Kaiser Permanente of Georgia Non-Formulary Conversion Document

Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of Comments (CRMs require QRM review) cost efficacy

Acanya (Clindamycin/Benzoyl Peroxide) 1.2/2.5% 1) Clindamycin 1% Gel AAA BID AND OTC Benzoyl Dispense Clindamycin as 1 copay and purchase Gel AAA BID Peroxide 5% Gel AAA BID 2) Erythromycin/Benzoyl OTC Benzoyl Peroxide Peroxide 3/5% Gel AAA BID

Accolate (Zafirlukast) 10, 20mg Tablet BID 1) Montelukast 10mg QHS 2) Qvar 40-80mcg 1-2 Document adequate therapeutic trial or intolerance PUFFS QD-BID 3) Flovent HFA 44mcg 2 PUFFS BID to Montelukast, Zafirlukast, and an Inhaled NOTE: Flovent HFA 44mcg for patients 4-11 years of Corticosteroid within the past 3 months age 4) Zafirlukast 10-20mg BID NF *Patients should have prescription for a Short- Acting Beta 2 Agonist (e.g. Proair) for asthma exacerbations Accu-Check Glucometer and Test Strips One Touch Ultra 2 Glucometer and One Touch Ultra Test Strips Accupril (Quinapril) 5, 10, 20, 40mg Tablet QD 1) Lisinopril 20-40mg QD 2) Benazepril 20-40mg QD Dose Conversion 3) Enalapril 10-40mg QD 4) Captopril 25-100mg TID Quinapril 5mg=Lisinopril 5mg / Quinapril 5) Ramipril 2.5-20mg QD 10mg=Lisinopril 10mg / Quinapril 20mg=Lisinopril 20mg / Quinapril 40mg=Lisinopril 40mg

Accuretic (Quinapril/HCTZ) 20/12.5, 20/25mg Tablet 2 Separate Medications Dose Conversion QD HCTZ QD AND 1) Lisinopril 20-40mg QD 2) Quinapril 20mg=Lisinopril 20mg Benazepril 20-40mg QD 3) Enalapril 10-40mg QD 4) NOTE: Consider Lisinopril/HCTZ 20/12.5, 20/25mg Captopril 25-100mg TID 5) Ramipril 2.5-20mg QD

Aceon (Perindopril) 4, 8mg Tablet QD 1) Lisinopril 10-40mg QD 2) Benazepril 20-40mg QD Dose Conversion 3) Enalapril 10-40mg QD 4) Captopril 25-100mg TID Aceon 4mg=Lisinopril10mg / Aceon 8mg=Lisinopril 5) Ramipril 2.5-20mg QD 40mg Acetasol HC (Acetic Acid/Hydrocortisone) 2/1% Otic 1) Neomycin/Polymyxin/Hydrocortisone 1% Solution 3-5 GTTS Q4-6H Suspension 1-2 GTTS Q4 HOURS 2) Neomycin/Polymyxin/Dexamethasone 0.1% Ophthalmic Suspension 1-2 GTTS Q4 HOURS 3) Acetic Acid 2% Solution 1-2 GTTS Q4-6 HOURS Aciphex (Rabeprazole) 20mg Tablet QD 1) Pantoprazole 40mg QD 2) OTC Omeprazole 20mg Excluded Medication QD 3) OTC Zegerid 20/1100mg QD 4) OTC Prevacid 15mg QD Aclovate (Alclometasone Dipropionate) 0.05% Low Potency Cream, Ointment AAA BID-TID Low Potency 1) Betamethasone Valerate 0.1% Lotion AAA QD-BID 2) Desonide 0.05% Cream, Ointment AAA BID-TID 3) Fluocinolone Acetonide 0.01% Solution AAA QD 4) Derma-Smoothe/FS 0.01% Oil AAA QD Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BID- QID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID

Actemra (Tocilizumab) 80mg/4ml, 200mg/10ml, 1) Humira 40mg QOW 2) Enbrel 50mg QW 400mg/20ml Intravenous Solution 8mg/kg Q4W Actiq (Fentanyl) 0.2, 0.4, 0.6, 0.8, 1.2, 1.6mg Buccal 1) Oxycodone/Acetaminophen 5/325-10/325mg Q6H Actiq is contraindicated in the management of acute Lozenge PRN (Maximum 4 units per day) 2) Morphine 15-30mg Q4H 3) Hydromorphone 2-8mg or postoperative pain including headache/migrane Q4-6H 4) Oxycodone 5-30mg Q4-6H 5) Morphine Solution 20mg/ml 0.5-1.5ml Q4H 6) Meperidine 50- 150mg Q3-4H Activella (Etradiol/Norethindrone Acetate) 0.5/0.1, 2 Separate Medications Dose Conversion 1/0.5mg Tablet QD Estradiol QD AND Nora-BE 0.35mg QD Norethindrone Acetate 0.5mg=Norethindrone 0.35mg Actonel (Risedronate) 5mg Tablet QD, 35mg Tablet 1) Alendronate 5, 10mg QD 2) Alendronate 70mg Osteoporosis Prophylaxis QW, 150mg Tablet QM QW 3) Alendronate 35mg QW 4) Fortical 200IU QD Alendronate 35mg QW or Alendronate 5mg QD Alternate nostrils 5) Ibandronate 150mg QM NF 6) Osteoporosis Treatment Actonel 5mg QD NF 7) Actonel 150mg QM NF 8) Alendronate 70mg QW or Alendronate 10mg QD Evista 60mg QD 9) Actonel 35mg QW NF Actonel (Risedronate) 30mg Tablet QD X2M Alendronate 40mg QD X6M

Page 1 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Actoplus Met (Metformin/Pioglitazone) 500/15, 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin Adjust based on patient response 850/15mg Tablet QD 500-1000mg (Maximum 2550mg QD) 3) Metformin American Diabetes Association ER 500-750mg (Maximum 2000mg QD) 4) Novolin R Recommendations (Insulin Regular) SC 30 minutes AC 5) Novolin N -Patient uncontrolled on maximum Metformin and (NPH) SC 15-30 minutes AC 6) Novolin 70/30 maximum Sulfonylurea=Do not initiate Actos and (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog initiate Novolin N (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos -Patient on Actos and Insulin=Discontinue Actos 15mg (Maximum 45mg QD) and maximize Novolin N

Actoplus Met XR (Metformin/Pioglitazone) 1000/15, 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin Adjust based on patient response 1000/30mg Extended Release Tablet QD 500-1000mg (Maximum 2550mg QD) 3) Metformin American Diabetes Association ER 500-750mg (Maximum 2000mg QD) 4) Novolin R Recommendations (Insulin Regular) SC 30 minutes AC 5) Novolin N -Patient uncontrolled on maximum Metformin and (NPH) SC 15-30 minutes AC 6) Novolin 70/30 maximum Sulfonylurea=Do not initiate Actos and (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog initiate Novolin N (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos -Patient on Actos and Insulin=Discontinue Actos 15mg (Maximum 45mg QD) and maximize Novolin N

Acuvail (Ketorolac) 0.45% Ophthalmic Solution 1 1) Diclofenac 0.1% 1GTT QID 2) Ketorolac 0.5% 1 GTT BID GTT QID 3) Prednisolone 1% 1-2 GTTS BID-QID 4) Fluorometholone 0.1% 1-2 GTTS BID-QID 5) Dexamethasone 0.1% 1-2 GTTS BID-QID 6) Ketorolac 0.4% 1 GTT QID 7) Flurbiprofen 0.03% 1 GTT QID NF 8) Vexol 1% 1-2 GTT QID NF 9) Bromfenac 0.09% 1 GTT QD-BID NF 10) Lotemax 0.5% 1-2 GTT QID NF 11) Nevanac 0.1% 1 GTT TID NF 12) Zylet 0.5/0.3% 1-2 GTT Q4-6H NF Aczone (Dapsone) 5% Gel AAA BID 1) Clindamycin 1% Gel AAA BID AND OTC Benzoyl Dispense Clindamycin or Erythromycin as 1 copay Peroxide 5% Gel AAA BID 2) Sodium and purchase OTC Benzoyl Peroxide Sulfacetamide/Sulfur 10/5% Lotion AAA BID 3) Erythromycin/Benzoyl Peroxide 3/5% Gel AAA BID

Adcirca (Tadalafil) 20mg Tablet 2T QD Pulmonary Hypertension 1) Viagra 50mg 0.5T TID 2) Cialis 20mg 2T QD Adipex-P (Phentermine) 37.5mg Tablet QD Excluded Medication (Exception: Obesity Rider) Adoxa (Doxycycline Monohydrate) 150mg Capsule; 1) Doxycycline Hyclate 50-100mg BID 2) Minocycline Dose Conversion 50, 75, 100mg Tablet BID 50-100mg BID Adoxa 50mg=Doxycycline Hyclate 50mg / Adoxa 100mg=Doxycycline Hyclate 100mg Advair Diskus (Fluticasone/Salmeterol) 100/50, 1) Qvar 40-80mcg 1-2 PUFFS QD-BID 2) Flovent Document adequate trial or intolerance to Qvar 250/50, 500/50mcg Inhalation Disk 1 PUFF BID HFA 44mcg 2 PUFFS BID NOTE: Flovent HFA 80mcg 2 PUFFS BID or Asmanex 220mcg 2 PUFFS 44mcg for patients 4-11 years of age 3) Asmanex QD within the past 3 months 110-220mcg 1-2 PUFFS QD 4) Dulera 100/5- *Patients should have prescription for a Short- 200/5mcg 2 PUFFS BID NF Acting Beta 2 Agonist (e.g. Proair) for asthma exacerbations Dose Conversion Advair 100/50mcg 1 PUFF BID=Albuterol Q4H PRN + Qvar 80mcg 1PUFF BID =Albuterol Q4H PRN + Flovent 44mcg 2 PUFFS BID

Advair 250/50mcg 1 PUFF BID=Albuterol Q4H PRN + Qvar 80mcg 2 PUFFS BID=Albuterol Q4H PRN + Asmanex 220mcg 2 PUFFS QD=Dulera 100/5mcg 2 PUFFS BID NF

Advair 500/50mcg 1 PUFF BID=Dulera 200/5mcg 2 PUFFS BID NF

Page 2 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Advair HFA (Fluticasone/Salmeterol) 45/21, 115/21, 1) Qvar 40-80mcg 1-2 PUFFS QD-BID 2) Flovent Document adequate trial or intolerance to Qvar 230/21mcg/Actuation Inhalation Aerosol Liquid 2 HFA 44mcg 2 PUFFS BID NOTE: Flovent HFA 80mcg 2 PUFFS BID or Asmanex 220mcg 2 PUFFS PUFFS BID 44mcg for patients 4-11 years of age 3) Asmanex QD within the past 3 months 110-220mcg 1-2 PUFFS QD 4) Dulera 100/5- *Patients should have prescription for a Short- 200/5mcg 2 PUFFS BID NF Acting Beta 2 Agonist (e.g. Proair) for asthma exacerbations Dose Conversion Advair HFA 45/21mcg 2 PUFFS BID=Albuterol Q4H PRN + Qvar 80mcg 1PUFF BID=Albuterol Q4H PRN + Flovent 44mcg 2 PUFFS BID

Advair HFA 115/21mcg 2 PUFFS BID=Albuterol Q4H PRN + Qvar 80mcg 2 PUFFS BID=Albuterol Q4H PRN + Asmanex 220mcg 2 PUFFS QD=Dulera 100/5mcg 2 PUFFS BID NF

Advair HFA 230/21mcg 2 PUFFS BID=Dulera 200/5mcg 2 PUFFS BID NF Advicor (Lovastatin/Niacin) 20/500mg, 20/750mg, 2 Separate Medications 20/1000mg, 40/1000mg Extended Release Tablet OTC Slo-Niacin 500mg QD (Titrate to 2000mg/day as QD tolerated using .PITTTSLONIACIN) AND Lovastatin 20-40mg QD Afinitor (Everolimus) 2.5, 5, 10mg Tablet QD 1) Torisel 25mg IV QW 2) Sutent 50mg QD NOTE: 4 Sutent preferred when initiating therapy weeks on then 2 weeks off Alamast (Pemirolast) 0.1% Ophthalmic Solution 1-2 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q3- GTTS QID 4 HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID 4) Crolom 4% 1-2 GTTS Q4-6 HOURS NF 5) Emadine 0.05% 1 GTT QID NF 6) Alocril 2% 1-2 GTTS BID NF 7) Optivar 0.05% 1 GTT BID NF 8) Alomide 0.1% 1-2 GTTS QID NF 9) Lastacaft 0.25% 1 GTT QD NF 10) Pataday 0.2% 1 GTT QD NF 11) Alrex 0.2% 1 GTT QID NF 12) Patanol 0.1% 1 GTT BID NF 13) Elestat 0.05 % 1 GTT BID NF Alesse (20mcg Ethinyl Estradiol/0.1mg 1) Aviane (20mcg Ethinyl Estradiol/0.1mg Equivalent Brand and Generic Products Levonorgestrel) Tablet QD Levonorgestrel) QD 2) Microgestin Fe 1/20 (20mcg Alesse=Aviane Ethinyl Estradiol/1mg Norethindrone) QD 3) Levora Document adequate therapeutic trial or intolerance (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD to at least 3 formulary oral contraceptives

Alinia (Nitazoxanide) 100mg/5ml Powder for Cryptosporidiosis Suspension; 500mg Tablet Q12H X3D No formulary alternative Giardiasis 1) Metronidazole 250mg TID X5-7D 2) Tindamax 2gm Single dose NF Allegra (Fexofenadine) 30, 60, 180mg Tablet QD- 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) Excluded Medication BID OTC Allegra 60mg BID 4) Fluticasone 2 SPRAYS IEN QD 5) Flunisolide 2 SPRAYS IEN BID

Allegra D (Fexofenadine/Pseudoephedrine) 60/120, 1) OTC Claritin D 5/120, 10/240mg QD-BID 2) OTC Excluded Medication 180/240mg Tablet QD-BID Zyrtec D 5/120mg BID 3) OTC Allegra D 60/120, 180/240mg QD-BID 4) Fluticasone 2 SPRAYS IEN QD 5) Flunisolide 2 SPRAYS IEN BID

Alocril (Nedocromil) 2% Ophthalmic Solution 1-2 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q3- GTTS BID 4 HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID 4) Crolom 4% 1-2 GTTS Q4-6 HOURS NF 5) Emadine 0.05% 1 GTT QID NF

Page 3 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Alomide (Lodoxamide) 0.1% Ophthalmic Solution 1- 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q3- 2 GTTS QID 4 HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID 4) Crolom 4% 1-2 GTTS Q4-6 HOURS NF 5) Emadine 0.05% 1 GTT QID NF 6) Alocril 2% 1-2 GTTS BID NF 7) Optivar 0.05% 1 GTT BID NF Alora (Estradiol) 0.025, 0.05, 0.075, 0.1mg/24 hr Vasomotor Symtoms Adjust to the lowest dose needed to control Transdermal Patch Apply twice weekly 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.025- symptoms based on patient response 0.1mg/24hr Apply weekly Vaginal/Vulvar Atrophy 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.025- 0.1mg/24hr Apply weekly 3) Premarin Vaginal 1gm Apply three times a week 4) Vagifem 10mcg Insert twice weekly 5) Estring 2mg Insert for 90 days

Alphagan P (Brimonidine) 0.1, 0.15% Ophthalmic 1) Brimonidine 0.2% 1 GTT TID 2) Brimonidine 0.15% Solution 1 GTT TID 1 GTT TID Alrex (Loteprednol) 0.2% Ophthalmic Suspension 1 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q3- GTT QID 4 HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID 4) Crolom 4% 1-2 GTTS Q4-6 HOURS NF 5) Emadine 0.05% 1 GTT QID NF 6) Alocril 2% 1-2 GTTS BID NF 7) Optivar 0.05% 1 GTT BID NF 8) Alomide 0.1% 1-2 GTTS QID NF 9) Lastacaft 0.25% 1 GTT QD NF 10) Pataday 0.2% 1 GTT QD NF Altavera (30mcg Ethinyl Estradiol/0.15mg 1) Reclipsen (30mcg Ethinyl Estradiol/0.15mg Equivalent Brand and Generic Products Levonorgestrel) Tablet QD Desogestrel) QD 2) Microgestin Fe 1.5/30 (30mcg Altavera=Levora Ethinyl Estradiol/1.5mg Norethindrone) QD 3) Levora Document adequate therapeutic trial or intolerance (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD to at least 3 formulary oral contraceptives

Alvesco (Ciclesonide) 80, 160mcg Inhalation 1) Qvar 40-80mcg 1-2 PUFFS QD-BID 2) Flovent Document adequate trial or intolerance to Qvar Aerosol Liquid 1-2 PUFFS BID HFA 44mcg 2 PUFFS BID NOTE: Flovent HFA 80mcg 2 PUFFS BID and Asmanex 220mcg 2 44mcg for patients 4-11 years of age 3) Asmanex PUFFS QD within the past 3 months 110-220mcg 1-2 PUFFS QD 4) Pulmicort Flexhaler Dose Conversion 90-180mcg 2 PUFFS BID NF 5) Flovent HFA 110- Alvesco 80mcg 1 PUFF QD=Qvar 40mcg 1 PUFF 220mcg 1-2 PUFFS BID NF QD=Flovent 44mcg 1 PUFF BID

Alvesco 160mcg 1 PUFF QD=Qvar 80mcg 1 PUFF QD=Flovent 44mcg 2 PUFFS BID Amaryl (Glimepiride) 1, 2, 4mg Tablet QD 1) Glipizide 5-15mg QD 2) Glyburide 2.5-10mg QD Adjust based on patient response Glipizide preferred if 65 years of age and older due to prolonged half life of Glyburide Amaryl (Glimepiride) 4mg Tablet BID 1) Glipizide 10-20mg BID 2) Glyburide 7.5-10mg BID Adjust based on patient response Glipizide preferred if 65 years of age and older due to prolonged half life of Glyburide Ambien CR (Zolpidem) 6.25, 12.5mg Extended 1) Trazodone 50-100mg QHS 2) Temazepam 15- Document adequate therapeutic trial or intolerance Release Tablet QHS 30mg QHS 3) Zolpidem 5-10mg QHS 4) Zaleplon 5- to Trazodone, Zolpidem, and at least 1 10mg QHS Benzodiazepine Amevive (Alefacept) 15mg Intramuscular Powder for Administered in a healthcare setting by healthcare Solution QW providers Amitiza (Lubiprostone) 8, 24mcg Liquid Filled 1) OTC Citrucel 1 TBSP in 8oz water QD-TID 2) OTC Capsule BID Benefiber 3T TID 3) OTC Metamucil 1 TBSP in 8oz water QD-TID 4) OTC Docusate 50mg QD 5) OTC Dulcolax 5-15mg QD 6) OTC Miralax 1 TBSP in 8oz water 7) Lactulose 15-30ml QD Amoxil (Amoxicillin) 875mg Tablet BID 1) Amoxicillin 500mg TID 2) Amoxicillin/Clavulanate 875/125mg BID

