
Yes 1 ribavirin REBETOL Generic Non-Formulary QL Yes 3 rilpivirine EDURANT Brand QL Yes 1 rimantadine FLUMADINE Generic QL Yes 1 ritonavir NORVIR Generic
QL Yes 2 saquinavir mesylate INVIRASE Formulary Brand
Non-Formulary PA, QL Yes 3 simeprevir OLYSIO Brand
Non-Formulary PA, QL No 3 sofosbuvir SOVALDI Brand
PA, QL No 2 sofosbuvir & velpatasvir EPCLUSA Formulary Brand
QL Yes 1 stavudine ZERIT Generic Non-Formulary QL Yes 3 telaprevir INCIVEK Brand
Non-Formulary ST Yes 3 telbivudine TYZEKA Brand
Non-Formulary QL Yes 3 tenofovir VIREAD Brand QL Yes 1 tenofovir 300 mg VIREAD Generic Non-Formulary PA, QL Yes 3 tenofovir alafenamide VEMLIDY Brand QL Yes 2 tipranavir APTIVUS Formulary Brand ST Yes 1 valacyclovir VALTREX Generic No 1 valganciclovir VALCYTE Generic QL Yes 2 zanamivir RELENZA Formulary Brand QL Yes 1 zidovudine RETROVIR Generic Urinary Antiinfectives
Kaiser Permanente, a TRICARE Prime Option Formulary 12 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
ST Yes 1 fosfomycin MONUROL Generic
ST No 1 methenamine hippurate HIPREX Generic
methenamine, sodium biphosphate, phenyl salicylate, Non-Formulary No 3 URELLE methylene blue, and Brand hyoscyamine
No 2 nitrofurantoin FURADANTIN Formulary Brand
No 1 nitrofurantoin macrocrystal MACRODANTIN Generic
No 1 nitrofurantoin monohydrate MACROBID Generic
Yes 1 trimethoprim PROLOPRIM Generic Antineoplastic Agents Antineoplastic Agents Non-Formulary Yes 3 abemaciclib VERZENIO Brand No 1 abiraterone ZYTIGA Generic Non-Formulary Yes 3 acalabrutinib CALQUENCE Brand PA, QL Yes 2 alpelisib PIQRAY Formulary Brand No 1 anastrozole ARIMIDEX Generic Non-Formulary QL No 3 avapritinib AYVAKIT Brand Non-Formulary Yes 3 axitinib INLYTA Brand
Non-Formulary PA No 3 azacitidine ONUREG Brand No 2 bexarotene TARGRETIN Formulary Brand No 1 bicalutamide CASODEX Generic Non-Formulary Yes 3 binimetinib MEKTOVI Brand
Non-Formulary PA Yes 3 bosutinib BOSULIF Brand Yes 2 busulfan MYLERAN Formulary Brand Yes 1 capecitabine XELODA Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 13 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status Non-Formulary PA No 3 capmatinib TABRECTA Brand Non-Formulary Yes 3 ceritinib ZYKADIA Brand Yes 2 chlorambucil LEUKERAN Formulary Brand Yes 2 cobimetinib COTELLIC Formulary Brand Yes 2 crizotinib XALKORI Formulary Brand
No 1 cyclophosphamide CYTOXAN Generic
Non-Formulary Yes 3 dacomitinib VIZIMPRO Brand PA, QL Yes 2 dasatinib SPRYCEL Formulary Brand Non-Formulary PA, QL Yes 3 darolutamide NUBEQA Brand
Non-Formulary PA No 3 decitabine & cedazuridine INQOVI Brand
Non-Formulary Yes 3 enasidenib IDHIFA Brand
Non-Formulary Yes 3 encorafenib BRAFTOVI Brand
Non-Formulary PA Yes 3 entrectinib ROZLYTREK Brand Yes 2 enzalutamide XTANDI Formulary Brand No 2 erlotinib TARCEVA Formulary Brand Yes 2 estramustine EMCYT Formulary Brand QL No 2 everolimus AFINITOR Formulary Brand No 1 exemestane AROMASIN Generic Non-Formulary Yes 3 gilteritinib XOSPATA Brand
Non-Formulary Yes 3 glasdegib DAURISMO Brand No 1 flutamide EULEXIN Generic No 1 hydroxyurea HYDREA Generic No 2 hydroxyurea DROXIA Formulary Brand QL Yes 2 ibrutinib IMBRUVICA Formulary Brand Non-Formulary QL Yes 3 Ibrutinib 140 mg, 280 mg IMBRUVICA Brand Yes 2 idelalisib ZYDELIG Formulary Brand PA No 1 imatinib mesylate GLEEVEC Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 14 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Non-Formulary Yes 3 ivosidenib TIBSOVO Brand Yes 2 ixazomib NINLARO Formulary Brand Yes 1 lapatinib TYKERB Generic Non-Formulary PA Yes 3 larotrectinib VITRAKVI Brand QL Yes 2 lenalidomide REVLIMID Formulary Brand Yes 2 lenvatinib LENVIMA Formulary Brand No 1 letrozole FEMARA Generic No 1 leuprolide acetate LUPRON Generic ST Yes 1 lomustine GLEOSTINE Generic Non-Formulary Yes 3 lorlatinib LORBRENA Brand
Non-Formulary Yes 3 mechlorethamine VALCHLOR Brand Yes 2 melphalan ALKERAN Formulary Brand No 1 mercaptopurine PURINETHOL Generic Non-Formulary ST No 3 methotrexate RASUVO Brand
Non-Formulary ST No 3 methotrexate OTREXUP Brand
ST No 1 methotrexate sodium RHEUMATREX Generic
Non-Formulary No 3 methotrexate sodium TREXALL Brand Yes 2 mitotane LYSODREN Formulary Brand PA Yes 2 nilotinib TASIGNA Formulary Brand Non-Formulary ST No 3 nilutamide NILANDRON Brand PA, QL Yes 2 niraparib ZEJULA Formulary Brand Non-Formulary PA No 3 olaparib LYNPARZA Brand QL Yes 2 palbociclib IBRANCE Formulary Brand Yes 2 pazopanib VOTRIENT Formulary Brand Non-Formulary No 3 pemigatinib PEMAZYRE Brand QL Yes 2 pomalidomide POMALYST Formulary Brand Non-Formulary PA Yes 3 ponatinib ICLUSIG Brand
Kaiser Permanente, a TRICARE Prime Option Formulary 15 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Non-Formulary PA No 3 pralsetinib GAVRETO Brand Yes 2 procarbazine MATULANE Formulary Brand Yes 2 regorafenib STIVARGA Formulary Brand Non-Formulary No 3 ripritinib QINLOCK Brand Non-Formulary PA No 3 rucaparib RUBRACA Brand Non-Formulary Yes 3 ruxolitinib JAKAFI Brand
Non-Formulary PA Yes 3 selinexor XPOVIO Brand
Non-Formulary PA No 3 selpercatinib RETEVMO Brand
Non-Formulary PA No 3 selumetinib KOSELUGO Brand Yes 2 sorafenib tosylate NEXAVAR Formulary Brand Yes 1 sunitinib malate SUTENT Generic Non-Formulary PA Yes 3 talazoparib TALZENNA Brand No 1 tamoxifen citrate NOLVADEX Generic Non-Formulary No 3 tazemetostat TAZVERIK Brand Yes 1 temozolomide TEMODAR Generic Non-Formulary PA No 3 tepotinib TEPMETKO Brand Yes 2 thioguanine TABLOID Formulary Brand Non-Formulary PA No 3 tivozanib FOTIVDA Brand Yes 2 topotecan HYCAMTIN Formulary Brand ST No 1 toremifene FARESTON Generic No 1 tretinoin VESANOID Generic Yes 2 trifluidine/tipiracil LONSURF Formulary Brand Non-Formulary PA No 3 tucatinib TUKYSA Brand Non-Formulary PA, QL Yes 3 pexidartinib TURALIO Brand Yes 2 vandetanib CAPRELSA Formulary Brand Yes 2 vemurafenib ZELBORAF Formulary Brand Yes 2 vorinostat ZOLINZA Formulary Brand Non-Formulary PA, QL Yes 3 zanubrutinib BRUKINSA Brand
Kaiser Permanente, a TRICARE Prime Option Formulary 16 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Autonomic Drugs Anticholinergic Agents
Yes 1 atropine sulfate ATROPINE SULFATE Generic
Yes 1 dicyclomine BENTYL Generic Yes 1 glycopyrrolate ROBINUL Generic Yes 1 glycopyrrolate ROBINULFORTE Generic Non-Formulary Yes 3 glycopyrrolate inhalation pow SEEBRI NEOHALER Brand
Non-Formulary ST Yes 3 glycopyrrolate nebulizer soln LONHALA MAGNAIR Brand
Yes 1 hyoscyamine sulfate LEVBID Generic
Yes 1 hyoscyamine sulfate LEVSIN Generic
Yes 1 hyoscyamine sulfate SYMAX Generic
Non-Formulary Yes 3 hyoscyamine sulfate SYMAX DUOTAB Brand
Yes 1 ipratropium bromide ATROVENT Generic
Yes 2 ipratropium bromide ATROVENT HFA Formulary Brand
ST Yes 1 methscopolamine PAMINE Generic
Yes 1 propantheline bromide PRO-BANTHINE Generic
Non-Formulary ST Yes 3 revefenacin YUPELRI Brand
Non-Formulary Yes 3 tiotropium SPIRIVA Brand
Yes 2 tiotropium 2.5 mcg SPIRIVA RESPIMAT Formulary Brand
Non-Formulary Yes 3 tiotropium 1.25 mcg SPIRIVA RESPIMAT Brand
Non-Formulary Yes 3 umeclidinium INCRUSE ELLIPTA Brand Smoking Cessation Agents Yes 1 nicotine gum NICORETTE Generic Non-Formulary QL, ST Yes 3 nicotine inhalation NICOTROL Brand
Kaiser Permanente, a TRICARE Prime Option Formulary 17 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 nicotine lozenge NICORETTE Generic Non-Formulary QL, ST Yes 3 nicotine nasal spray NICOTROL Brand Yes 1 nicotine patch NICODERM Generic Non-Formulary ST Yes 3 varenicline CHANTIX Brand Parasympathomimetic (Cholinergic) Agents
Yes 1 bethanechol chloride URECHOLINE Generic
Yes 1 cevimeline hcl EVOXAC Generic Yes 1 donepezil ARICEPT Generic Yes 1 donepezil ARICEPT ODT Generic
Yes 1 galantamine hydrobromide RAZADYNE Generic
Yes 1 galantamine hydrobromide ER RAZADYNE ER Generic
Yes 1 neostigmine bromide PROSTIGMIN Generic
ST Yes 1 pilocarpine SALAGEN Generic
Yes 1 pyridostigmine MESTION TIMESPAN Generic
Yes 1 pyridostigmine MESTION Generic
Yes 1 rivastigmine tartrate EXELON Generic
Yes 2 rivastigmine tartrate (solution) EXELON Formulary Brand
Skeletal Muscle Relaxants Yes 1 baclofen LIORESAL Generic ST No 1 carisoprodol SOMA Generic
ST No 1 carisoprodol & aspirin SOMA COMPOUND Generic
PARAFON FORTE No 1 chlorzoxazone Generic DSC No 1 cyclobenzaprine FLEXERIL Generic cyclobenzaprine extended- Non-Formulary No 3 AMRIX release Brand
No 1 dantrolene sodium DANTRIUM Generic
ST No 1 metaxalone SKELAXIN Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 18 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
No 1 methocarbamol ROBAXIN Generic
No 1 orphenadrine citrate NORFLEX Generic
Yes 1 orphenadrine, aspirin, & caffeine NORGESIC Generic
No 1 tizanidine ZANAFLEX Generic Sympatholytic (Adrenergic Blocking) Agents Yes 1 alfuzosin UROXATRAL Generic
No 1 dihydroergotamine mesylate D.H.E.45 Generic
ST No 2 dihydroergotamine mesylate MIGRANAL Formulary Brand
Yes 1 ergoloid mesylates HYDERGINE Generic
No 1 ergotamine & caffeine CAFERGOT Generic
ST No 1 phenoxybenzamine DIBENZYLINE Generic
Non-Formulary ST Yes 3 silodosin RAPAFLO Brand Yes 1 tamsulosin hcl FLOMAX Generic Sympathomimetic (Adrenergic) Agents
Yes 1 albuterol nebulizer solution ACCUNEB Generic
Yes 1 albuterol sulfate PROAIR HFA Generic
Non-Formulary Yes 3 albuterol sulfate PROVENTIL HFA Brand Non-Formulary Yes 3 albuterol sulfate VENTOLIN HFA Brand COMBIVENT Non-Formulary Yes 3 albuterol sulfate & ipratropium RESPIMAT Brand
Yes 1 albuterol sulfate & ipratropium DUONEB Generic
Yes 1 albuterol sulfate tablet VOSPIRE ER Generic
Yes 1 arformoterol BROVANA Generic
PA Yes 1 droxidopa NORTHERA Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 19 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
No 1 epinephrine ADRENACLICK Generic Non-Formulary PA No 3 epinephrine AUVI-Q Brand
Non-Formulary No 3 epinephrine EPIPEN Brand
Non-Formulary No 3 epinephrine EPIPEN JR Brand
Non-Formulary No 3 epinephrine TWINJECT Brand
Non-Formulary Yes 3 formoterol fumarate FORADIL Brand
XOPENEX ST Yes 1 levalbuterol nebulizer solution Generic NEBULIZER
ST Yes 1 levalbuterol tartrate XOPENEX HFA Generic
Yes 1 midodrine hcl PROAMATINE Generic STRIVERDI Yes 2 olodaterol Formulary Brand RESPIMAT
MAXAIR Non-Formulary ST Yes 3 pirbuterol acetate AUTOHALER Brand Yes 1 terbutaline sulfate BRETHINE Generic Non-Formulary Yes 3 umeclidinium & vilanterol ANORO ELLIPTA Brand Blood Formation, Coagulation, and Thrombosis Coagulants and Anticoagulants Yes 2 aminocaproic acid AMICAR Formulary Brand Yes 1 anagrelide AGRYLIN Generic Non-Formulary ST Yes 3 apixaban ELIQUIS Brand
ST Yes 1 aspirin & dipyridamole AGGRENOX Generic
Non-Formulary ST Yes 3 betrixaban BEVYXXA Brand Yes 1 cilostazol PLETAL Generic
Yes 1 clopidogrel PLAVIX Generic
QL Yes 2 dabigatran PRADAXA Formulary Brand
Kaiser Permanente, a TRICARE Prime Option Formulary 20 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Non-Formulary ST Yes 3 dalteparin FRAGMIN Brand Yes 1 dipyridamole PERSANTINE Generic Non-Formulary ST Yes 3 edoxaban SAVAYSA Brand No 1 enoxaparin LOVENOX Generic ST No 1 fondaparinux ARIXTRA Generic
No 1 heparin HEPARIN SODIUM Generic
Yes 1 pentoxifylline TRENTAL Generic Yes 1 prasugrel EFFIENT Generic Non-Formulary QL, ST Yes 3 rivaroxaban XARELTO Brand Yes 2 ticagrelor BRILINTA Formulary Brand ST Yes 1 tranexamic acid LYSTEDA Generic Non-Formulary ST Yes 3 vorapaxar ZONTIVITY Brand No 1 warfarin COUMADIN Generic Hematopoietic Agents Yes 2 darbepoetin alfa ARANESP Formulary Brand Yes 2 eltrombopag PROMACTA Formulary Brand Yes 2 epoetin alfa PROCRIT Formulary Brand Non-Formulary Yes 3 epoetin alfa EPOGEN Brand
Non-Formulary Yes 3 filgrastim NEUPOGEN Brand
No 2 filgrastim (vials only) NIVESTYM Formulary Brand
Yes 2 filgrastim ZARXIO Formulary Brand Yes 2 oprelvekin NEUMEGA Formulary Brand Non-Formulary Yes 3 pegfilgrastim NEULASTA Brand
Non-Formulary Yes 3 pegfilgrastim-jmdb FULPHILA Brand Yes 2 sargramostim LEUKINE Formulary Brand Cardiovascular Drugs α-Adrenergic Blocking Agents Yes 1 doxazosin CARDURA Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 21 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 prazosin MINIPRESS Generic Yes 1 terazosin HYTRIN Generic Antilipemic Agents Non-Formulary PA Yes 3 alirocumab PRALUENT Brand Yes 1 atorvastatin LIPITOR Generic Non-Formulary PA Yes 3 bempedoic acid NEXLETOL Brand Non-Formulary PA Yes 3 bempedoic acid & ezetimibe NEXLIZET Brand
Yes 1 cholestyramine light QUESTRAN LIGHT Generic
Yes 1 cholestyramine QUESTRAN Generic ST Yes 1 colesevelam WELCHOL Generic Yes 1 colestipol COLESTID Generic
Yes 3 Non-Formulary evolocumab REPATHA Brand PA No 3 Yes 1 ezetimibe ZETIA Generic Non-Formulary Yes 3 ezetimibe & simvastatin VYTORIN Brand Yes 1 fenofibrate LOFIBRA TAB Generic Yes 1 fenofibrate TRICOR Generic
Yes 1 fenofibrate, micronized LOFIBRA CAP Generic
Yes 1 fenofibric acid TRILIPIX Generic
ST Yes 1 fluvastatin extended-release LESCOL XL Generic
ST Yes 1 fluvastatin LESCOL Generic Yes 1 gemfibrozil LOPID Generic
PA Yes 1 icosapent VASCEPA Generic
Non-Formulary PA Yes 3 lomitapide JUXTAPID Brand Yes 1 lovastatin MEVACOR Generic Non-Formulary Yes 3 lovastatine extended-release ALTOPREV Brand
Non-Formulary PA Yes 3 mipomersen sodium KYNAMRO Brand
Kaiser Permanente, a TRICARE Prime Option Formulary 22 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
ST Yes 1 niacin NIASPAN Generic Non-Formulary Yes 3 niacin & lovastatin ADVICOR Brand
Yes 1 omega-3 acid ethyl esters LOVAZA Generic
Non-Formulary Yes 3 omega-3-carboxylic acid EPANOVA Brand
Non-Formulary ST Yes 3 pitavastatin LIVALO Brand Yes 1 pravastatin PRAVACHOL Generic Yes 1 rosuvastatin CRESTOR Generic Non-Formulary ST Yes 3 rosuvastatin EZALLOR SPRINKLE Brand Yes 1 simvastatin ZOCOR Generic Calcium Channel Blocking Agents Yes 1 amlodipine NORVASC Generic
Yes 1 amlodipine & benazepril LOTREL Generic
ST Yes 1 amlodipine & atorvastatin CADUET Generic
Non-Formulary Yes 3 amlodipine & olmesartan AZOR Brand
ST Yes 1 amlodipine & telmisartan TWYNSTA Generic
ST Yes 1 amlodipine & valsartan EXFORGE Generic
amlodipine, valsartan & ST Yes 1 EXFORGE HCT Generic hydrochlorothiazide
amlodipine, olmesartan & ST Yes 1 TRIBENZOR Generic hydrochlorothiazide
Yes 1 diltiazem extended-release CARDIZEM CD Generic
Yes 1 diltiazem extended-release TIAZAC Generic
Yes 1 diltiazem extended-release CARTIA XT Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 23 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 diltiazem extended-release CARDIZEM LA Generic
Yes 1 diltiazem CARDIZEM Generic Yes 1 felodipine PLENDIL Generic ST Yes 1 isradipine DYNACIRC Generic Yes 1 nicardipine CARDENE Generic Yes 1 nifedipine PROCARDIA Generic
Yes 1 nifedipine extended-release ADALAT CC Generic
Yes 1 nifedipine extended-release PROCARDIA XL Generic
Yes 1 nimodipine NIMOTOP Generic ST Yes 1 nisoldipine SULAR Generic
ST Yes 1 trandolapril & verapamil TARKA Generic
Yes 1 verapamil sustained-release cap VERELAN Generic
Non-Formulary Yes 3 verapamil COVERA-HS Brand
Yes 1 verapamil extended-release cap VERELAN PM Generic
Yes 1 verapamil sustained-release cap CALAN SR Generic
Yes 1 verapamil sustained-release tab ISOPTIN SR Generic
Cardiac Drugs Yes 1 amiodarone PACERONE Generic Yes 1 digoxin LANOXIN Generic Yes 1 disopyramide NORPACE Generic
Yes 2 disopyramide controlled-release NORPACE CR Formulary Brand
Yes 1 dofetilide TIKOSYN Generic Non-Formulary ST Yes 3 dronedarone MULTAQ Brand Yes 1 flecainide TAMBOCOR Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 24 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Non-Formulary Yes 3 Ivabradine CORLANOR Brand Yes 1 mexiletine MEXITIL Generic Yes 1 propafenone RYTHMOL Generic Non-Formulary Yes 3 propafenone RYTHMOL SR Brand
ST Yes 1 quinidine gluconate QUINAGLUTE Generic
Yes 1 quinidine QUINIDINE SULFATE Generic
QL Yes 1 ranolazine RANEXA Generic Non-Formulary Yes 3 sacubitril & valsartan ENTRESTO Brand Hypotensive Agents
ST Yes 1 clonidine extended-release KAPVAY Generic
Yes 1 clonidine CATAPRES Generic
Yes 1 clonidine transdermal CATAPRES-TTS Generic
Yes 1 guanfacine TENEX Generic Yes 1 hydralazine APRESOLINE Generic Yes 1 methyldopa ALDOMET Generic
methyldopa & Yes 1 ALDORIL-25 Generic hydrochlorothiazide
Yes 1 minoxidil LONITEN Generic Non-Formulary Yes 3 reserpine SERPASIL Brand Renin-Angiotensin-Aldosterone System Inhibitors Non-Formulary ST Yes 3 aliskiren TEKTURNA Brand
aliskiren, amlodipine & Non-Formulary ST Yes 3 AMTURNIDE hydrochlorothiazide Brand
Non-Formulary Yes 3 aliskiren & amlodipine TEKAMLO Brand
Kaiser Permanente, a TRICARE Prime Option Formulary 25 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Non-Formulary ST Yes 3 aliskiren & hydrochlorothiazide TEKTURNA HCT Brand
Non-Formulary Yes 3 aliskiren & valsartan VALTURNA Brand
Non-Formulary ST Yes 3 azilsartan EDARBI Brand
Non-Formulary ST Yes 3 azilsartan & chlorthalidone EDARBYCLOR Brand Yes 1 benazepril LOTENSIN Generic
Yes 1 benazepril & hydrochlorothiazide LOTENSIN HCT Generic
ST Yes 1 candesartan ATACAND Generic
candesartan & ST Yes 1 ATACAND HCT Generic hydrochlorothiazide
Yes 1 captopril CAPOTEN Generic
Yes 1 captopril & hydrochlorothiazide CAPOZIDE Generic
Yes 1 enalapril VASOTEC Generic
Yes 1 enalapril & hydrochlorothiazide VASERETIC Generic
ST Yes 1 eplerenone INSPRA Generic Non-Formulary ST Yes 3 eprosartan TEVETEN Brand
Non-Formulary Yes 3 eprosartan & hydrochlorothiazide TEVETEN PLUS Brand
ST Yes 1 fosinopril MONOPRIL Generic
ST Yes 1 fosinopril & hydrochlorothiazide MONOPRIL HCT Generic
ST Yes 1 irbesartan AVAPRO Generic
ST Yes 1 irbesartan & hydrochlorothiazide AVALIDE Generic
Yes 1 lisinopril ZESTRIL Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 26 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 lisinopril & hydrochlorothiazide ZESTORETIC Generic
Yes 1 losartan COZAAR Generic
Yes 1 losartan & hydrochlorothiazide HYZAAR Generic
ST Yes 1 moexipril UNIVASC Generic
ST Yes 1 moexipril & hydrochlorothiazide UNIRETIC Generic
ST Yes 1 olmesartan BENICAR Generic
ST Yes 1 olmesartan & hydrochlorothiazide BENICAR HCT Generic
ST Yes 1 perindopril ACEON Generic ST Yes 1 quinapril hcl ACCUPRIL Generic
ST Yes 1 quinapril & hydrochlorothiazide ACCURETIC Generic
Yes 1 ramipril ALTACE Generic
spironolactone & Yes 1 ALDACTAZIDE Generic hydrochlorothiazide
Yes 1 spironolactone ALDACTONE Generic ST Yes 1 telmisartan MICARDIS Generic
ST Yes 1 telmisartan & hydrochlorothiazide MICARDIS HCT Generic
ST Yes 1 trandolapril MAVIK Generic Yes 1 valsartan DIOVAN Generic
Yes 1 valsartan & hydrochlorothiazide DIOVAN HCT Generic
Vasodilating Agents No 2 ambrisentan LETAIRIS Formulary Brand No 2 bosentan TRACLEER Formulary Brand
Kaiser Permanente, a TRICARE Prime Option Formulary 27 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Non-Formulary Yes 3 isosorbide dinitrate & hydralazine BIDIL Brand
ST Yes 1 isosorbide dinitrate ISORDIL TITRADOSE Generic
Yes 1 isosorbide mononitrate IMDUR Generic
Yes 2 macitentan OPSUMIT Formulary Brand Non-Formulary Yes 3 nitroglycerin aerosol NITROMIST Brand
Yes 1 nitroglycerin solution NITROLINGUAL Generic
Yes 1 nitroglycerin sublingual NITROSTAT Generic
Yes 2 nitroglycerin topical ointment NITRO-BID Formulary Brand
Yes 1 nitroglycerin transdermal patch NITRO-DUR Generic
nitroglycerin transdermal patch Yes 2 NITRO-DUR Formulary Brand 0.8 mg strength
Non-Formulary ST Yes 3 nitroglycerin (intra-anal) RECTIV Brand Yes 1 papaverine PAVABID Generic Non-Formulary Yes 3 riociguat ADEMPAS Brand Yes 1 sildenafil REVATIO Generic Non-Formulary No 3 tadalafil ADCIRCA Brand
Non-Formulary No 3 treprostinil ORENITRAM Brand No 2 treprostinil REMODULIN Formulary Brand β-Adrenergic Blocking Agents Yes 1 acebutolol SECTRAL Generic Yes 1 atenolol TENORMIN Generic
Yes 1 atenolol & chlorthalidone TENORETIC Generic
ST Yes 1 betaxolol KERLONE Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 28 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 bisoprolol & hydrochlorothiazide ZIAC Generic
Yes 1 bisoprolol ZEBETA Generic Yes 1 carvedilol COREG Generic Non-Formulary ST Yes 3 carvedilol phosphate COREG CR Brand Yes 1 labetalol TRANDATE Generic KAPSPARGO Non-Formulary ST Yes 3 metoprolol SPRINKLE Brand
Yes 1 metoprolol & hydrochlorothiazide LOPRESSOR HCT Generic
Yes 1 metoprolol succinate TOPROL XL Generic
Yes 1 metoprolol tartrate LOPRESSOR Generic Yes 1 nadolol CORGARD Generic
Yes 1 nadolol & bendroflumethiazide CORZIDE Generic
Non-Formulary ST Yes 3 nebivolol BYSTOLIC Brand
Non-Formulary ST Yes 3 penbutolol LEVATOL Brand ST Yes 1 pindolol VISKEN Generic
Yes 1 propranolol & hydrochlorothiazide INDERIDE Generic
Non-Formulary Yes 3 propranolol extended-release INNOPRAN XL Brand Yes 1 propranolol INDERAL Generic
Yes 1 propranolol sustained-release INDERAL LA Generic
Yes 1 sotalol BETAPACE Generic Yes 1 sotalol BETAPACE AF Generic Yes 1 timolol BLOCADREN Generic Central Nervous System Agents Analgesics and Antipyretics TYLENOL W/ No 1 acetaminophen & codeine Generic CODEINE
Kaiser Permanente, a TRICARE Prime Option Formulary 29 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
acetaminophen, caffeine, & No 1 TREZIX Generic dihydrocodeine
No 1 buprenorphine SUBUTEX Generic
QL No 1 buprenorphine& naloxone tablet SUBOXONE Generic
Non-Formulary QL No 3 buprenorphine & naloxone film SUBOXONE Brand
QL, ST No 1 buprenorphine transdermal BUTRANS Generic
No 1 butalbital & acetaminophen PHRENILIN Generic
Non-Formulary No 3 butalbital & acetaminophen PHRENILIN FORTE Brand
butalbital, acetaminophen, & No 1 FIORICET Generic caffeine
butalbital, acetaminophen, FIORICET W/ No 1 Generic caffeine, & codeine CODEINE
No 1 butalbital, aspirin, & caffeine FIORINAL Generic
butalbital, aspirin, caffeine, & FIORINAL W/ No 1 Generic codeine CODEINE
QL No 1 butorphanol tartrate STADOL Generic
SOMA COMPOUND ST No 1 carisoprodol, aspirin, & codeine Generic W/ CODEINE
ST No 1 celecoxib CELEBREX Generic ST No 1 codeine CODEINE SULF Generic
No 1 diclofenac potassium CATAFLAM Generic