Page 4 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Ampyra (Dalfampridine) 10mg Tablet BID Ampyra is delivered directly to patient via KP CA Criteria Restricted Medication Specialty Pharmacy QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. KP CA Specialty Pharmacy MD Line 650-301-5799 / Patient Line 1-877-404- 5777 / Fax Line 650-301-5790 Amrix (Cyclobenzaprine) 15, 30mg Extended 1) Cyclobenzaprine 10mg TID 2) Chlorzoxazone 250- Dose Conversion Release Capsule QD 500mg TID 3) Carisoprodol 350mg TID 4) Tizanidine Amrix 15mg QD=Cyclobenzaprine 10mg 0.5T TID / 4mg TID 5) Methocarbamol 500-750mg QID 6) Amrix 30mg QD=Cyclobenzaprine 10mg TID Baclofen 10-20mg TID Analpram-HC (Hydrocortisone Acetate/Pramoxine) 1) OTC Hydrocortisone 0.5-1% Cream, Ointment 1/1% Cream QD-BID AAA BID-QID 2) OTC Prax 1% Cream, Lotion AAA BID-QID 3) Hydrocortisone 2.5% Cream, Lotion, Ointment AAA BID-QID 4) Hydrocortisone 25mg Suppository BID 5) Hydrocortisone 100mg/60ml Enema QD-BID 6) Proctofoam-HC 1/1% QD-BID

AndroGel 1% (Testosterone) 25mg/2.5gm, 1) Testosterone Cypionate 200mg/ml IM Q2-4W 2) 50mg/5gm Gel Apply QAM Androderm Patch 2-4mg/24hr Apply QPM 3) AndroGel Pump 1.62% Apply 2 pumps QAM NF 4) AndrogGel Pump 1% Apply 4 pumps QAM NF AndroGel Pump 1% (Testosterone) 1) Testosterone Cypionate 200mg/ml IM Q2-4W 2) 1.25gm/Actuation Gel Apply 4 pumps QAM Androderm Patch 2-4mg/24hr Apply QPM 3) AndroGel Pump 1.62% Apply 2 pumps QAM NF AndroGel Pump 1.62% (Testosterone) 1) Testosterone Cypionate 200mg/ml IM Q2-4W 2) 20.25mg/Actuation Gel Apply 2 pumps QAM Androderm Patch 2-4mg/24hr Apply QPM Angeliq (Drospirenone/Estradiol) 0.5/1mg Tablet QD 2 Separate Medications Adjust to the lowest dose needed to control Estradiol Tablet 1mg QD AND 1) symptoms based on patient response Medroxyprogesterone 2.5-5mg QD 2) Nora-BE 0.35mg QD 3) Norethindrone 5mg QD Ansaid (Flurbiprofen) 50, 100mg Tablet BID-TID 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg BID 3) Ibuprofen 400-800mg TID-QID Antara (Fenofibrate Micronized) 43, 130mg Capsule 1) Gemfibrozil 600mg BID 2) Fenofibrate 54-160mg Dose Conversion QD QD Antara 43mg=Fenofibrate 54mg / Antara 130mg=Fenofibrate 160mg Fenofibrate preferred if current statin therapy Gemfibrozil preferred if reduced renal function Anzemet (Dolasetron) 50, 100mg Tablet 1 hour prior 1) Metoclopramide 1-2mg/kg 30 minutes prior to to chemotherapy chemotherapy 2) Prochlorperazine 5-10mg Q6H 3) Dexamethasone 20mg 30 minutes prior to chemotherapy 4) Ondansetron 4-8mg 30 minutes prior to chemotherapy 5) Ondansetron 4-8mg ODT 30 minutes prior to chemotherapy 6) Transderm Scop 1.5mg Apply Q72H NF 7) Granisetron 2mg 1 hour prior to chemotherapy NF Apidra (Insulin Glulisine) 100U/ml Injection Solution 1) Novolin R (Insulin Regular) SC 30 minutes AC 2) Adjust based on patient response SC 15 minutes AC NovoLog (Insulin Aspart) SC 5-10 minutes AC NF

Aplenzin (Bupropion Hydrobromide) 174, 348, 1) Fluoxetine 20-40mg QD 2) Citalopram 20-40mg Dose Conversion 522mg Extended Release Tablet QD QD 3) Sertraline 50-100mg QD 4) Paroxetine 10- Aplenzin 174mg=Bupropion HCL SR/XL 150mg / 40mg QD 5) Escitalopram 10-20mg QD 6) Bupropion Aplenzin 348mg=Bupropion HCL SR/XL 300mg SR/XL 300mg QD 7) Venlafaxine ER 75-225mg QD Document adequate therapeutic trial or intolerance 8) Pristiq 50-100mg QD NF 9) Cymbalta 30-60mg to 2 SSRIs, Bupropion SR/XL, and Venlafaxine BID NF Apri (30mcg Ethinyl Estradiol/0.15mg Desogestrel) 1) Reclipsen (30mcg Ethinyl Estradiol/0.15mg Equivalent Brand and Generic Products Tablet QD Desogestrel) QD 2) Microgestin Fe 1.5/30 (30mcg Apri=Reclipsen Ethinyl Estradiol/1.5mg Norethindrone) QD 3) Levora Document adequate therapeutic trial or intolerance (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD to at least 3 formulary oral contraceptives

Page 5 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Apriso (Mesalamine) 0.375gm Extended Release 1) Sulfasalazine 500mg (2-4gm QD) 2) Colazal Capsule 1.5gm QAM 750mg (2.25gm TID for 8-12 weeks) 3) Asacol 400mg (800mg TID) 4) Dipentum 550mg BID NF 5) Pentasa 250, 500mg (1gm QID) Arcapta Neohaler (Indacaterol Maleate) 75mcg Serevent 50mcg 1 PUFF BID Dose Conversion Inhalation Capsule QD Arcapta Neohaler 75mg QD=Serevent 50mcg 1 PUFF BID Aromasin (Exemestane) 25mg Tablet QD 1) Anastrozole 1mg QD 2) Letrozole 2.5mg QD Aricept ODT (Donepezil) 5, 10mg Orally 1) Galantamine 4-12mg BID, Galantamine ER 8- Document adequate therapeutic trial or intolerance Disintegrating Tablet QD 24mg QD 2) Namenda 5-10mg BID 3) Rivastigmine to Aricept, Exelon Solution, and Razadyne Solution 6mg BID 4) Aricept 5-10mg QD 5) Exelon 2mg/ml Solution 3ml BID 6) Exelon 4.5-9.6mg/24hr Patch QD NF 7) Razadyne 4mg/ml 1-3 ml BID NF

Arixtra (Fondaparinux) 2.5/0.5, 7.5/0.6, 10/0.8, Enoxaparin 1.5 mg/kg QD or 1mg/kg BID Arixtra preferred if history of Heparin-Induced 5/0.4mg/ml Subcutaneous Solution QD Thrombocytopenia (HIT) Arthrotec (Diclofenac/Misoprostol) 50/0.2, 75/0.2mg 2 Separate Medications Enteric Coated Tablet BID-TID Diclofenac BID-TID AND Misoprostol BID-TID Asacol HD (Mesalamine) 800mg Delayed Release 1) Sulfasalazine 500mg (2-4gm QD) 2) Colazal Tablet 2T TID X6W 750mg (2.25gm TID for 8-12 weeks) 3) Asacol 400mg (800mg TID) 4) Dipentum 550mg BID NF 5) Pentasa 250, 500mg (1gm QID) Ascensia Breeze Glucometer and Test Strips One Touch Ultra 2 Glucometer and One Touch Ultra Document member is unable to accurately use One Test Strips Touch Ultra 2 Glucometer and One Touch Ultra Test Strips due to impaired dexterity Asendin (Amoxapine) 25, 50, 100, 150mg Tablet 1) Nortriptyline 25-150mg QHS 2) Amitriptyline 50- BID-TID 150mg QD 3) Doxepin 25-150mg QD 4) Imipramine 50-150mg QD 5) Desipramine 50-150mg QD

Astelin (Azelastine Hydrochloride) 137mcg/Actuation 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) Document adequate therapeutic trial or intolerance Nasal Spray 2 SPRAYS IEN BID OTC Allegra 60mg BID 4) Fluticasone 2 SPRAYS to Claritin, Zyrtec, or Allegra and at least 1 Nasal IEN QD 5) Flunisolide 2 SPRAYS IEN BID Steroid Azelastine is indicated for the treatment of vasomotor rhinitis Astepro (Azelastine Hydrochloride) 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) Document adequate therapeutic trial or intolerance 205.5mcg/Actuation Nasal Spray 1 SPRAY IEN BID OTC Allegra 60mg BID 4) Fluticasone 2 SPRAYS to Claritin, Zyrtec, or Allegra, at least 1 Nasal IEN QD 5) Flunisolide 2 SPRAYS IEN BID 6) Steroid, and Azelastine Azelastine 2 SPRAYS IEN BID NF Azelastine is indicated for the treatment of vasomotor rhinitis Atacand (Candesartan) 4, 8, 16, 32mg Tablet QD 1) Lisinopril 10-40mg QD NOTE: If Angiotensin Dose Conversion Converting Enzyme Inhibitor allergy or Atacand 4mg=Lisinopril 10mg=Losartan 25mg / contraindication consider Angiotensin Receptor Atacand 8mg=Lisinopril 20mg=Losartan 50mg / Blocker 2) Losartan 25-100mg QD 3) Valsartan 80- Atacand 16mg=Lisinopril 40mg=Losartan 100mg / 320mg QD NF 4) Irbesartan 75-300mg QD NF Atacand 32mg=No Formulary Alternative Atacand HCT (Candesartan/HCTZ) 16/12.5, 2 Separate Medications Dose Conversion 32/12.5mg Tablet QD HCTZ 12.5mg QD AND 1) Lisinopril 40mg QD NOTE: Atacand 16mg=Lisinopril 40mg=Losartan 100mg / If Angiotensin Converting Enzyme Inhibitor allergy or Atacand 32mg=No Formulary Alternative contraindication consider Angiotensin Receptor NOTE: Consider Losartan/HCTZ 100/12.5mg Blocker 2) Losartan 100mg QD 3) Valsartan 320mg QD NF 4) Irbesartan 300mg QD NF

Atelvia (Risedronate Sodium) 35mg Delayed 1) Alendronate 10mg QD 2) Alendronate 70mg QW Release Tablet QW 3) Fortical 200IU QD Alternate nostrils 4) Ibandronate 150mg QM NF 5) Actonel 5mg QD NF 6) Actonel 150mg QM NF 7) Evista 60mg QD 8) Actonel 35mg QW NF Atrovent (Ipratropium) 0.03, 0.06% Nasal Spray 2 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) Document adequate therapeutic trial or intolerance SPRAYS IEN BID-QID OTC Allegra 60mg BID 4) Fluticasone 2 SPRAYS to Claritin, Zyrtec, or Allegra and at least 1 Nasal IEN QD 5) Flunisolide 2 SPRAYS IEN BID Steroid

Page 6 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Augmentin (Amoxicillin/Clavulanate) 1) Amoxicillin 125mg/5ml Suspension BID 2) 125mg/31.25mg/5ml Powder for Suspension BID Amoxicillin/Clavulanate 200mg/28.5mg/5ml Suspension BID 3) Amoxicillin 125mg Chew Tablet BID 4) Amoxicillin/Clavulanate 125/31.25mg Chew Tablet BID Augmentin (Amoxicillin/Clavulanate) 1) Amoxicillin 250mg Capsule 2) Amoxicillin 250mg 250mg/62.5mg/5ml Powder for Suspension BID Chew Tablet BID 3) Amoxicillin 250mg/5ml Suspension BID 4) Amoxicillin/Clavulanate 200mg/28.5mg/5ml Suspension BID Augmentin XR (Amoxicillin/Clavulanate) 2 Separate Medications 1000/62.5mg Extended Release Tablet 2T BID Amoxicillin/Clavulanate 875/125mg BID AND Amoxicillin 250mg BID Auvi-Q (Epinephrine) 0.15-0.3mg/0.3ml Injection Epinephrine 0.15-0.3mg/0.3ml Injection Device PRN Auvi-Q to Epinephrine is a 1:1 Conversion Device PRN Avalide (Irbesartan/HCTZ) 150/12.5, 300/12.5, 2 Separate Medications Dose Conversion 300/25mg Tablet QD HCTZ 12.5-25mg QD AND 1) Lisinopril 20-40mg QD Avapro 150mg=Lisinopril 20mg=Losartan 50mg / NOTE: If Angiotensin Converting Enzyme Inhibitor Avapro 300mg=Lisinopril 40mg=Losartan 100mg allergy or contraindication consider Angiotensin NOTE: Consider Lisinopril/HCTZ 20/12.5mg or Receptor Blocker 2) Losartan 50-100mg QD 3) Losartan/HCTZ 50/12.5, 100/12.5, 100/25mg Valsartan 160-320mg QD NF 4) Irbesartan 150- 300mg QD NF Avandamet (Metformin/Rosiglitazone) 500/2, 500/4, 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin Adjust based on patient response 1000/2, 1000/4mg Tablet QD-BID 500-1000mg (Maximum 2550mg QD) 3) Metformin American Diabetes Association ER 500-750mg (Maximum 2000mg QD) 4) Novolin R Recommendations (Insulin Regular) SC 30 minutes AC 5) Novolin N -Patient uncontrolled on maximum Metformin and (NPH) SC 15-30 minutes AC 6) Novolin 70/30 maximum Sulfonylurea=Do not initiate Actos and (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog initiate Novolin N (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos -Patient on Actos and Insulin=Discontinue Actos 15mg (Maximum 45mg QD) and maximize Novolin N Dose Conversion Avandia 2mg=Actos 15mg / Avandia 4mg=Actos 30mg / Avandia 8mg=Actos 45mg Avandia (Rosiglitazone) 2, 4, 8mg Tablet QD-BID 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin Adjust based on patient response 500-1000mg (Maximum 2550mg QD) 3) Metformin American Diabetes Association ER 500-750mg (Maximum 2000mg QD) 4) Novolin R Recommendations (Insulin Regular) SC 30 minutes AC 5) Novolin N -Patient uncontrolled on maximum Metformin and (NPH) SC 15-30 minutes AC 6) Novolin 70/30 maximum Sulfonylurea=Do not initiate Actos and (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog initiate Novolin N (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos -Patient on Actos and Insulin=Discontinue Actos 15mg (Maximum 45mg QD) and maximize Novolin N Dose Conversion Avandia 2mg=Actos 15mg / Avandia 4mg=Actos 30mg / Avandia 8mg=Actos 45mg Avapro (Irbesartan) 75, 150, 300mg Tablet QD 1) Lisinopril 10-40mg QD NOTE: If Angiotensin Dose Conversion Converting Enzyme Inhibitor allergy or Avapro 75mg=Lisinopril 10mg=Losartan 25mg / contraindication consider Angiotensin Receptor Avapro 150mg=Lisinopril 20mg=Losartan 50mg / Blocker 2) Losartan 25-100mg QD 3) Valsartan 80- Avapro 300mg=Lisinopril 40mg=Losartan 100mg 320mg QD NF 4) Irbesartan 75-300mg QD NF AVC Vaginal (Sulfanilamide) 15% Vaginal Cream 1) OTC Mycelex (Clotrimazole 1%) QHS 2) OTC QD-BID Monistat (Miconazole) QHS 3) OTC Vagistat (Tioconazole 6.5%) QHS 4) Fluconazole 150mg QD

Avelox (Moxifloxacin) 400mg Tablet QD X7-14D Community Acquired Pneumonia 1) Levofloxacin 750mg QD X5D 2) Levofloxacin 500mg QD X10D 3) Azithromycin 500mg QD X5D 4) Cefuroxime 500mg BID X10D Sinusitis 1) SMZ-TMP DS BID X7D 2) Doxycycline 100mg BID X7D 3) Amoxicillin 1000mg BID X7D 4) Azithromycin 500mg QD X3D

Page 7 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Avinza (Morphine Sulfate) 30, 45, 60, 75, 90, 120mg 1) Morphine ER 60-100mg BID 2) Fentanyl 25- Dose Conversion Extended Release Capsule QD 100mcg/hr Q72H 3) Butrans 5-20mcg/hr QW NF 4) Morphine 30mg=Butrans 5mcg/hr=Tapentadol Nucynta ER 50-250mg BID NF 200mg / Morphine 90mg=Fentanyl 25mcg/hr Document adequate therapeutic trial or intolerance to Morphine ER and Fentanyl Avodart (Dutasteride) 0.5mg Capsule QD Finasteride 5mg QD Axert (Almotriptan) 6.25, 12.5mg Tablet PRN 1) Sumatriptan 25-100mg PRN 2) Sumatriptan 5- Quantity Limit 20mg Nasal Spray PRN 3) Naratriptan 1-2.5mg PRN Axert 6.25-12.5mg=6 Tablets 4) Sumatriptan 6mg/ml Subcutaneous Solution PRN Maxalt MLT 5-10mg=9 Tablets 5) Maxalt MLT 5-10mg PRN NF 6) Zomig 5mg PRN Naratriptan 1-2.5mg=9 Tablets NF 7) Zomig 2.5mg PRN NF 8) Relpax 20-40mg PRN Relpax 20-40mg=6 Tablets NF Sumatriptan 25-100mg=9 Tablets Zomig 2.5mg=6 Tablets Zomig 5mg=3 Tablets Axid Pulvules (Nizatidine) 150, 300mg Capsule QD- 1) OTC Famotidine 10-20mg QD-BID 2) OTC BID Ranitidine 75-150mg QD-BID 3) Cimetidine 400- 800mg QD-BID Axiron (Testosterone) 30mg/1.5ml Topical Solution 1) Testosterone Cypionate 200mg/ml IM Q2-4W 2) Apply 1 pump to each axilla QAM Androderm Patch 2-4mg/24hr Apply QPM 3) AndroGel Pump 1.62% Apply 2 pumps QAM NF 4) AndrogGel Pump 1% Apply 4 pumps QAM NF 5) AndroGel 1% (25mg/2.5gm-50mg/5gm) Apply QAM NF 6) Testim 1% Gel Apply QAM NF AzaSite (Azithromycin) 1% Ophthalmic Solution 1 Blepharitis GTT BID 1) Neomycin/Polymyxin/Hydrocortisone 1% Suspension 1-2 GTTS Q4H 2) Neomycin/Polymyxin/Dexamethasone 0.1% Suspension 1-2 GTTS Q4H 3) Sulfacetamide/Prednisolone 10/0.25% Solution 1-2 GTTS Q2-3H 4) Erythromycin 0.5% Ointment APPLY RIBBON Q4H 5) Tobramycin/Dexamethasone 0.3/0.1% 1-2 GTTS Q4-6H 6) Neomycin/Polymyxin/Bacitracin Ointment APPLY RIBBON Q4H 7) Restasis 0.05% 1 GTT BID Conjunctivitis 1) Ofloxacin 0.3% Solution 1-2 GTTS QID 2) Ciprofloxacin 0.3% Solution 1-2 GTTS Q4HS NF 3) Sodium Sulfacetamide 10% Solution 1-3 GTTS Q2- 3H 4) Gentamicin 0.3% Solution 1-2 GTTS QID 5) Erythromycin 0.5% Ointment APPLY RIBBON Q4H 6) Vigamox Solution 0.5% 1 GTT BID NF 7) Ciloxan 0.3% Ointment APPLY RIBBON BID-TID NF 8) Zymaxid 0.5% Solution 1 GTT QID 9) Quixin 0.5% Solution 1-2 GTTS Q4H NF