ST No 1 diclofenac sodium VOLTAREN Generic ST No 1 diclofenac sodium PENNSAID Generic
No 1 diclofenac sodium & misoprostol ARTHROTEC Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 30 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
diclofenac sodium extended No 1 VOLTAREN XR Generic release ST No 1 diflunisal DIFLUNISAL Generic No 1 etodolac LODINE Generic Non-Formulary ST No 3 fenoprofen calcium NALFON Brand
Non-Formulary No 3 fentanyl film ONSOLIS Brand
Non-Formulary No 3 fentanyl intranasal LAZANDA Brand ST No 1 fentanyl lozenge ACTIQ Generic Non-Formulary No 3 fentanyl tablet FENTORA Brand
QL No 1 fentanyl transdermal DURAGESIC Generic
ST No 1 flurbiprofen ANSAID Generic
ST No 1 hydrocodone ZOHYDRO ER Generic
No 1 hydrocodone er HYSINGLA ER Generic
No 1 hydrocodone & acetaminophen NORCO Generic
No 1 hydrocodone & ibuprofen VICOPROFEN Generic
Non-Formulary No 3 hydromorphone oral suspension DILAUDID Brand
No 1 hydromorphone tablet DILAUDID Generic
Non-Formulary ST No 3 hydromorphone tablet EXALGO Brand No 1 ibuprofen MOTRIN Generic No 1 indomethacin INDOCIN Generic No 1 ketoprofen KETOPROFEN Generic QL No 1 ketorolac tablet TORADOL Generic
ST No 1 levorphanol LEVO-DROMORAN Generic
ST No 1 meclofenamate MECLOMEN Generic QL, ST No 1 mefenamic acid PONSTEL Generic No 1 meloxicam MOBIC Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 31 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
ST No 1 meperidine tablet DEMEROL Generic No 1 methadone DOLOPHINE Generic MORPHINE No 2 morphine Formulary Brand SULFATE No 1 morphine MSIR Generic Non-Formulary No 3 morphine beads AVINZA Brand
morphine extended-release Non-Formulary No 3 KADIAN capsule Brand
No 1 morphine extended-release tablet MS CONTIN Generic
Non-Formulary ST No 3 morphine & naltrexone EMBEDA Brand No 1 nabumetone RELAFEN Generic Yes 1 nalbuphine NUBAIN Generic No 1 naproxen NAPROSYN Generic No 1 naproxen sodium ANAPROX Generic
No 1 naproxen sodium ER NAPRELAN Generic
Yes 1 opium & belladonna alkaloids B & O SUPPRETTES Generic
Non-Formulary Yes 3 opium tincture OPIUM Brand ST No 1 oxaprozin DAYPRO Generic ST No 1 oxycodone ROXICODONE Generic
No 1 oxycodone & acetaminophen PERCOCET Generic
No 2 oxycodone & acetaminophen ROXICET Formulary Brand
Non-Formulary No 3 oxycodone & acetaminophen er XARTEMIS XR Brand
No 1 oxycodone & aspirin PERCODAN Generic
Non-Formulary QL No 3 oxycodone & ibuprofen COMBUNOX Brand
QL, ST No 1 oxycodone controlled-release OXYCONTIN Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 32 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
ST No 1 oxymorphone OPANA Generic
ST No 1 oxymorphone extended-release OPANA ER Generic
No 1 pentazocine & naloxone TALWIN NX Generic
ST No 1 piroxicam FELDENE Generic Yes 1 salsalate DISALCID Generic No 1 sulindac CLINORIL Generic Non-Formulary QL, ST Yes 3 tapentadol NUCYNTA Brand No 1 tolmetin sodium TOLECTIN 600 Generic No 1 tramadol ULTRAM Generic
No 1 tramadol & acetaminophen ULTRACET Generic
ST No 1 tramadol extended-release ULTRAM ER Generic
Anorexigenic Agents and Respiratory and Cerebral Stimulants
Non-Formulary ST No 3 amphetamine sulfate EVEKEO Brand
Non-Formulary ST No 3 amphetamine extended-release ADZENYS ER Brand
amphetamine & No 1 ADDERALL Generic dextroamphetamine
amphetamine & No 1 dextroamphetamine extended- ADDERALL XR Generic release
amphetamine & Non-Formulary ST No 3 dextroamphetamine extended- MYDAYIS Brand release
QL, ST (ST-Brand No 1 armodafinil NUVIGIL Generic only)
QL No 1 dexmethylphenidate FOCALIN Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 33 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
dexmethylphenidate extended- No 1 FOCALIN XR Generic release
QL No 1 dextroamphetamine sulfate DEXTROSTAT Generic
dextroamphetamine sulfate QL No 1 DEXEDRINE Generic extended-release
Non-Formulary QL, ST Yes 3 lisdexamfetamine VYVANSE Brand
ST No 1 methamphetamine DESOXYN Generic
No 1 methylphenidate METHYLIN Generic No 1 methylphenidate RITALIN Generic methylphenidate extended- QL No 1 METADATE ER Generic release
methylphenidate extended- QL No 1 CONCERTA Generic release
methylphenidate extended- No 1 METADATE CD Generic release
methylphenidate extended- QL, ST No 1 RITALIN LA Generic release
methylphenidate sustained QL No 1 RITALIN SR Generic release
methylphenidate transdermal Non-Formulary QL, ST No 3 DAYTRANA patch Brand
Methylphenidate extended- Non-Formulary ST No 3 COTEMPLA XR-ODT release disintegrating tablet Brand
QL No 1 modafinil PROVIGIL Generic Anticonvulsants Non-Formulary ST Yes 3 brivaracetam BRIVIACT Brand Yes 1 carbamazepine TEGRETOL Generic
carbamazepine extended-release Yes 1 CARBATROL Generic cap
carbamazepine extended-release Non-Formulary Yes 3 EQUETRO cap Brand
Kaiser Permanente, a TRICARE Prime Option Formulary 34 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
carbamazepine extended-release Yes 1 TEGRETOL XR Generic tab
Non-Formulary QL, ST Yes 3 cenobamate XCOPRI Brand
Non-Formulary Yes 3 clobazam ONFI Brand
Non-Formulary ST Yes 3 clobazam SYMPAZAN Brand No 1 clonazepam KLONOPIN Generic No 1 diazepam DIASTAT Generic
No 2 diazepam DIASTAT ACUDIAL Formulary Brand
Yes 1 divalproex sodium DEPAKOTE Generic DEPAKOTE Yes 1 divalproex sodium capsule Generic SPRINKLE
divalproex sodium extended Yes 1 DEPAKOTE ER Generic release
Non-Formulary Yes 3 eslicarbazepine APTIOM Brand
Non-Formulary ST Yes 3 ethontoin PEGANONE Brand Yes 1 ethosuximide ZARONTIN Generic Non-Formulary ST Yes 3 ezogaine POTIGA Brand ST Yes 1 felbamate FELBATOL Generic Non-Formulary PA No 3 fenfluramine FINTEPLA Brand Non-Formulary ST Yes 3 gabapentin GRALISE Brand No 1 gabapentin NEURONTIN Generic Non-Formulary ST No 3 gabapentin HORIZANT Brand
Non-Formulary QL, ST Yes 3 lacosamide VIMPAT Brand Yes 1 lamotrigine LAMICTAL Generic
Yes 1 lamotrigine extended-release LAMICTAL XR Generic
Yes 1 levetiracetam KEPPRA Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 35 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status Non-Formulary ST Yes 3 levetiracetam SPRITAM Brand
Yes 1 levetiracetam extended-release KEPPRA XR Generic
Yes 2 methsuximide CELONTIN Formulary Brand Yes 1 oxcarbazepine TRILEPTAL Generic Non-Formulary Yes 3 perampanel FYCOMPA Brand
phenytoin sodium extended- Yes 1 DILANTIN Generic release
phenytoin sodium extended- Yes 1 PHENYTEK Generic release
Yes 1 phenytoin suspension DILANTIN Generic
Yes 1 pregabalin LYRICA Generic Yes 1 pregabalin er LYRICA CR Generic Yes 1 primidone MYSOLINE Generic
ST Yes 1 rufinamide BANZEL Generic
Non-Formulary PA Yes 3 stiripentol DIACOMIT Brand ST Yes 1 tiagabine GABITRIL Generic
Yes 1 topiramate capsule TOPAMAX SPRINKLE Generic
topiramate capsule extended Non-Formulary ST Yes 3 TROKENDI XR release Brand Yes 1 topiramate tablet TOPAMAX Generic Yes 1 valproate sodium DEPAKENE Generic Yes 1 valproic acid DEPAKENE Generic Non-Formulary PA No 3 vigabatrin SABRIL Brand Yes 1 zonisamide ZONEGRAN Generic Antimigraine Agents ST No 1 almotriptan AXERT Generic Non-Formulary QL, ST No 3 diclofenac CAMBIA Brand
No 1 ergotamine & caffeine MIGERGOT Generic
ST No 1 eletriptan RELPAX Generic ST No 1 frovatriptan FROVA Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 36 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status Non-Formulary PA, QL No 3 lasmitidan REYVOW Brand No 1 naratriptan AMERGE Generic Non-Formulary PA, QL No 3 rimegepant NURTEC ODT Brand No 1 rizatriptan MAXALT Generic
No 1 rizatriptan orally disintegrating MAXALT MLT Generic
QL No 1 sumatriptan IMITREX Generic Non-Formulary ST No 3 sumatriptan (nasal) TOSYMRA Brand Non-Formulary ST No 3 sumatriptan & naproxen TREXIMET Brand Non-Formulary PA, QL Yes 3 ubrogepant UBRELVY Brand ST No 1 zolmitriptan ZOMIG Generic
No 1 zolmitriptan orally disintegrating ZOMIG ZMT Generic
Antiparkinsonian Agents Yes 1 amantadine SYMMETREL Generic Non-Formulary ST Yes 3 amantadine ER GOCOVRI Brand
Non-Formulary ST Yes 3 apomorphine APOKYN Brand
Non-Formulary ST Yes 3 apomorphine KYNMOBI Brand Yes 1 benztropine COGENTIN Generic Yes 1 bromocriptine PARLODEL Generic Non-Formulary ST Yes 3 bromocriptine CYCLOSET Brand Yes 1 cabergoline DOSTINEX Generic Non-Formulary ST Yes 3 carbidopa LODOSYN Brand
Yes 1 carbidopa & levodopa SINEMET Generic
Non-Formulary Yes 3 carbidopa & levodopa PARCOPA Brand
carbidopa & levodopa extended Non-Formulary ST Yes 3 RYTARY release Brand
Kaiser Permanente, a TRICARE Prime Option Formulary 37 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
carbidopa & levodopa extended Yes 1 SINEMET CR Generic release
carbidopa, levodopa, & Yes 2 STALEVO Formulary Brand entacapone
Yes 1 entacapone COMTAN Generic Non-Formulary PA Yes 3 levophed (oral inhalation) INBRIJA Brand
Non-Formulary ST Yes 3 opicapone ONGENTYS Brand Yes 1 pramipexole MIRAPEX Generic
Yes 1 pramipexole extended-release MIRAPEX ER Generic
Non-Formulary ST Yes 3 rasagiline AZILECT Brand Yes 1 ropinirole REQUIP Generic
ST Yes 1 ropinirole extended-release REQUIP XL Generic
Non-Formulary ST Yes 3 rotigotine NEUPRO Brand Yes 1 selegiline ELDEPRYL Generic Non-Formulary ST Yes 3 selegiline ZELAPAR Brand
Non-Formulary ST Yes 3 selegiline transdermal EMSAM Brand Yes 2 tolcapone TASMAR Formulary Brand Yes 1 trihexyphenidyl ARTANE Generic Anxiolytics, Sedatives, and Hypnotics No 1 alprazolam XANAX Generic
No 1 alprazolam extended-release XANAX XR Generic
Non-Formulary No 3 alprazolam orally disintegrating NIRAVAM Brand No 1 buspirone BUSPAR Generic No 1 chlordiazepoxide LIBRIUM Generic ST No 1 clorazepate TRANXENE Generic No 1 diazepam VALIUM Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 38 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
ST Yes 1 doxepin (sleep) SILENOR Generic
No 1 estazolam PROSOM Generic ST No 1 eszopiclone LUNESTA Generic No 1 flurazepam DALMANE Generic No 1 hydroxyzine hcl ATARAX Generic
ST No 1 hydroxyzine pamoate VISTARIL Generic
No 1 lorazepam ATIVAN Generic No 1 meprobamate MILTOWN Generic ST No 1 oxazepam SERAX Generic No 1 phenobarbital PHENOBARBITAL Generic ST No 1 ramelteon ROZEREM Generic Non-Formulary ST Yes 3 suvorexant BELSOMRA Brand
Non-Formulary PA Yes 3 tasimelteon HETLIOZ Brand No 1 temazepam RESTORIL Generic No 1 triazolam HALCION Generic No 1 zaleplon SONATA Generic Non-Formulary Yes 3 zolipdem sublingual EDLUAR Brand No 1 zolpidem AMBIEN Generic Non-Formulary No 3 zolpidem extended-release AMBIEN CR Brand
Non-Formulary No 3 zolpidem oral spray ZOLPIMIST Brand
Non-Formulary ST No 3 zolpidem sublingual INTERMEZZO Brand Central Nervous System Agents Miscellaneous ST Yes 1 acamprosate CAMPRAL Generic Non-Formulary ST Yes 3 atomoxetine STRATTERA Brand
Non-Formulary PA Yes 3 cannabidiol EPIDIOLEX Brand
Non-Formulary PA Yes 3 deutetrabenazine AUSTEDO Brand
Non-Formulary PA Yes 3 dextromethorphan & quinidine NUEDEXTA Brand
Kaiser Permanente, a TRICARE Prime Option Formulary 39 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 guanfacine extended-release INTUNIV Generic
Non-Formulary ST Yes 3 lofexidine LUCEMYRA Brand No 1 memantine NAMENDA Generic Non-Formulary No 3 memantine er & donepezil NAMZARIC Brand
Non-Formulary QL, ST Yes 3 milnacipran SAVELLA Brand
Non-Formulary PA Yes 3 pitolisant WAKIX Brand
Non-Formulary PA Yes 3 ponesimod PONVORY Brand Yes 1 riluzole RILUTEK Generic Non-Formulary PA Yes 3 solriamfetol SUNOSI Brand
Non-Formulary PA Yes 3 sodium oxybate XYREM Brand
Non-Formulary PA No 3 tetrabenazine XENAZINE Brand
Non-Formulary PA Yes 3 valbenazine INGREZZA Brand Opioid Antagonists No 1 naloxone NARCAN Generic
QL No 2 naloxone nasal spray NARCAN Formulary Brand
No 1 naltrexone REVIA Generic Psychotherapeutic Agents Yes 1 amitriptyline ELAVIL Generic
Yes 1 amitriptyline & perphenazine TRIAVIL Generic
Yes 1 amoxapine ASENDIN Generic Yes 1 aripiprazole tablet ABILIFY Generic Non-Formulary ST Yes 3 aripiprazole solution ABILIFY Brand
Non-Formulary ST Yes 3 aripiprazole ABILIFY DISCMELT Brand
ST Yes 1 asenapine SAPHRIS Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 40 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Non-Formulary QL, ST Yes 3 brexpiprazole REXULTI Brand Yes 1 bupropion WELLBUTRIN Generic
Yes 1 bupropion extended-release WELLBUTRIN XL Generic
Non-Formulary ST Yes 3 bupropion hydrobromide APLENZIN Brand
Yes 1 bupropion sustained-release WELLBUTRIN SR Generic
Non-Formulary ST Yes 3 bupropion (smoking deterrent) ZYBAN Brand
Non-Formulary QL, ST Yes 3 cariprazine VRAYLAR Brand
No 1 chlordiazepoxide & amitriptyline LIMBITROL DS Generic
Yes 1 chlorpromazine THORAZINE Generic Yes 1 citalopram CELEXA Generic Yes 1 clomipramine ANAFRANIL Generic No 1 clozapine CLOZARIL Generic No 1 clozapine FAZACLO Generic Yes 1 desipramine NORPRAMIN Generic
desvenlafaxine succinate ST Yes 1 PRISTIQ Generic extended release
ST Yes 1 desvenlafaxine extended release KHEDEZLA Generic
Yes 1 doxepin SINEQUAN Generic Yes 1 duloxetine CYMBALTA Generic Yes 1 escitalopram LEXAPRO Generic Yes 1 fluoxetine PROZAC Generic Non-Formulary Yes 3 fluoxetine PROZAC WEEKLY Brand
Non-Formulary Yes 3 fluoxetine SARAFEM Brand Yes 1 fluphenazine PROLIXIN Generic Yes 1 fluvoxamine LUVOX Generic Yes 1 haloperidol HALDOL Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 41 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Non-Formulary ST Yes 3 iloperidone FANAPT Brand Yes 1 imipramine TOFRANIL Generic
Yes 1 imipramine pamoate TOFRANIL-PM Generic
Non-Formulary ST Yes 3 isocarboxazid MARPLAN Brand
Non-Formulary QL Yes 3 levomilnacipran FETZIMA Brand
LITHIUM Yes 1 lithium carbonate capsule Generic CARBONATE
lithium carbonate extended Yes 1 LITHOBID Generic release Yes 1 lithium citrate CIBALITH-S Generic ST Yes 1 loxapine LOXITANE Generic Non-Formulary QL, ST Yes 3 lurasidone LATUDA Brand ST Yes 1 maprotiline LUDIOMIL Generic Yes 1 mirtazapine REMERON Generic Yes 1 nefazodone SERZONE Generic Yes 1 nortriptyline PAMELOR Generic Yes 1 olanzapine ZYPREXA Generic
Yes 1 olanzapine & fluoxetine hcl SYMBYAX Generic
Yes 1 olanzapine orally disintegrating ZYPREXA ZYDIS Generic
ST Yes 1 paliperidone INVEGA Generic Yes 1 paroxetine PAXIL Generic Non-Formulary Yes 3 paroxetine extended-release PAXIL CR Brand
Non-Formulary Yes 3 paroxetine mesylate PEXEVA Brand Yes 1 perphenazine TRILAFON Generic Yes 1 phenelzine NARDIL Generic Non-Formulary PA Yes 3 pimavanserin NUPLAZID Brand ST Yes 1 pimozide ORAP Generic ST Yes 1 protriptyline VIVACTIL Generic Yes 1 quetiapine SEROQUEL Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 42 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 quetiapine extended-release SEROQUEL XR Generic
Yes 1 risperidone RISPERDAL Generic Non-Formulary Yes 3 risperidone orally disintegrating RISPERDALM-TAB Brand Yes 1 sertraline ZOLOFT Generic Yes 1 thioridazine MELLARIL Generic Yes 1 thiothixene NAVANE Generic
Yes 1 tranylcypromine sulfate PARNATE Generic
Yes 1 trazodone DESYREL Generic Non-Formulary Yes 3 trazodone extended-release OLEPTRO Brand Yes 1 trifluoperazine STELAZINE Generic ST Yes 1 trimipramine SURMONTIL Generic Yes 1 venlafaxine EFFEXOR Generic
Yes 1 venlafaxine extended-release EFFEXOR XR Generic
Non-Formulary QL, ST Yes 3 vilazodone VIIBRYD Brand
Non-Formulary QL, ST Yes 3 vortioxetine TRINTELLIX Brand Yes 1 ziprasidone GEODON Generic Diabetic Supplies Diabetic Supplies
ONE TOUCH ULTRA QL Yes 2 blood sugar diagnostic Formulary Brand TEST STRIPS
ONE TOUCH VERIO QL Yes 2 blood sugar diagnostic Formulary Brand TEST STRIPS
ACCU-CHEK TEST QL Yes 2 blood sugar diagnostic Formulary Brand STRIPS
ASCENSIA TEST QL Yes 2 blood sugar diagnostic Formulary Brand STRIPS
FREESTYLE TEST QL Yes 2 blood sugar diagnostic Formulary Brand STRIPS
PRODIGY TEST QL Yes 2 blood sugar diagnostic Formulary Brand STRIPS
Kaiser Permanente, a TRICARE Prime Option Formulary 43 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
ONE TOUCH ULTRA QL Yes 2 blood-glucose meter Formulary Brand 2
ONE TOUCH VERIO QL Yes 2 blood-glucose meter Formulary Brand FLEX
QL Yes 2 blood-glucose meter ACCU-CHEK Formulary Brand
QL Yes 2 blood-glucose meter ASCENSIA BREEZE Formulary Brand
FREESTYLE QL Yes 2 blood-glucose meter Formulary Brand SYSTEM
ONE TOUCH ULTRA QL Yes 2 blood-glucose meter Formulary Brand SMART
ONE TOUCH QL Yes 2 blood-glucose meter Formulary Brand ULTRAMINI
QL Yes 2 blood-glucose meter PRODIGY Formulary Brand
OMNIPOD DASHTM ST Yes 2 Insulin delivery system Formulary Brand PODs
BD INSULIN QL Yes 2 syringe with needle,disposable Formulary Brand SYRINGE Electrolytic, Caloric and Water Balance Acidifying and Alkalinizing Agents
citric acid, sodium citrate, & Non-Formulary Yes 3 CYTRA-3 potassium citrate Brand
Yes 1 potassium citrate UROCIT-K Generic
Yes 2 potassium citrate & citric acid POLYCITRA-K Formulary Brand
Non-Formulary Yes 3 sodium citrate & citric acid BICITRA Brand Ammonia Detoxicants Non-Formulary ST Yes 3 carglumic acid CARBAGLU Brand
Non-Formulary PA Yes 3 glycerol phenylbutyrate RAVICTI Brand
Non-Formulary No 3 sodium phenylbutyrate BUPHENYL Brand
Non-Formulary Yes 3 lactulose CHRONULAC Brand
Kaiser Permanente, a TRICARE Prime Option Formulary 44 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 lactulose ENULOSE Generic Non-Formulary Yes 3 lactulose KRISTALOSE Brand Diuretics ST Yes 1 amiloride MIDAMOR Generic
Yes 1 amiloride & hydrochlorothiazide MODURETIC Generic
Yes 1 bumetanide BUMEX Generic ST Yes 1 chlorothiazide DIURIL Generic Yes 1 chlorthalidone HYGROTON Generic Non-Formulary ST Yes 3 ethacrynic acid EDECRIN Brand Yes 1 furosemide LASIX Generic
Yes 1 hydrochlorothiazide MICROZIDE Generic
Yes 1 indapamide LOZOL Generic
ST Yes 1 methyclothiazide METHYCLOTHIAZIDE Generic
Yes 1 metolazone ZAROXOLYN Generic
PA No 1 tolvaptan JYNARQUE Generic
Non-Formulary QL No 3 tolvaptan SAMSCA Brand Yes 1 torsemide DEMADEX Generic Non-Formulary ST Yes 3 triamterene DYRENIUM Brand
Yes 1 triamterene & hydrochlorothiazide DYAZIDE Generic
Yes 1 triamterene & hydrochlorothiazide MAXZIDE Generic
Ion-Removing Agnets
ST Yes 1 sevelamer carbonate RENVELA Generic
No 1 sodium polystyrene sulfonate SPS Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 45 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Non-Formulary Yes 3 sucroferric oxyhydroxide VELPHORO Brand
Non-Formulary ST Yes 3 lanthanum carbonate FOSRENOL Brand
Non-Formulary ST Yes 3 patiromer VELTASSA Brand ST Yes 1 sevelamer hcl RENAGEL Generic Non-Formulary ST Yes 3 sodium zirconium cyclosilicate LOKELMA Brand Replacement Products Yes 2 calcium acetate ELIPHOS Formulary Brand Yes 1 calcium acetate PHOSLO Generic Yes 2 calcium acetate PHOSLYRA Formulary Brand
potassium bicarbonate & Yes 1 K-LYTE/CL Generic potassium chloride
Yes 1 potassium chloride K-DUR Generic
K-TAB 10, KLOR- Yes 1 potassium chloride Generic CON 20 MEQ
Non-Formulary ST Yes 3 potassium chloride powder KLOR-CON 20 MEQ Brand
Non-Formulary Yes 3 potassium chloride solution KCL SOLUTION Brand
Yes 1 potassium gluconate KAON Generic
Yes 2 potassium phosphate PHOSPHA Formulary Brand
Non-Formulary Yes 3 potassium phosphate, monobasic K-PHOS NEUTRAL Brand
Yes 2 potassium phosphate, monobasic K-PHOS ORIGINAL Formulary Brand
Uricosuric Agents
Yes 1 colchicine & probenecid COL-BENEMID Generic
Yes 1 probenecid BENEMID Generic Enzymes
Kaiser Permanente, a TRICARE Prime Option Formulary 46 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Enzymes Yes 2 dornase alfa PULMOZYME Formulary Brand Eye, Ear, Nose and Throat (EENT) Anti-infectives Non-Formulary Yes 3 azithromycin (ophth) AZASITE Brand
No 1 bacitracin & polmyxin B (ophth) POLYSPORIN Generic
No 1 bacitracin (ophth) AK-TRACIN Generic Non-Formulary ST Yes 3 besilfoxacin BESIVANCE Brand
No 1 chlorhexidine (mouth-throat) PERIDEX Generic
Non-Formulary No 3 ciprofloxacin (ophth) ointment CILOXAN Brand
No 1 ciprofloxacin (ophth) solution CILOXAN Generic
No 1 erythromycin (ophth) ROMYCIN Generic
Non-Formulary ST Yes 3 ganciclovir (ophth) ZIRGAN Brand
ST No 1 gatifloxacin (ophth) ZYMAXID Generic
No 1 gentamicin (ophth) GENTAK Generic
No 1 levofloxacin (ophth) QUIXIN Generic
No 1 moxifloxacin (ophth) VIGAMOX Generic
Yes 2 natamycin NATACYN Formulary Brand
neomycin, bacitracin & polymyxin No 1 NEO-POLYCIN Generic b (ophth)
neomycin, polymycin b & No 1 NEOSPORIN Generic gramicidin (ophth)
No 1 ofloxacin (ophth) OCUFLOX Generic No 1 ofloxacin (otic) FLOXIN Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 47 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
polymyxin b & trimethoprim No 1 POLYTRIM Generic (ophth)
sulfacetamide sodium (ophth) No 1 SULFAC Generic ointment
sulfacetamide sodium (ophth) No 1 BLEPH-10 Generic solution
tobramycin sulfate (ophth) No 2 TOBREX Formulary Brand ointment
tobramycin sulfate (ophth) No 1 TOBREX Generic solution No 1 trifluridine VIROPTIC Generic Anti-Inflammatory Agents
bacitracin, neomycin, polymyxin No 1 NEO-POLYCIN HC Generic B & hydrocortisone (ophth)
Non-Formulary ST Yes 3 bromfenac (ophth) PROLENSA Brand
Non-Formulary ST Yes 3 bromfenac (ophth) XIBROM Brand
ciprofloxacin & dexamethasone No 1 CIPRODEX Generic (ophth)
ciprofloxacin & hydrocortisone Non-Formulary ST No 3 CIPRO HC (otic) Brand
Non-Formulary QL, ST Yes 3 cyclosporine (ophth) CEQUA Brand
Non-Formulary QL, ST Yes 3 cyclosporine (ophth) RESTASIS Brand
Yes 1 dexamethasone (ophth) solution DECADRON Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 48 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
dexamethasone (ophth) Yes 2 MAXIDEX Formulary Brand suspension
No 1 diclofenac sodium (ophth) VOLTAREN Generic
Non-Formulary ST Yes 3 difluprednate DUREZOL Brand
Non-Formulary ST Yes 3 fluocinolone acetonide (otic) DERMOTIC Brand
Yes 1 fluorometholone (ophth) FML Generic
Non-Formulary Yes 3 fluorometholone (ophth) FML FORTE Brand
Non-Formulary ST Yes 3 fluorometholone (ophth oint) FML OINT Brand
Yes 2 fluorometholone acetate FLAREX Formulary Brand
ST No 1 flurbiprofen (ophth) OCUFEN Generic