Azelex (Azelaic Acid) 20 % Cream AAA BID 1) Clindamycin 1% Gel AAA BID AND OTC Benzoyl Dispense Clindamycin or Erythromycin as 1 copay Peroxide 5% Gel AAA BID 2) Sodium and purchase OTC Benzoyl Peroxide Sulfacetamide/Sulfur 10/5% Lotion AAA BID 3) Erythromycin/Benzoyl Peroxide 3/5% Gel AAA BID

Azilect (Rasagiline) 0.5, 1mg Tablet QD 1) Carbidopa/Levodopa ER 25/100mg BID 2) Bromocriptine 2.5mg QD 3) Amantadine 100mg BID 4) Selegiline 5mg QD Azopt (Brinzolamide) 1% Ophthalmic Suspension 1 1) Methazolamide 50-100mg BID-TID 2) Dorzolamide GTT TID 2% 1 GTT TID 3) Dorzolamide/Timolol 2/0.5% 1 GTT BID 4) Acetazolamide 250mg QD-QID

Page 8 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Azor (Amlodipine/Olmesartan) 2 Separate Medications Dose Conversion 5/20, 5/40, 10/20, 10/40mg Tablet QD Amlodipine 5-10mg QD AND 1) Lisinopril 20-40mg Benicar 20mg=Lisinopril 20mg=Losartan 50mg / QD NOTE: If Angiotensin Converting Enzyme Benicar 40mg=Lisinopril 40mg=Losartan 100mg Inhibitor allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan 50-100mg QD 3) Valsartan 160-320mg QD NF 4) Irbesartan 150- 300mg QD NF B12 Vitamins (Cyanocobalamin, Hydroxocobalamin, OTC Vitamin B12 (Cyanocobalamin) 50, 100, 250, Excluded Medication Metanx) QD 500, 1000mcg QD Available OTC Bactroban (Mupirocin) 2% Cream, Ointment AAA Mupirocin 2% Ointment AAA TID TID Bactroban Nasal (Mupirocin) 2% Nasal Ointment Mupirocin 2% Ointment Apply IEN BID MRSA Colonization Apply 1/2 tube IEN BID Mupirocin 2% Ointment may be administered with a cotton swab to the anterior nares Balziva (35mcg Ethinyl 1) Sprintec (35mcg Ethinyl Estradiol/0.25mg Document adequate therapeutic trial or intolerance Estradiol/0.4mgNorethindrone) Tablet QD Norgestimate) QD 2) Necon 1/35 (35mcg Ethinyl to at least 3 formulary oral contraceptives Estradiol/1mg Norethindrone) QD 3) Necon 0.5/35 (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD 4) Zovia 1/35 (35mcg Ethinyl Estradiol/1mg Ethynodiol diacetate) QD 5) Brevicon (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD Banzel (Rufinamide) 40mg/ml Suspension; 200, 1) Lamotrigine 100-200mg BID 2) Carbamazepine 400mg Tablet BID 800-1600mg QD 3) Topiramate 200mg BID 4) Phenytoin 100mg TID 5) Levetiracetam 500-1500mg BID 6) Zonisamide 100mg TID NF 7) Gabapentin 300- 600mg TID 8) Levetiracetam ER 1000mg QD 9) Oxcarbazepine 600mg BID NF 10) Divalproex 250- 500mg TID 11) Lyrica 50-200mg TID NF 12) Vimpat 100-200mg BID NF Beconase (Beclomethasone Dipropionate) 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) Age Recommendations 0.042mg/Actuation Nasal Aerosol Powder 1-2 OTC Allegra 60mg BID 4) Fluticasone 2 SPRAYS Fluticasone=4 years of age and older / SPRAYS IEN BID IEN QD 5) Flunisolide 2 SPRAYS IEN BID 6) Flunisolide=6 years of age and older / Triamcinolone 2 SPRAYS IEN QD NF 7) Veramyst 2 Triamcinolone=2 years of age and older / SPRAYS IEN QD NF 8) QNASL 2 SPRAYS IEN QD Veramyst=2 years of age and older / QNASL=12 NF 9) Nasonex 2 SPRAYS IEN QD NF 10) Zetonna 1 years of age and older / Nasonex=2 years of age SPRAY IEN QD NF 11) Omnaris 2 SPRAYS IEN QD and older / Zetonna=12 years of age and older / NF 12) Rhinocort AQ 2 SPRAYS IEN BID NF Omnaris=6 years of age and older / Rhinocort Aqua=6 years of age and older / Beconase=6 years of age and older Belviq (Lorcaserin Hydrochloride) 10mg Tablet BID Excluded Medication (Exception: Obesity Rider) Benicar (Olmesartan) 5, 20, 40mg Tablet QD 1) Lisinopril 10-40mg QD NOTE: If Angiotensin Dose Conversion Converting Enzyme Inhibitor allergy or Benicar 20mg=Lisinopril 20mg=Losartan 50mg / contraindication consider Angiotensin Receptor Benicar 40mg=Lisinopril 40mg= Losartan 100mg Blocker 2) Losartan 25-100mg QD 3) Valsartan 80- 320mg QD NF 4) Irbesartan 75-300mg QD NF Benicar HCT (Olmesartan/HCTZ) 20/12.5, 40/12.5, 2 Separate Medications Dose Conversion 40/25mg Tablet QD HCTZ 12.5-25mg QD AND 1) Lisinopril 20-40mg QD Benicar 20mg=Lisinopril 20mg=Losartan 50mg / NOTE: If Angiotensin Converting Enzyme Inhibitor Benicar 40mg=Lisinopril 40mg= Losartan 100mg allergy or contraindication consider Angiotensin NOTE: Consider Lisinopril/HCTZ 20/12.5mg or Receptor Blocker 2) Losartan 50-100mg QD 3) Losartan/HCTZ 50/12.5, 100/12.5, 100/25mg Valsartan 160-320mg QD NF 4) Irbesartan 150- 300mg QD NF Benzac AC (Benzoyl Peroxide) 5, 10% Liquid AAA OTC Benzoyl Peroxide 5-10% Liquid AAA QD-BID Excluded Medication QD-BID BenzaClin (Clindamycin/Benzoyl Peroxide) 1/5% Gel 1) Clindamycin 1% Gel AAA BID AND OTC Benzoyl Dispense Clindamycin as 1 copay and purchase AAA BID Peroxide 5% Gel AAA BID 2) Erythromycin/Benzoyl OTC Benzoyl Peroxide Peroxide 3/5% Gel AAA BID

Page 9 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Bepreve (Bepotastine) 1.5% Ophthalmic Solution 1 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q3- GTT BID 4 HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID 4) Crolom 4% 1-2 GTTS Q4-6 HOURS NF 5) Emadine 0.05% 1 GTT QID NF 6) Alocril 2% 1-2 GTTS BID NF 7) Optivar 0.05% 1 GTT BID NF 8) Alomide 0.1% 1-2 GTTS QID NF 9) Lastacaft 0.25% 1 GTT QD NF 10) Pataday 0.2% 1 GTT QD NF 11) Alrex 0.2% 1 GTT QID NF 12) Patanol 0.1% 1 GTT BID NF 13) Elestat 0.05 % 1 GTT BID NF 14) Alamast 0.1% 1-2 GTTS QID NF

Berinert (C1 Esterase Inhibitor) 500U Intravenous 1) Danazol 200mg BID-TID 2) Oxandrolone 2.5-20mg Criteria Restricted Medication Powder for Solution 20U/kg Q3-4D BID-QID NF QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Besivance (Besifloxacin Hydrochloride) 0.6% 1) Ofloxacin 0.3% Solution 1-2 GTTS QID 2) Ophthalmic Suspension 1 GTT TID X7D Ciprofloxacin 0.3% Solution 1-2 GTTS Q4HS NF 3) Sodium Sulfacetamide 10% Solution 1-3 GTTS Q2- 3H 4) Gentamicin 0.3% Solution 1-2 GTTS QID 5) Erythromycin 0.5% Ointment APPLY RIBBON Q4H 6) Vigamox Solution 0.5% 1 GTT BID NF 7) Ciloxan 0.3% Ointment APPLY RIBBON BID-TID NF 8) Zymaxid 0.5% Solution 1 GTT QID 9) Quixin 0.5% Solution 1-2 GTTS Q4H NF 10) AzaSite 1% Solution 1 GTT BID Betapace AF (Sotalol AF) 80, 120, 160mg Tablet Sotalol 80mg BID QD-BID Betaseron (Interferon Beta-1b) 0.3mg Subcutaneous Extavia 0.25mg QOD Equivalent Brand and Generic Products Powder for Solution 0.25mg QOD Betaseron=Extavia Beyaz (20mcg Ethinyl Estradiol/3mg Drospirenone) 1) Reclipsen (30mcg Ethinyl Estradiol/0.15 Document adequate therapeutic trial or intolerance Tablet QD Desogestrel) QD 2) Microgestin Fe 1/20 (20mcg to at least 3 formulary oral contraceptives Ethinyl Estradiol/1mg Norethindrone) QD 3) Aviane (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel) QD

Biaxin XL (Clarithromycin) 500mg Extended Release 1) Clarithromycin 500mg BID 2) Azithromycin Day 1: Biaxin XL to Clarithromycin is a 1:1 Conversion Tablet 2T QD 500mg Day 2-5: 250mg QD 3) Erythromycin 333mg EC Q8H 4) Erythromycin 250mg EC Q6H BiDil (Isosorbide Dinitrate/Hydralazine) 20/37.5mg 2 Separate Medications Tablet TID Isosorbide Dinitrate 20mg TID AND Hydralazine 25mg 1.5T TID Biltricide (Praziquantel) 600mg Tablet 25mg/kg TID 1) Paromomycin 250mg 25-35mg/kg/day divided TID X1D X5-10D 2) Albenza 400mg Single dose Boniva (Ibandronate) 150mg Tablet QM 1) Alendronate 10mg QD 2) Alendronate 70mg QW 3) Fortical 200IU QD Alternate nostrils 4) Ibandronate 150mg QM NF Botox (Onabotulinumtoxin A) 200U Injection Powder Administered in a healthcare setting by healthcare Criteria Restricted Medication for Solution; 100U Intramuscular Powder for Solution providers QRM approval required prior to being dispensed for Q12-16W Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Brilinta (Ticagrelor) 90mg Tablet BID Clopidogrel 75mg QD

Bromday (Bromfenac) 0.09% Ophthalmic Solution 1 1) Diclofenac 0.1% 1GTT QID 2) Ketorolac 0.5% 1 GTT QD GTT QID 3) Prednisolone 1% 1-2 GTTS BID-QID 4) Fluorometholone 0.1% 1-2 GTTS BID-QID 5) Dexamethasone 0.1% 1-2 GTTS BID-QID 6) Ketorolac 0.4% 1 GTT QID 7) Flurbiprofen 0.03% 1 GTT QID NF 8) Vexol 1% 1-2 GTT QID NF 9) Bromfenac 0.09% 1 GTT QD-BID NF

Page 10 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Bumex (Bumetanide) 0.5, 1, 2mg Tablet QD 1) Bumetanide 0.5-1mg QD 2) Furosemide 20-80mg Dose Conversion QD Bumetanide 0.5mg=Furosemide 20mg / Bumetanide 1mg=Furosemide 40mg / Bumetanide 2mg=Furosemide 80mg Butrans (Buprenorphine) 5, 10, 20mcg/hr 1) Morphine ER 60-100mg BID 2) Fentanyl 25- Dose Conversion Transdermal Patch Apply QW 100mcg/hr Q72H Morphine 30mg=Butrans 5mcg/hr / Morphine 90mg=Fentanyl 25mcg/hr Document adequate therapeutic trial or intolerance to Morphine ER and Fentanyl Bydureon (Exenatide) 2mg Extended Release 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin Criteria Restricted Medication Subcutaneous Powder for Suspension QW 500-1000mg (Maximum 2550mg QD) 3) Metformin QRM approval required prior to being dispensed for ER 500-750mg (Maximum 2000mg QD) 4) Novolin R Commercial, Multi-Choice, Self-Funded, and Triple (Insulin Regular) SC 30 minutes AC 5) Novolin N Tier members. (NPH) SC 15-30 minutes AC 6) Novolin 70/30 Provider must call 404-364-7320 (Option 2) to (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog initiate review by QRM department. (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos 15mg (Maximum 45mg QD)

Byetta (Exenatide) 250mcg/ml Subcutaneous 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin Criteria Restricted Medication Solution BID 500-1000mg (Maximum 2550mg QD) 3) Metformin QRM approval required prior to being dispensed for ER 500-750mg (Maximum 2000mg QD) 4) Novolin R Commercial, Multi-Choice, Self-Funded, and Triple (Insulin Regular) SC 30 minutes AC 5) Novolin N Tier members. (NPH) SC 15-30 minutes AC 6) Novolin 70/30 Provider must call 404-364-7320 (Option 2) to (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog initiate review by QRM department. (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos 15mg (Maximum 45mg QD)

Bystolic (Nebivolol) 2.5, 5, 10, 20mg Tablet QD 1) Atenolol 50-100mg QD 2) Metoprolol 100-450mg Dose Conversion QD 3) Acebutolol 400-800mg QD 4) Bisoprolol 2.5- Bystolic 2.5mg QD=Metoprolol Tartrate 12.5mg BID 20mg QD 5) Carvedilol 12.5-25mg BID 6) Labetalol / Bystolic 5mg QD=Metoprolol Tartrate 25mg BID / 200-400mg BID Bystolic 10mg=Metoprolol Tartrate 50mg BID / Bystolic 20mg QD=Metoprolol Tartrate 100mg BID

Caduet (Amlodipine/Atorvastatin) 2.5/10, 2.5/20, 2 Separate Medications Atorvastatin to minimize drug interactions and risk 2.5/40, 5/10, 5/20, 5/40, 5/80, 10/10, 10/20, 10/40, Amlodipine 2.5-10mg QD AND Atorvastatin 10-80mg of myalgias if current therapy with: 10/80mg Tablet QD QD -Amlodipine (Maximum Simvastatin 20mg)

Campral (Acamprosate) 333mg Enteric Coated 1) Naltrexone 50mg QD 2) Disulfiram 250-500mg QD Tablet 2T TID Capex (Fluocinolone Acetonide) 0.01% Shampoo Low Potency QD Low Potency 1) Betamethasone Valerate 0.1% Lotion AAA QD-BID 2) Desonide 0.05% Cream, Ointment AAA BID-TID 3) Fluocinolone Acetonide 0.01% Solution AAA QD 4) Derma-Smoothe/FS 0.01% Oil AAA QD Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BID- QID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID

Carac (Fluorouracil) 0.5% Cream AAA BID 1) Fluorouracil 5% Solution AAA BID 2) Efudex 5% Cream AAA BID 3) Fluoroplex 1% Cream AAA BID

Cardene SR (Nicardipine) 30, 45, 60mg Extended 1) Amlodipine 5-10mg QD 2) Verapamil SR 180- Dose Conversion Release Capsule BID 240mg BID 3) Diltiazem ER 240-360mg QD 4) Cardene SR 30mg BID=Nifedipine ER 30mg QD / Nifedipine ER 30-60mg QD 5) Felodipine 2.5-20mg Cardene SR 45mg BID=Nifedipine ER 60 QD / QD Cardene SR 60mg BID=Nifedipine ER 90mg QD Carmol HC (Hydrocortisone/Urea) 1/10% Cream 2 Separate Medications AAA BID OTC Hydrocortisone 1% Cream AAA BID-QID AND OTC Carmol 10 (Urea 10%) Cream AAA BID Catapres TTS-1,TTS-2, TTS-3 Transdermal Patch Clonidine 0.1-0.3mg BID Dose Conversion Apply QW Catapres TTS-1=Clonidine 0.1mg BID / Catapres TTS-2=Clonidine 0.2mg BID / Catapres TTS- 3=Clonidine 0.3mg BID

Page 11 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Caverject (Alprostadil) 10, 20, 40mcg Excluded Medication Intracavernosal Powder for Solution; 0.02mg/ml (Exception: Sexual Dysfunction Rider) Intracavernosal Solution PRN Cayston (Aztreonam) 75mg/vial Inhalation Powder 1) Tobi 300mg/5ml BID NF 2) Colistimethate for Solution TID 150mg/ml BID NF Cayston is delivered directly to patient via Foundation Care Pharmacy Cedax (Ceftibuten) 400mg Capsule; 90mg/5ml, 1) Cefdinir 125mg/5ml-250mg/5ml 7mg/kg BID 3rd 180mg/5ml Powder for Suspension QD 3rd Generation 2) Pediazole (Erythromycin Generation Ethylsuccinate/Sulfisoxazole) 50mg/kg divided TID- QID Ceftin (Cefuroxime) 125mg/5ml, 250mg/5ml Powder 1) Cefuroxime 250-500mg BID 2nd Generation 2) for Suspension BID 2nd Generation Cefdinir 125mg/5ml-250mg/5ml BID 3rd Generation 3) Ceflacor 250-500mg BID-TID 2nd Generation

Cefzil (Cefprozil) 125mg/5ml, 250mg/5ml Powder for 1) Cefuroxime 250-500mg BID 2nd Generation 2) Suspension; 250, 500mg Tablet BID 2nd Cefdinir 125mg/5ml-250mg/5ml BID 3rd Generation Generation 3) Ceflacor 250-500mg BID-TID 2nd Generation

Celebrex (Celecoxib) 50, 100, 200, 400mg Capsule 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg Document NSAID GI Risk Score > 21 and adequate BID BID 3) Ibuprofen 400-800mg TID-QID 4) Sulindac therapeutic trial or intolerance to Etodolac, 150-200mg BID 5) Etodolac 200-500mg BID-TID 6) Meloxicam, and Nabumetone Nabumetone 500-750mg BID 7) Lidocaine 5% Ointment AAA Q4H 8) Diclofenac 25-100mg BID-TID 9) Indomethacin 25-75mg QD-BID 10) Tolmetin 200- 600mg TID Cenestin (Conjugated Estrogen Synthetic A) 0.3, Vasomotor Symtoms Adjust to the lowest dose needed to control 0.45, 0.625, 0.9, 1.25mg Tablet QD 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.025- symptoms based on patient response 0.1mg/24hr Apply weekly Dose Conversion Vaginal/Vulvar Atrophy Cenestin 0.3mg=Estradiol 0.5mg / Cenestin 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.025- 0.45mg=Estradiol 0.75mg / Cenestin 0.1mg/24hr Apply weekly 3) Premarin Vaginal 1gm 0.625mg=Estradiol 1mg / Cenestin 0.9mg=Estradiol Apply three times a week 4) Vagifem 10mcg Insert 1.5mg / Cenestin 1.25mg=Estradiol 2mg twice weekly 5) Estring 2mg Insert for 90 days