No 2 gentamicin & prednisolone PRED-G Formulary Brand
hydrocortisone & acetic acid Yes 1 ACETASOL HC Generic (otic) No 1 ketorolac (ophth) ACULAR Generic No 1 ketorolac (ophth) ACULAR LS Generic Non-Formulary QL, ST Yes 3 lifitegrast XIIDRA Brand
Non-Formulary Yes 3 loteprednol ALREX Brand
ST Yes 1 loteprednol LOTEMAX Generic
Non-Formulary Yes 3 loteprednol & tobramycin ZYLET Brand
neomycin, colistin, Non-Formulary No 3 hydrocortisone & thonzonium CORTISPORIN-TC Brand (otic)
neomycin, polymyxin B & No 1 MAXITROL Generic dexamethasone (ophth)
Kaiser Permanente, a TRICARE Prime Option Formulary 49 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
neomycin, polymyxin B & Non-Formulary No 3 CORTISPORIN hydrocortisone (ophth) Brand
neomycin, polymyxin B & No 1 CORTISPORIN Generic hydrocortisone (otic)
Non-Formulary ST Yes 3 nepafenac NEVANAC Brand
Non-Formulary ST Yes 3 nepafenac ILEVRO Brand
Yes 1 prednisolone acetate (ophth) OMNIPRED Generic
Yes 1 prednisolone acetate (ophth) PRED FORTE Generic
Yes 2 prednisolone acetate (ophth) PRED MILD Formulary Brand
prednisolone sodium phosphate Non-Formulary Yes 3 INFLAMASE FORTE (ophth) Brand
prednisolone sodium phosphate Yes 1 PREDNISOL Generic (ophth)
Non-Formulary ST Yes 3 rimexolone VEXOL Brand
sulfacetamide sodium & No 1 BLEPHAMIDE Generic prednisolone
tobramycin & dexamethasone No 2 TOBRADEX Formulary Brand ointment
tobramycin & dexamethasone No 1 TOBRADEX Generic suspension
Antiallergic Agents Non-Formulary ST Yes 3 aflcaftadine LASTACAFT Brand Yes 1 azelastine ASTELIN Generic ST Yes 1 azelastine ASTEPRO Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 50 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
ST Yes 1 azelastine & fluticasone DYMISTA Generic
ST Yes 1 azelastine (ophth) OPTIVAR Generic Non-Formulary ST Yes 3 beclomethasone BECONASE AQ Brand Non-Formulary ST Yes 3 beclomethasone QNASL Brand
ST Yes 1 bepotastine BEPREVE Generic
ST Yes 1 budesonide RHINOCORT Generic
Non-Formulary ST Yes 3 carbinozamine RYVENT Brand
Non-Formulary ST Yes 3 certirizine ZERVIATE Brand
ST Yes 1 cromolyn sodium (ophth) OPTICROM Generic
Non-Formulary ST Yes 3 emedastine EMADINE Brand ST Yes 1 epinastine (ophth) ELESTAT Generic ST Yes 1 flunisolide FLUNISOLIDE Generic ST Yes 1 fluticasone FLONASE Generic
grass pollen allergen extract (5 Non-Formulary Yes 3 ORALAIR glass extract) Brand
Non-Formulary ST Yes 3 lodoxamide tromethamine ALOMIDE Brand
Non-Formulary Yes 3 house dust mite allergen extract ODACTRA Brand
Non-Formulary ST Yes 3 nedocromil sodium (ophth) ALOCRIL Brand
Non-Formulary ST Yes 3 olopatadine PATADAY Brand
Non-Formulary ST Yes 3 olopatadine (nasal) PATANASE Brand
ST Yes 1 olopatadine (ophth) PATANOL Generic
Non-Formulary ST Yes 3 olopatadine (ophth) PAZEO Brand
Kaiser Permanente, a TRICARE Prime Option Formulary 51 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
short ragweed pollen allergen Non-Formulary Yes 3 RAGWITEK extract Brand
timothy grass pollen allergen Non-Formulary Yes 3 GRASTEK extract Brand
Antiglaucoma Agents Yes 1 acetazolamide DIAMOX Generic
Yes 1 acetazolamide DIAMOX SEQUELS Generic
Yes 1 betaxolol hcl BETOPTIC Generic Yes 2 betaxolol hcl BETOPTIC S Formulary Brand Non-Formulary ST Yes 3 bimatoprost LUMIGAN Brand Yes 1 brimonidine ALPHAGAN Generic
Yes 1 brimonidine tartrate ALPHAGAN P Generic
Non-Formulary ST Yes 3 brimonidine & timolol COMBIGAN Brand
ST Yes 1 brinzolamide AZOPT Generic
ISOPTO Yes 2 carbachol Formulary Brand CARBACHOL ST Yes 1 carteolol (ophth) OCUPRESS Generic Yes 1 dorzolamide TRUSOPT Generic
Yes 1 dorzolamide & timolol COSOPT Generic
PHOSPHOLINE Yes 2 ecothiophate Formulary Brand IODIDE Yes 1 latanoprost XALATAN Generic Non-Formulary PA Yes 3 latanoprostene bunod VYZULTA Brand Yes 1 levobunolol BETAGAN Generic Yes 1 methazolamide NEPTAZANE Generic Yes 1 metipranolol OPTIPRANOLOL Generic Non-Formulary PA Yes 3 netarsudil RHOPRESSA Brand Yes 1 pilocarpine ISOPTO CARPINE Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 52 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Non-Formulary Yes 3 pilocarpine gel PILOPINE HS Brand
Non-Formulary ST Yes 3 timolol BETIMOL Brand
Non-Formulary ST Yes 3 timolol ISTALOL Brand ST Yes 1 timolol TIMOPTIC Generic Non-Formulary ST Yes 3 timolol TIMOPTIC-XE Brand
Non-Formulary ST Yes 3 tafluprost ZIOPTAN Brand
Non-Formulary ST Yes 3 travoprost TRAVATAN Z Brand
Non-Formulary Yes 3 unoprostone isopropyl RESCULA Brand EENT Drugs, Miscellaneous Yes 1 acetic acid VOSOL Generic Non-Formulary ST Yes 3 apraclonidine IOPIDINE Brand Non-Formulary ST Yes 3 artificial tear insert LACRISERT Brand
Non-Formulary PA Yes 3 cenegermin-bkbj OXERVATE Brand Local Anesthetics
Yes 1 antipyrine & benzocaine AURODEX Generic
XYLOCAINE No 1 lidocaine (mouth-throat) Generic VISCOUS Yes 1 proparacaine OPTHETIC Generic Mydriatics
Yes 1 atropine ISOPTO ATROPINE Generic
ISOPTO Yes 2 homatropine Formulary Brand HOMATROPINE
Yes 2 scopolamine (ophth) ISOPTO HYOSCINE Formulary Brand
Vasoconstrictors ST Yes 1 tetrahydrozoline TYZINE Generic Gastrointestinal Drugs Anti-inflammatory Agents
Kaiser Permanente, a TRICARE Prime Option Formulary 53 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
ST No 1 alosetron LOTRONEX Generic Yes 1 balsalazide COLAZAL Generic Non-Formulary Yes 3 balsalazide GIAZO Brand
Non-Formulary PA Yes 3 budesonide er XHANCE Brand
Non-Formulary PA Yes 3 eluxadoline VIBERZI Brand
Yes 2 mesalamine controlled-release PENTASA Formulary Brand
Yes 2 mesalamine suppository CANASA Formulary Brand
Yes 1 mesalamine suspension ROWASA Generic
Yes 2 mesalamine tablet LIALDA Formulary Brand
Non-Formulary ST Yes 3 olsalazine DIPENTUM Brand
Non-Formulary ST Yes 3 plecanatide TRULANCE Brand Antidiarrhea Agents Non-Formulary ST Yes 3 difenoxin & atropine MOTOFEN Brand
No 1 diphenoxylate & atropine LOMOTIL Generic
Non-Formulary Yes 3 paregoric PAREGORIC Brand Antiemetics QL No 1 aprepitant EMEND Generic Non-Formulary ST Yes 3 dolasetron ANZEMET Brand No 1 dronabinol MARINOL Generic Non-Formulary ST No 3 granisetron KYTRIL Brand
Non-Formulary No 3 granisetron SANCUSO Brand
Non-Formulary ST Yes 3 nabilone CESAMET Brand
Yes 2 netupitant & palonosetron AKYNZEO Formulary Brand
Kaiser Permanente, a TRICARE Prime Option Formulary 54 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
No 1 ondansetron ZOFRAN Generic
ondansetron (orally No 1 ZOFRAN ODT Generic disintegrating)
QL No 1 prochlorperazine COMPAZINE Generic Non-Formulary Yes 3 rolapitant VARUBI Brand
ST Yes 1 scopolamine hydrobromide TRANSDERM-SCOP Generic
ST No 1 trimethobenzamide TIGAN Generic
Antiulcer Agents and Acid Suppressants
amoxicillin, clarithromycin, & Non-Formulary No 3 PREVPAC lansoprazole Brand
Yes 1 cimetidine TAGAMET Generic Non-Formulary ST Yes 3 dexlansoprazole DEXILANT Brand ST No 1 esomeprazole NEXIUM Generic Yes 1 famotidine PEPCID Generic Yes 1 lansoprazole PREVACID Generic Yes 1 misoprostol CYTOTEC Generic ST Yes 1 nizatidine AXID Generic Yes 1 omeprazole PRILOSEC Generic Yes 1 pantoprazole PROTONIX Generic ST Yes 1 rabeprazole ACIPHEX Generic Yes 1 sucralfate tablets CARAFATE Generic Non-Formulary Yes 3 sucralfate suspension CARAFATE Brand Cathartics and Laxatives
polyethylene glycol-electrolyte Non-Formulary Yes 3 HALFLYTELY solution Brand
polyethylene glycol-electrolyte ST Yes 1 MOVIPREP Generic solution
polyethylene glycol-electrolyte Yes 1 COLYTE Generic solution
Kaiser Permanente, a TRICARE Prime Option Formulary 55 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
polyethylene glycol-electrolyte Yes 1 GOLYTELY Generic solution
polyethylene glycol-electrolyte Yes 1 GAVILYTE-C Generic solution
polyethylene glycol-electrolyte Yes 1 NULYTELY Generic solution
Non-Formulary ST Yes 3 sodium phosphates OSMOPREP Brand
Non-Formulary No 3 sodium phosphates VISICOL Brand
sodium picosulfate-mag ox- Non-Formulary ST No 3 CLENPIQ anhydrous citric acid Brand
Digestants
pancrelipase (lipase-protease- Yes 2 CREON Formulary Brand amylase)
pancrelipase (lipase-protease- Yes 2 ZENPEP Formulary Brand amylase)
pancrelipase (lipase-protease- Yes 2 PANCREAZE Formulary Brand amylase)
pancrelipase (lipase-protease- Non-Formulary Yes 3 VIOKACE amylase) Brand
pancrelipase (lipase-protease- Non-Formulary Yes 3 PERTZYE amylase) Brand
GI Drugs, Miscellaneous
Yes 1 clidinium & chlordiazepoxide LIBRAX Generic
Non-Formulary QL, ST Yes 3 linaclotide LINZESS Brand
ST Yes 1 lubiprostone AMITIZA Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 56 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Non-Formulary ST Yes 3 mepenzolate CANTIL Brand Yes 1 metoclopramide REGLAN Generic Non-Formulary ST Yes 3 methylnaltrexone RELISTOR Brand
phenobarbital and belladonna Non-Formulary No 3 DONNATAL alkaloids Brand
Non-Formulary ST No 3 prucalopride MOTEGRITY Brand
Non-Formulary Yes 3 teduglutide GATTEX Brand Yes 1 ursodiol ACTIGALL Generic Yes 1 ursodiol URSO Generic Yes 1 ursodiol URSO FORTE Generic Gold Compounds Gold Compounds Yes 2 auranofin RIDAURA Formulary Brand Heavy Metal Antagonists Heavy Metal Antagonists Non-Formulary No 3 deferasirox EXJADE Brand No 1 deferasirox JADENU Generic No 1 deferasirox JADENU SPRINKLES Generic
Yes 1 deferiprone FERRIPROX Generic
No 2 penicillamine CUPRIMINE Formulary Brand No 1 penicillamine DEPEN Generic Non-Formulary ST Yes 3 succimer CHEMET Brand
Non-Formulary ST No 3 trientine SYPRINE Brand Hormones and Synthetic Substitutes Adrenals ST No 1 budesonide ENTOCORT EC Generic Non-Formulary PA No 3 budesonide UCERIS Brand
Kaiser Permanente, a TRICARE Prime Option Formulary 57 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
ST Yes 1 cortisone acetate CORTONE ACETATE Generic
Yes 1 dexamethasone DECADRON Generic
Yes 1 fludrocortisone FLORINEF ACETATE Generic
Non-Formulary PA No 3 hydrocortisone ALKINDI SPRINKLE Brand Yes 1 hydrocortisone CORTEF Generic
Yes 1 methylprednisolone MEDROL Generic
Yes 1 prednisolone PRELONE Generic
Yes 1 prednisolone acetate PREDNISOLONE Generic
Yes 1 prednisolone sodium phosphate ORAPRED Generic
Yes 1 prednisolone sodium phosphate ORAPRED ODT Generic
Yes 1 prednisolone sodium phosphate PEDIAPRED Generic
Yes 1 prednisone PREDNISONE Generic Non-Formulary Yes 3 prednisone RAYOS Brand Anabolic Steroid Non-Formulary ST Yes 3 oxymetholone ANADROL-50 Brand Androgens Yes 1 danazol DANOCRINE Generic Yes 2 fluoxymesterone ANDROXY Formulary Brand
Yes 2 methyltestosterone ANDROID 10 Formulary Brand
Non-Formulary Yes 3 methyltestosterone METHITEST Brand
Yes 1 methyltestosterone TESTRED Generic
Yes 1 oxandrolone OXANDRIN Generic Non-Formulary ST Yes 3 testosterone ANDRODERM Brand
Kaiser Permanente, a TRICARE Prime Option Formulary 58 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 testosterone ANDROGEL Generic Yes 1 testosterone TESTIM Generic Non-Formulary Yes 3 testosterone FORTESTA Brand
DEPO- Yes 1 testosterone cypionate Generic TESTOSTERONE Contraceptives
QL Yes 1 desogestrel & ethinyl estradiol APRI Generic
Non-Formulary QL Yes 3 desogestrel & ethinyl estradiol DESOGEN Brand
Non-Formulary QL Yes 3 desogestrel & ethinyl estradiol ORTHO-CEPT Brand
QL Yes 1 desogestrel & ethinyl estradiol RECLIPSEN Generic
desogestrel & ethinyl estradiol QL Yes 1 KARIVA Generic (biphasic)
desogestrel & ethinyl estradiol QL Yes 1 CYCLESSA Generic (triphasic)
desogestrel & ethinyl estradiol QL Yes 1 VELIVET Generic (triphasic)
Non-Formulary ST Yes 3 drospirenone SLYND Brand
QL Yes 1 drospirenone & ethinyl estradiol GIANVI Generic
QL Yes 1 drospirenone & ethinyl estradiol OCELLA Generic
QL Yes 1 drospirenone & ethinyl estradiol YASMIN Generic
QL Yes 1 drospirenone & ethinyl estradiol YAZ Generic
drospirenone & ethinyl estradiol Non-Formulary QL Yes 3 BEYAZ w/ folate Brand
drospirenone & ethinyl estradiol Non-Formulary QL, ST Yes 3 SAFYRAL w/ folate Brand
Kaiser Permanente, a TRICARE Prime Option Formulary 59 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
No 1 estradiol cypionate DELESTROGEN Generic
No 1 estradiol valerate DEPO-ESTRADIOL Generic
Non-Formulary QL, ST Yes 3 estradiol valerate & dienogest NATAZIA Brand
ethynodiol diacetate & ethinyl QL Yes 1 KELNOR Generic estradiol
ethynodiol diacetate & ethinyl QL Yes 1 ZOVIA Generic estradiol
QL Yes 2 etonogestrel & ethinyl estradiol NUVARING Formulary Brand
lactic acid & citric acid & Non-Formulary ST No 3 PHEXXI potassium bitartrate Brand AGE Yes 1 levonorgestrel PLAN B Generic
QL Yes 1 levonorgestrel & ethinyl estradiol LUTERA Generic
QL Yes 1 levonorgestrel & ethinyl estradiol LESSINA Generic
QL Yes 1 levonorgestrel & ethinyl estradiol PORTIA Generic
Non-Formulary QL Yes 3 levonorgestrel & ethinyl estradiol NORDETTE-28 Brand
levonorgestrel & ethinyl estradiol QL Yes 1 INTROVALE Generic (91-day)
levonorgestrel & ethinyl estradiol Non-Formulary QL Yes 3 LOSEASONIQUE (91-day) Brand
levonorgestrel & ethinyl estradiol QL Yes 1 SEASONALE Generic (91-day)
levonorgestrel & ethinyl estradiol Non-Formulary QL Yes 3 SEASONIQUE (91-day) Brand
levonorgestrel & ethinyl estradiol QL Yes 1 AMYTHYST Generic (continuous)
Kaiser Permanente, a TRICARE Prime Option Formulary 60 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
levonorgestrel & ethinyl estradiol Non-Formulary QL Yes 3 LYPREL (continuous) Brand
levonorgestrel & ethinyl estradiol Non-Formulary ST No 3 TWIRLA (transdermal) Brand
levonorgestrel & ethinyl estradiol QL Yes 1 TRIVORA Generic (triphasic)
Non-Formulary QL Yes 3 norelgestromin & ethinyl estradiol ORTHO EVRA Brand
QL, ST Yes 1 norelgestromin & ethinyl estradiol ZAFEMY Generic
QL Yes 1 norethindrone CAMILA Generic QL Yes 1 norethindrone NORA-BE Generic Non-Formulary QL Yes 3 norethindrone NOR-QD Brand
QL Yes 1 norethindrone & ethinyl estradiol BALZIVA Generic
Non-Formulary QL Yes 3 norethindrone & ethinyl estradiol BREVICON Brand
QL Yes 1 norethindrone & ethinyl estradiol JUNEL Generic
QL Yes 1 norethindrone & ethinyl estradiol MICROGESTIN Generic
Non-Formulary QL Yes 3 norethindrone & ethinyl estradiol MODICON Brand
QL Yes 1 norethindrone & ethinyl estradiol NECON Generic
Non-Formulary QL Yes 3 norethindrone & ethinyl estradiol NORINYL 1+35 Brand
QL Yes 1 norethindrone & ethinyl estradiol NORTREL 1/35 Generic
QL Yes 1 norethindrone & ethinyl estradiol OVCON-35 Generic
Non-Formulary QL Yes 3 norethindrone & ethinyl estradiol OVCON-50 Brand
norethindrone & ethinyl estradiol QL Yes 1 NECON 10/11 Generic (biphasic)
Kaiser Permanente, a TRICARE Prime Option Formulary 61 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
norethindrone & ethinyl estradiol QL Yes 1 ARANELLE Generic (triphasic)
norethindrone & ethinyl estradiol QL Yes 1 NORTREL 7/7/7 Generic (triphasic)
norethindrone & ethinyl estradiol Non-Formulary QL Yes 3 ORTHO-NOVUM (triphasic) Brand
norethindrone & ethinyl estradiol Non-Formulary QL Yes 3 TRI-NORINYL (triphasic) Brand
norethindrone & ethinyl estradiol Non-Formulary QL Yes 3 ESTROSTEP FE w/ ferrous fumarate Brand
norethindrone & ethinyl estradiol Non-Formulary QL, ST Yes 3 FEMCON FE w/ ferrous fumarate Brand
norethindrone & ethinyl estradiol QL Yes 1 GENERESS FE Generic w/ ferrous fumarate
norethindrone & ethinyl estradiol Non-Formulary QL Yes 3 JUNEL FE w/ ferrous fumarate Brand
norethindrone & ethinyl estradiol QL Yes 1 MICROGESTIN FE Generic w/ ferrous fumarate
norethindrone & ethinyl estradiol Non-Formulary QL, ST Yes 3 MINASTRIN 24 FE w/ ferrous fumarate Brand
norethindrone acetate & ethinyl Non-Formulary QL Yes 3 LOESTRIN 24 FE estradiol w/ ferrous fumarate Brand
norethindrone acetate & ethinyl Non-Formulary QL Yes 3 LOESTRIN FE estradiol w/ ferrous fumarate Brand
norethindrone acetate & ethinyl QL Yes 1 TILIA Generic estradiol w/ ferrous fumarate
Kaiser Permanente, a TRICARE Prime Option Formulary 62 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
norethindrone acetate & ethinyl Non-Formulary QL, ST Yes 3 estradiol w/ ferrous fumarate LO LOESTRIN FE Brand (biphasic)
Non-Formulary QL Yes 3 norethindrone-mestranol NORINYL 1+50 Brand
Non-Formulary QL Yes 3 norethindrone-mestranol ORTHO-NOVUM Brand
QL Yes 1 norgestimate & ethinyl estradiol CRYSELLE Generic
QL Yes 1 norgestimate & ethinyl estradiol MONONESSA Generic
Non-Formulary QL Yes 3 norgestimate & ethinyl estradiol ORTHO-CYCLEN Brand
QL Yes 1 norgestimate & ethinyl estradiol SPRINTEC Generic
QL Yes 1 norgestimate & ethinyl estradiol TRINESSA Generic
norgestimate & ethinyl estradiol Non-Formulary QL Yes 3 ORTHO TRI-CYCLEN (triphasic) Brand
norgestimate & ethinyl estradiol QL Yes 1 TRI-LO-SPRINTEC Generic (triphasic)
norgestimate & ethinyl estradiol QL Yes 1 TRI-SPRINTEC Generic (triphasic)
Non-Formulary QL Yes 3 norgestrel & ethinyl estradiol LO/OVRAL-28 Brand
QL Yes 1 norgestrel & ethinyl estradiol LOW-OGESTREL Generic
QL Yes 1 norgestrel & ethinyl estradiol OGESTREL Generic
Non-Formulary QL, ST Yes 3 segesterone & ethinyl estradiol ANNOVERA Brand Yes 2 ulipristal ELLA Formulary Brand Diabetic Agents Yes 1 acarbose PRECOSE Generic Non-Formulary PA Yes 3 albiglutide TANZEUM Brand
Kaiser Permanente, a TRICARE Prime Option Formulary 63 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
PA Yes 1 alogliptin NESINA Generic
PA Yes 1 alogliptin & metformin KAZANO Generic
PA Yes 1 alogliptin & pioglitazone OSENI Generic
Non-Formulary PA Yes 3 canagliflozin INVOKANA Brand
Non-Formulary PA Yes 3 canagliflozin & metformin INVOKAMET Brand
ST Yes 1 chlorpropamide CHLORPROPAMIDE Generic
Non-Formulary PA Yes 3 dapagliflozin FARXIGA Brand
Non-Formulary PA Yes 3 dapagliflozin & metformin XIGDUO XR Brand
Non-Formulary PA Yes 3 dulaglutide TRULICITY Brand
PA, QL Yes 2 empagliflozin JARDIANCE 25 MG Formulary Brand
Non-Formulary PA Yes 3 empagliflozin & lingaliptin GLYXAMBI Brand
Non-Formulary PA Yes 3 empagliflozin & metformin SYNJARDY Brand
Non-Formulary PA Yes 3 ertufliglozin STEGLATRO Brand
Non-Formulary PA Yes 3 ertugliflozin & metformin SEGLUROMET Brand
Yes 3 Non-Formulary ertugliflozin & sitagliptin STEGLUJAN Brand PA Yes 3 Non-Formulary PA, QL Yes 3 exenatide BYETTA Brand
Non-Formulary PA,QL Yes 3 exenatide extended-release BYDUREON Brand Yes 1 glimepiride AMARYL Generic Yes 1 glipizide GLUCOTROL Generic
Yes 1 glipizide & metformin METAGLIP Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 64 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 glipizide extended-release GLUCOTROL XL Generic
No 2 glucagon BAQSIMI Formulary Brand GLUCAGON No 1 glucagon Generic EMERGENCY KIT
GLUCAGEN Non-Formulary No 3 glucagon HYPOKIT Brand AGE No 2 glucagon GVOKE Formulary Brand Yes 1 glyburide DIABETA Generic
Yes 1 glyburide & metformin GLUCOVANCE Generic
Yes 1 glyburide micronized GLYNASE Generic
Non-Formulary PA,QL Yes 3 insulin (oral inhalation) AFREZZA Brand
Non-Formulary ST Yes 3 insulin aspart NOVOLOG Brand
Non-Formulary ST Yes 3 insulin aspart FIASP Brand
Non-Formulary ST Yes 3 insulin aspart FIASP FLEXPEN Brand
insulin aspart protamine & insulin Non-Formulary ST Yes 3 NOVOLOG MIX 70/30 aspart Brand
insulin aspart protamine & insulin NOVOLOG MIX 70/30 Non-Formulary ST Yes 3 aspart FLEXPEN Brand
Non-Formulary ST Yes 3 insulin degludec TRESIBA Brand
Non-Formulary Yes 3 insulin degludec/insulin aspart RYZODEG 70/30 Brand
Non-Formulary PA, QL Yes 3 Insulin degludec/ liraglutide XULTOPHY Brand
Non-Formulary ST Yes 3 insulin detemir LEVEMIR Brand
Non-Formulary ST Yes 3 insulin glargine LANTUS Brand
Non-Formulary ST Yes 3 insulin glargine LANTUS SOLOSTAR Brand
Kaiser Permanente, a TRICARE Prime Option Formulary 65 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Non-Formulary ST Yes 3 insulin glargine BASAGLAR Brand
Non-Formulary PA, QL Yes 3 Insulin glargine/ lixisenatide SOLIQUA Brand
Non-Formulary ST Yes 3 insulin glulisine APIDRA Brand
Non-Formulary PA Yes 3 insulin isophane NOVOLIN N Brand Yes 2 insulin isophane HUMULIN N Formulary Brand HUMULIN N Non-Formulary ST Yes 3 insulin isophane KWIKPEN Brand
Non-Formulary PA Yes 3 insulin isophane & regular insulin NOVOLIN 70/30 Brand
Non-Formulary Yes 3 insulin isophane & regular insulin HUMULIN 50/50 Brand
Yes 2 insulin isophane & regular insulin HUMULIN 70/30 Formulary Brand
HUMULIN 70/30 Non-Formulary ST Yes 3 insulin isophane & regular insulin KIWKPEN Brand
Non-Formulary ST Yes 3 insulin lispro HUMALOG Brand
Non-Formulary ST Yes 3 insulin lispro HUMALOG KWIKPEN Brand
Non-Formulary ST Yes 3 insulin lispro ADMELOG Brand
Non-Formulary ST Yes 3 insulin lispro-aabc LYUMJEV Brand
insulin lispro protamine & insulin Non-Formulary Yes 3 HUMALOG MIX 50/50 lispro Brand
insulin lispro protamine & insulin Non-Formulary ST Yes 3 HUMALOG MIX 75/25 lispro Brand
insulin lispro protamine & insulin HUMALOG MIX 75/25 Non-Formulary ST Yes 3 lispro KWIKPEN Brand
Non-Formulary PA Yes 3 insulin regular NOVOLIN R Brand Yes 2 insulin regular HUMULIN R Formulary Brand ST Yes 2 insulin regular HUMULIN R U-500 Formulary Brand
Kaiser Permanente, a TRICARE Prime Option Formulary 66 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status HUMULIN R U-500 Non-Formulary ST Yes 3 insulin regular KWIKPEN Brand Non-Formulary PA Yes 3 linagliptin TRADJENTA Brand
Non-Formulary PA Yes 3 linagliptin & metformin JENTADUETO Brand
Non-Formulary PA, QL Yes 3 liraglutide VICTOZA Brand
Non-Formulary PA, QL Yes 3 lixisenatide ADLYXIN Brand Yes 1 metformin GLUCOPHAGE Generic PA Yes 1 metformin ER FORTAMET Generic PA Yes 1 metformin ER GLUMETZA Generic
ST Yes 1 metformin RIOMET Generic
Yes 1 metformin extended-release GLUCOPHAGE XR Generic
Non-Formulary PA Yes 3 mifepristone KORLYM Brand
Non-Formulary ST Yes 3 miglitol GLYSET Brand ST Yes 1 nateglinide STARLIX Generic Yes 1 pioglitazone ACTOS Generic Non-Formulary Yes 3 pioglitazone & glimepiride DUETACT Brand
Non-Formulary Yes 3 pioglitazone & metformin ACTOPLUS MET Brand
Non-Formulary PA Yes 3 pramlintide acetate SYMLIN Brand ST Yes 1 repaglinide PRANDIN Generic
ST Yes 1 repaglinide & metformin PRANDIMET Generic
Non-Formulary ST Yes 3 rosiglitazone AVANDIA Brand