Chantix (Varenicline) 0.5, 1mg Tablet 1mg BID 1) OTC Nicoderm 7, 14, 21mg/day Patch Apply QD 2) Document adequate therapeutic trial or intolerance OTC Nicorette 2, 4mg Gum Chew 3-24 QD 3) to Nicotine Replacement Therapy and/or Bupropion Bupropion SR 150mg QD-BID SR

Cialis (Tadalafil) 2.5, 5mg Tablet QD; 10, 20mg Excluded Medication Tablet PRN (Exception: Sexual Dysfunction Rider) Ciloxan (Ciprofloxacin) 0.3% Ophthalmic Ointment 1) Ofloxacin 0.3% Solution 1-2 GTTS QID 2) APPLY RIBBON BID-TID; 0.3% Ophthalmic Solution Ciprofloxacin 0.3% Solution 1-2 GTTS Q4HS NF 3) 1-2 GTTS Q4H Sodium Sulfacetamide 10% Solution 1-3 GTTS Q2- 3H 4) Gentamicin 0.3% Solution 1-2 GTTS QID 5) Erythromycin 0.5% Ointment APPLY RIBBON Q4H 6) Vigamox Solution 0.5% 1 GTT BID NF 7) Ciloxan 0.3% Ointment APPLY RIBBON BID-TID NF

Cimzia (Certolizumab Pegol) 200mg Subcutaneous 1) Humira 40mg QOW (CD/RA) 2) Enbrel 50mg QW Crohns Disease (CD) Powder for Solution, 200mg/ml Subcutaneous (RA) 3) Remicade 5mg/kg Q8W NF (CD/RA) Document adequate therapeutic trial or intolerance Solution 400mg Q4W (CD/RA) to Humira and Remicade Rheumatoid Arthritis (RA) Document adequate therapeutic trial or intolerance to Humira, Enbrel, and Remicade Remicade Infusion KP GI or Rheumatology Contact CU Infusion Center 770-431-4367 or SW Infusion Center 770-603-3663 Network GI or Rheumatology Contact Provider Relations 404-364-4934

Page 12 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Cinryze (C1 Esterase Inhibitor) 500 U Intravenous Administered in a healthcare setting by healthcare Criteria Restricted Medication Powder for Solution Q3-4D providers QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Cipro Hc (Ciprofloxacin/Hydrocortisone) 0.2/1% Otic 1) Ofloxacin 0.3% Solution 10 GTTS QD 2) Suspension 3 GTTS BID Neomycin/Polymyxin/Hydrocortisone 1% Suspension 1-2 GTTS Q4 HOURS 3) Neomycin/Polymyxin/Dexamethasone 0.1% Ophthalmic Suspension 1-2 GTTS Q4 HOURS 4) Acetic Acid 2% Solution 1-2 GTTS Q4-6 HOURS 5) Ciprodex 0.3/0.1% Suspension 4 GTTS BID Clarinex (Desloratadine) 5mg Tablet; 5mg Orally 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) Excluded Medication Disintegrating Tablet; 0.5mg/ml Syrup QD OTC Allegra 60mg BID 4) Fluticasone 2 SPRAYS IEN QD 5) Flunisolide 2 SPRAYS IEN BID

Cleocin Vaginal (Clindamycin) 2% Cream; 100mg 1) Clindamycin 300mg BID 2) Metronidazole 500mg Suppository QHS BID 3) Metronidazole 0.75% Vaginal Gel QHS NF

Climara Pro (Estradiol/Levonorgestrel) 2 Separate Medications Adjust to the lowest dose needed to control 0.045/0.015mg/24hr Transdermal Patch Apply 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.025- symptoms based on patient response weekly 0.1mg/24hr Apply weekly AND 1) Medroxyprogesterone 2.5-5mg QD 2) Nora-BE 0.35mg QD 3) Norethindrone 5mg QD Clobex (Clobetasol) 0.05% Lotion, Shampoo, Spray Very High Potency AAA BID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID

Cloderm (Clocortolone Pivalate) 0.1% Cream AAA Medium-High Potency TID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BID- QID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BID- QID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QD- BID Coartem (Artemether/Lumefantrine) 20/120mg 1) Aralen 500mg (Day 1: 1gm, 500mg 6-8 hours later Tablet Day1: 80/480mg, 80/480mg 8 hours later Day Day 2: 500mg Day 3: 500mg) NF 2) Lariam 1250mg 2: 80/480mg BID Day 3: 80/480mg BID (Single dose) NF Colcrys (Colchicine) 0.6mg Tablet QD-BID Gout Prophylaxis Quantity Limit 1) Allopurinol 100-800mg QD 2) Probenecid 250- Gout Prophylaxis (30 Day Supply)=60 Tablets 1000mg BID Gout Treatment=9 Tablets Gout Treatment 1) Prednisone 40mg X3D decreased by 10mg Q3D to 5mg X3D 2) Ibuprofen 400mg TID-QID 3) Etodolac 400mg BID-TID 4) Indomethacin 25mg QD-BID

Colestid (Colestipol) 5gm Powder for Suspension 5- 1) Cholestyramine 4gm 8-16gm QD 2) 30gm QD Cholestyramine Light 4gm 8-16gm QD 3) Colestipol 1gm 2-16gm QD Combigan (Brimonidine/Timolol) 0.2/0.5% 2 Separate Medications Ophthalmic Solution 1 GTT BID Brimonidine 0.2% 1 GTT BID AND Timolol 0.5% 1 GTT BID

Page 13 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Combipatch (Estradiol/Norethindrone Acetate) 2 Separate Medications Adjust to the lowest dose needed to control 0.05/0.14mg/24hr, 0.05/0.25mg/24hr Transdermal Vasomotor Symtoms symptoms based on patient response Patch Apply twice weekly 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.025- 0.1mg/24hr Apply weekly AND 1) Medroxyprogesterone 2.5-5mg QD 2) Nora-BE 0.35mg QD 3) Norethindrone 5mg QD Vaginal/Vulvar Atrophy 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.025- 0.1mg/24hr Apply weekly 3) Premarin Vaginal 1gm Apply three times a week 4) Vagifem 10mcg Insert twice weekly 5) Estring 2mg Insert for 90 days AND 1) Medroxyprogesterone 2.5-5mg QD 2) Nora-BE 0.35mg QD 3) Norethindrone 5mg QD

Combunox (Ibuprofen/Oxycodone) 400/5mgTablet 2 Separate Medications QID Ibuprofen 400mg QID AND Oxycodone 5mg QID Complera (Rilpivirine Atripla (Efavirenz/Emtricitabine/Tenofovir Disoproxil Hydrochloride/Emtricitabine/Tenofovir Disoproxil Fumarate) Tablet 600/200/300mg QD Fumarate) 25/200/300mg Tablet QD Condylox (Podofilox) 0.5% Solution AAA BID Condylox 0.5% Gel AAA BID ConZip (Tramadol) 100, 200, 300mg Variable 1) Tramadol 50mg Q4-6H PRN 2) ConZip 100mg=Tramadol 25mg Immediate Release Release Capsule QD Hydrocodone/Acetaminophen 5/325mg Q4-6H 3) + Tramadol 75mg Extended Release / ConZip Codeine/APAP 15/300, 30/300, 60/300mg Q4H 200mg=Tramadol 50mg Immediate Release + Tramadol 150mg Extended Release / ConZip 300mg=Tramadol 50mg Immediate Release + Tramadol 250mg Extended Release Cordran (Flurandrenolide) 0.05% Lotion AAA BID- Medium Potency TID Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BID- QID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BID- QID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID Cordran (Flurandrenolide) 4mcg/cm Tape Apply Q12-Medium-High Potency 24H Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BID- QID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BID- QID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QD- BID Coreg CR (Carvedilol Phosphate) 10, 20, 40, 80mg 1) Propranolol 120-240mg QD 2) Nadolol 240-320mg Dose Conversion Extended Release Capsule QD QD 3) Carvedilol 12.5-25mg BID 4) Labetalol 200- Coreg CR 10mg QD=Carvedilol 3.125mg BID / 400mg BID Coreg CR 20mg QD=Carvedilol 6.25mg BID / Coreg CR 40mg QD=Carvedilol 12.5mg BID / Coreg CR 80mg QD=Carvedilol 25mg BID Cortisporin (Hydrocortisone Acetate/Neomycin 2 Separate Medications Sulfate/Polymyxin B Sulfate) Cream AAA BID-QID OTC Hydrocortisone 0.5% Cream AND OTC Lowest Potency Neosporin (Neomycin/Polymixin B/Bacitracin) Corzide (Nadolol/Bendroflumethiazide) 40/5, 80/5mg 2 Separate Medications Tablet QD Nadolol QD AND 1) HCTZ 25mg QD 2) Chlorthalidone 50mg QD Cosopt PF (Dorzolamide Hydrochloride/Timolol Dorzolamide/Timolol 2/0.5% 1 GTT BID Maleate) 2/0.5% Ophthalmic Solution 1 GTT BID Creon (Pancrelipase) 3, 6, 12, 24 Unit Delayed 1) Pancrelipase 5 Unit 10000 Lipase Units/kg QD 2) Release Capsule 10000 Lipase Units/kg QD Zenpep 5-20 Unit 10000 Lipase Units/kg QD

Page 14 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Crestor (Rosuvastatin) 5, 10, 20, 40mg Tablet QD 1) Simvastatin 20-40mg QD 2) Pravastatin 40-80mg Crestor to minimize drug interactions and risk of QD 3) Atorvastatin 10-80mg QD myalgias if current therapy with: -Clarithromycin, Cyclosporine, Danazol, Erythromycin, Gemfibrozil, HIV Protease Inhibitors, Itraconazole, Ketoconazole, Nefazodone, Posaconazole,Telithromycin -Diltiazem, Verapamil (Maximum Lovastatin 40mg, Pravastatin 40mg, or Simvastatin 10mg) -Amiodarone, Amlodipine, Ranolazine (Maximum Simvastatin 20mg) Dose Conversion Crestor 5mg=Atorvastatin 10mg=Pravastatin 40mg=Simvastatin 20mg / Crestor 10mg=Atorvastatin 20mg=Pravastatin 80mg=Simvastatin 40mg / Crestor 20mg=Atorvastatin 40mg / Crestor 40mg=Atorvastatin 80mg Crinone (Progesterone) 4% Vaginal Gel QOD Medroxyprogesterone 5-10mg QD Crolom (Cromolyn) 4% Ophthalmic Solution 1-2GTT 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q3- Q4-6 HOURS 4 HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID Cryselle (30mcg Ethinyl Estradiol/0.3 Norgestrel) 1) Reclipsen (30mcg Ethinyl Estradiol/0.15mg Document adequate therapeutic trial or intolerance Tablet QD Desogestrel) QD 2) Microgestin Fe 1.5/30 (30mcg to at least 3 formulary oral contraceptives Ethinyl Estradiol/1.5mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD

Cutivate (Fluticasone Propionate) 0.005% Ointment High Potency AAA BID High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BID- QID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QD- BID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Cutivate (Fluticasone Propionate) 0.05% Cream, Medium Potency Lotion AAA BID Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BID- QID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BID- QID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID Cuvposa (Glycopyrrolate) 1mg/5ml Oral Solution 1) Benztropine 2mg TID-QID 2) Trihexphenidyl 2mg BID-TID TID 3) Trihexphenidyl 0.4mg/ml NF 4) Glycopyrrolate 1mg TID-QID 5) Atrovent 1-2 PUFFS TID 6) Transderm Scop 1.5mg Patch Apply Q72H NF

Cyclessa (25 mcg Ethinyl Estradiol/0.1mg 1) Tri-Sprintec (35mcg Ethinyl Estradiol/0.18mg Document adequate therapeutic trial or intolerance Desogestrel x 7days, 25 mcg EE/0.125mg Norgestimate x 7 days, 35mcg EE/0.215mg NG x 7 to at least 3 formulary oral contraceptives Desogestrel x 7 days, 25 mcg EE/0.15mg days, 35mcg EE/0.25mg NGx 7 days) QD 2) Desogestrel x 7 days) Tablet QD Reclipsen (30mcg Ethinyl Estradiol/0.15 Desogestrel) QD 3) Trivora (30mcg Ethinyl Estradiol/0.05mg Levonorgestrel x 6 days, 40mcg EE/0.075mg LVNGL x 5 days, 30mcg EE/0.125mg LVNGL x 10 days) QD 4) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) QD 5) Leena (35mcg Ethinyl Estradiol/0.5mg Norethindrone x 7 days, 35mcg EE/1mg NE x 9 days, 35mcg EE/0.5mg NE x 5 days) QD

Page 15 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Cyclocort (Amcinonide) 0.1% Cream, Lotion AAA High Potency BID-TID High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BID- QID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QD- BID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Cyclocort (Amcinonide) 0.1% Ointment AAA BID - Very High Potency TID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID

Cymbalta (Duloxetine) 20, 30, 60mg Delayed Major Depressive Disorder or Generalized Anxiety Major Depressive Disorder or Generalized Release Capsule QD Disorder Anxiety Disorder 1) Fluoxetine 20-40mg QD 2) Citalopram 20-40mg Document adequate therapeutic trial or intolerance QD 3) Sertraline 50-100mg QD 4) Paroxetine 10- to 2 SSRIs and Venlafaxine 40mg QD 5) Escitalopram 10-20mg QD 6) Diabetic Peripheral Neuropathic Pain Nefazodone 50-250mg BID NF 7) Bupropion SR/XL Document adequate therapeutic trial or intolerance 300mg QD 8) Venlafaxine ER 75-225mg QD 9) to 1 TCA*, Tramadol*; and Venlafaxine Pristiq 50-100mg QD NF Non-Diabetic Peripheral Neuropathic Pain Diabetic Peripheral Neuropathic Pain Document adequate therapeutic trial or intolerance 1) Amitriptyline (AMT)* 50mg QHS 2) Nortriptyline to 1 TCA*, Tramadol*, and Cyclobenzaprine (NRT)* (<65 YOA: 25mg/>65 YOA: 10mg) QHS 3) Fibromyalgia Cyclobenzaprine* 10mg TID 4) Tramadol* 50mg BID Document adequate therapeutic trial or intolerance 5) Venlafaxine ER 225mg QD to 1 TCA*, Tramadol*, and Cyclobenzaprine Non-Diabetic Peripheral Neuropathic Pain Post Herpetic Neuralgia 1) AMT* 50mg QHS 2) NRT* (<65 YOA: 25mg/>65 Document adequate therapeutic trial or intolerance YOA: 10mg) QHS 3) Cyclobenzaprine* 10mg TID 4) to1 TCA* and Gabapentin Tramadol* 50mg BID HIV Associated Polyneuropathy Fibromyalgia Document adequate therapeutic trial or intolerance 1) AMT* 50mg QHS 2) NRT* (<65 YOA: 25mg/>65 to Lamotrigine YOA: 10mg) QHS 3) Cyclobenzaprine* 10mg TID 4) Trigeminal Neuralgia Tramadol* 50mg BID Document adequate therapeutic trial or intolerance Post Herpetic Neuralgia to Carbamazepine and Oxcarbazepine NF 1) NRT* (<65 YOA: 25mg/>65 YOA: 10mg) QHS 2) Migrane Prophylaxis Gabapentin 600mg TID 3) Lidocaine 5% Ointment Document adequate therapeutic trial or intolerance AAA to Topiramate, Divalproex, 1 Beta Blocker, and 1 HIV Associated Polyneuropathy TCA* 1) Lamotrigine 200-400mg QD Trigeminal Neuralgia *Not recommended in the elderly and not a required medication for patients over 65 years old 1) Carbamazepine 200-1200mg QD 2) Oxcarbazepine 600-1800mg QD NF Migrane Prophylaxis 1) AMT* 10 150mg QD 2) Propranolol 80mg BID TID Cytovene (Ganciclovir) 250, 500mg Capsule CMV Retinitis Prophylaxis 1000mg TID 1) Valcyte 450mg 2T QD 2) Valcyte 50mg/ml 18ml QD CMV Retinitis Treatment 1) Valcyte 450mg 2T BID 2) Valcyte 50mg/ml 18ml BID

Page 16 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Daliresp (Roflumilast) 500mcg Tablet QD 1) Ipratropium 0.02% Inhalation Solution QID 2) Aminophylline 100-200mg BID-TID 3) Proair HFA (Albuterol) 0.09mg Inhalation Aerosol Powder Q4H PRN 4) Theophylline 100-300 TID-QID 5) Albuterol 0.5% Inhalation Solution QID 6) Combivent Respimat (Albuterol Sulfate/Ipratropium Bromide) 100/20mcg/Actuation Inhalation Spray QID 7) Spiriva 18mcg QD Dalmane (Flurazepam) 15, 30mg Capsule QHS 1) Temazepam 15mg QHS 2) Lorazepam 0.5mg QHS 3) Oxazepam 10-30mg QHS 4) Trazodone 50-100mg QHS 5) Zolpidem 5-10mg QHS 6) Hydroxyzine 10- 25mg QHS Dantrium (Dantrolene) 25, 50, 100mg Capsule TID 1) Cyclobenzaprine 10mg TID 2) Chlorzoxazone 250- 500mg TID 3) Carisoprodol 350mg TID 4) Tizanidine 4mg TID 5) Methocarbamol 500-750mg QID 6) Baclofen 10-20mg TID Daytrana (Methylphenidate) 10mg/9hr, 15mg/9hr, 1) Adderall XR 5-30mg QAM 2) Methylphenidate SR Document adequate therapeutic trial or intolerance 20mg/9hr, 30mg/9hr Transdermal Patch Apply 1 (generic for Concerta) 18-54mg QAM to Adderall XR and Methylphenidate SR patch up to 9 hours Dose Conversion Daytrana 10mg=Methylphenidate SR 18mg / Daytrana 15mg=Methylphenidate SR 27mg / Daytrana 20mg=Methylphenidate SR 36mg / Daytrana 30mg=Methylphenidate SR 54mg

Daypro (Oxaprozin) 600mg Tablet BID-TID 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg BID 3) Ibuprofen 400-800mg TID-QID 4) Sulindac 150-200mg BID 5) Etodolac 200-500mg BID-TID 6) Nabumetone 500-750mg BID 7) Lidocaine 5% Ointment AAA Q4H 8) Diclofenac 25-100mg BID-TID 9) Indomethacin 25-75mg QD-BID 10) Tolmetin 200- 600mg TID Demadex (Torsemide) 5, 10, 20, 100mg Tablet QD 1) Bumetanide 0.5-1mg QD 2) Furosemide 20-80mg Dose Conversion QD Torsemide 10mg=Bumetanide 0.5mg=Furosemide 20mg / Torsemide 20mg=Bumetanide 1mg=Furosemide 40mg / Torsemide 40mg=Bumetanide 2mg=Furosemide 80mg

Denavir (Penciclovir) 1% Cream AAA Q2H 1) OTC Abreva 10% Cream AAA Q4H 2) Acyclovir 400mg BID Depo-Testosterone (Testosterone Cypionate) 1) Testosterone Cypionate 200mg/ml IM Q2-4W 2) 100mg/ml Intramuscular Suspension Q2-4W Androderm Patch 2-4mg/24hr Apply QPM Dermatop (Prednicarbate) 0.1% Cream, Ointment Medium Potency AAA BID Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BID- QID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BID- QID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID Desonate (Desonide) 0.05% Gel AAA BID Low Low Potency Potency 1) Betamethasone Valerate 0.1% Lotion AAA QD-BID 2) Desonide 0.05% Cream, Ointment AAA BID-TID 3) Fluocinolone Acetonide 0.01% Solution AAA QD 4) Derma-Smoothe/FS 0.01% Oil AAA QD Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BID- QID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID

Detrol (Tolterodine) 1, 2mg Tablet BID 1) Oxybutinin 5mg BID-TID 2) Oxybutynin XL 5-15mg QD 3) Oxytrol 3.9mg/day Patch Apply twice weekly 4) Trospium 20mg BID NF 5) Tolterodine 1-2mg BID NF

Page 17 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Detrol LA (Tolterodine) 2, 4mg Extended Release 1) Oxybutinin 5mg BID-TID 2) Oxybutynin XL 5-15mg Capsule QD QD 3) Oxytrol 3.9mg/day Patch Apply twice weekly 4) Trospium 20mg BID NF 5) Tolterodine 1-2mg BID NF 6) Toviaz 4-8mg QD NF 7) Enablex 7.5-15mg QD NF

Dexilant (Dexlansoprazole) 30, 60mg Capsule QD 1) Pantoprazole 40mg QD 2) OTC Omeprazole 20mg Excluded Medication QD 3) OTC Zegerid 20/1100mg QD 4) OTC Prevacid 15mg QD Didrex (Benzphetamine) 50mg Tablet QD-TID Excluded Medication (Exception: Obesity Rider) Differin (Adapalene) 0.1% Cream, Gel, Lotion AAA Retin-A 0.025-0.1% Cream, Gel AAA QHS Excluded Medication for patients > 36 YOA QHS Dificid (Fidaxomicin) 200mg Tablet BID X10D 1) Metronidazole 500mg TID X10-14D 2) Vancomycin KPGA Approved Compound 50mg/ml Solution 125mg QID X10-14D

Diflucan (Fluconazole) 10, 40mg/ml Oral Powder for 1) Nystatin 100000 Suspension 4-6ml QID 2) Suspension QD Clotrimazole 10mg Troche QID Diovan (Valsartan) 80, 160, 320mg Tablet QD 1) Lisinopril 10-40mg QD NOTE: If Angiotensin Dose Conversion Converting Enzyme Inhibitor allergy or Diovan 80mg=Lisinopril 10mg=Losartan 25mg / contraindication consider Angiotensin Receptor Diovan 160mg=Lisinopril 20mg=Losartan 50mg / Blocker 2) Losartan 25-100mg QD 3) Valsartan 80- Diovan 320mg=Lisinopril 40mg=Losartan 100mg 320mg QD NF Diovan HCT (Valsartan/HCTZ) 80/12.5, 160/12.5, 2 Separate Medications Dose Conversion 320/12.5, 160/25, 320/25mg Tablet QD HCTZ 12.5-25mg QD AND 1) Lisinopril 10-40mg QD Diovan 80mg=Lisinopril 10mg=Losartan 25mg / NOTE: If Angiotensin Converting Enzyme Inhibitor Diovan 160mg=Lisinopril 20mg=Losartan 50mg / allergy or contraindication consider Angiotensin Diovan 320mg=Lisinopril 40mg=Losartan 100mg Receptor Blocker 2) Losartan 25-100mg QD 3) NOTE: Consider Lisinopril/HCTZ 10/12.5, 20/12.5, Valsartan 80-320mg QD NF 20/25mg or Losartan/HCTZ 50/12.5, 100/12.5, 100/25mg Dipentum (Olsalazine) 250mg Capsule 2T BID 1) Sulfasalazine 500mg (2-4gm QD) 2) Colazal 750mg (2.25gm TID for 8-12 weeks) 3) Asacol 400mg (800mg TID) 4) Dipentum 550mg BID NF 5) Pentasa 250, 500mg (1gm QID) Diprolene (Betamethasone Dipropionate Very High Potency Augmented) 0.05% Lotion, Ointment AAA QD-BID 1) Betamethasone Dipropionate Augmented 0.05% Ultra High Potency Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID

Diprolene AF (Betamethasone Dipropionate Very High Potency Augmented) 0.05% Cream AAA QD- BID Ultra High 1) Betamethasone Dipropionate Augmented 0.05% Potency Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID

Page 18 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Diprosone (Betamethasone Dipropionate) 0.05% High Potency Ointment AAA QD-BID Very High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BID- QID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QD- BID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Divigel (Estradiol) 0.25, 0.5, 1mg Gel Apply QD 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.025- Adjust to the lowest dose needed to control alternating right or left upper thigh 0.1mg/24hr Apply weekly symptoms based on patient response Dolobid (Diflunisal) 250, 500mg Tablet BID-TID 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg BID 3) Ibuprofen 400-800mg TID-QID 4) Sulindac 150-200mg BID 5) Etodolac 200-500mg BID-TID 6) Nabumetone 500-750mg BID 7) Lidocaine 5% Ointment AAA Q4H 8) Diclofenac 25-100mg BID-TID

Doral (Quazepam) 15mg Tablet QHS 1) Temazepam 15mg QHS 2) Lorazepam 0.5mg QHS 3) Oxazepam 10-30mg QHS 4)Trazodone 50-100mg QHS 5) Zolpidem 5-10mg QHS 6) Hydroxyzine 10- 25mg QHS Doryx (Doxycycline Hyclate) 75, 100, 150mg 1) Doxycycline Hyclate 50-100mg BID 2) Minocycline Dose Conversion Delayed Release Tablet QD-BID 50-100mg BID Doryx 100mg QD=Doxycycline 50mg BID Duac (Clindamycin/Benzoyl Peroxide) 1/5% Gel 1) Clindamycin 1% Gel AAA BID AND OTC Benzoyl Dispense Clindamycin as 1 copay and purchase AAA BID Peroxide 5% Gel AAA BID 2) Erythromycin/Benzoyl OTC Benzoyl Peroxide Peroxide 3/5% Gel AAA BID

Duetact (Glimepiride/Pioglitazone) 2/30, 4/30mg 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin Adjust based on patient response Tablet QD 500-1000mg (Maximum 2550mg QD) 3) Metformin American Diabetes Association ER 500-750mg (Maximum 2000mg QD) 4) Novolin R Recommendations (Insulin Regular) SC 30 minutes AC 5) Novolin N -Patient uncontrolled on maximum Metformin and (NPH) SC 15-30 minutes AC 6) Novolin 70/30 maximum Sulfonylurea=Do not initiate Actos and (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog initiate Novolin N (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos -Patient on Actos and Insulin=Discontinue Actos 15mg (Maximum 45mg QD) and maximize Novolin N Glipizide preferred if 65 years of age and older due to prolonged half life of Glyburide Duexis (Ibuprofen/Famotidine) 800/26.6mg Tablet 2 Separate Medications TID Ibuprofen 800mg TID AND OTC Famotidine 20mg TID Dulera (Mometasone/Formoterol) 100/5, 200/5mcg 1) Qvar 40-80mcg 1-2 PUFFS QD-BID 2) Asmanex Document adequate trial or intolerance to Qvar Inhalation Aerosol Powder 2 PUFFS BID 110-220mcg 1-2 PUFFS QD 80mcg 2 PUFFS BID or Asmanex 220mcg 2 PUFFS QD within the past 3 months *Patients should have prescription for a Short- Acting Beta 2 Agonist (e.g. Proair) for asthma exacerbations Dose Conversion Dulera 100/5mcg 2 PUFFS BID=Albuterol Q4H PRN + Qvar 80mcg 2 PUFFS BID=Albuterol Q4H PRN + Asmanex 220mcg 2 PUFFS QD

Dulera 200/5 2 PUFFS BID=No formulary alternative DuoNeb (Albuterol Sulfate/Ipratropium Bromide) 1) Albuterol 0.5% Inhalation Solution QID AND 3/0.5mg/3ml Inhalation Solution QID Ipratropium 0.02% Inhalation Solution QID 2) Combivent Respimat (Albuterol Sulfate/Ipratropium Bromide) 100/20mcg/Actuation Inhalation Spray QID

Durezol (Difluprednate) 0.05% Ophthalmic Emulsion 1) Prednisolone 1% 1-2 GTTS BID-QID 2) 1GTT BID-QID Fluorometholone 0.1% 1-2 GTTS BID-QID 3) Dexamethasone 0.1% 1-2 GTTS BID-QID

Page 19 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Duricef (Cefadroxil) 500mg Capsule; 250mg/5ml, 1) Cephalexin 250-500mg BID 1st Generation 500mg/5ml Powder for Suspension; 1gm Tablet QD- 2)Cefuroxime 250-500mg BID 2nd Generation 3) BID 1st Generation Cefdinir 125mg/5ml-250mg/5ml BID 3rd Generation 4) Ceflacor 250-500mg BID-TID 2nd Generation

Dymista (Azelastine Hydrochloride/Fluticasone 2 Separate Medications Document adequate therapeutic trial or intolerance Propionate) 137/50mcg/Actuation Nasal Spray 1 Fluticasone 2 SPRAYS IEN QD AND Azelastine 2 to Claritin, Zyrtec, or Allegra and at least 1 Nasal SPRAY IEN BID SPRAYS IEN BID NF Steroid Azelastine is indicated for the treatment of vasomotor rhinitis Dynacin (Minocycline) 75mg Tablet BID 1) Doxycycline Hyclate 50-100mg BID 2) Minocycline 50-100mg BID DynaCirc CR (Isradipine) 5, 10mg Extended 1) Amlodipine 5-10mg QD 2) Verapamil SR 180- Dose Conversion Release Tablet QD 240mg BID 3) Diltiazem ER 240-360mg QD 4) DynaCirc CR 5mg=Nifedipine ER 30mg QD / Nifedipine ER 30-60mg QD 5) Felodipine 2.5-20mg DynaCirc CR 10mg=Nifedipine ER 60mg QD QD Dyrenium (Triamterene) 50, 100mg Capsule QD 1) Amiloride/HCTZ 5/50mg QD 2) Triamterene/HCTZ 37.5/25-75/50mg QD 3) Spironolactone 50-100mg Tablet QD Edarbi (Azilsartan Medoxomil) 40, 80mg Tablet QD 1) Lisinopril 40mg QD NOTE: If Angiotensin Dose Conversion Converting Enzyme Inhibitor allergy or Edarbi 40mg=Lisinopril 40mg=Losartan 100mg / contraindication consider Angiotensin Receptor Edarbi 80mg=No formulary alternative (Consider Blocker 2) Losartan 100mg QD combination therapy)=Lisinopril/HCTZ 20/12.5mg 2T QD=Losartan/HCTZ 100/25mg Edarbyclor (Azilsartan/Chlorthalidone) 40/12.5, 2 Separate Medications Dose Conversion 40/25mg Tablet QD Chlorthalidone 25mg QD AND 1) Lisinopril 40mg QD Edarbi 40mg=Lisinopril 40mg=Losartan 100mg NOTE: If Angiotensin Converting Enzyme Inhibitor allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan 100mg QD

Edecrin (Ethacrynic acid) 25mg Tablet QD 1) Bumetanide 0.5-1mg QD 2) Furosemide 20-80mg Dose Conversion QD Ethacrynic Acid 25mg=Bumetanide 0.5mg=Furosemide 20mg Edluar (Zolpidem) 5, 10mg Sublingual Tablet QHS 1) Trazodone 50-100mg QHS 2) Temazepam 15- Document adequate therapeutic trial or intolerance 30mg QHS 3) Zolpidem 5-10mg QHS 4) Zaleplon 5- to Trazodone, Zolpidem, and at least 1 10mg QHS 5) Ambien CR 6.25-12.5mg QHS NF Benzodiazepine Edurant (Rilpivirine) 25mg Tablet QD Intelence 200mg BID Effient (Prasugrel) 5, 10mg Tablet QD Clopidogrel 75mg QD Efudex (Fluorouracil) 2% Solution AAA BID 1) Fluorouracil 5% Solution AAA BID 2) Efudex 5% Cream AAA BID 3) Carac 0.5% Cream AAA BID NF 4) Fluoroplex 1% Cream AAA BID Egrifta (Tesamorelin) 1mg Subcutaneous Powder for Egrifta is delivered directly to patient via KP CA Excluded Medication Solution 2mg SQ QD Specialty Pharmacy KP CA Specialty Pharmacy MD Line 650-301-5799 / Patient Line 1-877-404- 5777 / Fax Line 650-301-5790 Elestat (Epinastine) 0.05 % Ophthalmic Solution 1 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q3- GTT BID 4 HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID 4) Crolom 4% 1-2 GTTS Q4-6 HOURS NF 5) Emadine 0.05% 1 GTT QID NF 6) Alocril 2% 1-2 GTTS BID NF 7) Optivar 0.05% 1 GTT BID NF 8) Alomide 0.1% 1-2 GTTS QID NF 9) Lastacaft 0.25% 1 GTT QD NF 10) Pataday 0.2% 1 GTT QD NF 11) Alrex 0.2% 1 GTT QID NF 12) Patanol 0.1% 1 GTT BID NF

Eldoquin Forte (Hydroquinone) 4% Cream AAA BID Excluded Medication

Elestrin (Estradiol) 0.06% Gel Apply 1-2 pumps to 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.025- Adjust to the lowest dose needed to control upper arm QD 0.1mg/24hr Apply weekly symptoms based on patient response

Page 20 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Eligard (Leuprolide Acetate) 7.5 (1 Month), 22.5 (3 Administered in a healthcare setting by healthcare Month), 30 (4 Month), 45mg (6 Month) providers Subcutaneous Powder for Suspension UAD Lupron Depot available via KP Oncology Floorstock

Elocon (Mometasone Furoate ) 0.1% Solution AAA High Potency QD High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BID- QID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QD- BID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Emadine (Emedastine) 0.05% Ophthalmic Solution 1 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q3- GTT QID 4 HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID 4) Crolom 4% 1-2 GTTS Q4-6 HOURS NF Emend (Aprepitant) 80, 125mg Capsule Day 1: 1) Metoclopramide 1-2mg/kg 30 minutes prior to Document current treatment with a) Cisplatin > 125mg 1 hour prior to chemotherapy Day 2-3: 80mg chemotherapy 2) Prochlorperazine 5-10mg Q6H 3) 50mg/m2 b) AC (Doxorubicin/Cyclophosphamide) c) QAM Dexamethasone 20mg 30 minutes prior to other highly emetogenic chemotherapy chemotherapy 4) Ondansetron 4-8mg 30 minutes prior to chemotherapy 5) Ondansetron 4-8mg ODT 30 minutes prior to chemotherapy Emsam (Selegiline) 6, 9, 12mg/24hr Transdermal 1) Fluoxetine 20-40mg QD 2) Citalopram 20-40mg Patch QD QD 3) Sertraline 50-100mg QD 4) Paroxetine 10- 40mg QD 5) Escitalopram 10-20mg QD 6) Bupropion SR/XL 300mg QD 7) Venlafaxine ER 75-225mg QD 8) Pristiq 50-100mg QD NF 9) Cymbalta 30-60mg BID NF Enablex (Darifenacin) 7.5, 15mg Extended Release 1) Oxybutinin 5mg BID-TID 2) Oxybutynin XL 5-15mg Tablet QD QD 3) Oxytrol 3.9mg/day Patch Apply twice weekly 4) Trospium 20mg BID NF 5) Tolterodine 1-2mg BID NF 6) Toviaz 4-8mg QD NF Enjuvia (Conjugated Estrogen Synthetic B) 0.3, Vasomotor Symtoms Adjust to the lowest dose needed to control 0.45, 0.625, 0.9, 1.25mg Tablet QD 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.025- symptoms based on patient response 0.1mg/24hr Apply weekly Dose Conversion Vaginal/Vulvar Atrophy Enjuvia 0.3mg=Estradiol 0.5mg / Enjuvia 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.025- 0.45mg=Estradiol 0.75mg / Enjuvia 0.1mg/24hr Apply weekly 3) Premarin Vaginal 1gm 0.625mg=Estradiol 1mg / Enjuvia 0.9mg=Estradiol Apply three times a week 4) Vagifem 10mcg Insert 1.5mg / Enjuvia 1.25mg=Estradiol 2mg twice weekly 5) Estring 2mg Insert for 90 days

Enpresse (30mcg Ethinyl Estradiol/0.05mg 1) Tri-Sprintec (35mcg Ethinyl Estradiol/0.18mg Equivalent Brand and Generic Products Levonorgestrel x 6 days, 40 mcg EE/0.075mg Norgestimate x 7 days, 35mcg EE/0.215mg NG x 7 Enpresse=Trivora LVNGL x 5 days, 30mcg EE/0.125mg LVNGL x 10 days, 35mcg EE/0.25mg NGx 7 days) QD 2) Trivora Document adequate therapeutic trial or intolerance days) Tablet QD (30mcg Ethinyl Estradiol/0.05mg Levonorgestrel x 6 to at least 3 formulary oral contraceptives days, 40mcg EE/0.075mg LVNGL x 5 days, 30mcg EE/0.125mg LVNGL x 10 days) QD 3) Leena (35mcg Ethinyl Estradiol/0.5mg Norethindrone x 7 days, 35mcg EE/1mg NE x 9 days, 35mcg EE/0.5mg NE x 5 days) QD

Entocort (Budesonide) 3mg Delayed Release 1) Prednisone 5-60mg QD 2) Sulfasalazine 500mg (2- Budesonide is indicated for the treatment of severe Capsule 2-3T QD 4gm QD) 3) Hydrocortisone 100mg Enema QHS 4) microscopic colitis Mesalamine 4gm Enema QHS 5) Colazal 750mg (2.25gm TID for 8-12 weeks) 6) Asacol 400mg (800mg TID) 7) Dipentum 550mg BID NF 8) Pentasa 250, 500mg (1gm QID) 9) Budesonide 3mg 2-3T QD NF

Page 21 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Enzone (Hydrocortisone Acetate/Pramoxine) 1/1% 1) OTC Hydrocortisone 0.5-1% Cream, Ointment Cream QD-BID AAA BID-QID 2) OTC Prax 1% Cream, Lotion AAA BID-QID 3) Hydrocortisone 2.5% Cream, Lotion, Ointment AAA BID-QID 4) Hydrocortisone 25mg Suppository BID 5) Hydrocortisone 100mg/60ml Enema QD-BID 6) Proctofoam-HC 1/1% QD-BID