Non-Formulary ST Yes 3 rosiglitazone & glimepiride AVANDARYL Brand
Non-Formulary ST Yes 3 rosiglitazone & metformin AVANDAMET Brand
Non-Formulary PA Yes 3 saxagliptin ONGLYZA Brand
Kaiser Permanente, a TRICARE Prime Option Formulary 67 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
saxagliptin & metformin Non-Formulary PA Yes 3 KOMBIGLYZE XR extended-release Brand
Non-Formulary PA Yes 3 sitagliptin & metformin JANUMET Brand
Non-Formulary PA Yes 3 sitagliptin & simvastatin JUVISYNC Brand
Non-Formulary PA Yes 3 sitagliptin phosphate JANUVIA Brand
Non-Formulary PA, QL Yes 3 semaglutide OZEMPIC Brand ST Yes 1 tolazamide TOLINASE Generic ST Yes 1 tolbutamide ORINASE Generic Estrogens and Antiestrogens
conjugated estrogens & Non-Formulary ST Yes 3 DUAVEE bazedoxifene Brand
conjugated estrogens & Non-Formulary Yes 3 PREMPHASE medroxyprogesterone acetate Brand
conjugated estrogens & Non-Formulary Yes 3 PREMPRO medroxyprogesterone acetate Brand
Non-Formulary Yes 3 drospirenone & estradiol ANGELIQ Brand
Non-Formulary ST Yes 3 esterified estrogens MENEST Brand Yes 1 estradiol ESTRACE TAB Generic Yes 1 estradiol GYNODIOL Generic Non-Formulary ST Yes 3 estradiol & levonorgestrel CLIMARA PRO Brand
Yes 1 estradiol & norethindrone ACTIVELLA Generic
Non-Formulary ST Yes 3 estradiol & norethindrone COMBIPATCH Brand
Non-Formulary Yes 3 estradiol & norgestimate PREFEST Brand
Kaiser Permanente, a TRICARE Prime Option Formulary 68 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Non-Formulary Yes 3 estradiol acetate FEMTRACE Brand
Non-Formulary ST Yes 3 estradiol acetate vaginal tablets FEMRING Brand
Non-Formulary ST Yes 3 estradiol gel DIVIGEL Brand
Non-Formulary ST Yes 3 estradiol gel ELESTRIN GEL Brand
Non-Formulary ST Yes 3 estradiol transdermal ALORA Brand
Yes 1 estradiol transdermal CLIMARA DIS Generic
Non-Formulary Yes 3 estradiol transdermal ESTRADERM Brand
Non-Formulary ST Yes 3 estradiol transderomal EVAMIST Brand
Non-Formulary ST Yes 3 estradiol transdermal MENOSTAR Brand
Yes 1 estradiol transdermal MINIVELLE Generic
Non-Formulary ST Yes 3 estradiol transdermal VIVELLE-DOT Brand
Yes 1 estradiol vaginal ESTRACE CREAM Generic
ST Yes 2 estradiol vaginal ESTRING Formulary Brand Non-Formulary Yes 3 estradiol vaginal VAGIFEM Brand Yes 1 estradiol vaginal YUVAFEM Generic Yes 1 estradiol vaginal ESTRACE Generic
Yes 1 estrogen, ester/me-testosterone ESTRATEST Generic
Non-Formulary ST Yes 3 estrogens, conjugated PREMARIN Brand
Non-Formulary Yes 3 estrogens, conjugated synthetic a CENESTIN Brand
Non-Formulary ST Yes 3 estrogens, conjugated synthetic b ENJUVIA Brand
Kaiser Permanente, a TRICARE Prime Option Formulary 69 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
ST Yes 2 estrogens, conjugated vaginal PREMARIN CREAM Formulary Brand
Yes 1 estropipate ORTHO-EST Generic
norethindrone acetate & ethinyl Yes 1 FEMHRT Generic estradiol
Non-Formulary ST Yes 3 ospemifene OSPHENA Brand Yes 1 raloxifene hcl EVISTA Generic
ESTROGEN AND PROGESTIN (COMBINATION PRODUCT)
Non-Formulary ST Yes 3 estradiol and progesterone BIJUVA Brand Gonadatropins Yes 2 nafarelin SYNAREL Formulary Brand Parathyroid Non-Formulary PA Yes 3 abaloparatide TYMLOS Brand ST Yes 1 calcitonin salmon FORTICAL Generic ST Yes 1 calcitonin salmon MIACALCIN Generic Non-Formulary PA No 3 teriparatide FORTEO Brand Pitutary Non-Formulary PA Yes 3 corticotropin ACTHAR Brand
Yes 1 desmopressin (non-refrigerated) DDAVP Generic
Non-Formulary Yes 3 desmopressin acetate STIMATE Brand Progestins
Yes 1 medroxyprogesterone acetate PROVERA Generic
No 1 megestrol acetate MEGACE Generic
Yes 1 norethindrone acetate AYGESTIN Generic
Yes 1 progesterone, micronized PROMETRIUM Generic
Somatotropin Agonists and Antagonists
Kaiser Permanente, a TRICARE Prime Option Formulary 70 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Non-Formulary PA Yes 3 somatropin GENTROPIN Brand
Non-Formulary PA Yes 3 somatropin HUMATROPE Brand
Non-Formulary PA Yes 3 somatropin NORDITROPIN Brand
Non-Formulary PA Yes 3 somatropin NUTROPIN AQ Brand
Non-Formulary PA Yes 3 somatropin OMNITROPE Brand
Non-Formulary PA Yes 3 somatropin SAIZEN Brand
Non-Formulary PA Yes 3 somatropin SEROSTIM Brand
Non-Formulary PA Yes 3 pegvisomant SOMAVERT Brand
Non-Formulary PA Yes 3 somatropin ZORBTIVE Brand Thyroid and Antihyroid Agent Yes 1 levothyroxine LEVOTHROID Generic Yes 1 levothyroxine LEVOXYL Generic Yes 1 levothyroxine SYNTHROID Generic
Yes 1 levothyroxine TIROSINT Generic
Yes 1 levothyroxine UNITHROID Generic Yes 1 liothyronine CYTOMEL Generic Non-Formulary ST Yes 3 liotrix THYROLAR Brand Yes 1 methimazole TAPAZOLE Generic
Yes 2 potassium iodide & iodine LUGOL’S SOLUTION Formulary Brand
Yes 1 propylthiouracil PROPYLTHIOURACIL Generic
Non-Formulary Yes 3 thyroid ARMOUR THYROID Brand Miscellaneous Therapeutic Agents Miscellanous Therapeutic Agents Yes 2 abatacept ORENCIA Formulary Brand Yes 1 acetylcysteine MUCOMYST-10 Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 71 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Non-Formulary PA Yes 3 adalimumab HUMIRA Brand
Non-Formulary PA Yes 3 adalimumab HUMIRA citrate free Brand Yes 1 alendronate FOSAMAX Generic Non-Formulary Yes 3 alendronate & cholecalciferol FOSAMAX PLUS D Brand Yes 1 allopurinol ZYLOPRIM Generic Non-Formulary PA Yes 3 amifampridine FIRDAPSE Brand
Non-Formulary ST Yes 3 anakinra KINERET Brand PA Yes 2 apremilast OTEZLA Formulary Brand Yes 1 azathioprine AZASAN Generic Yes 1 azathioprine IMURAN Generic Non-Formulary PA Yes 3 baricitnib OLUMIANT Brand
Non-Formulary Yes 3 bedaquiline SIRTURO Brand
Non-Formulary Yes 3 belimumab BENLYSTA Brand
Non-Formulary PA No 3 berotralstat ORLADEYO Brand
Non-Formulary ST Yes 3 betaine CYSTADANE POWD Brand
Non-Formulary PA Yes 3 brodalumab SILIQ Brand
Non-Formulary PA Yes 3 c-1 esterase inhibitor HAEGARDA Brand
Non-Formulary PA Yes 3 canakinumab ILARIS Brand
Non-Formulary PA Yes 3 certolizumab Pegol CIMZIA Brand
Non-Formulary PA Yes 3 cholic acid CHOLBAM Brand No 2 cinacalcet SENSIPAR Formulary Brand ST Yes 1 colchicine COLCRYS Generic Yes 1 cyclosporine SANDIMMUNE Generic
Yes 1 cyclosporine, modified NEORAL Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 72 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Non-Formulary PA Yes 3 cysteamine delayed-release PROCYSBI Brand
Non-Formulary ST Yes 3 cysteamine immediate-release CYSTAGON Brand
No 1 dalfampridine AMPYRA Generic Non-Formulary PA, QL Yes 3 dichlorphenamide KEVEYIS Brand
Non-Formulary PA Yes 3 daflazacort EMFLAZA Brand
PA Yes 1 dimethyl fumarate TECFIDERA Generic
Non-Formulary PA Yes 3 dupilumab DUPIXENT Brand Yes 1 disulfiram ANTABUSE Generic ST Yes 1 dutasteride AVODART Generic
Yes 1 dutasteride & tamsulosin JALYN Generic
Non-Formulary PA Yes 3 elagolix ORILISSA Brand
elagolix, estradiol, norethindrone; Non-Formulary PA Yes 3 ORIAHNN elagolix Brand
Non-Formulary PA Yes 3 eliglustat CERDELGA Brand
Non-Formulary PA Yes 3 emicizumab-kxwh HEMLIBRA Brand
Non-Formulary PA Yes 3 erenumab-aooe AIMOVIG Brand
Non-Formulary PA Yes 3 etanercept ENBREL Brand ST Yes 1 etidronate DIDRONEL Generic
QL No 1 everolimus ZORTRESS Generic
Non-Formulary ST Yes 3 febuxostat ULORIC Brand
Non-Formulary PA Yes 3 fingolimod GILENYA Brand
Non-Formulary PA Yes 3 fostamatinib TAVALISSE Brand
Kaiser Permanente, a TRICARE Prime Option Formulary 73 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Non-Formulary PA Yes 3 galcanezumab EMGALITY Brand
Non-Formulary PA Yes 3 guselkumab TREMFYA Brand
PA No 1 glatiramer acetate COPAXONE 20 mg Generic
PA No 1 glatiramer acetate COPAXONE 40 mg Generic
No 1 glatiramer acetate GLATOPA Generic Non-Formulary PA Yes 3 golimumab SIMPONI Brand ST Yes 1 ibandronate BONIVA Generic Non-Formulary PA No 3 icatibant FIRAZYR Brand
Non-Formulary PA Yes 3 immune globulin HYQVIA Brand
Non-Formulary PA Yes 3 immune globulin HIZENTRA Brand
Non-Formulary PA Yes 3 inotersen TEGSEDI Brand
Non-Formulary PA Yes 3 interferon beta-1a AVONEX Brand
Non-Formulary PA Yes 3 interferon beta-1a PLEGRIDY Brand
Non-Formulary PA Yes 3 interferon beta-1a REBIF Brand
Non-Formulary PA Yes 3 interferon beta-1a REBIF REBIDOSE Brand
Non-Formulary Yes 3 interferon beta-1b BETASERON Brand Yes 2 interferon beta-1b EXTAVIA Formulary Brand
Yes 2 interferon gamma-1b ACTIMMUNE Formulary Brand
Non-Formulary PA Yes 3 ixekizumab TALTZ Brand
Non-Formulary PA Yes 3 lanadelumab TAKHZYRO Brand
SOMATULINE Non-Formulary Yes 3 lanreotide DEPOT Brand
Kaiser Permanente, a TRICARE Prime Option Formulary 74 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Non-Formulary Yes 3 lesinurad ZURAMPIC Brand Yes 1 leflunomide ARAVA Generic Yes 1 leucovorin LEUCOVORIN Generic Non-Formulary PA Yes 3 l-glutamine ENDARI Brand Yes 2 mesna MESNEX Formulary Brand
methenamine, sodium biphosphate, phenyl salicylate, No 1 URO-MP Generic methylene blue, and hyoscyamine
Yes 1 methylergonovine maleate METHERGINE Generic
Non-Formulary Yes 3 metreleptin MYALEPT Brand
Non-Formulary Yes 3 mifepristone MIFEPREX Brand
Non-Formulary PA Yes 3 migalastat GALAFOLD Brand
Non-Formulary PA No 3 miglustat ZAVESCA Brand
Yes 1 mycophenolate mofetil CELLCEPT Generic
Yes 1 mycophenolate sodium MYFORTIC Generic
Non-Formulary Yes 3 nitisinone ORFADIN Brand
Non-Formulary PA No 3 octreotide acetate MYCAPSSA Brand No 1 octreotide acetate SANDOSTATIN Generic Non-Formulary PA No 3 osilodrostat ISTURISA Brand Non-Formulary PA No 3 ozanimod ZEPOSIA Brand Non-Formulary PA Yes 3 parathyroid hormone NATPARA Brand
Non-Formulary PA Yes 3 pasireotide SIGNIFOR Brand
Kaiser Permanente, a TRICARE Prime Option Formulary 75 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
peanut (arachis hypogaea) Non-Formulary PA No 3 PALFORZIA allergen powder Brand
Yes 1 pediatric multivitamins w/ fluoride POLY-VI-FLOR Generic
pediatric multivitamins w/ fluoride POLY-VI-FLOR Yes 1 Generic & iron W/IRON
pediatric vitamins a, c, & d, w/ Yes 1 TRI-VI-FLOR Generic fluoride
pediatric vitamins a, c, & d, w/ Yes 1 TRI-VI-FLOR W/IRON Generic fluoride & iron
Non-Formulary PA Yes 3 pegvaliase PALYNZIQ Brand
PA Yes 2 pentosan polysulfate sodium ELMIRON Formulary Brand
Non-Formulary PA Yes 3 risankizumab SKYRIZI Brand
Non-Formulary PA Yes 3 risdiplam EVRYSDI Brand
ST Yes 1 risedronate sodium ACTONEL Generic
Non-Formulary Yes 3 risedronate sodium ATELVIA Brand
PA Yes 1 sapropterin dihydrochloride KUVAN Generic
Non-Formulary PA Yes 3 sarilumab KEVZARA Brand
Non-Formulary PA Yes 3 satralizumab ENSPRYNG Brand
Non-Formulary PA Yes 3 secukinumab COSENTYX Brand
Non-Formulary PA No 3 setmelanotide IMCIVREE Brand
Non-Formulary No 3 sirolimus solution RAPAMUNE Brand Yes 1 sirolimus RAPAMUNE Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 76 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Non-Formulary Yes 3 sodium fluoride FLUORABON BASIC Brand Yes 1 sodium fluoride FLUORITAB Generic Yes 1 sodium fluoride LURIDE CHEW Generic
Yes 1 sodium fluoride (dental) PREVIDENT Generic
PREVIDENT 5000 Yes 1 sodium fluoride (dental) Generic PLUS
Yes 1 sodium fluoride drops LURIDE DROPS Generic
Yes 2 stannous fluoride GEL-KAM Formulary Brand Yes 1 tacrolimus PROGRAF Generic No 1 tadalafil CIALIS Generic Non-Formulary PA Yes 3 teriflunomide AUBAGIO Brand QL Yes 2 thalidomide THALOMID Formulary Brand Non-Formulary PA Yes 3 tildrakizumab-asmn ILUMYA Brand
Non-Formulary ST Yes 3 tiludronate SKELID Brand Yes 2 tocilizumab ACTEMRA Formulary Brand Yes 2 tofacitinib XELJANZ Formulary Brand Non-Formulary PA No 3 trihepatanoin DOJOLVI Brand Non-Formulary PA No 3 upadacitinib RINVOQ Brand Non-Formulary PA, QL Yes 3 ustekinumab STELARA Brand
Non-Formulary PA No 3 voclosporin LUPKYNIS Brand
Non-Formulary PA, QL Yes 3 voxelotor OXBRYTA Brand Respiratory Tract Agents Antitussives
Yes 1 benzonatate TESSALON PERLES Generic
Yes 1 guaifenesin & codeine CHERATUSSIN AC Generic
Non-Formulary No 3 hydrocodone & chlorpheniramine TUSSIONEX Brand
Kaiser Permanente, a TRICARE Prime Option Formulary 77 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
No 1 hydrocodone & homatropine HYCODAN Generic
PHENERGAN W/ No 1 promethazine & codeine Generic CODEINE
promethazine & No 1 PROMETHAZINE-DM Generic dextromethorphan
promethazine, phenylephrine & PHENERGAN VC No 1 Generic codeine W/CODEINE
pseudoephedrine, Non-Formulary Yes 3 M-END MAX D brompheniramine & codeine Brand
Anti-Inflammatory Agents Non-Formulary Yes 3 cromolyn sodium GASTROCROM Brand Yes 1 cromolyn sodium INTAL Generic Yes 1 montelukast SINGULAIR Generic Non-Formulary ST Yes 3 zafirlukast ACCOLATE Brand ST No 1 zileuton ZYFLO CR Generic Non-Formulary ST No 3 zileuton ZYFO Brand Respiratory Agents, Miscellaneous Non-Formulary Yes 3 beclomethasone dipropionate QVAR RediHaler Brand
PULMICORT Non-Formulary Yes 3 budesonide FLEXHALER Brand
PULMICORT Yes 1 budesonide Generic RESPULES
Non-Formulary ST Yes 3 budesonide & formoterol SYMBICORT Brand Yes 2 ciclesonide ALVESCO Formulary Brand
Non-Formulary PA Yes 3 Elaxacaftor, tezacaftor & ivacaftor TRIKAFTA Brand
fluticasone & salmeterol (100/50 ST Yes 1 WIXELA INHUB Generic mcg)
Kaiser Permanente, a TRICARE Prime Option Formulary 78 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
fluticasone & salmeterol (250/50 Yes 1 WIXELA INHUB Generic mcg and 500/50 mcg)
Non-Formulary ST Yes 3 fluticasone & salmeterol ADVAIR HFA Brand
Non-Formulary ST Yes 3 fluticasone & vilanterol BREO ELLIPTA Brand
FLOVENT DISKUS Non-Formulary Yes 3 fluticasone propionate AER Brand
Non-Formulary Yes 3 fluticasone propionate FLOVENT HFA Brand
fluticasone & umeclidinium & Non-Formulary ST Yes 3 TRELEGY ELLIPTA vilanterol Brand
UTIBRON Non-Formulary Yes 3 glycopyrrolate & indacaterol NEOHALER Brand
ARCAPTA Non-Formulary ST Yes 3 indacaterol NEOHALER Brand
Non-Formulary PA Yes 3 ivacaftor KALYDECO Brand
Non-Formulary PA Yes 3 lumacaftor& ivacaftor ORKAMBI Brand
Non-Formulary ST Yes 3 mometasone & formoterol DULERA Brand
Yes 2 mometasone furoate ASMANEX Formulary Brand
Non-Formulary PA Yes 3 mepolizumab NUCALA Brand
Non-Formulary Yes 3 nintedanib OFEV Brand
Non-Formulary PA Yes 3 omalizumab XOLAIR Brand
Non-Formulary Yes 3 pirfenidone ESBRIET Brand
Yes 2 roflumilast DALIRESP Formulary Brand
Non-Formulary Yes 3 salmeterol SEREVENT DISKUS Brand
Non-Formulary Yes 3 sodium chloride HYPERSAL Brand
Kaiser Permanente, a TRICARE Prime Option Formulary 79 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Non-Formulary PA Yes 3 tezacaftor & ivacaftor SYMDEKO Brand
Yes 2 tiotropium bromide and olodaterol STIOLTO RESPIMAT Formulary Brand
Skin and Mucous Membrane Agents Anti-infectives (Skin and Mucous Membranes) ST Yes 1 acyclovir ZOVIRAX Generic Non-Formulary ST Yes 3 acyclovir & hydrocortisone XERESE Brand Non-Formulary Yes 3 benzoyl peroxide & erythromycin BENZAMYCIN Brand
Non-Formulary ST Yes 3 butenafine MENTAX Brand
Non-Formulary Yes 3 butoconazole nitrate (vaginal) GYNAZOLE-1 Brand No 1 ciclopirox LOPROX Generic No 1 ciclopirox PENLAC Generic
ST Yes 1 clindamycin & benzoyl peroxide BENZACLIN Generic
Yes 1 clindamycin & benzoyl peroxide DUAC Generic
Non-Formulary PA Yes 3 clindamycin & benzoyl peroxide ONEXTON Brand
Yes 1 clindamycin phosphate (topical) CLEOCIN T Generic
Yes 1 clindamycin phosphate (topical) CLINDAGEL Generic
Non-Formulary Yes 3 clindamycin phosphate (topical) EVOCLIN Brand
No 1 clindamycin phosphate (vaginal) CLEOCIN Generic
Non-Formulary ST No 3 clindamycin phosphate (vaginal) CLINDESSE Brand
No 1 clotrimazole MYCELEX Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 80 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
No 1 clotrimazole & betamethasone LOTRISONE Generic
Non-Formulary ST Yes 3 crotamiton EURAX Brand No 1 econazole nitrate SPECTAZOLE Generic Non-Formulary Yes 3 erythromycin (acne acid) AKNE-MYCIN Brand
Yes 1 erythromycin (acne acid) ERYGEL Generic
No 1 gentamicin sulfate (topical) GARAMYCIN Generic
Non-Formulary Yes 3 hexachlorophene PHISOHEX Brand
Yes 1 iodoquinol & hydrocortisone VYTONE Generic
No 1 ketoconazole (topical) NIZORAL Generic
No 1 lindane KWELL Generic Non-Formulary ST No 3 mafenide acetate SULFAMYLON Brand No 1 malathion OVIDE Generic
No 1 metronidazole (topical) METROCREAM Generic
No 1 metronidazole (topical) METROGEL Generic
No 1 metronidazole (topical) METROLOTION Generic
METROGEL- No 1 metronidazole (vaginal) Generic VAGINAL
Non-Formulary No 3 miconazole nitrate & zinc oxide VUSION Brand
No 1 mupirocin BACTROBAN Generic Non-Formulary No 3 mupirocin calcium BACTROBAN NASAL Brand
Non-Formulary Yes 3 na sulfacetm/avobenzone/sulfur ROSAC Brand
ST No 1 naftifine cream NAFTIN Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 81 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Non-Formulary ST No 3 naftifine gel NAFTIN Brand No 1 nystatin (topical) NYSTATIN Generic NYSTATIN & Yes 1 nystatin & triamcinolone Generic TRIAMCINOLONE Non-Formulary ST No 3 oxiconazole nitrate OXISTAT Brand
Non-Formulary ST No 3 oxymetazoline RHOFADE Brand
Non-Formulary ST Yes 3 penciclovir DENAVIR Brand No 1 permethrin ELIMITE Generic Non-Formulary ST Yes 3 retapamulin ALTABAX Brand
Non-Formulary No 3 selenium sulfide SELSEB Brand
Non-Formulary No 3 selenium sulfide SELSUN RX Brand
Non-Formulary ST Yes 3 sertaconazole nitrate ERTACZO Brand No 1 silver sulfadiazine SILVADENE Generic Non-Formulary Yes 3 spinosad NATROBA Brand
Non-Formulary ST Yes 3 sulconazole nitrate EXELDERM Brand
Yes 1 sulfacetamide sodium (acne) KLARON Generic
Non-Formulary Yes 3 sulfacetamide sodium (acne) SEB-PREV Brand
Non-Formulary Yes 3 sulfanilamide AVC VAGINAL Brand ST No 1 terconazole TERAZOL 7 Generic
ST No 1 terconazole (vaginal) TERAZOL 3 Generic
Anti-inflammatory Agents (Skin and Mucous Membranes)
Yes 1 alclometasone dipropionate ACLOVATE Generic
ST Yes 1 amcinonide CYCLOCORT Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 82 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
bacitracin, polymyxin, neomycin Non-Formulary ST No 3 CORTISPORIN & hydrocortisone Brand
benzoyl peroxide & Non-Formulary Yes 3 VANOXIDE-HC hydrocortisone Brand
betamethasone dipropionate Yes 1 DIPROSONE Generic (topical)
betamethasone dipropionate Yes 1 DIPROLENE Generic augmented
Yes 1 betamethasone valerate LUXIQ Generic
Yes 1 betamethasone valerate VALISONE Generic
ST No 1 calcipotriene & betamethasone TACLONEX Generic
Yes 1 clobetasol propionate CLOBEX Generic
No 1 clobetasol propionate TEMOVATE Generic
Yes 1 clobetasol propionate emollient TEMOVATE E Generic
Non-Formulary No 3 clobetasol propionate emulsion OLUX-E Brand
ST Yes 1 clocortolone pivalate CLODERM Generic
Non-Formulary PA Yes 3 crisaborole EUCRISA Brand QL Yes 1 desonide DESOWEN Generic ST Yes 1 desoximetasone TOPICORT Generic
ST Yes 1 diflorasone diacetate APEXICON Generic
Non-Formulary Yes 3 fluocinolone acetonide CAPEX SHAMPOO Brand
DERMA- Yes 1 fluocinolone acetonide Generic SMOOTHE/FS OIL
Kaiser Permanente, a TRICARE Prime Option Formulary 83 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 fluocinolone acetonide SYNALAR Generic
Yes 1 fluocinonide LIDEX Generic Non-Formulary Yes 3 fluocinonide VANOS Brand
Yes 1 fluocinonide emollient LIDEX-E Generic
Generic; ST (Tape Yes 1, 3 flurandrenolide CORDRAN Non-Formulary Only) Brand
ST Yes 1 fluticasone propionate (topical) CUTIVATE Generic
Non-Formulary ST Yes 3 halcinonide HALOG Brand
Yes 1 halobetasol propionate ULTRAVATE Generic
Yes 1 hydrocortisone (intrarectal) CORTENEMA Generic
Non-Formulary Yes 3 hydrocortisone (rectal) ANUSOL-HC Brand
Yes 1 hydrocortisone (rectal) PROCTOCORT Generic
Yes 1 hydrocortisone (topical) HYTONE Generic
Yes 1 hydrocortisone acetate & urea CARMOL HC Generic
hydrocortisone acetate Non-Formulary Yes 3 CORTIFOAM (intrarectal) Brand
Yes 1 hydrocortisone butyrate LOCOID Generic
hydrocortisone butyrate Non-Formulary Yes 3 LOCOID LIPOCREAM hydrophilic lipo base Brand
Non-Formulary Yes 3 hydrocortisone probutate PANDEL Brand
Yes 1 hydrocortisone valerate WESTCORT Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 84 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 mometasone furoate ELOCON Generic
ST Yes 1 nystatin & triamcinolone MYCOLOG II Generic
ST Yes 1 prednicarbate DERMATOP Generic
Yes 1 triamcinolone acetonide (topical) KENALOG Generic
Antipruritics and Local Anesthetics Non-Formulary ST Yes 3 doxepin (antipuritic) ZONALON Brand
Non-Formulary Yes 3 hydrocortisone & pramoxine ANALPRAM HC Brand
Non-Formulary Yes 3 hydrocortisone & pramoxine PRAMOSONE Brand
Non-Formulary Yes 3 hydrocortisone & pramoxine PRAMOSONE-E Brand
Non-Formulary Yes 3 hydrocortisone & pramoxine PROCTOFOAM-HC Brand
ST Yesline 1 lidocaine LIDODERM Generic
No 1 lidocaine (jelly, topical) XYLOCAINE Generic
Non-Formulary No 3 lidocaine & hydrocortisone LIDAMANTLE Brand
Yes 1 lidocaine & prilocaine EMLA Generic
Non-Formulary ST No 3 lidocaine & tetracaine SYNERA PATCH Brand Yes 1 pramoxine PROCTOFOAM Generic Astringents
Yes 2 aluminum chloride hexahydrate HYPERCARE Formulary Brand
Keratolytic Agents Non-Formulary No 3 sulfacetamide sodium & sulfur AVAR Brand
Yes 1 sulfacetamide sodium & sulfur PLEXION Generic
Non-Formulary No 3 sulfacetamide sodium & sulfur PLEXION SCT Brand
Kaiser Permanente, a TRICARE Prime Option Formulary 85 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
No 1 sulfacetamide sodium & sulfur ROSULA Generic
Yes 1 urea CARMOL Generic Keratoplastic Agents Non-Formulary ST Yes 3 anthralin DRITHO-CREME HP Brand
Non-Formulary Yes 3 anthralin ZITHRANOL-RR Brand Cell Stimulants and Proliferants QL, AGE Yes 1 tretinoin RETIN-A Generic Non-Formulary QL, AGE Yes 3 tretinoin microspheres RETIN-A MICRO Brand Skin and Mucous Membrane Agents, Miscellaneous No 1 acitretin SORIATANE Generic QL, AGE, Yes 1 adapalene DIFFERIN Generic ST QL, AGE, Non-Formulary Yes 3 adapalene & benzoyl peroxide EPIDUO ST Brand
Non-Formulary QL, AGE Yes 3 alitretinoin PANRETIN Brand
Yes 1 ammonium lactate LAC-HYDRIN Generic
Non-Formulary ST Yes 3 azelaic acid FINACEA Brand