Epiduo (Adapalene/Benzoyl Peroxide) 0.1/2.5% Gel 2 Separate Medications Excluded Medication for patients > 36 YOA AAA QD OTC Benzoyl Peroxide 2.5% AAA QD AND 1) Retin- Dispense Retin-A or Differin as 1 copay and A 0.025-0.1% Cream, Gel AAA QHS 2) Differin 0.1% purchase OTC Benzoyl Peroxide Cream AAA QD NF Epifoam (Hydrocortisone Acetate/Pramoxine) 1/1% 1) OTC Hydrocortisone 0.5-1% Cream, Ointment Foam QD-BID AAA BID-QID 2) OTC ProctoFoam 1% QD-BID 3) Hydrocortisone 2.5% Cream, Lotion, Ointment AAA BID-QID 4) Hydrocortisone 25mg Suppository BID 5) Hydrocortisone 100mg/60ml Enema QD-BID 6) Proctofoam-HC 1/1% QD-BID EpiPen (Epinephrine) 0.3mg/0.3ml Injection Device Epinephrine 0.3mg/0.3ml Injection Device PRN EpiPen to Epinephrine 0.3mg/0.3ml is a 1:1 PRN Conversion EpiPen Jr (Epinephrine) 0.15mg/0.3ml Injection Epinephrine 0.15mg/0.3ml Injection Device PRN EpiPen Jr to Epinephrine 0.15mg/0.3ml is a 1:1 Device PRN Conversion Epivir HBV (Lamivudine) 5mg/ml Solution; 100mg 1) Epivir 10mg/ml 10ml QD 2) Epivir 150mg QD Tablet QD Epogen (Epoetin Alfa) 2000, 3000, 4000, 10000, Procrit (Epoetin Alfa) 2000, 3000, 4000, 10000, Epogen to Procrit is a 1:1 Conversion 20000U/ml Injection Solution QW 20000, 40000U/ml QW Estrace (Estradiol) 0.1mg/gm Vaginal Cream 1gm 1) Estradiol QD 2) Climara Patch 0.025-0.1mg/24hr Adjust to the lowest dose needed to control Apply three times a week Apply weekly 3) Premarin Vaginal 1gm Apply three symptoms based on patient response times a week 4) Vagifem 10mcg Insert twice weekly 5) Estring 2mg Insert for 90 days

Estraderm (Estradiol) 0.05, 0.1mg/24hr Transdermal Vasomotor Symtoms Adjust to the lowest dose needed to control Patch Apply twice weekly 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.025- symptoms based on patient response 0.1mg/24hr Apply weekly Vaginal/Vulvar Atrophy 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.025- 0.1mg/24hr Apply weekly 3) Premarin Vaginal 1gm Apply three times a week 4) Vagifem 10mcg Insert twice weekly 5) Estring 2mg Insert for 90 days

Estrasorb (Estradiol) 2.5mg/gm Transdermal 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.025- Adjust to the lowest dose needed to control Emulsion Apply QD to each thigh 0.1mg/24hr Apply weekly symptoms based on patient response EstroGel (Estradiol) 0.06% Gel Apply 1.25gm QD on Vasomotor Symtoms Adjust to the lowest dose needed to control the arm from wrist to shoulder 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.025- symptoms based on patient response 0.1mg/24hr Apply weekly Vaginal/Vulvar Atrophy 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.025- 0.1mg/24hr Apply weekly 3) Premarin Vaginal 1gm Apply three times a week 4) Vagifem 10mcg Insert twice weekly 5) Estring 2mg Insert for 90 days

EstroStep Fe (20 mcg Ethinyl Estradiol/1mg 1) Tri-Sprintec (35mcg Ethinyl Estradiol/0.18mg Document adequate therapeutic trial or intolerance Norethindrone x 5 days, 30mcg EE/1mg NE x 7 Norgestimate x 7 days, 35mcg EE/0.215mg NG x 7 to at least 3 formulary oral contraceptives days, 35mcg EE/1mg NE x 9 days) Tablet QD days, 35mcg EE/0.25mg NGx 7 days) QD 2) Trivora (30mcg Ethinyl Estradiol/0.05mg Levonorgestrel x 6 days, 40mcg EE/0.075mg LVNGL x 5 days, 30mcg EE/0.125mg LVNGL x 10 days) QD 3) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) QD 4) Necon 1/35 (35mcg Ethinyl Estradiol/1mg Norethindrone) QD 5) Leena (35mcg Ethinyl Estradiol/0.5mg Norethindrone x 7 days, 35mcg EE/1mg NE x 9 days, 35mcg EE/0.5mg NE x 5 days) QD

Page 22 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Evamist (Estradiol) 1.53mg/Actuation Transdermal 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.025- Adjust to the lowest dose needed to control Spray Apply 1-3 sprays to adjacent, non-overlapping 0.1mg/24hr Apply weekly symptoms based on patient response area on the inner surface of the forearm

Evoclin (Clindamycin) 1% Foam AAA QD 1) Clindamycin 1% Solution AAA BID 2) Clindamycin 1% Gel AAA BID 3) Clindamycin 1% Lotion AAA BID

Evoxac (Cevimeline) 30mg Capsule TID 1) Pilocarpine 0.5, 1, 2, 3, 4, 6% Ophthalmic Solution Ophthalmic Solution may be administered orally 5-10 GTTS PO TID 2) Pilocarpine 5mg TID-QID NF

Exalgo (Hydromorphone Hydrochloride) 8, 12, 16, 1) Morphine ER 60-100mg BID 2) Fentanyl 25- Dose Conversion 32mg Extended Release Tablet QD 100mcg/hr Q72H 3) Butrans 5-20mcg/hr QW NF 4) Morphine 30mg=Butrans 5mcg/hr=Hydromorphone Nucynta ER 50-250mg BID NF 5) Avinza 30-120mg 7.5mg=Oxycodone 20mg=Oxymorphone QD NF 6) Opana ER 5-40mg BID NF 7) Oxycontin 10- 10mg=Tapentadol 200mg / Morphine 80mg BID NF 8) Kadian 10-200mg QD NF 90mg=Fentanyl 25mcg/hr Document adequate therapeutic trial or intolerance to Morphine ER and Fentanyl Exelderm (Sulconazole) 1% Cream, Solution QD- 1) OTC Lamisil Ultra (Butenafine 1%) QD-BID 2) OTC BID Lotrimin AF (Clotrimazole 1%) BID 3) OTC Micatin (Miconazole 1%) BID 4) Ketoconazole 2% Cream QD

Exelon (Rivastigmine) 4.6mg/24hr, 9.5mg/24 hr 1) Galantamine 4-12mg BID, Galantamine ER 8- Document adequate therapeutic trial or intolerance Patch QD 24mg QD 2) Aricept 5-10mg QD 3) Namenda 5-10mg to Galantamine, Aricept, Namenda, and Exelon QD-BID 4) Exelon Capsule 1.5-6mg BID 5) Exelon Capsule or Solution Solution 2mg/ml 3ml BID Exforge (Amlodipine/Valsartan) 5/160, 5/320, 2 Separate Medications Dose Conversion 10/160, 10/320mg Tablet QD Amlodipine 5-10mg QD AND 1) Lisinopril 20-40mg Diovan 160mg=Lisinopril 20mg=Losartan 50mg / QD NOTE: If Angiotensin Converting Enzyme Diovan 320mg=Lisinopril 40mg=Losartan 100mg Inhibitor allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan 50-100mg QD 3) Valsartan 160-320mg QD NF Exforge HCT (Amlodipine/Valsartan/HCTZ) 3 Separate Medications Dose Conversion 5/160/12.5, 5/160/25, 10/160/12.5, 10/160/25, Amlodipine 5-10mg QD AND HCTZ 12.5-25mg QD 1) Diovan 160mg=Lisinopril 20mg=Losartan 50mg / 10/320/25mg Tablet QD Lisinopril 20-40mg QD NOTE: If Angiotensin Diovan 320mg=Lisinopril 40mg=Losartan 100mg Converting Enzyme Inhibitor allergy or NOTE: Consider Lisinopril/HCTZ 20/12.5mg or contraindication consider Angiotensin Receptor Losartan/HCTZ 50/12.5, 100/25mg Blocker 2) Losartan 50-100mg QD 3) Valsartan 160- 320mg QD NF Fabior (Tazarotene) 0.1% Foam AAA QPM Retin-A 0.025-0.1% Cream, Gel AAA QHS Excluded Medication for patients > 36 YOA Famvir (Famcyclovir) 125, 250, 500mg Tablet BID- Genital Herpes Episodic Treatment TID 1) Acyclovir 200mg Q4H 2) Acyclovir 400mg TID 3) Acyclovir 800mg BID 4) Valacyclovir 1gm BID X7D NF Genital Herpes Suppressive Treatment 1) Acyclovir 400mg BID 2) Valacyclovir 500mg QD NF Herpes Zoster Treatment 1) Acyclovir 800mg Q4H 2) Valacyclovir 1gm TID X7D NF Fanapt (Iloperidone) 1, 2, 4, 6, 8, 10, 12mg Tablet 1) Risperidone 4mg QD 2) Haloperidol 0.5-5mg BID- BID TID 3) Thiothixene 2mg TID 4) Quetiapine 400- 800mg QD 5) Ziprasidone 20-80mg BID 6) Olanzapine 10mg QD 7) Olanzapine ODT 10mg QD 8) Latuda 40-80mg QD NF 9) Abilify 10-15mg QD 10) Saphris 5-10mg BID NF Fareston (Toremifene Citrate) 60mg Tablet QD 1) Tamoxifen 20-40mg QD 2) Faslodex 50mg/ml IM QM

Page 23 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Felbatol (Felbamate) 600mg/5mL Suspension; 400, 1) Lamotrigine 100-200mg BID 2) Carbamazepine 600mg Tablet TID-QID 800-1600mg QD 3) Topiramate 200mg BID 4) Phenytoin 100mg TID 5) Levetiracetam 500-1500mg BID 6) Zonisamide 100mg TID NF 7) Gabapentin 300- 600mg TID 8) Levetiracetam ER 1000mg QD 9) Oxcarbazepine 600mg BID NF 10) Divalproex 250- 500mg TID 11) Lyrica 50-200mg TID NF 12) Vimpat 100-200mg BID NF 13) Banzel 400mg BID NF 14) Gabitril 16 mg BID-TID NF Feldene (Piroxicam) 10, 20mg Capsule QD Meloxicam 7.5-15mg QD Femcon Fe (35mcg Ethinyl Estradiol/0.4mg 1) Sprintec (35mcg Ethinyl Estradiol/0.25mg Document adequate therapeutic trial or intolerance Norethindrone) Tablet QD Norgestimate) QD 2) Necon 1/35 (35mcg Ethinyl to at least 3 formulary oral contraceptives Estradiol/1mg Norethindrone) QD 3) Necon 0.5/35 (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD 4) Zovia 1/35 (35mcg Ethinyl Estradiol/1mg Ethynodiol diacetate) QD 5) Brevicon (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD Femhrt 1/5 (Ethinyl Estradiol/Norethindrone Acetate) 2 Separate Medications Adjust to the lowest dose needed to control 5mcg/1mg Tablet QD 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.025- symptoms based on patient response 0.1mg/24hr Apply weekly AND 1) Dose Conversion Medroxyprogesterone 2.5-5mg QD 2) Nora-BE Ethinyl Estradiol 5mcg=Estradiol 1mg 0.35mg QD 3) Norethindrone 5mg QD Femring (Estradiol Acetate) 0.05, 0.1mg/24hr Vasomotor Symtoms Adjust to the lowest dose needed to control Vaginal Insert Insert for 90 days 1) Estradiol QD 2) Climara Patch 0.025-0.1mg/24hr symptoms based on patient response Apply weekly Vaginal/Vulvar Atrophy 1) Estradiol QD 2) Climara Patch 0.025-0.1mg/24hr Apply weekly 3) Premarin Vaginal 1gm Apply three times a week 4) Vagifem 10mcg Insert twice weekly 5) Estring 2mg Insert for 90 days

Fentora (Fentanyl) 100, 200, 300, 400, 600, 800mg 1) Oxycodone/Acetaminophen 5/325-10/325mg Q6H Fentora is only approved for management of Buccal Tablet PRN 2) Morphine 15-30mg Q4H 3) Hydromorphone 2-8mg breakthrough cancer pain in patients tolerant to Q4-6H 4) Oxycodone 5-30mg Q4-6H 5) Morphine opioid therapy Solution 20mg/ml 0.5-1.5ml Q4H 6) Meperidine 50- 150mg Q3-4H Finacea (Azelaic Acid) 15% Gel AAA BID 1) Doxycycline 50–200mg QD 2) Minocycline 50–200mg QD 3) Metronidazole 0.75% Cream, Gel AAA BID Firazyr (Icatibant Acetate) 10mg/ml Subcutaneous Criteria Restricted Medication Solution 3ml SC QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Flector (Diclofenac Epolamine) 1.3% Topical Patch 1) OTC Aspercreme AAA BID-QID 2) Meloxicam 7.5- AAA BID 15mg QD 3) Naproxen 250-550mg BID 4) Ibuprofen 400-800mg TID-QID 5) Sulindac 150-200mg BID 6) Etodolac 200-500mg BID-TID 7) Nabumetone 500- 750mg BID 8) Lidocaine 5% Ointment AAA Q4H 9) Diclofenac 25-100mg BID-TID 10) Indomethacin 25- 75mg QD-BID 11) Tolmetin 200-600mg TID

Page 24 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Flovent HFA (Fluticasone) 110, 220mcg Inhalation 1) Qvar 40-80mcg 1-2 PUFFS QD-BID 2) Flovent Document adequate therapeutic trial or intolerance Aerosol Powder 1-2 PUFFS BID HFA 44mcg 2 PUFFS BID NOTE: Flovent HFA to Qvar 80mcg 2 PUFFS BID and Asmanex 220mcg 44mcg for patients 4-11 years of age 3) Asmanex 2 PUFFS QD within the past 3 months 110-220mcg 1-2 PUFFS QD 4) Pulmicort Flexhaler Flovent is swallowed for the treatment of 90-180mcg 2 PUFFS BID NF eosinophilic esophagitis Dose Conversion Flovent 110mcg 1-2 PUFFS BID=Qvar 80mcg 2 PUFFS BID=Asmanex 110mcg 1-2 PUFFS BID

Flovent 220mcg 1-2 PUFFS BID=Asmanex 220mcg 1-2 PUFFS BID

Florone (Diflorasone Diacetate) 0.05% Ointment High Potency AAA QD-QID High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BID- QID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QD- BID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID FML Forte (Fluorometholone) 0.25% Ophthalmic 1) Prednisolone 1% 1-2 GTTS BID-QID 2) Suspension 1 GTT BID-QID Fluorometholone 0.1% 1-2 GTTS BID-QID 3) Dexamethasone 0.1% 1-2 GTTS BID-QID Focalin (Dexmethylphenidate) 2.5, 5, 10mg Tablet 1) Methylphenidate 5-20mg BID-TID 2) Amphetamine Document adequate therapeutic trial or intolerance BID Salt Combo 5-30mg QD-BID 3) Dexmethylphenidate to Methylphenidate and Amphetamine Salt Combo 2.5-10mg BID NF Dose Conversion Focalin 5mg=Amphetamine Salt Combo 5mg=Methylphenidate 10mg

Focalin XR (Dexmethylphenidate) 5, 10, 15, 20, 1) Adderall XR 5-30mg QAM 2) Methylphenidate SR Document adequate therapeutic trial or intolerance 30mg Extended Release Capsule QD (generic for Concerta) 18-54mg QAM to Adderall XR and Methylphenidate SR Dose Conversion Focalin 5mg=Amphetamine Salt Combo 5mg=Methylphenidate 10mg

Folic Acid Vitamins (Deplin, Folvite, Folacin-800, FA- OTC Folic Acid 0.4, 0.8,1mg QD Excluded Medication 8) QD Available OTC Foradil Aerolizer (Formoterol Fumarate) 12mcg 1) Serevent 50mcg 1 PUFF BID 2) Arcapta Neohaler Dose Conversion Inhalation Capsule BID 75mcg QD NF Foradil 12mcg BID=Serevent 50mcg 1 PUFF BID=Arcapta Neohaler 75mg QD Fortamet (Metformin) 500, 1000mg Extended 1) Metformin 500-1000mg (Maximum 2550mg QD) 2) Adjust based on patient response Release Tablet QD Metformin ER 500-750mg (Maximum 2000mg QD)

Forteo (Teriparatide) 250mcg/ml Subcutaneous 1) Alendronate 10mg QD 2) Alendronate 70mg QW Document a) diagnosis of osteoporosis (T-Score ≤ - Solution 20mcg QD 3) Fortical 200IU QD Alternate nostrils 4) Ibandronate 2.5) b) adequate therapeutic trial or intolerance to 150mg QM NF 5) Actonel 5mg QD NF 6) Actonel Bisphosphonate or SERM c) vertebral or fragility 150mg QM NF 7) Evista 60mg QD 8) Actonel 35mg fracture prior to approval of Forteo for a total of 24 QW NF months with no renewal Fosamax Plus D (Alendronate/Cholecalciferol) Alendronate 70 mg Tablet QW 70mg/2800 IU, 70mg/5600 IU Tablet QW Fosrenol (Lanthanum Carbonate) 500, 750, 1000mg 1) Phoslyra 667mg/5ml 15ml with meals 2) Eliphos Chewable Tablet 1T with meals 667mg 3C with meals 3) Renvela 800mg 3T with meals Fragmin (Dalteparin) 10000/1, 2500/0.2, 15000/0.6, Enoxaparin 1.5 mg/kg QD or 1mg/kg BID 5000/0.2, 7500/0.3, 18000/0.72, 12500/0.5, 25000IU/ml Subcutaneous Solution QD

Freestyle Glucometer and Test Strips One Touch Ultra 2 Glucometer and One Touch Ultra Test Strips

Page 25 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Frova (Frovatriptan) 2.5mg Tablet PRN 1) Sumatriptan 25-100mg PRN 2) Sumatriptan 5- Quantity Limit 20mg Nasal Spray PRN 3) Naratriptan 1-2.5mg PRN Axert 6.25-12.5mg=6 Tablets 4) Sumatriptan 6mg/ml Subcutaneous Solution PRN Frova 2.5mg=9 Tablets 5) Maxalt MLT 5-10mg PRN NF 6) Zomig 5mg PRN Maxalt MLT 5-10mg=9 Tablets NF 7) Zomig 2.5mg PRN NF 8) Relpax 20-40mg PRN Naratriptan 1-2.5mg=9 Tablets NF 9) Axert 6.25-12.5mg PRN NF 10) Treximet Relpax 20-40mg=6 Tablets 500/85mg PRN NF Sumatriptan 25-100mg=9 Tablets Treximet 500/85mg=9 Tablets Zomig 2.5mg=6 Tablets Zomig 5mg=3 Tablets Gabitril (Tiagabine) 2, 4, 12, 16mg Tablet QD 1) Lamotrigine 100-200mg BID 2) Carbamazepine 800-1600mg QD 3) Topiramate 200mg BID 4) Phenytoin 100mg TID 5) Levetiracetam 500-1500mg BID 6) Zonisamide 100mg TID NF 7) Gabapentin 300- 600mg TID 8) Levetiracetam ER 1000mg QD 9) Oxcarbazepine 600mg BID NF 10) Divalproex 250- 500mg TID 11) Lyrica 50-200mg TID NF 12) Vimpat 100-200mg BID NF 13) Banzel 400mg BID NF