Non-Formulary ST Yes 3 azelaic acid (acne) AZELEX Brand Yes 2 becaplermin REGRANEX Formulary Brand Non-Formulary No 3 bexarotene (topical) TARGRETIN Brand
Non-Formulary PA, QL Yes 3 brimonidine (topical) MIRVASO Brand Yes 1 calcipotriene DOVONEX Generic Non-Formulary Yes 3 calcipotriene SORILUX Brand Yes 2 calcitriol (topical) VECTICAL Formulary Brand Non-Formulary AGE, ST No 3 clindamycin & tretinoin VELTIN Brand
Non-Formulary AGE, ST No 3 clindamycin & tretinoin ZIANA Brand Yes 2 collagenase SANTYL Formulary Brand
Kaiser Permanente, a TRICARE Prime Option Formulary 86 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
ST Yes 1 dapsone (topical) ACZONE Generic
Non-Formulary ST Yes 3 diclofenac epolamine FLECTOR Brand
Non-Formulary ST Yes 3 diclofenac sodium PENNSAID Brand ST Yes 1 diclofenac sodium VOLTAREN GEL Generic diclofenac sodium (actinic Non-Formulary Yes 3 SOLARAZE keratosis) Brand
Non-Formulary ST Yes 3 doxepin (antipuritic) PRUDOXIN Brand
Non-Formulary ST Yes 3 doxycycline (rosacea) ORACEA Brand
Non-Formulary No 3 fluorouracil (topical) CARAC Brand
Yes 1 fluorouracil (topical) EFUDEX Generic
Yes 2 fluorouracil (topical) FLUOROPLEX Formulary Brand
Yes 1 imiquimod ALDARA Generic
Yes 1 imiquimod ZYCLARA Generic
Non-Formulary PA Yes 3 ingenol mebutate PICATO Brand No 1 isotretinoin ACCUTANE Generic No 1 isotretinoin CLARAVIS Generic
Non-Formulary Yes 3 lactic acid (ammonium lactate) LACTINOL Brand
Yes 2 methoxsalen 8-MOP Formulary Brand
Yes 1 methoxsalen, rapid OXSORALEN-ULTRA Generic
Yes 2 pimecrolimus ELIDEL Formulary Brand Yes 1 podofilox CONDYLOX Generic Non-Formulary ST Yes 3 sinecatechins VEREGEN Brand
Yes 1 tacrolimus (topical) PROTOPIC Generic
Non-Formulary ST Yes 3 tazarotene FABIOR Brand
Kaiser Permanente, a TRICARE Prime Option Formulary 87 Kaiser Permanente, a TRICARE® Prime Option Formulary
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
QL, AGE, Non-Formulary Yes 3 tazarotene TAZORAC ST Brand Smooth Muscle Relaxants Smooth Muscle Relaxants Yes 1 darifenacin ENABLEX Generic Non-Formulary ST Yes 3 dyphylline LUFYLLIN Brand
Non-Formulary ST Yes 3 fesoterodine TOVIAZ Brand
Non-Formulary ST Yes 3 flavoxate FLAVOXATE Brand
Non-Formulary ST Yes 3 mirabegron MYRBETRIQ Brand Yes 1 oxybutynin DITROPAN Generic
Yes 1 oxybutynin extended-release DITROPAN XL Generic
Non-Formulary Yes 3 oxybutynin transdermal OXYTROL Brand Yes 1 solifenacin VESICARE Generic Yes 1 theophylline UNIPHYL Generic ST Yes 1 tolterodine DETROL Generic
ST Yes 1 tolterodine extended-release DETROL LA Generic
Yes 1 trospium SANCTURA Generic Non-Formulary Yes 3 trospium extended-release SANCTURA XR Brand
Non-Formulary ST Yes 3 vibegron GEMTESA Brand Vitamins Vitamins Yes 1 calcitriol ROCALTROL Generic ST Yes 1 doxercalciferol HECTOROL Generic Yes 1 ergocalciferol DRISDOL Generic Yes 1 niacin NIACOR Generic ST Yes 1 paricalcitol ZEMPLAR Generic Yes 1 phytonadione MEPHYTON Generic
Kaiser Permanente, a TRICARE Prime Option Formulary 88 Kaiser Permanente, a TRICARE® Prime Option Formulary INDEX OF DRUGS ADALAT CC ...... 24 8 adalimumab ...... 72 adapalene ...... 86 8-MOP ...... 87 adapalene & benzoyl peroxide ...... 86 ADCIRCA ...... 28 A ADDERALL ...... 33 ADDERALL XR ...... 33 abacavir sulfate & lamivudine ...... 8 adefovir dipivoxil ...... 9 abacavir sulfate solution ...... 8 ADEMPAS ...... 28 abacavir sulfate tablet ...... 8 ADLYXIN...... 67 abacavir, dolutegravir & lamivudine ...... 9 ADMELOG ...... 66 abacavir, lamivudine & zidovudine ...... 9 ADOXA ...... 5 abaloparatide ...... 70 ADRENACLICK ...... 20 abatacept ...... 71 ADVAIR DISKUS ...... 78, 79 abemaciclib ...... 13 ADVAIR HFA ...... 79 ABILIFY ...... 40 ADVICOR ...... 23 ABILIFY DISCMELT ...... 40 ADZENYS ER ...... 33 abiraterone ...... 13 AFINITOR ...... 14 acalabrutinib ...... 13 aflcaftadine ...... 50 acamprosate ...... 39 AFREZZA ...... 65 acarbose ...... 63 AGGRENOX ...... 20 ACCOLATE ...... 78 AGRYLIN ...... 20 ACCU-CHEK ...... 43, 44 AIMOVIG...... 73 ACCU-CHEK TEST STRIPS ...... 43 AKNE-MYCIN ...... 81 ACCUNEB ...... 19 AK-TRACIN ...... 47 ACCUPRIL ...... 27 AKYNZEO ...... 54 ACCURETIC ...... 27 albendazole ...... 4 ACCUTANE ...... 87 ALBENZA ...... 4 acebutolol ...... 28 albiglutide ...... 63 ACEON ...... 27 albuterol nebulizer solution ...... 19 acetaminophen & codeine ...... 29 albuterol sulfate...... 19 acetaminophen, caffeine, & dihydrocodeine ...... 30 albuterol sulfate & ipratropium ...... 19 ACETASOL HC ...... 49 albuterol sulfate tablet ...... 19 acetazolamide ...... 52 alclometasone dipropionate ...... 82 acetic acid ...... 49, 53 ALDACTAZIDE ...... 27 acetylcysteine ...... 71 ALDACTONE ...... 27 ACIPHEX ...... 55 ALDARA ...... 87 acitretin ...... 86 ALDOMET ...... 25 ACLOVATE ...... 82 ALDORIL-25 ...... 25 ACTEMRA ...... 77 alendronate ...... 72 ACTHAR...... 70 alendronate & cholecalciferol ...... 72 ACTIGALL ...... 57 alfuzosin ...... 19 ACTIMMUNE ...... 74 ALINIA ...... 8 ACTIQ ...... 31 alirocumab ...... 22 ACTIVELLA ...... 68 aliskiren ...... 25, 26 ACTONEL ...... 76 aliskiren & amlodipine ...... 25 ACTOPLUS MET ...... 67 aliskiren & hydrochlorothiazide ...... 26 ACTOS ...... 67 aliskiren & valsartan ...... 26 ACULAR ...... 49 aliskiren, amlodipine & hydrochlorothiazide ...... 25 ACULAR LS ...... 49 alitretinoin ...... 86 acyclovir ...... 9, 80 ALKERAN ...... 15 acyclovir & hydrocortisone ...... 80 ALKINDI SPRINKLE ...... 58 ACZONE ...... 87 allopurinol ...... 72
Kaiser Permanente, a TRICARE Prime Option Formulary 89 Kaiser Permanente, a TRICARE® Prime Option Formulary almotriptan ...... 36 amphetamine & dextroamphetamine extended-release ...... 33 ALOCRIL ...... 51 amphetamine extended-release ...... 33 alogliptin ...... 64 amphetamine sulfate ...... 33 alogliptin & metformin ...... 64 AMPICILLIN ...... 5 alogliptin & pioglitazone ...... 64 ampicillin sodium ...... 5 ALOMIDE ...... 51 AMPYRA ...... 73 ALORA ...... 69 AMRIX ...... 18 alosetron ...... 54 AMTURNIDE ...... 25 alpelisib ...... 13 AMYTHYST ...... 60 ALPHAGAN ...... 52 ANADROL-50 ...... 58 ALPHAGAN P...... 52 ANAFRANIL ...... 41 alprazolam ...... 38 anagrelide ...... 20 alprazolam extended-release ...... 38 anakinra ...... 72 alprazolam orally disintegrating ...... 38 ANALPRAM HC ...... 85 ALREX ...... 49 ANAPROX ...... 32 ALTABAX ...... 82 anastrozole ...... 13 ALTACE ...... 27 ANCOBON ...... 7 ALTOPREV ...... 22 ANDRODERM...... 58 aluminum chloride hexahydrate ...... 85 ANDROGEL ...... 59 ALVESCO ...... 78 ANDROID 10 ...... 58 amantadine ...... 37 ANDROXY ...... 58 amantadine ER...... 37 ANGELIQ ...... 68 AMARYL...... 64 ANNOVERA ...... 63 AMBIEN ...... 39 ANORO ELLIPTA ...... 20 AMBIEN CR ...... 39 ANSAID ...... 31 ambrisentan ...... 27 ANTABUSE ...... 73 amcinonide...... 82 anthralin ...... 86 AMERGE ...... 37 antipyrine & benzocaine ...... 53 AMICAR ...... 20 ANUSOL-HC ...... 84 amifampridine ...... 72 ANZEMET ...... 54 amikacin liposomal inhalation ...... 4 APEXICON ...... 83 amiloride ...... 45 APIDRA ...... 66 amiloride & hydrochlorothiazide ...... 45 apixaban ...... 20 aminocaproic acid ...... 20 APLENZIN ...... 41 amiodarone ...... 24 APOKYN ...... 37 AMITIZA ...... 56 apomorphine ...... 37 amitriptyline ...... 40, 41 apraclonidine ...... 53 amitriptyline & perphenazine ...... 40 apremilast ...... 72 amlodipine ...... 23, 25 aprepitant ...... 54 amlodipine & atorvastatin ...... 23 APRESOLINE ...... 25 amlodipine & benazepril ...... 23 APRI ...... 59 amlodipine & olmesartan ...... 23 APTIOM ...... 35 amlodipine & telmisartan...... 23 APTIVUS...... 12 amlodipine & valsartan ...... 23 ARALEN ...... 8 amlodipine, olmesartan & hydrochlorothiazide ...... 23 ARANELLE ...... 62 amlodipine, valsartan & hydrochlorothiazide ...... 23 ARANESP ...... 21 ammonium lactate ...... 86, 87 ARAVA ...... 75 amoxapine ...... 40 ARBINOXA ...... 4 amoxicillin...... 1, 4, 55 ARCAPTA NEOHALER ...... 79 amoxicillin & clavulanate potassium ...... 4 arformoterol ...... 19 amoxicillin & clavulanate potassium extended-release ...... 4 ARICEPT ...... 18 amoxicillin, clarithromycin, & lansoprazole ...... 55 ARICEPT ODT ...... 18 AMOXIL ...... 4 ARIKAYCE ...... 4 amphetamine & dextroamphetamine ...... 33 ARIMIDEX ...... 13
Kaiser Permanente, a TRICARE Prime Option Formulary 90 Kaiser Permanente, a TRICARE® Prime Option Formulary aripiprazole ...... 40 AVELOX ...... 6 aripiprazole solution ...... 40 AVINZA ...... 32 aripiprazole tablet ...... 40 AVLOSULFON ...... 7 ARIXTRA ...... 21 AVODART ...... 73 armodafinil ...... 33 AVONEX ...... 74 ARMOUR THYROID ...... 71 AXERT ...... 36 AROMASIN ...... 14 AXID ...... 55 ARTANE ...... 38 axitinib ...... 13 artemether & lumefantrine ...... 8 AYGESTIN ...... 70 ARTHROTEC ...... 30 AYVAKIT ...... 13 artificial tear insert ...... 53 azacitidine ...... 13 ASCENSIA BREEZE ...... 44 AZASAN ...... 72 ASCENSIA TEST STRIPS ...... 43 AZASITE ...... 47 asenapine...... 40 azathioprine ...... 72 ASENDIN ...... 40 azelaic acid ...... 86 ASMANEX ...... 79 azelaic acid (acne)...... 86 aspirin & dipyridamole ...... 20 azelastine ...... 50, 51 ASTELIN ...... 50 azelastine & fluticasone ...... 51 ASTEPRO ...... 50 azelastine (ophth) ...... 51 ATACAND ...... 26 AZELEX ...... 86 ATACAND HCT ...... 26 AZILECT ...... 38 ATARAX ...... 39 azilsartan...... 26 atazanavir & cobicistat ...... 9 azilsartan & chlorthalidone ...... 26 atazanavir sulfate 150 mg...... 9 azithromycin ...... 5, 47 atazanavir sulfate 200 mg, 300 mg ...... 9 azithromycin (ophth) ...... 47 ATELVIA...... 76 AZOPT ...... 52 atenolol ...... 28 AZOR ...... 23 atenolol & chlorthalidone...... 28 AZULFIDINE ...... 6 ATIVAN ...... 39 atomoxetine ...... 39 B atorvastatin ...... 22, 23 atovaquone ...... 8 B & O SUPPRETTES ...... 32 atovaquone & proguanil ...... 8 bacitracin & polmyxin B (ophth) ...... 47 ATRIPLA ...... 10 bacitracin (ophth) ...... 47 atropine ...... 17, 53, 54 bacitracin, neomycin, polymyxin B & hydrocortisone (ophth) .. 48 atropine sulfate ...... 17 bacitracin, polymyxin, neomycin & hydrocortisone ...... 83 ATROPINE SULFATE ...... 17 baclofen ...... 18 ATROVENT ...... 17 BACTRIM DS ...... 6 ATROVENT HFA ...... 17 BACTROBAN ...... 81 AUBAGIO ...... 77 BACTROBAN NASAL ...... 81 AUGMENTIN ...... 4 balsalazide ...... 54 AUGMENTIN XR ...... 4 BALZIVA ...... 61 auranofin ...... 57 BANZEL ...... 36 AURODEX ...... 53 BAQSIMI ...... 65 AUSTEDO ...... 39 BARACLUDE ...... 10 AUVI-Q ...... 20 baricitnib ...... 72 AVALIDE ...... 26 BASAGLAR ...... 66 AVANDAMET ...... 67 BD INSULIN SYRINGE ...... 44 AVANDARYL ...... 67 becaplermin ...... 86 AVANDIA ...... 67 beclomethasone ...... 51, 78 avapritinib ...... 13 beclomethasone dipropionate ...... 78 AVAPRO ...... 26 BECONASE AQ ...... 51 AVAR ...... 85 bedaquiline ...... 72 AVC VAGINAL ...... 82 belimumab ...... 72
Kaiser Permanente, a TRICARE Prime Option Formulary 91 Kaiser Permanente, a TRICARE® Prime Option Formulary BELSOMRA ...... 39 bisoprolol...... 29 bempedoic acid ...... 22 bisoprolol & hydrochlorothiazide ...... 29 bempedoic acid & ezetimibe ...... 22 BLEPH-10 ...... 48 benazepril...... 23, 26 BLEPHAMIDE ...... 50 benazepril & hydrochlorothiazide ...... 26 BLOCADREN ...... 29 BENEMID ...... 46 blood sugar diagnostic ...... 43 BENICAR ...... 27 blood-glucose meter ...... 44 BENICAR HCT ...... 27 boceprevir ...... 9 BENLYSTA ...... 72 BONIVA...... 74 BENTYL ...... 17 bosentan ...... 27 BENZACLIN ...... 80 BOSULIF...... 13 BENZAMYCIN ...... 80 bosutinib ...... 13 benznidazole ...... 4 BRAFTOVI ...... 14 benzonatate ...... 77 BREO ELLIPTA ...... 79 benzoyl peroxide & erythromycin ...... 80 BRETHINE ...... 20 benzoyl peroxide & hydrocortisone ...... 83 BREVICON ...... 61 benztropine ...... 37 brexpiprazole ...... 41 bepotastine ...... 51 BRILINTA ...... 21 BEPREVE ...... 51 brimonidine ...... 52, 86 berotralstat ...... 72 brimonidine & timolol ...... 52 besilfoxacin ...... 47 brimonidine (topical) ...... 86 BESIVANCE ...... 47 brimonidine tartrate ...... 52 BETAGAN ...... 52 brinzolamide ...... 52 betaine ...... 72 brivaracetam ...... 34 betamethasone dipropionate (topical) ...... 83 BRIVIACT ...... 34 betamethasone dipropionate augmented ...... 83 brodalumab ...... 72 betamethasone valerate ...... 83 bromfenac (ophth) ...... 48 BETAPACE ...... 29 bromocriptine...... 37 BETAPACE AF...... 29 BROVANA ...... 19 BETASERON ...... 74 BRUKINSA ...... 16 betaxolol ...... 28, 52 budesonide ...... 51, 54, 57, 78 betaxolol hcl ...... 52 budesonide & formoterol ...... 78 bethanechol chloride ...... 18 budesonide er ...... 54 BETIMOL ...... 53 bumetanide ...... 45 BETOPTIC ...... 52 BUMEX ...... 45 BETOPTIC S ...... 52 BUPHENYL ...... 44 betrixaban ...... 20 buprenorphine ...... 30 BEVYXXA ...... 20 buprenorphine & naloxone film ...... 30 bexarotene ...... 13, 86 buprenorphine transdermal ...... 30 bexarotene (topical) ...... 86 buprenorphine& naloxone tablet ...... 30 BEXDELA...... 5 bupropion ...... 41 BEYAZ ...... 59 bupropion (smoking deterrent)...... 41 BIAXIN ...... 5 bupropion extended-release ...... 41 BIAXIN XL ...... 5 bupropion hydrobromide ...... 41 bicalutamide ...... 13 bupropion sustained-release ...... 41 BICITRA ...... 44 BUSPAR ...... 38 bictegravir & emtricitabine & tenofovir ...... 9 buspirone ...... 38 BIDIL ...... 28 busulfan ...... 13 BIJUVA ...... 70 butalbital & acetaminophen ...... 30 BIKTARVY ...... 9 butalbital, acetaminophen, & caffeine ...... 30 BILTRICIDE ...... 4 butalbital, acetaminophen, caffeine, & codeine ...... 30 bimatoprost ...... 52 butalbital, aspirin, & caffeine ...... 30 binimetinib ...... 13 butalbital, aspirin, caffeine, & codeine ...... 30 bismuth subcitrate & metronidazole ...... 4 butenafine ...... 80
Kaiser Permanente, a TRICARE Prime Option Formulary 92 Kaiser Permanente, a TRICARE® Prime Option Formulary butoconazole nitrate (vaginal) ...... 80 CARDENE ...... 24 butorphanol tartrate ...... 30 CARDIZEM ...... 23, 24 BUTRANS ...... 30 CARDIZEM CD ...... 23 BYDUREON ...... 64 CARDIZEM LA ...... 24 BYETTA ...... 64 CARDURA ...... 21 BYSTOLIC ...... 29 carglumic acid ...... 44 cariprazine ...... 41 C carisoprodol ...... 18, 30 carisoprodol & aspirin ...... 18 c-1 esterase inhibitor ...... 72 carisoprodol, aspirin, & codeine ...... 30 cabergoline ...... 37 CARMOL...... 84, 86 CADUET...... 23 CARMOL HC ...... 84 CAFERGOT ...... 19 carteolol (ophth) ...... 52 CALAN SR ...... 24 CARTIA XT ...... 23 calcipotriene ...... 83, 86 carvedilol ...... 29 calcipotriene & betamethasone...... 83 carvedilol phosphate ...... 29 calcitonin salmon ...... 70 CASODEX ...... 13 calcitriol ...... 86, 88 CATAFLAM ...... 30 calcitriol (topical) ...... 86 CATAPRES ...... 25 calcium acetate ...... 46 CATAPRES-TTS ...... 25 CALQUENCE ...... 13 CECLOR ...... 5 CAMBIA ...... 36 cefaclor ...... 5 CAMILA ...... 61 cefadroxil...... 5 CAMPRAL ...... 39 cefdinir ...... 5 canagliflozin ...... 64 cefditoren ...... 5 canagliflozin & metformin ...... 64 cefixime ...... 5 canakinumab ...... 72 cefixime solution ...... 5 CANASA...... 54 cefpodoxime ...... 5 candesartan ...... 26 cefprozil ...... 5 candesartan & hydrochlorothiazide ...... 26 CEFTIN ...... 5 cannabidiol ...... 39 cefuroxime axetil ...... 5 CANTIL ...... 57 CEFZIL ...... 5 capecitabine ...... 13 CELEBREX ...... 30 CAPEX SHAMPOO ...... 83 celecoxib ...... 30 capmatinib ...... 14 CELEXA ...... 41 CAPOTEN ...... 26 CELLCEPT ...... 75 CAPOZIDE ...... 26 CELONTIN ...... 36 CAPRELSA ...... 16 cenegermin-bkbj ...... 53 captopril ...... 26 CENESTIN ...... 69 captopril & hydrochlorothiazide ...... 26 cenobamate ...... 35 CARAC ...... 87 cephalexin...... 5 CARAFATE ...... 55 CEQUA ...... 48 carbachol ...... 52 CERDELGA ...... 73 CARBAGLU ...... 44 ceritinib ...... 14 carbamazepine ...... 34, 35 certirizine...... 51 carbamazepine extended-release cap ...... 34 certolizumab Pegol ...... 72 carbamazepine extended-release tab ...... 35 CESAMET ...... 54 CARBATROL ...... 34 cevimeline hcl ...... 18 carbidopa ...... 37, 38 CHANTIX ...... 18 carbidopa & levodopa...... 37, 38 CHEMET ...... 57 carbidopa & levodopa extended release ...... 37, 38 CHERATUSSIN AC...... 77 carbidopa, levodopa, & entacapone ...... 38 chlorambucil ...... 14 carbinoxamine maleate ...... 4 chlordiazepoxide ...... 38, 41, 56 carbinozamine ...... 51 chlordiazepoxide & amitriptyline ...... 41
Kaiser Permanente, a TRICARE Prime Option Formulary 93 Kaiser Permanente, a TRICARE® Prime Option Formulary chlorhexidine (mouth-throat) ...... 47 clobazam...... 34, 35 chloroquine phosphate ...... 8 clobetasol propionate ...... 83 chlorothiazide ...... 45 clobetasol propionate emollient ...... 83 chlorpheniramine, phenylephrine & pyrilamine ...... 4 clobetasol propionate emulsion ...... 83 chlorpromazine ...... 41 CLOBEX ...... 83 chlorpropamide...... 64 clocortolone pivalate ...... 83 CHLORPROPAMIDE ...... 64 CLODERM ...... 83 chlorthalidone ...... 26, 28, 45 clomipramine ...... 41 chlorzoxazone ...... 18 clonazepam ...... 35 CHOLBAM ...... 72 clonidine ...... 25 cholestyramine ...... 22 clonidine extended-release ...... 25 cholestyramine light ...... 22 clonidine transdermal ...... 25 cholic acid ...... 72 clopidogrel ...... 20 CHRONULAC ...... 44 clorazepate ...... 38 CIALIS ...... 77 clotrimazole ...... 80, 81 CIBALITH-S ...... 42 clotrimazole & betamethasone ...... 81 ciclesonide ...... 78 clozapine ...... 41 ciclopirox ...... 80 CLOZARIL ...... 41 cilostazol...... 20 COARTEM ...... 8 CILOXAN ...... 47 cobimetinib ...... 14 CIMDUO ...... 11 codeine ...... 29, 30, 77, 78 cimetidine ...... 55 CODEINE SULF ...... 30 CIMZIA ...... 72 COGENTIN ...... 37 cinacalcet ...... 72 COLAZAL ...... 54 CIPRO ...... 5, 48 COL-BENEMID ...... 46 CIPRO HC ...... 48 colchicine ...... 46, 72 CIPRODEX ...... 48 colchicine & probenecid ...... 46 ciprofloxacin ...... 5, 47, 48 COLCRYS ...... 72 ciprofloxacin & dexamethasone (ophth) ...... 48 colesevelam ...... 22 ciprofloxacin & hydrocortisone (otic) ...... 48 COLESTID ...... 22 ciprofloxacin (ophth) ointment ...... 47 colestipol ...... 22 ciprofloxacin (ophth) solution ...... 47 collagenase ...... 86 citalopram...... 41 COLYTE ...... 55 citric acid, sodium citrate, & potassium citrate ...... 44 COMBIGAN ...... 52 CLARAVIS ...... 87 COMBIPATCH ...... 68 clarithromycin ...... 5, 55 COMBIVENT RESPIMAT ...... 19 clarithromycin extended-release ...... 5 COMBIVIR ...... 11 CLENPIQ ...... 56 COMBUNOX ...... 32 CLEOCIN ...... 5, 80 COMPAZINE ...... 55 CLEOCIN HCL ...... 5 COMPLERA ...... 10 CLEOCIN PEDIATRIC ...... 5 COMTAN ...... 38 CLEOCIN T ...... 80 CONCERTA ...... 34 clidinium & chlordiazepoxide ...... 56 CONDYLOX ...... 87 CLIMARA DIS...... 69 conjugated estrogens & bazedoxifene ...... 68 CLIMARA PRO...... 68 conjugated estrogens & medroxyprogesterone acetate ...... 68 CLINDAGEL ...... 80 COPAXONE 20 mg ...... 74 clindamycin & benzoyl peroxide ...... 80 COPAXONE 40 mg ...... 74 clindamycin & tretinoin ...... 86 CORDRAN ...... 84 clindamycin hcl ...... 5 COREG ...... 29 clindamycin palmitate ...... 5 COREG CR ...... 29 clindamycin phosphate (topical) ...... 80 CORGARD ...... 29 clindamycin phosphate (vaginal) ...... 80 CORLANOR ...... 25 CLINDESSE ...... 80 CORTEF ...... 58 CLINORIL...... 33 CORTENEMA ...... 84
Kaiser Permanente, a TRICARE Prime Option Formulary 94 Kaiser Permanente, a TRICARE® Prime Option Formulary corticotropin ...... 70 daflazacort ...... 73 CORTIFOAM ...... 84 DAKLINZA ...... 9 cortisone acetate ...... 58 dalfampridine ...... 73 CORTISPORIN ...... 49, 50, 83 DALIRESP ...... 79 CORTISPORIN-TC ...... 49 DALMANE ...... 39 CORTONE ACETATE ...... 58 dalteparin ...... 21 CORZIDE ...... 29 danazol ...... 58 COSENTYX ...... 76 DANOCRINE ...... 58 COSOPT ...... 52 DANTRIUM ...... 18 COTELLIC ...... 14 dantrolene sodium ...... 18 COTEMPLA XR-ODT ...... 34 dapagliflozin ...... 64 COUMADIN ...... 21 dapagliflozin & metformin ...... 64 COVERA-HS ...... 24 dapsone ...... 7, 87 COZAAR ...... 27 dapsone (topical) ...... 87 CREON ...... 56 DARAPRIM ...... 8 CRESEMBA ...... 7 darbepoetin alfa ...... 21 CRESTOR ...... 23 darifenacin ...... 88 crisaborole ...... 83 darolutamide ...... 14 CRIXIVAN ...... 11 darunavir & cobicistat ...... 9 crizotinib ...... 14 darunavir ethanolate ...... 9 cromolyn sodium ...... 51, 78 darunavir/cobicistat/FTC/tenofovir ...... 9 cromolyn sodium (ophth) ...... 51 dasatinib ...... 14 crotamiton ...... 81 DAURISMO ...... 14 CRYSELLE ...... 63 DAYPRO ...... 32 CUPRIMINE ...... 57 DAYTRANA ...... 34 CUTIVATE ...... 84 DDAVP ...... 70 CYCLESSA ...... 59 DECADRON ...... 48, 58 cyclobenzaprine ...... 18 decitabine & cedazuridine ...... 14 cyclobenzaprine extended-release ...... 18 DECLOMYCIN ...... 5 CYCLOCORT ...... 82 deferasirox ...... 57 cyclophosphamide ...... 14 deferiprone ...... 57 cycloserine ...... 7 delafloxacin ...... 5 CYCLOSET ...... 37 delavirdine mesylate ...... 9 cyclosporine ...... 48, 72 DELESTROGEN ...... 60 cyclosporine (ophth) ...... 48 DELSTRIGO ...... 10 cyclosporine, modified ...... 72 DEMADEX ...... 45 CYMBALTA ...... 41 demeclocycline ...... 5 cyproheptadine ...... 4 DEMEROL ...... 32 CYSTADANE POWD ...... 72 DENAVIR ...... 82 CYSTAGON ...... 73 DEPAKENE ...... 36 cysteamine delayed-release ...... 73 DEPAKOTE ...... 35 cysteamine immediate-release ...... 73 DEPAKOTE ER ...... 35 CYTOMEL ...... 71 DEPAKOTE SPRINKLE ...... 35 CYTOTEC ...... 55 DEPEN ...... 57 CYTOVENE ...... 11 DEPO-ESTRADIOL...... 60 CYTOXAN ...... 14 DEPO-TESTOSTERONE ...... 59 CYTRA-3 ...... 44 DERMA-SMOOTHE/FS OIL ...... 83 DERMATOP ...... 85 D DERMOTIC ...... 49 DESCOVY ...... 10 D.H.E.45 ...... 19 desipramine ...... 41 dabigatran ...... 20 desmopressin (non-refrigerated) ...... 70 daclatasvir ...... 9 desmopressin acetate ...... 70 dacomitinib ...... 14 DESOGEN ...... 59
Kaiser Permanente, a TRICARE Prime Option Formulary 95 Kaiser Permanente, a TRICARE® Prime Option Formulary desogestrel & ethinyl estradiol ...... 59 difluprednate ...... 49 desogestrel & ethinyl estradiol (biphasic) ...... 59 digoxin ...... 24 desogestrel & ethinyl estradiol (triphasic) ...... 59 dihydroergotamine mesylate ...... 19 desonide ...... 83 DILANTIN ...... 36 DESOWEN ...... 83 DILAUDID ...... 31 desoximetasone ...... 83 diltiazem ...... 23, 24 DESOXYN ...... 34 diltiazem extended-release ...... 23, 24 desvenlafaxine extended release ...... 41 dimethyl fumarate ...... 73 desvenlafaxine succinate extended release ...... 41 DIOVAN ...... 27 DESYREL ...... 43 DIOVAN HCT ...... 27 DETROL ...... 88 DIPENTUM ...... 54 DETROL LA ...... 88 diphenoxylate & atropine ...... 54 deutetrabenazine ...... 39 DIPROLENE ...... 83 dexamethasone ...... 48, 49, 50, 58 DIPROSONE ...... 83 dexamethasone (ophth) solution ...... 48 dipyridamole ...... 20, 21 dexamethasone (ophth) suspension ...... 49 DISALCID ...... 33 DEXEDRINE ...... 34 disopyramide ...... 24 DEXILANT ...... 55 disopyramide controlled-release ...... 24 dexlansoprazole ...... 55 disulfiram...... 73 dexmethylphenidate ...... 33, 34 DITROPAN ...... 88 dexmethylphenidate extended-release ...... 34 DITROPAN XL ...... 88 dextroamphetamine sulfate ...... 34 DIURIL ...... 45 dextroamphetamine sulfate extended-release...... 34 divalproex sodium ...... 35 dextromethorphan & quinidine ...... 39 divalproex sodium capsule ...... 35 DEXTROSTAT ...... 34 divalproex sodium extended release ...... 35 DIABETA ...... 65 DIVIGEL ...... 69 DIACOMIT ...... 36 dofetilide ...... 24 DIAMOX ...... 52 DOJOLVI...... 77 DIAMOX SEQUELS ...... 52 dolasetron ...... 54 DIASTAT ...... 35 DOLOPHINE ...... 32 DIASTAT ACUDIAL ...... 35 dolutegravir ...... 9 diazepam ...... 35, 38 dolutegravir & lamivudine ...... 9 DIBENZYLINE ...... 19 dolutegravir & rilpivirine ...... 9 dichlorphenamide ...... 73 donepezil...... 18, 40 diclofenac ...... 30, 31, 36, 49, 87 DONNATAL ...... 57 diclofenac epolamine ...... 87 doravirine ...... 9, 10 diclofenac potassium ...... 30 doravirine, lamivudine, tenofovir ...... 10 diclofenac sodium ...... 30, 31, 49, 87 dornase alfa ...... 47 diclofenac sodium & misoprostol ...... 30 DORYX ...... 5 diclofenac sodium (actinic keratosis) ...... 87 dorzolamide ...... 52 diclofenac sodium (ophth)...... 49 dorzolamide & timolol ...... 52 diclofenac sodium extended release ...... 31 DOSTINEX ...... 37 dicloxacillin ...... 5 DOVATO ...... 9 dicyclomine ...... 17 DOVONEX ...... 86 didanosine ...... 9 doxazosin ...... 21 didanosine solution ...... 9 doxepin ...... 39, 41, 85, 87 DIDRONEL ...... 73 doxepin (antipuritic) ...... 85, 87 difenoxin & atropine ...... 54 doxepin (sleep) ...... 39 DIFFERIN...... 86 doxercalciferol ...... 88 DIFICID ...... 6 doxycycline ...... 5, 87 diflorasone diacetate ...... 83 doxycycline (rosacea) ...... 87 DIFLUCAN ...... 7 doxycycline hyclate ...... 5 diflunisal ...... 31 doxycycline monohydrate ...... 5 DIFLUNISAL ...... 31 DRISDOL ...... 88
Kaiser Permanente, a TRICARE Prime Option Formulary 96 Kaiser Permanente, a TRICARE® Prime Option Formulary DRITHO-CREME HP ...... 86 ELAVIL ...... 40 dronabinol ...... 54 Elaxacaftor, tezacaftor & ivacaftor ...... 78 dronedarone ...... 24 elbasvir & grazoprevir ...... 10 drospirenone ...... 59, 68 ELDEPRYL ...... 38 drospirenone & estradiol ...... 68 ELESTAT ...... 51 drospirenone & ethinyl estradiol ...... 59 ELESTRIN GEL ...... 69 drospirenone & ethinyl estradiol w/ folate ...... 59 eletriptan ...... 36 DROXIA ...... 14 ELIDEL ...... 87 droxidopa ...... 19 eliglustat ...... 73 DUAC...... 80 ELIMITE ...... 82 DUAVEE...... 68 ELIPHOS ...... 46 DUETACT ...... 67 ELIQUIS ...... 20 dulaglutide ...... 64 ELLA ...... 63 DULERA ...... 79 ELMIRON ...... 76 duloxetine ...... 41 ELOCON ...... 85 DUONEB ...... 19 eltrombopag ...... 21 dupilumab...... 73 eluxadoline ...... 54 DUPIXENT ...... 73 elvitegravir, cobicistat, emtricitabine, & tenofovir ...... 10 DURAGESIC ...... 31 EMADINE ...... 51 DUREZOL ...... 49 EMBEDA ...... 32 DURICEF ...... 5 EMCYT ...... 14 dutasteride ...... 73 emedastine ...... 51 dutasteride & tamsulosin...... 73 EMEND ...... 54 DYAZIDE ...... 45 EMFLAZA ...... 73 DYMISTA ...... 51 EMGALITY ...... 74 DYNACIN ...... 6 emicizumab-kxwh ...... 73 DYNACIRC ...... 24 EMLA ...... 85 DYNAPEN ...... 5 empagliflozin ...... 64 dyphylline ...... 88 empagliflozin & lingaliptin ...... 64 DYRENIUM ...... 45 empagliflozin & metformin ...... 64 EMSAM ...... 38 E emtricitabine ...... 9, 10 emtricitabine & tenofovir ...... 9, 10 E.E.S...... 6 emtricitabine, rilpivirine, & tenofovir ...... 10 E.S.P ...... 5 EMTRIVA ...... 10 econazole nitrate ...... 81 ENABLEX ...... 88 ecothiophate ...... 52 enalapril ...... 26 EDARBI ...... 26 enalapril & hydrochlorothiazide ...... 26 EDARBYCLOR...... 26 enasidenib ...... 14 EDECRIN ...... 45 ENBREL ...... 73 EDLUAR ...... 39 encorafenib ...... 14 edoxaban ...... 21 ENDARI...... 75 EDURANT ...... 12 enfuvirtide ...... 10 efavirenz 400 mg, lamivudine & tenofvir ...... 10 ENJUVIA ...... 69 efavirenz 600 mg ...... 10 enoxaparin ...... 21 efavirenz 600 mg, lamivudine & tenofvir ...... 10 ENSPRYNG ...... 76 efavirenz, emtricitabine & tenofovir ...... 10 entacapone ...... 38 EFFEXOR ...... 43 entecavir ...... 10 EFFEXOR XR...... 43 ENTOCORT EC ...... 57 EFFIENT ...... 21 entrectinib ...... 14 efinaconazole ...... 7 ENTRESTO ...... 25 EFUDEX ...... 87 ENULOSE ...... 45 elagolix ...... 73 enzalutamide ...... 14 elagolix, estradiol, norethindrone ...... 73 EPANOVA ...... 23
Kaiser Permanente, a TRICARE Prime Option Formulary 97 Kaiser Permanente, a TRICARE® Prime Option Formulary EPCLUSA ...... 12 estradiol gel ...... 69 EPIDIOLEX ...... 39 estradiol transdermal ...... 69 EPIDUO ...... 86 estradiol transderomal ...... 69 epinastine (ophth) ...... 51 estradiol vaginal ...... 69 epinephrine ...... 20 estradiol valerate ...... 60 EPIPEN ...... 20 estradiol valerate & dienogest ...... 60 EPIPEN JR ...... 20 estramustine ...... 14 EPIVIR ...... 11 ESTRATEST ...... 69 EPIVIR HBV ...... 11 ESTRING ...... 69 eplerenone ...... 26 estrogen, ester/me-testosterone ...... 69 epoetin alfa ...... 21 estrogens, conjugated ...... 69, 70 EPOGEN ...... 21 estrogens, conjugated synthetic a ...... 69 eprosartan ...... 26 estrogens, conjugated synthetic b ...... 69 eprosartan & hydrochlorothiazide ...... 26 estrogens, conjugated vaginal ...... 70 EPZICOM ...... 8 estropipate ...... 70 EQUETRO ...... 34 ESTROSTEP FE ...... 62 erenumab-aooe ...... 73 eszopiclone ...... 39 ergocalciferol ...... 88 etanercept ...... 73 ergoloid mesylates ...... 19 ethacrynic acid ...... 45 ergotamine & caffeine ...... 19, 36 ethambutol ...... 7 erlotinib ...... 14 ethionamide ...... 7 ERTACZO ...... 82 ethontoin ...... 35 ertufliglozin ...... 64 ethosuximide ...... 35 ertugliflozin & metformin ...... 64 ethynodiol diacetate & ethinyl estradiol ...... 60 ertugliflozin & sitagliptin ...... 64 etidronate ...... 73 ERYGEL ...... 81 etodolac ...... 31 ERY-TAB ...... 6 etonogestrel & ethinyl estradiol ...... 60 ERYTHROCIN ...... 6 etravirine ...... 10 ERYTHROMYCIN ...... 5 EUCRISA ...... 83 erythromycin & sulfisoxazole ...... 5 EULEXIN...... 14 erythromycin (acne acid)...... 81 EURAX ...... 81 erythromycin (ophth)...... 47 EVAMIST ...... 69 erythromycin base ...... 5, 6 EVEKEO ...... 33 erythromycin base delayed-release ...... 6 everolimus ...... 14, 73 erythromycin ethylsuccinate ...... 6 EVISTA ...... 70 erythromycin sterate ...... 6 EVOCLIN ...... 80 ESBRIET ...... 79 evolocumab ...... 22 escitalopram ...... 41 EVOTAZ ...... 9 eslicarbazepine ...... 35 EVOXAC ...... 18 esomeprazole ...... 55 EVRYSDI ...... 76 estazolam ...... 39 EXALGO ...... 31 esterified estrogens ...... 68 EXELDERM ...... 82 ESTRACE ...... 68, 69 EXELON ...... 18 ESTRACE CREAM ...... 69 exemestane ...... 14 ESTRACE TAB ...... 68 exenatide ...... 64 ESTRADERM ...... 69 exenatide extended-release ...... 64 estradiol ...... 59, 60, 61, 62, 63, 68, 69, 70, 73 EXFORGE ...... 23 estradiol & levonorgestrel ...... 68 EXFORGE HCT ...... 23 estradiol & norethindrone ...... 68 EXJADE ...... 57 estradiol & norgestimate ...... 68 EXTAVIA ...... 74 estradiol acetate ...... 69 EZALLOR SPRINKLE ...... 23 estradiol acetate vaginal tablets ...... 69 ezetimibe...... 22 estradiol and progesterone ...... 70 ezetimibe & simvastatin ...... 22 estradiol cypionate ...... 60 ezogaine ...... 35
Kaiser Permanente, a TRICARE Prime Option Formulary 98 Kaiser Permanente, a TRICARE® Prime Option Formulary F FLECTOR ...... 87 FLEXERIL ...... 18 FABIOR ...... 87 FLOMAX ...... 19 famciclovir ...... 10 FLONASE ...... 51 famotidine...... 55 FLORINEF ACETATE ...... 58 FAMVIR ...... 10 FLOVENT DISKUS AER ...... 79 FANAPT ...... 42 FLOVENT HFA ...... 79 FARESTON ...... 16 FLOXIN ...... 47 FARXIGA ...... 64 fluconazole ...... 7 FAZACLO...... 41 flucytosine ...... 7 febuxostat...... 73 fludrocortisone...... 58 felbamate ...... 35 FLUMADINE ...... 12 FELBATOL ...... 35 flunisolide ...... 51 FELDENE...... 33 FLUNISOLIDE...... 51 felodipine ...... 24 fluocinolone acetonide ...... 49, 83, 84 FEMARA ...... 15 fluocinolone acetonide (otic) ...... 49 FEMCON FE ...... 62 fluocinonide ...... 84 FEMHRT ...... 70 fluocinonide emollient ...... 84 FEMRING...... 69 FLUORABON BASIC ...... 77 FEMTRACE ...... 69 FLUORITAB ...... 77 fenfluramine ...... 35 fluorometholone (ophth oint) ...... 49 fenofibrate ...... 22 fluorometholone (ophth)...... 49 fenofibrate, micronized ...... 22 fluorometholone acetate ...... 49 fenofibric acid ...... 22 FLUOROPLEX ...... 87 fenoprofen calcium ...... 31 fluorouracil (topical) ...... 87 fentanyl film ...... 31 fluoxetine...... 41, 42 fentanyl intranasal ...... 31 fluoxymesterone ...... 58 fentanyl lozenge ...... 31 fluphenazine ...... 41 fentanyl tablet ...... 31 flurandrenolide ...... 84 fentanyl transdermal ...... 31 flurazepam ...... 39 FENTORA ...... 31 flurbiprofen ...... 31, 49 FERRIPROX ...... 57 flurbiprofen (ophth) ...... 49 fesoterodine ...... 88 flutamide ...... 14 FETZIMA ...... 42 fluticasone...... 51, 78, 79, 84 FIASP ...... 65 fluticasone & salmeterol...... 78, 79 FIASP FLEXPEN ...... 65 fluticasone & salmeterol (100/50 mcg) ...... 78 fidaxomicin ...... 6 fluticasone & salmeterol (250/50 mcg and 500/50 mcg) ...... 79 filgrastim ...... 21 fluticasone & umeclidinium & vilanterol ...... 79 filgrastim (vials only) ...... 21 fluticasone & vilanterol ...... 79 FINACEA ...... 86 fluticasone propionate ...... 79, 84 fingolimod ...... 73 fluticasone propionate (topical) ...... 84 FINTEPLA ...... 35 fluvastatin ...... 22 FIORICET ...... 30 fluvastatin extended-release ...... 22 FIORICET W/ CODEINE ...... 30 fluvoxamine ...... 41 FIORINAL...... 30 FML...... 49 FIORINAL W/ CODEINE...... 30 FML FORTE ...... 49 FIRAZYR ...... 74 FML OINT ...... 49 FIRDAPSE ...... 72 FOCALIN ...... 33, 34 FLAGYL ...... 8 FOCALIN XR ...... 34 FLAGYL ER ...... 8 fondaparinux ...... 21 FLAREX ...... 49 FORADIL ...... 20 flavoxate ...... 88 formoterol fumarate ...... 20 FLAVOXATE ...... 88 FORTAMET ...... 67 flecainide ...... 24 FORTEO ...... 70
Kaiser Permanente, a TRICARE Prime Option Formulary 99 Kaiser Permanente, a TRICARE® Prime Option Formulary FORTESTA ...... 59 gilteritinib ...... 14 FORTICAL ...... 70 glasdegib...... 14 FOSAMAX ...... 72 glatiramer acetate ...... 74 FOSAMAX PLUS D ...... 72 GLATOPA ...... 74 fosamprenavir calcium ...... 10 glecaprevir & pibrentasvir ...... 11 fosfomycin ...... 13 GLEEVEC ...... 14 fosinopril ...... 26 GLEOSTINE ...... 15 fosinopril & hydrochlorothiazide ...... 26 glimepiride ...... 64, 67 FOSRENOL ...... 46 glipizide ...... 64, 65 fostamatinib ...... 73 glipizide & metformin ...... 64 fostemsavir ...... 11 glipizide extended-release ...... 65 FOTIVDA ...... 16 GLUCAGEN HYPOKIT ...... 65 FRAGMIN...... 21 glucagon ...... 65 FREESTYLE SYSTEM ...... 44 GLUCAGON EMERGENCY KIT ...... 65 FREESTYLE TEST STRIPS ...... 43 GLUCOPHAGE ...... 67 FROVA ...... 36 GLUCOPHAGE XR ...... 67 frovatriptan ...... 36 GLUCOTROL ...... 64, 65 FULPHILA ...... 21 GLUCOTROL XL ...... 65 FURADANTIN ...... 13 GLUCOVANCE ...... 65 furosemide ...... 45 GLUMETZA ...... 67 FUZEON...... 10 glyburide ...... 65 FYCOMPA ...... 36 glyburide & metformin ...... 65 glyburide micronized ...... 65 G glycerol phenylbutyrate ...... 44 glycopyrrolate ...... 17, 79 gabapentin ...... 35 glycopyrrolate & indacaterol ...... 79 GABITRIL ...... 36 glycopyrrolate inhalation pow...... 17 GALAFOLD ...... 75 glycopyrrolate nebulizer soln ...... 17 galantamine hydrobromide ...... 18 GLYNASE ...... 65 galantamine hydrobromide ER ...... 18 GLYSET ...... 67 galcanezumab ...... 74 GLYXAMBI ...... 64 ganciclovir ...... 11, 47 GOCOVRI ...... 37 ganciclovir (ophth) ...... 47 golimumab ...... 74 GARAMYCIN ...... 6, 81 GOLYTELY ...... 56 GASTROCROM ...... 78 GRALISE ...... 35 gatifloxacin (ophth) ...... 47 granisetron ...... 54 GATTEX ...... 57 grass pollen allergen extract (5 glass extract) ...... 51 GAVILYTE-C ...... 56 GRASTEK ...... 52 GAVRETO ...... 16 GRIFULVIN V ...... 7 GEL-KAM ...... 77 griseofulvin microsize ...... 7 gemfibrozil ...... 22 griseofulvin ultramicrosize ...... 7 GEMTESA ...... 88 GRIS-PEG ...... 7 GENERESS FE ...... 62 guaifenesin & codeine ...... 77 GENTAK...... 47 guanfacine ...... 25, 40 gentamicin & prednisolone ...... 49 guanfacine extended-release...... 40 gentamicin (ophth) ...... 47 guselkumab ...... 74 gentamicin sulfate ...... 6, 81 GVOKE ...... 65 gentamicin sulfate (topical) ...... 81 GYNAZOLE-1 ...... 80 GENTROPIN ...... 71 GYNODIOL ...... 68 GENVOYA ...... 10 GEODON ...... 43 H GIANVI ...... 59 GIAZO ...... 54 HAEGARDA ...... 72 GILENYA ...... 73 halcinonide ...... 84
Kaiser Permanente, a TRICARE Prime Option Formulary 100 Kaiser Permanente, a TRICARE® Prime Option Formulary HALCION ...... 39 hydrocortisone (topical) ...... 84 HALDOL ...... 41 hydrocortisone acetate & urea ...... 84 HALFLYTELY ...... 55 hydrocortisone acetate (intrarectal) ...... 84 halobetasol propionate ...... 84 hydrocortisone butyrate ...... 84 HALOG ...... 84 hydrocortisone butyrate hydrophilic lipo base ...... 84 haloperidol ...... 41 hydrocortisone probutate ...... 84 HARVONI ...... 11 hydrocortisone valerate ...... 84 HECTOROL ...... 88 hydromorphone oral suspension ...... 31 HELIDAC ...... 4 hydromorphone tablet ...... 31 HEMLIBRA ...... 73 hydroxychloroquine sulfate ...... 8 heparin ...... 21 hydroxyurea ...... 14 HEPARIN SODIUM ...... 21 hydroxyzine hcl ...... 39 HEPSERA ...... 9 hydroxyzine pamoate ...... 39 HETLIOZ ...... 39 HYGROTON ...... 45 hexachlorophene ...... 81 hyoscyamine sulfate ...... 17 HIPREX ...... 13 HYPERCARE ...... 85 HIZENTRA ...... 74 HYPERSAL ...... 79 homatropine ...... 53, 78 HYQVIA...... 74 HORIZANT ...... 35 HYSINGLA ER ...... 31 house dust mite allergen extract ...... 51 HYTONE ...... 84 HUMALOG ...... 66 HYTRIN ...... 22 HUMALOG KWIKPEN ...... 66 HYZAAR ...... 27 HUMALOG MIX 50/50 ...... 66 HUMALOG MIX 75/25 ...... 66 I HUMALOG MIX 75/25 KWIKPEN ...... 66 HUMATIN ...... 8 ibandronate ...... 74 HUMATROPE...... 71 IBRANCE ...... 15 HUMIRA ...... 72 ibrutinib ...... 14 HUMIRA citrate free ...... 72 Ibrutinib 140 mg, 280 mg ...... 14 HUMULIN 50/50 ...... 66 ibuprofen ...... 31, 32 HUMULIN 70/30 ...... 66 icatibant ...... 74 HUMULIN 70/30 KIWKPEN ...... 66 ICLUSIG ...... 15 HUMULIN N ...... 66 icosapent...... 22 HUMULIN N KWIKPEN...... 66 idelalisib ...... 14 HUMULIN R ...... 66, 67 IDHIFA ...... 14 HUMULIN R U-500 ...... 66, 67 ILARIS ...... 72 HUMULIN R U-500 KWIKPEN ...... 67 ILEVRO ...... 50 HYCAMTIN ...... 16 iloperidone ...... 42 HYCODAN ...... 78 ILUMYA ...... 77 HYDERGINE ...... 19 imatinib mesylate ...... 14 hydralazine...... 25, 28 IMBRUVICA ...... 14 HYDREA ...... 14 IMCIVREE ...... 76 hydrochlorothiazide...... 23, 25, 26, 27, 29, 45 IMDUR ...... 28 hydrocodone ...... 31, 77, 78 imipramine ...... 42 hydrocodone & acetaminophen ...... 31 imipramine pamoate ...... 42 hydrocodone & chlorpheniramine ...... 77 imiquimod ...... 87 hydrocodone & homatropine ...... 78 IMITREX ...... 37 hydrocodone & ibuprofen ...... 31 immune globulin ...... 74 hydrocodone er ...... 31 Immune globulin ...... 74 hydrocortisone ...... 48, 49, 50, 58, 80, 81, 83, 84, 85 IMPAVIDO ...... 8 hydrocortisone & acetic acid (otic) ...... 49 IMURAN ...... 72 hydrocortisone & pramoxine ...... 85 INBRIJA ...... 38 hydrocortisone (intrarectal) ...... 84 INCIVEK ...... 12 hydrocortisone (rectal) ...... 84 INCRUSE ELLIPTA ...... 17
Kaiser Permanente, a TRICARE Prime Option Formulary 101 Kaiser Permanente, a TRICARE® Prime Option Formulary indacaterol ...... 79 isavuconazonium ...... 7 indapamide ...... 45 ISENTRESS ...... 12 INDERAL ...... 29 ISENTRESS HD ...... 12 INDERAL LA ...... 29 isocarboxazid ...... 42 INDERIDE ...... 29 isoniazid ...... 7 indinavir sulfate ...... 11 ISOPTIN SR ...... 24 INDOCIN ...... 31 ISOPTO ATROPINE ...... 53 indomethacin ...... 31 ISOPTO CARBACHOL ...... 52 INFERGEN ...... 11 ISOPTO CARPINE ...... 52 INFLAMASE FORTE ...... 50 ISOPTO HOMATROPINE ...... 53 ingenol mebutate ...... 87 ISOPTO HYOSCINE ...... 53 INGREZZA ...... 40 ISORDIL ...... 28 INLYTA ...... 13 ISORDIL TITRADOSE ...... 28 INNOPRAN XL ...... 29 isosorbide dinitrate ...... 28 inotersen ...... 74 isosorbide dinitrate & hydralazine ...... 28 Inotersen ...... 74 isosorbide mononitrate ...... 28 INQOVI ...... 14 isotretinoin ...... 87 INSPRA ...... 26 isradipine...... 24 insulin (oral inhalation) ...... 65 ISTALOL ...... 53 insulin aspart ...... 65 ISTURISA ...... 75 insulin aspart protamine & insulin aspart ...... 65 itraconazole ...... 7 insulin degludec ...... 65 Ivabradine ...... 25 Insulin degludec/ liraglutide ...... 65 ivacaftor...... 78, 79, 80 insulin degludec/insulin aspart ...... 65 ivermectin ...... 4 Insulin delivery system ...... 44 ivermectin (topical) ...... 4 insulin detemir ...... 65 ivosidenib ...... 15 insulin glargine ...... 65, 66 ixazomib ...... 15 Insulin glargine/ lixisenatide ...... 66 ixekizumab ...... 74 insulin glulisine ...... 66 insulin isophane ...... 66 J insulin isophane & regular insulin ...... 66 insulin lispro ...... 66 JADENU ...... 57 insulin lispro protamine & insulin lispro ...... 66 JADENU SPRINKLES ...... 57 insulin lispro-aabc ...... 66 JAKAFI ...... 16 insulin regular ...... 66, 67 JALYN ...... 73 INTAL...... 78 JANUMET ...... 68 INTELENCE ...... 10 JANUVIA ...... 68 interferon alfacon-1 ...... 11 JARDIANCE 25 MG ...... 64 interferon beta-1a ...... 74 JENTADUETO ...... 67 interferon beta-1b ...... 74 JUBLIA ...... 7 Interferon beta-1b ...... 74 JULUCA ...... 9 interferon gamma-1b ...... 74 JUNEL ...... 61, 62 INTERMEZZO ...... 39 JUNEL FE ...... 62 INTROVALE ...... 60 JUVISYNC ...... 68 INTUNIV ...... 40 JUXTAPID ...... 22 INVEGA ...... 42 JYNARQUE ...... 45 INVIRASE ...... 12 INVOKAMET ...... 64 K INVOKANA ...... 64 iodoquinol & hydrocortisone ...... 81 KADIAN ...... 32 IOPIDINE ...... 53 KALETRA ...... 11 ipratropium bromide ...... 17 KALYDECO ...... 79 irbesartan ...... 26 KAON ...... 46 irbesartan & hydrochlorothiazide ...... 26 KAPSPARGO SPRINKLE ...... 29
Kaiser Permanente, a TRICARE Prime Option Formulary 102 Kaiser Permanente, a TRICARE® Prime Option Formulary KAPVAY ...... 25 Lamivudine & tenofovir ...... 11 KARIVA ...... 59 lamivudine & zidovudine ...... 9, 11 KAZANO...... 64 lamotrigine ...... 35 KCL SOLUTION ...... 46 lamotrigine extended-release...... 35 K-DUR ...... 46 lanadelumab ...... 74 KEFLEX ...... 5 LANOXIN ...... 24 KELNOR...... 60 lanreotide ...... 74 KENALOG ...... 85 lansoprazole ...... 55 KEPPRA ...... 35, 36 lanthanum carbonate ...... 46 KEPPRA XR ...... 36 LANTUS ...... 65 KERLONE ...... 28 LANTUS SOLOSTAR ...... 65 KERYDIN ...... 7 lapatinib ...... 15 KETEK ...... 6 LARIAM ...... 8 ketoconazole ...... 7, 81 larotrectinib ...... 15 ketoconazole (topical) ...... 81 LASIX ...... 45 ketoprofen ...... 31 lasmitidan ...... 37 KETOPROFEN...... 31 LASTACAFT ...... 50 ketorolac (ophth) ...... 49 latanoprost ...... 52 ketorolac tablet ...... 31 latanoprostene bunod ...... 52 KEVEYIS ...... 73 LATUDA ...... 42 KEVZARA ...... 76 LAZANDA ...... 31 KHEDEZLA ...... 41 ledipasvir & sofosbuvir ...... 11 KINERET ...... 72 lefamulin ...... 6 KLARON...... 82 leflunomide ...... 75 KLONOPIN ...... 35 lenalidomide ...... 15 KLOR-CON 20 MEQ ...... 46 lenvatinib ...... 15 K-LYTE/CL ...... 46 LENVIMA ...... 15 KOMBIGLYZE XR ...... 68 LESCOL ...... 22 KORLYM ...... 67 LESCOL XL ...... 22 KOSELUGO ...... 16 lesinurad ...... 75 K-PHOS NEUTRAL ...... 46 LESSINA ...... 60 K-PHOS ORIGINAL ...... 46 LETAIRIS ...... 27 KRISTALOSE ...... 45 letermovir ...... 11 K-TAB 10, KLOR-CON 20 MEQ ...... 46 letrozole ...... 15 KUVAN ...... 76 leucovorin ...... 75 KWELL ...... 81 LEUCOVORIN ...... 75 KYNAMRO ...... 22 LEUKERAN ...... 14 KYNMOBI...... 37 LEUKINE...... 21 KYTRIL ...... 54 leuprolide acetate ...... 15 levalbuterol nebulizer solution ...... 20 L levalbuterol tartrate ...... 20 LEVAQUIN ...... 6 labetalol ...... 29 LEVATOL ...... 29 LAC-HYDRIN ...... 86 LEVBID ...... 17 lacosamide ...... 35 LEVEMIR ...... 65 LACRISERT ...... 53 levetiracetam ...... 35, 36 lactic acid & citric acid & potassium bitartrate ...... 60 levetiracetam extended-release ...... 36 lactic acid (ammonium lactate) ...... 87 levobunolol ...... 52 LACTINOL ...... 87 LEVO-DROMORAN ...... 31 lactulose ...... 44, 45 levofloxacin ...... 6, 47 LAMICTAL ...... 35 levofloxacin (ophth) ...... 47 LAMICTAL XR ...... 35 levomilnacipran ...... 42 LAMISIL ...... 7 levonorgestrel ...... 60, 61, 68 lamivudine ...... 8, 9, 10, 11 levonorgestrel & ethinyl estradiol ...... 60, 61