Gebauer Ethyl Chloride (Ethyl Chloride) 100% OTC Aerofreeze Topical Spray AAA PRN (Trichloromonofluoromethane/Dichlorodifluoromethan e) AAA PRN Gianvi (20mcg Ethinyl Estradiol/3mg Drospirenone) 1) Reclipsen (30mcg Ethinyl Estradiol/0.15 Document adequate therapeutic trial or intolerance Tablet QD Desogestrel) QD 2) Microgestin Fe 1/20 (20mcg to at least 3 formulary oral contraceptives Ethinyl Estradiol/1mg Norethindrone) QD 3) Aviane (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel) QD

Gilenya (Fingolimod) 0.5mg Capsule QD Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Glucotrol XL (Glipizide) 5, 10, 20mg Extended Glipizide 5-10mg QD-BID Adjust based on patient response Release Tablet QD Glipizide preferred if 65 years of age and older due to prolonged half life of Glyburide Glucovance (Glyburide/Metformin) 1.25/250, 2 Separate Medications 2.5/500, 5/500mg Tablet BID Glyburide BID AND Metformin BID Glynase PresTab (Micronized Glyburide) 1.5, 3, 6mg 1) Glipizide QD 2) Glyburide QD Dose Conversion Tablet QD Glynase 1.5mg=Glipizide 5mg=Glyburide 2.5mg / Glynase 3mg=Glipizide 10mg=Glyburide 5mg / Glynase 6mg=Glipizide 20mg=Glyburide 10mg Adjust based on patient response Glipizide preferred if 65 years of age and older due to prolonged half life of Glyburide Glyset (Miglitol) 25, 50, 100mg Tablet TID 1) Glipizide 5-15mg QD 2) Glyburide 2.5-10mg QD Adjust based on patient response Glipizide preferred if 65 years of age and older due to prolonged half life of Glyburide Golytely (Polyethylene Glycol 3350/Potassium Polyethylene Glycol 3350/Potassium -Fill to 4L mark with water and shake vigorously to Chloride/Sodium Bicarbonate/Sodium Chloride/Sodium Bicarbonate/Sodium dissolve Chloride/Sodium Sulfate) Chloride/Sodium Sulfate Powder for Solution -Chill prior to administration to improve palatability 236/2.97/6.74/5.86/22.74gm Powder for Solution -Refrigerate and use within 48 hours -Drink 240mL every 10 minutes until rectal effluent is clear or 4L are consumed

Gralise (Gabapentin) 300, 600mg Tablet 1800mg 1) Nortriptyline (<65 YOA: 25mg/>65 YOA: 10mg) QD QHS 2) Gabapentin 600mg TID 3) Lidocaine 5% Ointment AAA Gris-PEG (Griseofulvin) 125mg Tablet QD-TID Gris-PEG 250mg TID Halcion (Triazolam) 0.125, 0.25mg Tablet QHS 1) Temazepam 15mg QHS 2) Lorazepam 0.5mg QHS 3) Oxazepam 10-30mg QHS 4) Trazodone 50-100mg QHS 5) Zolpidem 5-10mg QHS

Page 26 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Halog (Halcinonide) 0.1% Cream AAA BID-TID High High Potency Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BID- QID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QD- BID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Halog (Halcinonide) 0.1% Ointment AAA BID-TID Very High Potency Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID

Hectorol (Doxercalciferol) 0.5, 1, 2.5mcg Capsule Calcitriol 0.25-1mcg QD QD Helidac Therapy (Bismuth Subsalicylate, 3 Separate Medications Dispense Antibiotics for copays and purchase OTC Metronidazole, Tetracycline) 262.4mg 2T QID, OTC Omeprazole 20mg BID AND Clarithromycin Omeprazole 250mg QID, 500mg QID X14D 500mg BID AND Amoxicillin 500mg 2C BID NOTE: If Penicillin allergy or contraindication consider Metronidazole 500mg BID Hizentra (Immune Globulin) 20% Subcutaneous IVIG Q4W IVIG Infusion Solution SC QW KP Hematology Contact CU Infusion Center 770-431-4367 or SW Infusion Center 770-603-3663 Network Hematology Contact Provider Relations 404-364-4934 Horizant (Gabapentin Enacarbil) 600mg Extended 1) Pramipexole 0.125mg QHS 2) Ropinirole 0.25-4mg Release Tablet QD QHS Humalog (Insulin Lispro) 100U/ml Injection Solution 1) Novolin R (Insulin Regular) SC 30 minutes AC 2) Adjust based on patient response SC 15 minutes AC NovoLog (Insulin Aspart) SC 5-10 minutes AC NF

Humalog Mix 50/50 (Insulin Lispro Protamine/Insulin 2 Separate Medications Adjust based on patient response Lispro) 100U/ml Injection Solution SC 15 minutes Novolin N (NPH) SC 15-30 minutes AC AND 1) Dose Conversion AC Novolin R (Insulin Regular) SC 30 minutes AC 2) Humalog Mix 50/50 20U=NPH 10U+Novolin R 10U NovoLog (Insulin Aspart) SC 5-10 minutes AC NF Humalog Mix 75/25 (Insulin Lispro Protamine/Insulin Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes Adjust based on patient response Lispro) 100U/ml Injection Solution SC 15 minutes AC OR Dose Conversion AC 2 Separate Medications Humalog Mix 75/25 20U=Novolin 70/30 20U=NPH Novolin N (NPH) SC 15-30 minutes AC AND 1) 15U+Novolin R 5U Novolin R (Insulin Regular) SC 30 minutes AC 2) NovoLog (Insulin Aspart) SC 5-10 minutes AC NF Humalog KwikPen (Insulin Lispro) 100U/ml Injection 1) Novolin R (Insulin Regular) SC 30 minutes AC 2) Adjust based on patient response Solution SC 15 minutes AC NovoLog (Insulin Aspart) SC 5-10 minutes AC NF Insulin Administration Device Document a) member is unable to accurately draw up insulin due to upper extremity amputation, visual impairment, young age, Parkinson's Disease, Rheumatoid Arthritis b) member administers doses < 5U c) school or day care requires insulin cartridge device for insulin administration while member is outside of primary caretaker's care

Page 27 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Humatrope (Somatropin) 6, 12, 24mg Injection Omnitrope (Somatropin) 5/1.5, 10/1.5mg/ml QW NF Criteria Restricted Medication Powder for Solution; 5mg Subcutaneous Powder for QRM approval required prior to being dispensed for Solution QW Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Humulin R (Insulin Regular) 500U/ml Injection 1) Novolin R (Insulin Regular) SC 30 minutes AC 2) Adjust based on patient response Solution SC 15 minutes AC Novolin N (NPH) SC 15-30 minutes AC 3) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 4) NovoLog (Insulin Aspart) SC 5-10 minutes AC NF

Hycamtin (Topotecan) Capsule 0.25, 1mg 1) Platinum-based Chemotherapy 2) Etoposide FDA approved for treatment of relapsed small cell 2 2.3mg/m /day PO X5D Q21D 50mg/m2/day X5D Q21D 3) Topotecan 1.5 mg/m2/day lung cancer (SCLC) IV X5D Q21D Hycodan (Hydrocodone Bitartrate/Homatropine 1) Cheratussin AC (Codeine/Guaifenesin) Methylbromide) 5mg/1.5mg/5ml Syrup 5ml Q4-6H 10mg/100mg/5ml Q4-6H PRN 2) PRN Promethazine/Codeine 6.25mg/10mg/5ml Q4-6H PRN 3) Hydrocodone Bitartrate/Homatropine Methylbromide 5/1.5mg Q4-6H PRN 4) Promethazine VC/Codeine (Promethazine/Codeine/Phenylephrine) 6.25mg/10mg/5mg/5ml Q4-6H PRN 5) Benzonatate 100-200mg TID PRN 6) Hydrocodone Bitartrate/Homatropine Methylbromide 5mg/1.5mg/5ml Syrup 5ml Q4-6H PRN NF

Hydrocortisone Acetate/Aloe 2% Cream, Gel AAA Lowest Potency BID-QID Lowest Potency 1) OTC Hydrocortisone 0.5-1% Cream, Ointment AAA BID-QID 2) Hydrocortisone 2.5% Cream, Lotion, Ointment AAA BID-QID Low Potency 1) Betamethasone Valerate 0.1% Lotion AAA QD-BID 2) Desonide 0.05% Cream, Ointment AAA BID-TID 3) Fluocinolone Acetonide 0.01% Solution AAA QD 4) Derma-Smoothe/FS 0.01% Oil AAA QD

HyoMax SR (Hyoscyamine) 0.375mg Extended 1) OTC Imodium A-D 4mg after first loose stool then Release Tablet BID 2mg after each subsequent loose stool 2) Dicyclomine 20mg QID 3) Belladonna Alkaloids/Phenobarbital 1-2T TID-QID 4) Diphenoxylate/Atropine 2.5/0.025mg/5ml 10ml QID 5) Diphenoxylate/Atropine 2.5/0.025mg 2T QID 6) Hyoscyamine SL 0.125mg 1-2T Q4H 7) Hyoscyamine 0.125mg 1-2T Q4H 8) Hyoscyamine Solution 0.125mg/ml 5-10ml Q4H Imitrex (Sumatriptan) 4mg/0.5ml Subcutaneous Sumatriptan 6mg/0.5ml Subcutaneous Solution PRN Solution PRN Incivek (Telaprevir) 375mg Tablet 2T TID 2 Separate Medications No initial fill Peg-Intron 1.5mcg/kg QW AND Ribavirin 800- Document a) chronic Hepatitis C genotype 1 b) 1400mg QD prescription from Gastroenterologist or Infectious Disease Specialist c) compensated liver disease d) active prescriptions for Interferon Alfa and Ribavirin

Inderal LA (Propranolol) 60, 80, 120, 160mg 1) Propranolol 120-240mg QD 2) Nadolol 240-320mg Dose Conversion Extended Release Capsule QD QD 3) Carvedilol 12.5-25mg BID 4) Labetalol 200- Propanolol ER 60mg=Propranolol 20mg 1.5T BID / 400mg BID Propanolol ER 80mg=Propanolol 40mg BID / Propranolol ER 120mg=Propranolol 60mg BID / Propanolol ER 160mg=Propranolol 80mg BID Infergen (Interferon Alfacon-1) 30mcg/ml 1) Pegasys 180mcg QW 2) PEG-Intron 150mcg QW Subcutaneous Solution QD

Inspra (Eplerenone) 25, 50mg Tablet QD 1) Amiloride/HCTZ 5/50mg QD 2) Triamterene/HCTZ 37.5/25-75/50mg QD 3) Spironolactone 50-100mg Tablet QD

Page 28 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Intuniv (Guanfacine Hydrochloride) 1, 2, 3, 4mg 1) Clonidine 0.1mg QD-TID 2) Guanfacine 1-4mg QD Document adequate therapeutic trial or intolerance Extended Release Tablet QD 3) Methylphenidate 5-20mg BID-TID 4) Amphetamine to 2 formulary alternatives and Guanfacine Salt Combo 5-30mg QD-BID 5) Dexmethylphenidate 2.5-10mg BID NF 6) Adderall XR 5-30mg QAM 7) Dextroamphetamine CR 5-15mg QD-BID 8) Dextroamphetamine 5-10mg QD-TID 9) Methylphenidate SR (generic for Concerta) 18-54mg QAM Invega (Paliperidone) 1.5, 3, 6, 9mg Extended 1) Risperidone 4mg QD 2) Haloperidol 0.5-5mg BID- Release Tablet QD TID 3) Thiothixene 2mg TID 4) Quetiapine 400- 800mg QD 5) Ziprasidone 20-80mg BID 6) Olanzapine 10mg QD 7) Olanzapine ODT 10mg QD 8) Latuda 40-80mg QD NF 9) Abilify 10-15mg QD 10) Saphris 5-10mg BID NF 11) Fanapt 6-12mg BID NF Iressa (Gefitinib) 250mg Tablet QD 1) Platinum-based Chemotherapy 2) Docetaxel FDA approved for treatment of locally advanced or 75mg/m2 IV Q21D metastatic nonsmall cell lung cancer (NSCLC) who have failed both Platinum and Docetaxel-based Chemotherapy Iron Vitamins (Ferrex Forte, Niferex, Niferex Forte) OTC Ferrex 150 QD Excluded Medication QD Available OTC Ismo (Isosorbide Mononitrate) 10, 20mg Tablet BID Isosorbide Mononitrate ER 30-120mg QD

Jalyn (Dutasteride/Tamsulosin) 0.5/0.4mg Capsule 2 Separate Medications QD Finasteride 5mg QD AND 1) Doxazosin 1-8mg QD 2) Terazosin 1-10mg QD 3) Tamsulosin 0.4mg QD 4) Alfuzosin ER 10mg QD NF Januvia (Sitagliptin) 25, 50, 100mg Tablet QD 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin Criteria Restricted Medication 500-1000mg (Maximum 2550mg QD) 3) Metformin QRM approval required prior to being dispensed for ER 500-750mg (Maximum 2000mg QD) 4) Novolin R Commercial, Multi-Choice, Self-Funded, and Triple (Insulin Regular) SC 30 minutes AC 5) Novolin N Tier members. (NPH) SC 15-30 minutes AC 6) Novolin 70/30 Provider must call 404-364-7320 (Option 2) to (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog initiate review by QRM department. (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos 15mg (Maximum 45mg QD)

Janumet (Metformin/Sitagliptin) 500/50, 1000/50mg 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin Criteria Restricted Medication Tablet QD 500-1000mg (Maximum 2550mg QD) 3) Metformin QRM approval required prior to being dispensed for ER 500-750mg (Maximum 2000mg QD) 4) Novolin R Commercial, Multi-Choice, Self-Funded, and Triple (Insulin Regular) SC 30 minutes AC 5) Novolin N Tier members. (NPH) SC 15-30 minutes AC 6) Novolin 70/30 Provider must call 404-364-7320 (Option 2) to (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog initiate review by QRM department. (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos 15mg (Maximum 45mg QD)

Jentadueto (Linagliptin/Metformin Hydrochloride) 2 Separate Medications Criteria Restricted Medication 2.5/500, 2.5/850, 2.5/1000mg Tablet BID Tradjenta 5mg 0.5T BID AND Metformin 500-1000mg QRM approval required prior to being dispensed for BID Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Junel 1/20 (20mcg Ethinyl Estradiol/1mg 1) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Document adequate therapeutic trial or intolerance Norethindrone) Tablet QD Norethindrone) QD 2) Aviane (20mcg Ethinyl to at least 3 formulary oral contraceptives Estradiol/0.1mg Levonorgestrel) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD

Page 29 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Juvisync (Simvastatin/Sitagliptin) 10/100, 20/100, 2 Separate Medications Criteria Restricted Medication 40/100mg Tablet QD Simvastatin 10-40mg QD AND 1) Glipizide 10mg QRM approval required prior to being dispensed for (Maximum 40mg QD) 2) Metformin 500-1000mg Commercial, Multi-Choice, Self-Funded, and Triple (Maximum 2550mg QD) 3) Metformin ER 500-750mg Tier members. (Maximum 2000mg QD) 4) Novolin R (Insulin Provider must call 404-364-7320 (Option 2) to Regular) SC 30 minutes AC 5) Novolin N (NPH) SC initiate review by QRM department. 15-30 minutes AC 6) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos 15mg (Maximum 45mg QD) Kadian (Morphine Sulfate) 10, 20, 30, 40, 50, 60, 70, 1) Morphine ER 60-100mg BID 2) Fentanyl 25- Dose Conversion 80, 100, 130, 150, 200mg Extended Release 100mcg/hr Q72H 3) Butrans 5-20mcg/hr QW NF 4) Morphine 30mg=Butrans 5mcg/hr=Oxycodone Capsule QD Nucynta ER 50-250mg BID NF 5) Avinza 30-120mg 20mg=Oxymorphone 10mg=Tapentadol 200mg / QD NF 6) Opana ER 5-40mg BID NF 7) Oxycontin 10- Morphine 90mg=Fentanyl 25mcg/hr 80mg BID NF Document adequate therapeutic trial or intolerance to Morphine ER and Fentanyl Kalbitor (Ecallantide) 10mg/ml Subcutaneous 1) Danazol 200mg BID-TID 2) Oxandrolone 2.5-20mg Criteria Restricted Medication Solution 3ml SC BID-QID NF 3) Berinert 20U/kg IV NF QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Kapvay (Clonidine) 0.1mg Extended Release Tablet 1) Clonidine 0.1mg QD-TID 2) Guanfacine 1-4mg QD Document adequate therapeutic trial or intolerance QHS-BID 3) Methylphenidate 5-20mg BID-TID 4) Amphetamine to 2 formulary alternatives and Clonidine Salt Combo 5-30mg QD-BID 5) Dexmethylphenidate 2.5-10mg BID NF 6) Adderall XR 5-30mg QAM 7) Dextroamphetamine CR 5-15mg QD-BID 8) Dextroamphetamine 5-10mg QD-TID 9) Methylphenidate SR (generic for Concerta) 18-54mg QAM Kariva (20mcg Ethinyl Estradiol/0.15mg Desogestrel 1) Reclipsen 0.25 (30mcg Ethinyl Estradiol/0.15 Document adequate therapeutic trial or intolerance x 21 days, 10mcg EE x 5 days) Tablet QD Desogestrel) QD 2) Microgestin Fe 1/20 (20mcg to at least 3 formulary oral contraceptives Ethinyl Estradiol/1mg Norethindrone) QD 3) Aviane (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel) QD

Kenalog (Triamcinolone Acetonide) 0.5% Cream, Very High Potency Ointment AAA BID-QID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID

Keppra XR 500, 750mg Extended Release Tablet 1) Lamotrigine 100-200mg BID 2) Carbamazepine QD-BID 800-1600mg QD 3) Topiramate 200mg BID 4) Phenytoin 100mg TID 5) Levetiracetam 500-1500mg BID 6) Zonisamide 100mg TID NF 7) Gabapentin 300- 600mg TID 8) Levetiracetam ER 1000mg QD

Kerlone (Betaxolol) 10, 20mg Tablet QD 1) Atenolol 50-100mg QD 2) Metoprolol 100-450mg Dose Conversion QD 3) Acebutolol 400-800mg QD 4) Bisoprolol 2.5- Betaxolol 10mg QD=Atenolol 50mg QD / Betaxolol 20mg QD 5) Carvedilol 12.5-25mg BID 6) Labetalol 20mg QD=Atenolol 100mg QD 200-400mg BID Ketek (Telithromycin) 300, 400mg Tablet 2T QD Community Acquired Pneumonia 1) Levofloxacin 750mg QD X5D 2) Levofloxacin 500mg QD X10D 3) Azithromycin 500mg QD X5D 4) Cefuroxime 500mg BID X10D