Kaiser Permanente, a TRICARE Prime Option Formulary 103 Kaiser Permanente, a TRICARE® Prime Option Formulary levonorgestrel & ethinyl estradiol (91-day) ...... 60 LODOSYN ...... 37 levonorgestrel & ethinyl estradiol (continuous) ...... 60, 61 lodoxamide tromethamine ...... 51 levonorgestrel & ethinyl estradiol (transdermal) ...... 61 LOESTRIN 24 FE ...... 62 levonorgestrel & ethinyl estradiol (triphasic) ...... 61 LOESTRIN FE...... 62, 63 levophed (oral inhalation) ...... 38 lofexidine ...... 40 levorphanol ...... 31 LOFIBRA CAP ...... 22 LEVOTHROID ...... 71 LOFIBRA TAB ...... 22 levothyroxine ...... 71 LOKELMA ...... 46 LEVOXYL ...... 71 lomitapide ...... 22 LEVSIN ...... 17 LOMOTIL ...... 54 LEXAPRO ...... 41 lomustine...... 15 LEXIVA ...... 10 LONHALA MAGNAIR ...... 17 l-glutamine ...... 75 LONITEN ...... 25 LIALDA ...... 54 LONSURF ...... 16 LIBRAX ...... 56 LOPID ...... 22 LIBRIUM ...... 38 lopinavir & ritonavir ...... 11 LIDAMANTLE ...... 85 LOPRESSOR ...... 29 LIDEX ...... 84 LOPRESSOR HCT ...... 29 LIDEX-E ...... 84 LOPROX ...... 80 lidocaine ...... 53, 85 lorazepam ...... 39 lidocaine & hydrocortisone ...... 85 LORBRENA ...... 15 lidocaine & prilocaine ...... 85 lorlatinib ...... 15 lidocaine & tetracaine ...... 85 losartan ...... 27 lidocaine (jelly, topical) ...... 85 losartan & hydrochlorothiazide ...... 27 lidocaine (mouth-throat) ...... 53 LOSEASONIQUE ...... 60 LIDODERM ...... 85 LOTEMAX ...... 49 lifitegrast ...... 49 LOTENSIN ...... 26 LIMBITROL DS ...... 41 LOTENSIN HCT ...... 26 linaclotide ...... 56 loteprednol ...... 49 linagliptin ...... 67 loteprednol & tobramycin ...... 49 linagliptin & metformin ...... 67 LOTREL ...... 23 lindane ...... 81 LOTRISONE ...... 81 linezolid ...... 6 LOTRONEX ...... 54 LINZESS ...... 56 lovastatin ...... 22, 23 LIORESAL ...... 18 lovastatine extended-release ...... 22 liothyronine...... 71 LOVAZA ...... 23 liotrix...... 71 LOVENOX ...... 21 LIPITOR ...... 22 LOW-OGESTREL ...... 63 liraglutide ...... 65, 67 loxapine ...... 42 lisdexamfetamine ...... 34 LOXITANE ...... 42 lisinopril ...... 26, 27 LOZOL ...... 45 lisinopril & hydrochlorothiazide ...... 27 lubiprostone ...... 56 LITHIUM CARBONATE ...... 42 LUCEMYRA ...... 40 lithium carbonate capsule ...... 42 LUDIOMIL ...... 42 lithium carbonate extended release ...... 42 LUFYLLIN ...... 88 lithium citrate ...... 42 luliconazole ...... 7 LITHOBID...... 42 lumacaftor& ivacaftor ...... 79 LIVALO ...... 23 LUMIGAN ...... 52 lixisenatide ...... 66, 67 LUNESTA ...... 39 LO LOESTRIN FE ...... 63 LUPKYNIS ...... 77 LO/OVRAL-28 ...... 63 LUPRON ...... 15 LOCOID ...... 84 lurasidone ...... 42 LOCOID LIPOCREAM ...... 84 LURIDE CHEW ...... 77 LODINE ...... 31 LURIDE DROPS ...... 77
Kaiser Permanente, a TRICARE Prime Option Formulary 104 Kaiser Permanente, a TRICARE® Prime Option Formulary LUTERA ...... 60 MEPHYTON ...... 88 LUVOX ...... 41 mepolizumab ...... 79 LUXIQ ...... 83 meprobamate ...... 39 LUZU ...... 7 MEPRON ...... 8 LYNPARZA ...... 15 mercaptopurine ...... 15 LYPREL ...... 61 mesalamine controlled-release ...... 54 LYRICA ...... 36 mesalamine suppository ...... 54 LYRICA CR ...... 36 mesalamine suspension ...... 54 LYSODREN ...... 15 mesalamine tablet ...... 54 LYSTEDA ...... 21 mesna ...... 75 LYUMJEV...... 66 MESNEX ...... 75 MESTION ...... 18 M MESTION TIMESPAN ...... 18 METADATE CD ...... 34 macitentan ...... 28 METADATE ER ...... 34 MACROBID ...... 13 METAGLIP ...... 64 MACRODANTIN ...... 13 metaxalone ...... 18 mafenide acetate ...... 81 metformin ...... 64, 65, 67, 68 MALARONE ...... 8 metformin ER ...... 67 malathion ...... 81 metformin extended-release ...... 67, 68 maprotiline ...... 42 methadone ...... 32 maraviroc ...... 11 methamphetamine ...... 34 MARINOL ...... 54 methazolamide ...... 52 MARPLAN ...... 42 methenamine hippurate ...... 13 MATULANE ...... 16 methenamine, sodium biphosphate, phenyl salicylate, MAVIK ...... 27 methylene blue, and hyoscyamine ...... 13, 75 MAVYRET ...... 11 METHERGINE ...... 75 MAXAIR AUTOHALER ...... 20 methimazole ...... 71 MAXALT ...... 37 METHITEST ...... 58 MAXALT MLT ...... 37 methocarbamol ...... 19 MAXIDEX ...... 49 methotrexate ...... 15 MAXITROL ...... 49 methotrexate sodium ...... 15 MAXZIDE ...... 45 methoxsalen ...... 87 mechlorethamine ...... 15 methoxsalen, rapid ...... 87 meclofenamate ...... 31 methscopolamine ...... 17 MECLOMEN ...... 31 methsuximide ...... 36 MEDROL ...... 58 methyclothiazide ...... 45 medroxyprogesterone acetate ...... 68, 70 METHYCLOTHIAZIDE...... 45 mefenamic acid ...... 31 methyldopa ...... 25 mefloquine ...... 8 methyldopa & hydrochlorothiazide ...... 25 MEGACE ...... 70 methylergonovine maleate ...... 75 megestrol acetate ...... 70 METHYLIN ...... 34 MEKTOVI ...... 13 methylnaltrexone ...... 57 MELLARIL ...... 43 methylphenidate ...... 34 meloxicam ...... 31 methylphenidate extended-release ...... 34 melphalan...... 15 Methylphenidate extended-release disintegrating tablet...... 34 memantine ...... 40 methylphenidate sustained release ...... 34 memantine er & donepezil ...... 40 methylphenidate transdermal patch ...... 34 M-END MAX D ...... 78 methylprednisolone ...... 58 MENEST ...... 68 methyltestosterone ...... 58 MENOSTAR ...... 69 metipranolol ...... 52 MENTAX ...... 80 metoclopramide ...... 57 mepenzolate ...... 57 metolazone ...... 45 meperidine tablet ...... 32 metoprolol ...... 29
Kaiser Permanente, a TRICARE Prime Option Formulary 105 Kaiser Permanente, a TRICARE® Prime Option Formulary metoprolol & hydrochlorothiazide ...... 29 moexipril & hydrochlorothiazide...... 27 metoprolol succinate...... 29 mometasone & formoterol ...... 79 metoprolol tartrate ...... 29 mometasone furoate ...... 79, 85 metreleptin ...... 75 MONODOX ...... 5 METROCREAM ...... 81 MONONESSA ...... 63 METROGEL ...... 81 MONOPRIL ...... 26 METROGEL-VAGINAL ...... 81 MONOPRIL HCT ...... 26 METROLOTION ...... 81 montelukast ...... 78 metronidazole ...... 4, 8, 81 MONUROL ...... 13 metronidazole (topical) ...... 81 morphine ...... 32 metronidazole (vaginal) ...... 81 morphine & naltrexone ...... 32 metronidazole extended-release ...... 8 morphine beads ...... 32 metronidazole, tetracycline & bismuth subsalicylate ...... 4 morphine extended-release capsule ...... 32 MEVACOR ...... 22 morphine extended-release tablet ...... 32 mexiletine ...... 25 MORPHINE SULFATE ...... 32 MEXITIL ...... 25 MOTEGRITY ...... 57 MIACALCIN ...... 70 MOTOFEN ...... 54 MICARDIS ...... 27 MOTRIN ...... 31 MICARDIS HCT ...... 27 MOVIPREP ...... 55 miconazole nitrate & zinc oxide ...... 81 moxifloxacin ...... 6, 47 MICROGESTIN ...... 61, 62 moxifloxacin (ophth) ...... 47 MICROGESTIN FE ...... 62 MS CONTIN ...... 32 MICROZIDE ...... 45 MSIR...... 32 MIDAMOR ...... 45 MUCOMYST-10 ...... 71 midodrine hcl ...... 20 MULTAQ ...... 24 MIFEPREX ...... 75 mupirocin ...... 81 mifepristone ...... 67, 75 mupirocin calcium ...... 81 migalastat ...... 75 MYALEPT ...... 75 MIGERGOT ...... 36 MYAMBUTOL ...... 7 miglitol ...... 67 MYCAPSSA ...... 75 miglustat ...... 75 MYCELEX ...... 80 MIGRANAL ...... 19 MYCIFRADIN ...... 6 milnacipran...... 40 MYCOBUTIN ...... 7 miltefosine ...... 8 MYCOLOG II ...... 85 MILTOWN ...... 39 mycophenolate mofetil ...... 75 MINASTRIN 24 FE ...... 62 mycophenolate sodium ...... 75 MINIPRESS ...... 22 MYCOSTATIN...... 7 MINIVELLE ...... 69 MYDAYIS ...... 33 MINOCIN ...... 6 MYFORTIC ...... 75 minocycline ...... 6 MYLERAN ...... 13 minoxidil ...... 25 MYRBETRIQ ...... 88 mipomersen sodium ...... 22 MYSOLINE ...... 36 mirabegron ...... 88 MIRAPEX ...... 38 N MIRAPEX ER ...... 38 mirtazapine ...... 42 na sulfacetm/avobenzone/sulfur ...... 81 MIRVASO...... 86 nabilone ...... 54 misoprostol ...... 30, 55 nabumetone ...... 32 mitotane ...... 15 nadolol ...... 29 MOBIC ...... 31 nadolol & bendroflumethiazide ...... 29 modafinil ...... 34 nafarelin ...... 70 MODICON ...... 61 naftifine cream...... 81 MODURETIC ...... 45 naftifine gel ...... 82 moexipril ...... 27 Naftifine gel ...... 82
Kaiser Permanente, a TRICARE Prime Option Formulary 106 Kaiser Permanente, a TRICARE® Prime Option Formulary NAFTIN ...... 81, 82 nevirapine tablet ...... 11 nalbuphine ...... 32 NEXAVAR ...... 16 NALFON ...... 31 NEXIUM ...... 55 naloxone ...... 30, 33, 40 NEXLETOL ...... 22 naloxone nasal spray ...... 40 NEXLIZET ...... 22 naltrexone ...... 32, 40 niacin ...... 23, 88 NAMENDA ...... 40 niacin & lovastatin ...... 23 NAMZARIC ...... 40 NIACOR ...... 88 NAPRELAN ...... 32 NIASPAN ...... 23 NAPROSYN ...... 32 nicardipine ...... 24 naproxen ...... 32, 37 NICODERM ...... 18 naproxen sodium ...... 32 NICORETTE ...... 17, 18 naproxen sodium ER ...... 32 nicotine gum ...... 17 naratriptan ...... 37 nicotine inhalation ...... 17 NARCAN ...... 40 nicotine lozenge ...... 18 NARDIL ...... 42 nicotine nasal spray...... 18 NATACYN ...... 47 nicotine patch ...... 18 natamycin ...... 47 nicotine spray ...... 17, 18 NATAZIA ...... 60 NICOTROL ...... 17, 18 nateglinide ...... 67 nifedipine...... 24 NATPARA ...... 75 nifedipine extended-release ...... 24 NATROBA ...... 82 NILANDRON ...... 15 NAVANE...... 43 nilotinib ...... 15 nebivolol ...... 29 nilutamide ...... 15 NEBUPENT ...... 8 nimodipine ...... 24 NECON ...... 61 NIMOTOP ...... 24 NECON 10/11...... 61 NINLARO ...... 15 nedocromil sodium (ophth) ...... 51 nintedanib ...... 79 nefazodone ...... 42 niraparib ...... 15 nelfinavir mesylate ...... 11 NIRAVAM ...... 38 neomycin sulfate ...... 6 nisoldipine ...... 24 neomycin, bacitracin & polymyxin b (ophth) ...... 47 nitazoxanide ...... 8 neomycin, colistin, hydrocortisone & thonzonium (otic) ...... 49 nitisinone ...... 75 neomycin, polymycin b & gramicidin (ophth) ...... 47 NITRO-BID ...... 28 neomycin, polymyxin B & dexamethasone (ophth) ...... 49 NITRO-DUR ...... 28 neomycin, polymyxin B & hydrocortisone (ophth) ...... 48, 50 nitrofurantoin ...... 13 neomycin, polymyxin B & hydrocortisone (otic) ...... 50 nitrofurantoin macrocrystal ...... 13 NEO-POLYCIN...... 47, 48 nitrofurantoin monohydrate ...... 13 NEO-POLYCIN HC ...... 48 nitroglycerin (intra-anal) ...... 28 NEORAL...... 72 nitroglycerin aerosol ...... 28 NEOSPORIN ...... 47 nitroglycerin solution ...... 28 neostigmine bromide ...... 18 nitroglycerin sublingual ...... 28 nepafenac ...... 50 nitroglycerin topical ointment ...... 28 NEPTAZANE ...... 52 nitroglycerin transdermal patch ...... 28 NESINA ...... 64 nitroglycerin transdermal patch 0.8 mg strength ...... 28 netarsudil ...... 52 NITROLINGUAL ...... 28 netupitant & palonosetron ...... 54 NITROMIST ...... 28 NEULASTA ...... 21 NITROSTAT ...... 28 NEUMEGA ...... 21 NIVESTYM ...... 21 NEUPOGEN ...... 21 nizatidine ...... 55 NEUPRO ...... 38 NIZORAL ...... 7, 81 NEURONTIN ...... 35 NOLVADEX ...... 16 NEVANAC ...... 50 NORA-BE ...... 61 nevirapine solution ...... 11 NORCO ...... 31
Kaiser Permanente, a TRICARE Prime Option Formulary 107 Kaiser Permanente, a TRICARE® Prime Option Formulary NORDETTE-28 ...... 60 nystatin ...... 7, 82, 85 NORDITROPIN ...... 71 NYSTATIN ...... 82 norelgestromin & ethinyl estradiol ...... 61 nystatin & triamcinolone...... 82, 85 norethindrone ...... 61, 62, 63, 68, 70, 73 NYSTATIN & TRIAMCINOLONE ...... 82 norethindrone & ethinyl estradiol ...... 61, 62 nystatin (topical) ...... 82 norethindrone & ethinyl estradiol (biphasic) ...... 61 norethindrone & ethinyl estradiol (triphasic) ...... 62 O norethindrone & ethinyl estradiol w/ ferrous fumarate ...... 62 norethindrone acetate ...... 62, 63, 70 OCELLA ...... 59 norethindrone acetate & ethinyl estradiol ...... 62, 63, 70 octreotide acetate ...... 75 norethindrone acetate & ethinyl estradiol w/ ferrous fumarate OCUFEN ...... 49 ...... 62, 63 OCUFLOX ...... 47 norethindrone acetate & ethinyl estradiol w/ ferrous fumarate OCUPRESS ...... 52 (biphasic) ...... 63 ODACTRA ...... 51 norethindrone-mestranol ...... 63 ODEFSEY ...... 10 NORFLEX ...... 19 OFEV ...... 79 norfloxacin ...... 6 ofloxacin (ophth) ...... 47 NORGESIC ...... 19 ofloxacin (otic) ...... 47 norgestimate & ethinyl estradiol ...... 63 OGESTREL ...... 63 norgestimate & ethinyl estradiol (triphasic) ...... 63 olanzapine ...... 42 norgestrel & ethinyl estradiol ...... 63 olanzapine & fluoxetine hcl ...... 42 NORINYL 1+35 ...... 61 olanzapine orally disintegrating ...... 42 NORINYL 1+50 ...... 63 olaparib ...... 15 NOROXIN ...... 6 OLEPTRO ...... 43 NORPACE ...... 24 olmesartan ...... 23, 27 NORPACE CR ...... 24 olmesartan & hydrochlorothiazide ...... 23, 27 NORPRAMIN ...... 41 olodaterol ...... 20, 80 NOR-QD ...... 61 olopatadine ...... 51 NORTHERA ...... 19 olopatadine (nasal) ...... 51 NORTREL 1/35 ...... 61 olopatadine (ophth) ...... 51 NORTREL 7/7/7 ...... 62 olsalazine ...... 54 nortriptyline ...... 42 OLUMIANT ...... 72 NORVASC ...... 23 OLUX-E ...... 83 NORVIR ...... 12 OLYSIO ...... 12 NOVOLIN 70/30 ...... 66 omadacycline ...... 6 NOVOLIN N ...... 66 omalizumab ...... 79 NOVOLIN R ...... 66 ombitasvir, paritaprevir & ritonavir ...... 11 NOVOLOG ...... 65 ombitasvir, paritaprevir, ritonavir, & dasabuvir ...... 11 NOVOLOG MIX 70/30 ...... 65 omega-3 acid ethyl esters ...... 23 NOVOLOG MIX 70/30 FLEXPEN ...... 65 omega-3-carboxylic acid ...... 23 NOXAFIL ...... 7 omeprazole ...... 55 NUBAIN ...... 32 OMNICEF ...... 5 NUBEQA ...... 14 OMNIPOD DASHTM PODs ...... 44 NUCALA ...... 79 OMNIPOD DASHTM SYSTEM KIT AND PODs ...... 44 NUCYNTA ...... 33 OMNIPRED ...... 50 NUEDEXTA ...... 39 OMNITROPE...... 71 NULYTELY ...... 56 ondansetron ...... 55 NUPLAZID ...... 42 ondansetron (orally disintegrating) ...... 55 NURTEC ODT ...... 37 ONE TOUCH ULTRA 2 ...... 44 NUTROPIN AQ ...... 71 ONE TOUCH ULTRA SMART ...... 44 NUVARING ...... 60 ONE TOUCH ULTRA TEST STRIPS ...... 43 NUVIGIL ...... 33 ONE TOUCH ULTRAMINI ...... 44 NUZYRA...... 6 ONE TOUCH VERIO FLEX ...... 44 NYDRAZID ...... 7 ONE TOUCH VERIO TEST STRIPS ...... 43
Kaiser Permanente, a TRICARE Prime Option Formulary 108 Kaiser Permanente, a TRICARE® Prime Option Formulary ONEXTON ...... 80 OXBRYTA ...... 77 ONFI ...... 35 oxcarbazepine ...... 36 ONGENTYS ...... 38 OXERVATE ...... 53 ONGLYZA ...... 67 oxiconazole nitrate...... 82 ONSOLIS ...... 31 OXISTAT...... 82 ONUREG ...... 13 OXSORALEN-ULTRA ...... 87 OPANA ...... 33 oxybutynin...... 88 OPANA ER ...... 33 oxybutynin extended-release ...... 88 opicapone...... 38 oxybutynin transdermal ...... 88 OPIUM ...... 32 oxycodone ...... 32 opium & belladonna alkaloids ...... 32 oxycodone & acetaminophen...... 32 opium tincture ...... 32 oxycodone & acetaminophen er ...... 32 oprelvekin ...... 21 oxycodone & aspirin ...... 32 OPSUMIT ...... 28 oxycodone & ibuprofen ...... 32 OPTHETIC ...... 53 oxycodone controlled-release ...... 32 OPTICROM ...... 51 OXYCONTIN ...... 32 OPTIPRANOLOL ...... 52 oxymetazoline ...... 82 OPTIVAR ...... 51 oxymetholone ...... 58 ORACEA ...... 5, 87 oxymorphone...... 33 ORALAIR ...... 51 oxymorphone extended-release ...... 33 ORAP...... 42 OXYTROL ...... 88 ORAPRED ...... 58 ozanimod ...... 75 ORAPRED ODT ...... 58 OZEMPIC ...... 68 ORENCIA ...... 71 ORENITRAM ...... 28 P ORFADIN ...... 75 ORIAHNN...... 73 PACERONE ...... 24 ORILISSA...... 73 palbociclib ...... 15 ORINASE ...... 68 PALFORZIA ...... 76 ORKAMBI...... 79 paliperidone ...... 42 ORLADEYO ...... 72 palivizumab ...... 12 orphenadrine citrate ...... 19 PALYNZIQ ...... 76 orphenadrine, aspirin, & caffeine ...... 19 PAMELOR ...... 42 ORTHO EVRA ...... 61 PAMINE ...... 17 ORTHO TRI-CYCLEN ...... 63 PANCREAZE ...... 56 ORTHO-CEPT ...... 59 pancrelipase (lipase-protease-amylase) ...... 56 ORTHO-CYCLEN ...... 63 PANDEL ...... 84 ORTHO-EST ...... 70 PANRETIN ...... 86 ORTHO-NOVUM ...... 62, 63 pantoprazole ...... 55 oseltamivir phosphate ...... 11 papaverine ...... 28 OSENI ...... 64 PARAFON FORTE DSC ...... 18 osilodrostat...... 75 parathyroid hormone ...... 75 OSMOPREP ...... 56 PARCOPA ...... 37 ospemifene ...... 70 paregoric ...... 54 OSPHENA ...... 70 PAREGORIC ...... 54 OTEZLA ...... 72 paricalcitol ...... 88 OTREXUP ...... 15 PARLODEL ...... 37 OVCON-35 ...... 61 PARNATE ...... 43 OVCON-50 ...... 61 paromomycin sulfate ...... 8 OVIDE ...... 81 paroxetine ...... 42 OXANDRIN ...... 58 paroxetine extended-release ...... 42 oxandrolone ...... 58 paroxetine mesylate ...... 42 oxaprozin ...... 32 pasireotide ...... 75 oxazepam...... 39 PATADAY ...... 51
Kaiser Permanente, a TRICARE Prime Option Formulary 109 Kaiser Permanente, a TRICARE® Prime Option Formulary PATANASE ...... 51 PHENERGAN VC W/CODEINE ...... 78 PATANOL ...... 51 PHENERGAN W/ CODEINE ...... 78 patiromer ...... 46 phenobarbital ...... 39, 57 PAVABID ...... 28 PHENOBARBITAL ...... 39 PAXIL...... 42 phenobarbital and belladonna alkaloids ...... 57 PAXIL CR ...... 42 phenoxybenzamine ...... 19 PAZEO ...... 51 PHENYTEK ...... 36 pazopanib...... 15 phenytoin sodium extended-release ...... 36 peanut (arachis hypogaea) allergen powder ...... 76 phenytoin suspension ...... 36 PEDIAPRED ...... 58 PHEXXI ...... 60 pediatric multivitamins w/ fluoride ...... 76 PHISOHEX ...... 81 pediatric multivitamins w/ fluoride & iron ...... 76 PHOSLO ...... 46 pediatric vitamins a, c, & d, w/ fluoride ...... 76 PHOSLYRA ...... 46 pediatric vitamins a, c, & d, w/ fluoride & iron ...... 76 PHOSPHA ...... 46 PEGANONE ...... 35 PHOSPHOLINE IODIDE ...... 52 PEGASYS ...... 12 PHRENILIN ...... 30 pegfilgrastim ...... 21 PHRENILIN FORTE ...... 30 pegfilgrastim-jmdb ...... 21 phytonadione ...... 88 peginterferon alfa-2a ...... 12 PICATO ...... 87 peginterferon-alfa 2b ...... 12 PIFELTRO ...... 9 PEG-INTRON ...... 12 pilocarpine ...... 18, 52, 53 pegvaliase ...... 76 pilocarpine gel ...... 53 pegvisomant ...... 71 PILOPINE HS ...... 53 PEMAZYRE ...... 15 pimavanserin ...... 42 pemigatinib...... 15 pimecrolimus ...... 87 penbutolol...... 29 pimozide ...... 42 penciclovir ...... 82 pindolol ...... 29 penicillamine ...... 57 pioglitazone ...... 64, 67 penicillin v potassium ...... 6 pioglitazone & glimepiride ...... 67 PENLAC ...... 80 pioglitazone & metformin ...... 67 PENNSAID ...... 30, 87 PIQRAY...... 13 pentamidine ...... 8 pirbuterol acetate ...... 20 PENTASA ...... 54 pirfenidone ...... 79 pentazocine & naloxone ...... 33 piroxicam...... 33 pentosan polysulfate sodium ...... 76 pitavastatin ...... 23 pentoxifylline ...... 21 pitolisant ...... 40 PEN-VK ...... 6 PLAN B ...... 60 PEPCID ...... 55 PLAQUENIL ...... 8 perampanel ...... 36 PLAVIX ...... 20 PERCOCET ...... 32 plecanatide ...... 54 PERCODAN ...... 32 PLEGRIDY ...... 74 PERIACTIN ...... 4 PLENDIL ...... 24 PERIDEX ...... 47 PLETAL ...... 20 perindopril ...... 27 PLEXION ...... 85 PERIOSTAT ...... 5 PLEXION SCT ...... 85 permethrin ...... 82 podofilox ...... 87 perphenazine ...... 40, 42 POLY HIST FORTE ...... 4 PERSANTINE...... 21 POLYCITRA-K ...... 44 PERTZYE...... 56 polyethylene glycol-electrolyte solution ...... 55, 56 PEXEVA ...... 42 polymyxin b & trimethoprim (ophth) ...... 48 pexidartinib...... 16 POLYSPORIN ...... 47 phenelzine ...... 42 POLYTRIM ...... 48 PHENERGAN ...... 4, 78 POLY-VI-FLOR ...... 76 PHENERGAN VC ...... 4, 78 POLY-VI-FLOR W/IRON ...... 76
Kaiser Permanente, a TRICARE Prime Option Formulary 110 Kaiser Permanente, a TRICARE® Prime Option Formulary pomalidomide ...... 15 PREMARIN CREAM ...... 70 POMALYST ...... 15 PREMPHASE ...... 68 ponatinib ...... 15 PREMPRO ...... 68 ponesimod ...... 40 PREPOPIK ...... 56 PONSTEL ...... 31 pretomanid ...... 7 PONVORY ...... 40 PRETOMANID ...... 7 PORTIA ...... 60 PREVACID ...... 55 posaconazole ...... 7 PREVIDENT ...... 77 potassium bicarbonate & potassium chloride ...... 46 PREVIDENT 5000 PLUS ...... 77 potassium chloride ...... 46 PREVPAC ...... 55 potassium chloride powder ...... 46 PREVYMIS ...... 11 potassium chloride solution ...... 46 PREZCOBIX ...... 9 potassium citrate ...... 44 PREZISTA ...... 9 potassium citrate & citric acid ...... 44 PRIFTIN ...... 8 potassium gluconate...... 46 PRILOSEC ...... 55 potassium iodide & iodine ...... 71 PRIMAQUINE ...... 8 potassium phosphate ...... 46 primaquine phosphate ...... 8 potassium phosphate, monobasic ...... 46 primidone ...... 36 POTIGA ...... 35 PRISTIQ ...... 41 PRADAXA ...... 20 PROAIR HFA ...... 19 pralsetinib ...... 16 PROAMATINE ...... 20 PRALUENT ...... 22 PRO-BANTHINE ...... 17 pramipexole ...... 38 probenecid ...... 46 pramipexole extended-release ...... 38 procarbazine ...... 16 pramlintide acetate ...... 67 PROCARDIA ...... 24 PRAMOSONE ...... 85 PROCARDIA XL ...... 24 PRAMOSONE-E ...... 85 prochlorperazine ...... 55 pramoxine ...... 85 PROCRIT ...... 21 PRANDIMET ...... 67 PROCTOCORT ...... 84 PRANDIN ...... 67 PROCTOFOAM ...... 85 prasugrel ...... 21 PROCTOFOAM-HC ...... 85 PRAVACHOL ...... 23 PROCYSBI ...... 73 pravastatin ...... 23 PRODIGY ...... 43, 44 praziquantel ...... 4 PRODIGY TEST STRIPS ...... 43 prazosin ...... 22 progesterone, micronized ...... 70 PRECOSE ...... 63 PROGRAF ...... 77 PRED FORTE ...... 50 PROLENSA ...... 48 PRED MILD ...... 50 PROLIXIN ...... 41 PRED-G ...... 49 PROLOPRIM ...... 13 prednicarbate ...... 85 PROMACTA ...... 21 PREDNISOL ...... 50 promethazine...... 4, 78 prednisolone ...... 49, 50, 58 promethazine & codeine ...... 78 PREDNISOLONE ...... 58 promethazine & dextromethorphan ...... 78 prednisolone acetate ...... 50, 58 promethazine & phenylephrine ...... 4 prednisolone acetate (ophth) ...... 50 promethazine, phenylephrine & codeine ...... 78 prednisolone sodium phosphate ...... 50, 58 PROMETHAZINE-DM ...... 78 prednisolone sodium phosphate (ophth) ...... 50 PROMETRIUM ...... 70 prednisone ...... 58 propafenone ...... 25 PREDNISONE ...... 58 propantheline bromide ...... 17 PREFEST...... 68 proparacaine ...... 53 pregabalin ...... 36 propranolol ...... 29 pregabalin er ...... 36 propranolol & hydrochlorothiazide ...... 29 PRELONE ...... 58 propranolol extended-release ...... 29 PREMARIN ...... 69, 70 propranolol sustained-release ...... 29
Kaiser Permanente, a TRICARE Prime Option Formulary 111 Kaiser Permanente, a TRICARE® Prime Option Formulary propylthiouracil ...... 71 ranolazine ...... 25 PROPYLTHIOURACIL ...... 71 RAPAFLO ...... 19 PROSOM ...... 39 RAPAMUNE ...... 76 PROSTIGMIN ...... 18 rasagiline...... 38 PROTONIX ...... 55 RASUVO ...... 15 PROTOPIC ...... 87 RAVICTI ...... 44 protriptyline ...... 42 RAYOS ...... 58 PROVENTIL HFA ...... 19 RAZADYNE ...... 18 PROVERA ...... 70 RAZADYNE ER ...... 18 PROVIGIL ...... 34 REBETOL ...... 12 PROZAC ...... 41 REBIF ...... 74 PROZAC WEEKLY ...... 41 REBIF REBIDOSE ...... 74 prucalopride ...... 57 RECLIPSEN ...... 59 PRUDOXIN ...... 87 RECTIV ...... 28 pseudoephedrine, brompheniramine & codeine ...... 78 REGLAN ...... 57 PULMICORT FLEXHALER ...... 78 regorafenib ...... 16 PULMICORT RESPULES ...... 78 REGRANEX ...... 86 PULMOZYME ...... 47 RELAFEN ...... 32 PURINETHOL ...... 15 RELENZA ...... 12 PYLERA ...... 4 RELISTOR ...... 57 pyrazinamide ...... 7 RELPAX ...... 36 PYRAZINAMIDE ...... 7 REMERON ...... 42 pyridostigmine ...... 18 REMODULIN ...... 28 pyrimethamine ...... 8 RENAGEL ...... 46 RENVELA ...... 45 Q repaglinide ...... 67 repaglinide & metformin ...... 67 QINLOCK ...... 16 REPATHA ...... 22 QNASL ...... 51 REQUIP ...... 38 QUALAQUIN ...... 8 REQUIP XL ...... 38 QUESTRAN ...... 22 RESCRIPTOR...... 9 QUESTRAN LIGHT ...... 22 RESCULA ...... 53 quetiapine...... 42, 43 reserpine ...... 25 quetiapine extended-release ...... 43 RESTASIS ...... 48 QUINAGLUTE ...... 25 RESTORIL ...... 39 quinapril & hydrochlorothiazide ...... 27 retapamulin ...... 82 quinapril hcl ...... 27 RETEVMO ...... 16 quinidine ...... 25, 39 RETIN-A ...... 86 quinidine gluconate ...... 25 RETIN-A MICRO ...... 86 QUINIDINE SULFATE ...... 25 RETROVIR ...... 12 quinine sulfate ...... 8 REVATIO ...... 28 QUIXIN ...... 47 revefenacin ...... 17 QVAR RediHaler ...... 78 REVIA ...... 40 REVLIMID ...... 15 R REXULTI ...... 41 REYATAZ ...... 9 rabeprazole ...... 55 REYVOW ...... 37 RAGWITEK ...... 52 RHEUMATREX ...... 15 raloxifene hcl ...... 70 RHINOCORT...... 51 raltegravir ...... 12 RHOFADE ...... 82 raltegravir (600mg) ...... 12 RHOPRESSA ...... 52 ramelteon ...... 39 ribavirin ...... 12 ramipril ...... 27 RIDAURA ...... 57 RANEXA...... 25 rifabutin ...... 7
Kaiser Permanente, a TRICARE Prime Option Formulary 112 Kaiser Permanente, a TRICARE® Prime Option Formulary RIFADIN ...... 8 RUKOBIA ...... 11 rifampin ...... 8 ruxolitinib ...... 16 rifapentine ...... 8 RYTARY ...... 37 rifaximin ...... 6 RYTHMOL ...... 25 rilpivirine ...... 9, 10, 12 RYTHMOL SR...... 25 RILUTEK ...... 40 RYVENT ...... 51 riluzole ...... 40 RYZODEG 70/30 ...... 65 rimantadine ...... 12 rimegepant ...... 37 S rimexolone ...... 50 RINVOQ ...... 77 SABRIL ...... 36 riociguat ...... 28 sacubitril & valsartan ...... 25 RIOMET ...... 67 SAFYRAL ...... 59 ripritinib ...... 16 SAIZEN ...... 71 risankizumab ...... 76 SALAGEN ...... 18 risdiplam ...... 76 salmeterol ...... 78, 79 risedronate sodium ...... 76 salsalate ...... 33 RISPERDAL ...... 43 SAMSCA ...... 45 RISPERDALM-TAB ...... 43 SANCTURA ...... 88 risperidone ...... 43 SANCTURA XR ...... 88 risperidone orally disintegrating ...... 43 SANCUSO ...... 54 RITALIN ...... 34 SANDIMMUNE ...... 72 RITALIN LA ...... 34 SANDOSTATIN ...... 75 RITALIN SR ...... 34 SANTYL ...... 86 ritonavir ...... 11, 12 SAPHRIS ...... 40 rivaroxaban ...... 21 sapropterin dihydrochloride ...... 76 rivastigmine tartrate ...... 18 saquinavir mesylate...... 12 rivastigmine tartrate (solution) ...... 18 SARAFEM ...... 41 rizatriptan ...... 37 sargramostim...... 21 rizatriptan orally disintegrating ...... 37 sarilumab ...... 76 ROBAXIN ...... 19 satralizumab ...... 76 ROBINUL ...... 17 SAVAYSA ...... 21 ROBINULFORTE ...... 17 SAVELLA ...... 40 ROCALTROL ...... 88 saxagliptin ...... 67, 68 roflumilast ...... 79 saxagliptin & metformin extended-release ...... 68 rolapitant ...... 55 scopolamine (ophth) ...... 53 ROMYCIN ...... 47 scopolamine hydrobromide ...... 55 ropinirole ...... 38 SEASONALE...... 60 ropinirole extended-release ...... 38 SEASONIQUE ...... 60 ROSAC ...... 81 SEB-PREV ...... 82 rosiglitazone ...... 67 secnidazole ...... 8 rosiglitazone & glimepiride ...... 67 SECTRAL ...... 28 rosiglitazone & metformin ...... 67 secukinumab ...... 76 ROSULA...... 86 SEEBRI NEOHALER ...... 17 rosuvastatin ...... 23 segesterone & ethinyl estradiol ...... 63 rotigotine ...... 38 SEGLUROMET ...... 64 ROWASA ...... 54 selegiline ...... 38 ROXICET ...... 32 selegiline transdermal ...... 38 ROXICODONE ...... 32 selenium sulfide ...... 82 ROZEREM ...... 39 selinexor ...... 16 ROZLYTREK ...... 14 selpercatinib ...... 16 RUBRACA ...... 16 SELSEB ...... 82 rucaparib ...... 16 SELSUN RX ...... 82 rufinamide ...... 36 selumetinib ...... 16
Kaiser Permanente, a TRICARE Prime Option Formulary 113 Kaiser Permanente, a TRICARE® Prime Option Formulary SELZENTRY ...... 11 sodium zirconium cyclosilicate...... 46 semaglutide ...... 68 sofosbuvir ...... 11, 12 SENSIPAR ...... 72 sofosbuvir & velpatasvir ...... 12 SEPTRA ...... 6 sofosbuvir, velpatasvir, voxilaprevir ...... 11 SERAX ...... 39 SOLARAZE ...... 87 SEREVENT DISKUS ...... 79 solifenacin ...... 88 SEROMYCIN ...... 7 SOLIQUA ...... 66 SEROQUEL ...... 42, 43 SOLODYN ...... 6 SEROQUEL XR ...... 43 SOLOSEC ...... 8 SEROSTIM ...... 71 solriamfetol ...... 40 SERPASIL ...... 25 SOMA ...... 18, 30 sertaconazole nitrate ...... 82 SOMA COMPOUND ...... 18, 30 sertraline...... 43 SOMA COMPOUND W/ CODEINE ...... 30 SERZONE ...... 42 somatropin ...... 71 setmelanotide ...... 76 SOMATULINE DEPOT ...... 74 sevelamer carbonate ...... 45 SOMAVERT ...... 71 sevelamer hcl ...... 46 SONATA ...... 39 short ragweed pollen allergen extract ...... 52 SOOLANTRA ...... 4 SIGNIFOR ...... 75 sorafenib tosylate ...... 16 sildenafil ...... 28 SORIATANE ...... 86 SILENOR ...... 39 SORILUX ...... 86 SILIQ ...... 72 sotalol ...... 29 silodosin ...... 19 SOVALDI ...... 12 SILVADENE ...... 82 SPECTAZOLE ...... 81 silver sulfadiazine ...... 82 SPECTRACEF ...... 5 simeprevir...... 12 spinosad ...... 82 SIMPONI ...... 74 SPIRIVA ...... 17 simvastatin ...... 22, 23, 68 SPIRIVA RESPIMAT ...... 17 sinecatechins ...... 87 spironolactone ...... 27 SINEMET ...... 37, 38 spironolactone & hydrochlorothiazide ...... 27 SINEMET CR ...... 37, 38 SPORANOX ...... 7 SINEQUAN ...... 41 SPRINTEC ...... 63 SINGULAIR ...... 78 SPRITAM ...... 36 sirolimus ...... 76 SPRYCEL ...... 14 sirolimus solution ...... 76 SPS...... 45 SIRTURO ...... 72 STADOL ...... 30 sitagliptin & metformin ...... 68 STALEVO ...... 38 sitagliptin & simvastatin ...... 68 stannous fluoride ...... 77 sitagliptin phosphate ...... 68 STARLIX ...... 67 SIVEXTRO ...... 6 stavudine...... 12 SKELAXIN ...... 18 STEGLATRO...... 64 SKELID ...... 77 STEGLUJAN ...... 64 SKYRIZI ...... 76 STELARA ...... 77 SLYND ...... 59 STELAZINE ...... 43 sodium chloride ...... 79 STIMATE ...... 70 sodium citrate & citric acid ...... 44 STIOLTO RESPIMAT ...... 80 sodium fluoride ...... 77 stiripentol...... 36 sodium fluoride (dental) ...... 77 STIVARGA ...... 16 sodium fluoride drops ...... 77 STRATTERA ...... 39 sodium oxybate ...... 40 STRIBILD ...... 10 sodium phenylbutyrate ...... 44 STRIVERDI RESPIMAT ...... 20 sodium phosphates...... 56 STROMECTOL ...... 4 sodium picosulfate-mag ox-anhydrous citric acid ...... 56 SUBOXONE ...... 30 sodium polystyrene sulfonate ...... 45 SUBUTEX ...... 30
Kaiser Permanente, a TRICARE Prime Option Formulary 114 Kaiser Permanente, a TRICARE® Prime Option Formulary succimer ...... 57 tacrolimus ...... 77, 87 sucralfate suspension ...... 55 tacrolimus (topical) ...... 87 sucralfate tablets ...... 55 tadalafil ...... 28, 77 sucroferric oxyhydroxide ...... 46 tafluprost ...... 53 SULAR ...... 24 TAGAMET ...... 55 sulconazole nitrate ...... 82 TAKHZYRO ...... 74 SULFAC ...... 48 talazoparib ...... 16 sulfacetamide sodium & prednisolone ...... 50 TALTZ ...... 74 sulfacetamide sodium & sulfur ...... 85, 86 TALWIN NX ...... 33 sulfacetamide sodium (acne) ...... 82 TALZENNA ...... 16 sulfacetamide sodium (ophth) ointment ...... 48 TAMBOCOR ...... 24 sulfacetamide sodium (ophth) solution ...... 48 TAMIFLU...... 11 sulfadiazine ...... 6, 82 tamoxifen citrate ...... 16 SULFADIAZINE ...... 6 tamsulosin hcl ...... 19 sulfamethoxazole & trimethoprim ...... 6 TANZEUM ...... 63 SULFAMYLON ...... 81 TAPAZOLE ...... 71 sulfanilamide ...... 82 tapentadol ...... 33 sulfasalazine ...... 6 TARCEVA ...... 14 sulindac ...... 33 TARGRETIN ...... 13, 86 sumatriptan ...... 37 TARKA ...... 24 sumatriptan & naproxen ...... 37 TASIGNA ...... 15 sumatriptan (nasal) ...... 37 tasimelteon ...... 39 sunitinib malate ...... 16 TASMAR ...... 38 SUNOSI ...... 40 tavaborole ...... 7 SUPRAX...... 5 TAVALISSE ...... 73 SURMONTIL ...... 43 tazarotene ...... 87, 88 SUSTIVA ...... 10 tazemetostat ...... 16 SUTENT ...... 16 TAZORAC ...... 88 suvorexant ...... 39 TAZVERIK ...... 16 SYMAX ...... 17 TECFIDERA ...... 73 SYMAX DUOTAB ...... 17 TECHNIVIE ...... 11 SYMBICORT ...... 78 tedizolid ...... 6 SYMBYAX ...... 42 teduglutide ...... 57 SYMDEKO ...... 80 TEGRETOL ...... 34, 35 SYMFI ...... 10 TEGRETOL XR ...... 35 SYMFI LO ...... 10 TEGSEDI ...... 74 SYMLIN ...... 67 TEKAMLO ...... 25 SYMMETREL ...... 37 TEKTURNA ...... 25, 26 SYMPAZAN ...... 35 TEKTURNA HCT ...... 26 SYMTUZA ...... 9 telaprevir ...... 12 SYNAGIS ...... 12 telbivudine...... 12 SYNALAR ...... 84 telithromycin ...... 6 SYNAREL ...... 70 telmisartan ...... 23, 27 SYNERA PATCH ...... 85 telmisartan & hydrochlorothiazide ...... 27 SYNJARDY ...... 64 temazepam ...... 39 SYNTHROID ...... 71 TEMODAR ...... 16 SYPRINE ...... 57 TEMOVATE ...... 83 syringe with needle,disposable ...... 44 TEMOVATE E ...... 83 temozolomide ...... 16 T TENEX ...... 25 tenofovir ...... 9, 10, 11, 12 TABLOID ...... 16 tenofovir 300 mg ...... 12 TABRECTA ...... 14 tenofovir alafenamide ...... 12 TACLONEX ...... 83 TENORETIC ...... 28
Kaiser Permanente, a TRICARE Prime Option Formulary 115 Kaiser Permanente, a TRICARE® Prime Option Formulary TENORMIN ...... 28 tizanidine ...... 19 TEPMETKO ...... 16 TOBI ...... 6, 7 tepotinib ...... 16 TOBI PODHALER ...... 6 TERAZOL 3 ...... 82 TOBRADEX ...... 50 TERAZOL 7 ...... 82 tobramycin & dexamethasone ointment ...... 50 terazosin ...... 22 tobramycin & dexamethasone suspension ...... 50 terbinafine ...... 7 tobramycin inhalation powder ...... 6 terbutaline sulfate ...... 20 tobramycin inhalation solution ...... 7 terconazole ...... 82 tobramycin sulfate (ophth) ointment...... 48 terconazole (vaginal) ...... 82 tobramycin sulfate (ophth) solution ...... 48 teriflunomide ...... 77 TOBREX ...... 48 teriparatide ...... 70 tocilizumab ...... 77 TESSALON PERLES ...... 77 tofacitinib ...... 77 TESTIM ...... 59 TOFRANIL ...... 42 testosterone ...... 58, 59, 69 TOFRANIL-PM ...... 42 testosterone cypionate ...... 59 tolazamide ...... 68 TESTRED ...... 58 tolbutamide ...... 68 tetrabenazine ...... 40 tolcapone ...... 38 tetracycline ...... 4, 6 TOLECTIN 600 ...... 33 TETRACYCLINE ...... 6 TOLINASE ...... 68 tetrahydrozoline ...... 53 tolmetin sodium ...... 33 TEVETEN...... 26 tolterodine ...... 88 TEVETEN PLUS ...... 26 tolterodine extended-release ...... 88 tezacaftor & ivacaftor ...... 78, 80 tolvaptan ...... 45 thalidomide...... 77 TOPAMAX ...... 36 THALOMID ...... 77 TOPAMAX SPRINKLE ...... 36 theophylline ...... 88 TOPICORT ...... 83 thioguanine ...... 16 topiramate capsule ...... 36 thioridazine...... 43 topiramate capsule extended release ...... 36 thiothixene ...... 43 topiramate tablet ...... 36 THORAZINE ...... 41 topotecan ...... 16 thyroid ...... 71 TOPROL XL ...... 29 THYROLAR ...... 71 TORADOL ...... 31 tiagabine ...... 36 toremifene ...... 16 TIAZAC ...... 23 torsemide ...... 45 TIBSOVO ...... 15 TOSYMRA ...... 37 ticagrelor...... 21 TOVIAZ ...... 88 TIGAN ...... 55 TRACLEER ...... 27 TIKOSYN ...... 24 TRADJENTA ...... 67 tildrakizumab-asmn...... 77 tramadol ...... 33 TILIA ...... 62 tramadol & acetaminophen ...... 33 tiludronate ...... 77 tramadol extended-release ...... 33 timolol ...... 29, 52, 53 TRANDATE ...... 29 TIMOPTIC ...... 53 trandolapril ...... 24, 27 TIMOPTIC-XE ...... 53 trandolapril & verapamil ...... 24 timothy grass pollen allergen extract ...... 52 tranexamic acid ...... 21 tiotropium ...... 17, 80 TRANSDERM-SCOP ...... 55 tiotropium 1.25 mcg ...... 17 TRANXENE ...... 38 tiotropium 2.5 mcg ...... 17 tranylcypromine sulfate ...... 43 tiotropium bromide and olodaterol ...... 80 TRAVATAN Z ...... 53 tipranavir...... 12 travoprost ...... 53 TIROSINT ...... 71 trazodone ...... 43 TIVICAY ...... 9 trazodone extended-release ...... 43 tivozanib ...... 16 TRECATOR ...... 7
Kaiser Permanente, a TRICARE Prime Option Formulary 116 Kaiser Permanente, a TRICARE® Prime Option Formulary TRELEGY ELLIPTA ...... 79 TYKERB ...... 15 TREMFYA ...... 74 TYLENOL W/ CODEINE ...... 29 TRENTAL ...... 21 TYMLOS ...... 70 treprostinil...... 28 TYZEKA ...... 12 TRESIBA ...... 65 TYZINE ...... 53 tretinoin ...... 16, 86 tretinoin microspheres ...... 86 U TREXALL ...... 15 TREXIMET ...... 37 UBRELVY ...... 37 TREZIX ...... 30 ubrogepant ...... 37 triamcinolone acetonide (topical) ...... 85 UCERIS...... 57 triamterene ...... 45 ulipristal ...... 63 triamterene & hydrochlorothiazide ...... 45 ULORIC...... 73 TRIAVIL ...... 40 ULTRACET ...... 33 triazolam ...... 39 ULTRAM ...... 33 TRIBENZOR ...... 23 ULTRAM ER ...... 33 TRICOR ...... 22 ULTRAVATE ...... 84 trientine ...... 57 umeclidinium ...... 17, 20, 79 trifluidine/tipiracil ...... 16 umeclidinium & vilanterol ...... 20, 79 trifluoperazine ...... 43 UNIPHYL ...... 88 trifluridine ...... 48 UNIRETIC ...... 27 trihepatanoin ...... 77 UNITHROID ...... 71 trihexyphenidyl ...... 38 UNIVASC ...... 27 TRIKAFTA ...... 78 unoprostone isopropyl ...... 53 TRILAFON ...... 42 upadacitinib ...... 77 TRILEPTAL ...... 36 urea...... 84, 86 TRILIPIX ...... 22 URECHOLINE...... 18 TRI-LO-SPRINTEC...... 63 URELLE ...... 13 trimethobenzamide ...... 55 UROCIT-K ...... 44 trimethoprim ...... 6, 13, 48 URO-MP ...... 75 trimipramine ...... 43 UROXATRAL ...... 19 TRINESSA ...... 63 URSO ...... 57 TRI-NORINYL...... 62 URSO FORTE...... 57 TRINTELLIX ...... 43 ursodiol ...... 57 TRI-SPRINTEC ...... 63 ustekinumab ...... 77 TRIUMEQ...... 9 UTIBRON NEOHALER ...... 79 TRI-VI-FLOR ...... 76 TRI-VI-FLOR W/IRON ...... 76 V TRIVORA ...... 61 TRIZIVIR ...... 9 VAGIFEM ...... 69 TROKENDI XR ...... 36 valacyclovir ...... 12 trospium ...... 88 valbenazine ...... 40 trospium extended-release ...... 88 VALCHLOR ...... 15 TRULANCE ...... 54 VALCYTE ...... 12 TRULICITY ...... 64 valganciclovir ...... 12 TRUSOPT ...... 52 VALISONE ...... 83 TRUVADA ...... 10 VALIUM ...... 38 tucatinib ...... 16 valproate sodium ...... 36 TUKYSA ...... 16 valproic acid ...... 36 TURALIO ...... 16 valsartan ...... 23, 25, 26, 27 TUSSIONEX ...... 77 valsartan & hydrochlorothiazide ...... 23, 27 TWINJECT ...... 20 VALTREX ...... 12 TWIRLA ...... 61 VALTURNA ...... 26 TWYNSTA ...... 23 VANCOCIN ...... 7
Kaiser Permanente, a TRICARE Prime Option Formulary 117 Kaiser Permanente, a TRICARE® Prime Option Formulary Vancomycin capsule...... 7 VIVACTIL ...... 42 vandetanib ...... 16 VIVELLE-DOT ...... 69 VANOS ...... 84 VIZIMPRO ...... 14 VANOXIDE-HC ...... 83 voclosporin ...... 77 VANTIN ...... 5 VOLTAREN ...... 30, 31, 49, 87 varenicline ...... 18 VOLTAREN GEL ...... 87 VARUBI ...... 55 VOLTAREN XR ...... 31 VASCEPA ...... 22 vorapaxar ...... 21 VASERETIC ...... 26 voriconazole suspension ...... 7 VASOTEC ...... 26 voriconazole tablet...... 7 VECTICAL ...... 86 vorinostat ...... 16 VELIVET...... 59 vortioxetine ...... 43 VELPHORO ...... 46 VOSEVI ...... 11 VELTASSA ...... 46 VOSOL ...... 53 VELTIN ...... 86 VOSPIRE ER ...... 19 VEMLIDY ...... 12 VOTRIENT ...... 15 vemurafenib ...... 16 voxelotor ...... 77 venlafaxine ...... 43 VRAYLAR ...... 41 venlafaxine extended-release ...... 43 VUSION ...... 81 VENTOLIN HFA ...... 19 VYTONE ...... 81 verapamil ...... 24 VYTORIN ...... 22 verapamil extended-release cap ...... 24 VYVANSE ...... 34 verapamil sustained-release cap ...... 24 VYZULTA ...... 52 verapamil sustained-release tab ...... 24 VEREGEN ...... 87 W VERELAN ...... 24 VERELAN PM ...... 24 WAKIX ...... 40 VERZENIO ...... 13 warfarin ...... 21 VESANOID ...... 16 WELCHOL ...... 22 VESICARE ...... 88 WELLBUTRIN ...... 41 VEXOL ...... 50 WELLBUTRIN SR ...... 41 VFEND ...... 7 WELLBUTRIN XL ...... 41 vibegron ...... 88 WESTCORT ...... 84 VIBERZI ...... 54 WIXELA INHUB ...... 78, 79 VICOPROFEN ...... 31 VICTOZA ...... 67 X VICTRELIS ...... 9 VIDEX ...... 9 XALATAN ...... 52 VIDEX EC ...... 9 XALKORI ...... 14 VIEKIRA ...... 11 XANAX ...... 38 vigabatrin ...... 36 XANAX XR ...... 38 VIGAMOX ...... 47 XARELTO ...... 21 VIIBRYD ...... 43 XARTEMIS XR ...... 32 vilazodone ...... 43 XCOPRI ...... 35 VIMPAT ...... 35 XELJANZ ...... 77 VIOKACE ...... 56 XELODA ...... 13 VIRACEPT ...... 11 XENAZINE ...... 40 VIRAMUNE ...... 11 XENLETA ...... 6 VIREAD ...... 12 XERESE ...... 80 VIROPTIC ...... 48 XHANCE ...... 54 VISICOL ...... 56 XIBROM ...... 48 VISKEN ...... 29 XIFAXAN...... 6 VISTARIL ...... 39 XIGDUO XR ...... 64 VITRAKVI ...... 15 XIIDRA ...... 49
Kaiser Permanente, a TRICARE Prime Option Formulary 118 Kaiser Permanente, a TRICARE® Prime Option Formulary XOLAIR ...... 79 ZIANA ...... 86 XOPENEX HFA ...... 20 zidovudine...... 9, 11, 12 XOPENEX NEBULIZER ...... 20 zileuton ...... 78 XOSPATA ...... 14 ZIOPTAN ...... 53 XPOVIO ...... 16 ziprasidone ...... 43 XTANDI ...... 14 ZIRGAN...... 47 XULANE ...... 61 ZITHRANOL-RR ...... 86 XULTOPHY ...... 65 ZITHROMAX ...... 5 XYLOCAINE ...... 53, 85 ZOCOR ...... 23 XYLOCAINE VISCOUS ...... 53 ZOFRAN ...... 55 XYREM ...... 40 ZOFRAN ODT ...... 55 ZOHYDRO ER ...... 31 Y ZOLINZA ...... 16 zolipdem sublingual ...... 39 YASMIN ...... 59 zolmitriptan ...... 37 YAZ ...... 59 zolmitriptan orally disintegrating ...... 37 YUPELRI ...... 17 ZOLOFT ...... 43 YUVAFEM ...... 69 zolpidem ...... 39 zolpidem extended-release ...... 39 Z zolpidem oral spray ...... 39 zolpidem sublingual ...... 39 ZAFEMY ...... 61 ZOLPIMIST ...... 39 zafirlukast ...... 78 ZOMIG ...... 37 zaleplon ...... 39 ZOMIG ZMT ...... 37 ZANAFLEX ...... 19 ZONALON ...... 85 zanamivir ...... 12 ZONEGRAN ...... 36 zanubrutinib ...... 16 zonisamide ...... 36 ZARONTIN ...... 35 ZONTIVITY ...... 21 ZAROXOLYN ...... 45 ZORBTIVE ...... 71 ZARXIO ...... 21 ZORTRESS ...... 73 ZAVESCA ...... 75 ZOVIA ...... 60 ZEBETA ...... 29 ZOVIRAX ...... 9, 80 ZEJULA ...... 15 ZURAMPIC ...... 75 ZELAPAR ...... 38 ZYBAN ...... 41 ZELBORAF ...... 16 ZYCLARA ...... 87 ZEMPLAR ...... 88 ZYDELIG...... 14 ZENPEP ...... 56 ZYFLO CR ...... 78 ZEPATIER ...... 10 ZYFO ...... 78 ZEPOSIA ...... 75 ZYKADIA...... 14 ZERIT ...... 12 ZYLET ...... 49 ZERVIATE ...... 51 ZYLOPRIM ...... 72 ZESTORETIC ...... 27 ZYMAXID ...... 47 ZESTRIL...... 26 ZYPREXA ...... 42 ZETIA...... 22 ZYPREXA ZYDIS ...... 42 ZIAC ...... 29 ZYTIGA ...... 13 ZIAGEN ...... 8 ZYVOX ...... 6
Kaiser Permanente, a TRICARE Prime Option Formulary 119 Kaiser Permanente, a TRICARE® Prime Option Formulary
NONDISCRIMINATION NOTICE 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 no cost aids and services to people with disabilities to communicate effectively with us, such as: • Qualified sign language interpreters • Written information in other formats, such as large print, audio, and accessible electronic formats
• Provide no cost language services to people whose primary language is not English, such as: • Qualified interpreters • Information written in other languages
If you need these services, call 1-888-865-5813 (TTY: 711)
If you believe that Kaiser Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by mail at: Member Relations Unit (MRU), Attn: Kaiser Civil Rights Coordinator, Nine Piedmont Center, 3495 Piedmont Road, NE Atlanta, GA 30305-1736. Telephone Number: 1-888- 865-5813.
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 20201, 1-800- 368-1019, 1-800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
60577109_ACA_1557_MarCom_GA_2017_Taglines Kaiser Permanente, a TRICARE® Prime Option Formulary
HELP IN YOUR LANGUAGE
ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-888-865-5813 (TTY: 711).
አማርኛ (Amharic) ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-888-865-5813 (TTY: 711).
. ملحوظة: إذا كنت ت تح دث العر بي ة، فإ ن خدمات ا ل مساعدة ا للغو ية تتوا فر لك بالمجان (Arabic) ا لعر بية اتصل ب رق م TTY( 1-888-865-5813: 711(.
中文 (Chinese) 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電
1-888-865-5813（TTY：711）。
توجه: اگر به ز با ن فارس ی گ ف تگو می کنيد، ت س ه ي الت ز با نی ب صورت را يگا ن بر ای (Farsi) فا رسی شما فراهم می ب اشد. با TTY) 1-888-865-5813: 711) ت ماس ب گيريد.
Français (French) ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-888-865-5813 (TTY: 711).
Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-888-865-5813 (TTY: 711).
ગજુ રુ તુ નુ : જો રો તો બો લતો હ , ત નન:શલો્ ક ભ ષો સહો ય (Gujarati) સચુ તમો ગજો સોવ ઓ
તમ ર મ ટો ઉપલ닍ધ છો . ફ ન કર 1-888-865-5813 (TTY: 711). Kreyòl Ayisyen (Haitian Creole) ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-888-865-5813 (TTY: 711).
हिन्दी (Hindi) ध्यान दे े : यिद आप ििेिेे दी बोलते िेे े तो आपके ललए मफु ्त मे े भाषा सिेायता िेवाए िेे उपलबे्ध िेे े । 1-888-865-5813 (TTY: 711) पर कॉल करे े । 日本語 (Japanese) 注意事項：日本語を話される場合、無料の言語支援をご利用い ただけます。1-888-865-5813（TTY: 711）まで、お電話にてご連絡ください。 한국어 (Korean) 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-888-865-5813 (TTY: 711) 번으로 전화해 주십시오.
60577109_ACA_1557_MarCom_GA_2017_Taglines Kaiser Permanente, a TRICARE® Prime Option Formulary
Naabeehó (Navajo) Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bee áká’ánída’áwo’dé̖ é̖ ’, t’áá jiik’eh, éí ná hóló̖ , koji̖ ’ hódíílnih 1-888-865-5813 (TTY: 711). Português (Portuguese) ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-888-865-5813 (TTY: 711).
Pусский (Russian) ВНИМАНИЕ: eсли вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-888-865-5813 (TTY: 711).
Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-865-5813 (TTY: 711). Tagalog (Tagalog) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-888-865-5813 (TTY: 711).
Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-888-865-5813 (TTY: 711).
60577109_ACA_1557_MarCom_GA_2017_Taglines