Page 30 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Kineret (Anakinra) 100mg/0.67ml Subcutaneous 1) Humira 40mg QOW 2) Enbrel 50mg QW 3) Remicade Infusion Solution QD Remicade 5mg/kg Q8W NF KP Rheumatology Contact CU Infusion Center 770-431-4367 or SW Infusion Center 770-603-3663 Network Rheumatology Contact Provider Relations 404-364-4934 Klaron (Sodium Sulfacetamide) 10% Lotion AAA BID 1) Sodium Sulfacetamide/Sulfur 10/5% Lotion AAA BID 2) Zencia Wash (Sodium Sulfacetamide/Sulfur) 9/4% Wash AAA BID Klor-Con 25 (Potassium Chloride) 25mEq Powder 1) K-Tab 10mEq Extended Release 2T QD 2) Klor- for Solution QD Con 20mEq Powder for Solution QD

Klor-Con M20 (Potassium Chloride) 20mEq 1) K-Tab 10mEq Extended Release 2T QD 2) Klor- Extended Release Tablet QD Con 20mEq Powder for Solution QD

Kombiglyze (Metformin/Saxagliptin) 500/5, 1000/2.5, 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin Criteria Restricted Medication 1000/5mg Extended Release Tablet QD 500-1000mg (Maximum 2550mg QD) 3) Metformin QRM approval required prior to being dispensed for ER 500-750mg (Maximum 2000mg QD) 4) Novolin R Commercial, Multi-Choice, Self-Funded, and Triple (Insulin Regular) SC 30 minutes AC 5) Novolin N Tier members. (NPH) SC 15-30 minutes AC 6) Novolin 70/30 Provider must call 404-364-7320 (Option 2) to (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog initiate review by QRM department. (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos 15mg (Maximum 45mg QD)

Kytril (Granisetron) 1mg Tablet 2T 1 hour prior to 1) Metoclopramide 1-2mg/kg 30 minutes prior to chemotherapy chemotherapy 2) Prochlorperazine 5-10mg Q6H 3) Dexamethasone 20mg 30 minutes prior to chemotherapy 4) Ondansetron 4-8mg 30 minutes prior to chemotherapy 5) Ondansetron 4-8mg ODT 30 minutes prior to chemotherapy 6) Transderm Scop 1.5mg Apply Q72H NF Lac-Hydrin (Ammonium Lactate) 12% Cream AAA OTC AmLactin (Ammonium Lactate) 12% Cream Excluded Medication BID AAA BID Available OTC Lacrisert (Hydroxypropyl Cellulose) 5mg Artificial 1) OTC GenTeal, Tears Again, Tears Naturale Free Tear Insert Insert QD-BID (Hydroxypropyl Methylcelluclose 0.3%) 1-2 GTT TID- QID 2) OTC Isopto Plain (Hydroxypropyl Methylcelluclose 0.5%) 1-2 GTT TID-QID 3) OTC Murocel (Methylcellulose 3%) 1-2 GTT TID-QID Lamisil (Terbinafine) 250mg Tablet QD-BID Thymol/Isopropyl Alcohol 4/99% Solution QD KPGA Approved Compound Finger Onychomycosis Document positive fungal culture prior to approval of one 6 week treatment Toe Onychomycosis Document a) positive fungal culture b) DM or Vascular Disease prior to approval one 12 week treatment Lantus (Insulin Glargine) 100U/ml Injection Solution 1) Novolin N (NPH) SC 15-30 minutes AC 2) Novolin -Lantus (< 30U QD) to Novolin N (QD dosing) is a SC QD 70/30 (NPH/Insulin Regular) SC 30 minutes AC 1:1 Conversion -Lantus (>30U QD) to Novlin N (BID dosing) is a 0.8:1 Conversion Document a) member with DM1 b) member undergoing dialysis c) adequate therapeutic trial or intolerance (Hypoglycemia) to NPH

Page 31 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Lantus Solostar (Insulin Glargine) 100U/ml Injection 1) Novolin N (NPH) SC 15-30 minutes AC 2) Novolin -Lantus (< 30U QD) to Novolin N (QD dosing) is a Solution SC QD 70/30 (NPH/Insulin Regular) SC 30 minutes AC 1:1 Conversion -Lantus (>30U QD) to Novlin N (BID dosing) is a 0.8:1 Conversion Document a) member with DM1 b) member undergoing dialysis c) adequate therapeutic trial or intolerance (Hypoglycemia) to NPH Insulin Administration Device Document a) member is unable to accurately draw up insulin due to upper extremity amputation, visual impairment, young age, Parkinson's Disease, Rheumatoid Arthritis b) member is administers doses < 5U

Lastacaft (Alcaftadine) 0.25% Ophthalmic Solution 1 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q3- GTT QD 4 HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID 4) Crolom 4% 1-2 GTTS Q4-6 HOURS NF 5) Emadine 0.05% 1 GTT QID NF 6) Alocril 2% 1-2 GTTS BID NF 7) Optivar 0.05% 1 GTT BID NF 8) Alomide 0.1% 1-2 GTTS QID NF Latisse (Bimatoprost) 0.03% Ophthalmic Solution Excluded Medication Apply QHS to upper eyelid margin Latuda (Lurasidone) 40, 80mg Tablet QD 1) Risperidone 4mg QD 2) Haloperidol 0.5-5mg BID- TID 3) Thiothixene 2mg TID 4) Quetiapine 400- 800mg QD 5) Ziprasidone 20-80mg BID 6) Olanzapine 10mg QD 7) Olanzapine ODT 10mg QD

Lescol (Fluvastatin) 20, 40mg Capsule QHS 1) Simvastatin 5-10mg QD 2) Pravastatin 10-20mg Dose Conversion QD Fluvastatin 20mg=Pravastatin 10mg=Simvastatin 5mg / Fluvastatin 40mg=Pravastatin 20mg=Simvastatin 10mg Lescol XL (Fluvastatin) 80mg Extended Release 1) Simvastatin 20mg QD 2) Pravastatin 40mg QD 3) Dose Conversion Tablet QHS Atorvastatin 10mg QD Fluvastatin 80mg=Atorvastatin 10mg=Pravastatin 40mg=Simvastatin 20mg Lessina (20mcg Ethinyl Estradiol/0.1mg 1) Aviane (20mcg Ethinyl Estradiol/0.1mg Equivalent Brand and Generic Products Levonorgestrel) Tablet QD Levonorgestrel) QD 2) Microgestin Fe 1/20 (20mcg Lessina=Aviane Ethinyl Estradiol/1mg Norethindrone) QD 3) Levora Document adequate therapeutic trial or intolerance (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD to at least 3 formulary oral contraceptives

Letairis (Ambrisentan) 5, 10mg Tablet QD 1) Tracleer 62.5-125mg BID 2) Flolan 2ng/kg/min 3) KP CA Specialty Pharmacy Remodulin 1.25-2.5ng/kg/min QW MD Line 650-301-5799 / Patient Line 1-877-404- Prescribing Physician must call Letairis Education 5777 / Fax Line 650-301-5790 Access Program 866-664-LEAP Letairis is delivered directly to patient via KP CA Specialty Pharmacy Levaquin (Levofloxacin) 25mg/ml Solution QD Community Acquired Pneumonia 1) Levofloxacin 750mg QD X5D 2) Levofloxacin 500mg QD X10D 3) Azithromycin 500mg QD X5D 4) Cefuroxime 500mg BID X10D Sinusitis 1) SMZ-TMP DS BID X7D 2) Doxycycline 100mg BID X7D 3) Amoxicillin 1000mg BID X7D 4) Azithromycin 500mg QD X3D Urinary Tract Infection 1) SMZ-TMP DS BID X3D 2) Ciprofloxacin 250mg BID X3D 3) Levofloxacin 250mg QD X3D 4) Nitrofurantoin Monohydrate 100mg BID X7D Levemir (Insulin Detemir) 100U/ml Injection Solution 1) Novolin N (NPH) SC 15-30 minutes AC 2) Novolin Document adequate therapeutic trial or intolerance SC QD-BID 70/30 (NPH/Insulin Regular) SC 30 minutes AC (Hypoglycemia) to NPH

Levitra (Vardenafil) 2.5, 5, 10, 20mg Tablet PRN Excluded Medication (Exception: Sexual Dysfunction Rider)

Page 32 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Lexapro (Escitalopram) 5mg/5ml Solution QD 1) Fluoxetine 20mg/5ml Solution 10-40mg QD 2) Paroxetine 10mg/5ml 10-40mg QD NF 3) Citalopram 10mg/5ml Solution 10-40mg QD NF 4) Sertraline 20mg/ml Solution 50-100mg QD NF Lialda (Mesalamine) 1.2gm Delayed Release Tablet 1) Sulfasalazine 500mg (2-4gm QD) 2) Colazal 2.4-4.8gm QD 750mg (2.25gm TID for 8-12 weeks) 3) Asacol 400mg (800mg TID) 4) Dipentum 550mg BID NF 5) Pentasa 250, 500mg (1gm QID) Lidoderm (Lidocaine) 5% Topical Patch Apply 1-3 1) OTC LMX 4 (Lidocaine 4% Cream) AAA QID 2) Lidoderm is only indicated for postherpetic neuralgia patches up to 12 hours OTC Axsain cream (Lidocaine 4%/Capsaicin 0.25% Cream) AAA QID 3) Lidocaine 2% Gel AAA QID 4) Lidocaine 5% Ointment AAA 5G QID Lipofen (Fenofibrate) 50, 150mg Capsule QD 1) Gemfibrozil 600mg BID 2) Fenofibrate 54-160mg Dose Conversion QD Lipofen 50mg=Fenofibrate 54mg / Lipofen 150mg=Fenofibrate 160mg Fenofibrate preferred if current statin therapy Gemfibrozil preferred if reduced renal function Livalo (Pitavastatin) 1, 2, 4mg Tablet QD 1) Simvastatin 10-40mg QD 2) Pravastatin 20-80mg Dose Conversion QD 3) Atorvastatin 10-20mg QD Pitavastatin 1mg=Pravastatin 20mg=Simvastatin 10mg / Pitavastatin 2mg=Atorvastatin 10mg=Pravastatin 40mg=Simvastatin 20mg / Pitavastatin 4mg=Atorvastatin 20mg=Pravastatin 80mg=Simvastatin 40mg Locoid (Hydrocortisone Butyrate) 0.1% Cream, Medium Potency Ointment, Solution AAA BID-TID Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BID- QID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BID- QID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID Locoid Lipocream (Hydrocortisone Butyrate) 0.1% Medium Potency Cream AAA BID-TID Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BID- QID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BID- QID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID Lodine XL (Etodolac) 400, 500, 600mg Extended 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg Release Tablet QD BID 3) Ibuprofen 400-800mg TID-QID 4) Sulindac 150-200mg BID 5) Etodolac 200-500mg BID-TID 6) Nabumetone 500-750mg BID Loestrin 21 1/20 (20mcg Ethinyl Estradiol/1mg 1) Aviane (20mcg Ethinyl Estradiol/0.1mg Document adequate therapeutic trial or intolerance Norethindrone) Tablet QD Levonorgestrel) QD 2) Microgestin Fe 1/20 (20mcg to at least 3 formulary oral contraceptives Ethinyl Estradiol/1mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD

Loestrin 24 Fe (20mcg Ethinyl Estradiol/1mg 1) Aviane (20mcg Ethinyl Estradiol/0.1mg Document adequate therapeutic trial or intolerance Norethindrone x 24 days) Tablet QD Levonorgestrel) QD 2) Microgestin Fe 1/20 (20mcg to at least 3 formulary oral contraceptives Ethinyl Estradiol/1mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD

Lo Loestrin Fe (10mcg Ethinyl Estradiol/1mg 1) Aviane (20mcg Ethinyl Estradiol/0.1mg Document adequate therapeutic trial or intolerance Norethindrone x 24 days, 10mcg EE x 2 days) Levonorgestrel) QD 2) Microgestin Fe 1/20 (20mcg to at least 3 formulary oral contraceptives Tablet QD Ethinyl Estradiol/1mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD

Lo/Ovral (30mcg Ethinyl Estradiol/0.3 Norgestrel) 1) Reclipsen (30mcg Ethinyl Estradiol/0.15mg Equivalent Brand and Generic Products Tablet QD Desogestrel) QD 2) Microgestin Fe 1.5/30 (30mcg Lo/Ovral=Cryselle Ethinyl Estradiol/1.5mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD

Page 33 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Loprox (Ciclopirox) 0.77% Cream; 0.77% Gel; 1% 1) OTC Lamisil Ultra (Butenafine 1%) QD-BID 2) OTC Shampoo BID Lotrimin AF (Clotrimazole 1%) BID 3) OTC Micatin (Miconazole 1%) BID 4) Ketoconazole 2% Cream QD

Loryna (20mcg Ethinyl Estradiol/3mg Drospirenone) 1) Reclipsen (30mcg Ethinyl Estradiol/0.15 Document adequate therapeutic trial or intolerance Tablet QD Desogestrel) QD 2) Microgestin Fe 1/20 (20mcg to at least 3 formulary oral contraceptives Ethinyl Estradiol/1mg Norethindrone) QD 3) Aviane (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel) QD

LoSeasonique (20mcg Ethinyl Estradiol/0.1mg 1) Aviane (20mcg Ethinyl Estradiol/0.1mg Equivalent Brand and Generic Products Levonorgestrel x 84 days, 10mcg EE x 7 days) Levonorgestrel) QD 2) Levora (30mcg Ethinyl LoSeasonique=Amethia Lo Tablet QD Estradiol/0.15mg Levonorgestrel) QD 3) Jolessa Levora Dose Recommendation (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel x 84 Day 1-84: Take 1 active tablet QD (Discard placebo days) QD NF 4) Amethia Lo (20mcg Ethinyl tablets from first 3 packets) Estradiol/0.1mg Levonorgestrel x 84 days, 10mcg EE Day 85-91: Take 1 placebo tablet QD x 7 days) QD NF

Lotemax (Loteprednol) 0.5% Ophthalmic 1) Diclofenac 0.1% 1GTT QID 2) Ketorolac 0.5% 1 Suspension 1-2 GTT QID GTT QID 3) Prednisolone 1% 1-2 GTTS BID-QID 4) Fluorometholone 0.1% 1-2 GTTS BID-QID 5) Dexamethasone 0.1% 1-2 GTTS BID-QID 6) Ketorolac 0.4% 1 GTT QID 7) Flurbiprofen 0.03% 1 GTT QID NF 8) Vexol 1% 1-2 GTT QID NF 9) Bromfenac 0.09% 1 GTT QD-BID NF Lotrel (Amlodipine/Benazepril) 2.5/10, 5/10, 5/20, 2 Separate Medications 10/20mg Tablet QD Amlodipine QD AND Benazapril QD Lotrisone (Betamethasone 2 Separate Medications Dispense Betamethasone Dipropionate as 1 copay Dipropionate/Clotrimazole) 0.05/1% Cream, Lotion Betamethasone Dipropionate 0.05% Cream AAA BID and purchase OTC Clotrimazole AAA BID AND OTC Clotrimazole 1% Gel AAA BID Lotronex (Alosetron) 0.5, 1mg Tablet BID 1) OTC Imodium A-D 4mg after first loose stool then 2mg after each subsequent loose stool 2) Dicyclomine 20mg QID 3) Belladonna Alkaloids/Phenobarbital 1-2T TID-QID 4) Diphenoxylate/Atropine 2.5/0.025mg/5ml 10ml QID 5) Diphenoxylate/Atropine 2.5/0.025mg 2T QID 6) Hyoscyamine SL 0.125mg 1-2T Q4H 7) Hyoscyamine 0.125mg 1-2T Q4H 8) Hyoscyamine Solution 0.125mg/ml 5-10ml Q4H 9) Hyoscyamine SR 0.375mg BID NF Prescribing Physician must call Prometheus Prescribing 888-423-5227

Lovaza (Omega-3-Acid Ethyl Esters) 1gm Liquid 1) OTC Omega-3 Fish Oil QD 2) Gemfibrozil 600mg Dose Conversion Filled Capsule QD BID 3) Fenofibrate 54-160mg QD Lovaza 1gm= EPA 465mg and DHA 375mg Lovaza is only FDA approved for TG > 500mg/dL Fenofibrate preferred if current statin therapy Gemfibrozil preferred if reduced renal function Low-Ogestrel (30mcg Ethinyl Estradiol/0.3 1) Reclipsen (30mcg Ethinyl Estradiol/0.15mg Equivalent Brand and Generic Products Norgestrel) Tablet QD Desogestrel) QD 2) Microgestin Fe 1.5/30 (30mcg Low-Ogestrel=Cryselle Ethinyl Estradiol/1.5mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD

Lumigan (Bimatoprost) 0.01, 0.03% Ophthalmic 1) Latanoprost 0.005% 1 GTT QPM 2) Travatan Z Solution 1 GTT QPM 0.004% 1 GTT QPM NF Lunesta (Eszopiclone) 1, 2, 3mg Tablet QHS 1) Trazodone 50-100mg QHS 2) Temazepam 15- Document adequate therapeutic trial or intolerance 30mg QHS 3) Zolpidem 5-10mg QHS 4) Zaleplon 5- to Trazodone, Zolpidem, and at least 1 10mg QHS 5) Ambien CR 6.25-12.5mg QHS NF 6) Benzodiazepine Rozerem 8mg QHS NF Lustra (Hydroquinone) 4% Cream AAA BID Excluded Medication

Page 34 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Luvox CR (Fluvoxamine) 100, 150mg Extended 1) Fluoxetine 20-40mg QD 2) Citalopram 20-40mg Document adequate therapeutic trial or intolerance Release Capsule QHS QD 3) Sertraline 50-100mg QD 4) Paroxetine 10- to at least 3 SSRIs 40mg QD 5) Escitalopram 10-20mg QD 6) Mirtazapine 45mg QHS 7) Fluvoxamine 50-300mg QD NF 8) Paxil CR 12.5-37.5mg QD NF 9) Viibryd 10- 40mg QD NF Luxiq (Betamethasone Valerate) 0.12% Foam AAA Low Potency BID Medium-High Potency Fluocinolone 0.01% Solution Medium-High Potency Betamethasone Valerate 0.1% Ointment AAA QD- BID Very High Potency Flucinonide 0.05% Gel, Ointment, Solution AAA BID- QID Ultra High Potency 1) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 2) Clobetasol Propionate 0.05% Solution AAA BID 3) Clobetasol 0.05% Aerosol AAA BID NF Lybrel (20mcg Ethinyl Estradiol/0.09mg 1) Aviane (20mcg Ethinyl Estradiol/0.1mg Document adequate therapeutic trial or intolerance Levonorgestrel) Tablet QD Levonorgestrel) QD 2) Microgestin Fe 1/20 (20mcg to at least 3 formulary oral contraceptives Ethinyl Estradiol/1mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD

Lyrica (Pregabalin) 25, 50, 75, 100, 150, 200, 225, Diabetic Peripheral Neuropathic Pain Diabetic Peripheral Neuropathic Pain 300mg Capsule BID-TID 1) Amitriptyline* 50mg QHS 2) Nortriptyline* (<65 Document adequate therapeutic trial or intolerance YOA: 25mg QHS / > 65 YOA: 10mg QHS) 3) to 1 TCA*, Tramadol*; and Venlafaxine Cyclobenzaprine* 10mg TID 4) Tramadol* 50mg BID Non-Diabetic Peripheral Neuropathic Pain 5) Venlafaxine ER 150 – 225mg QD Document adequate therapeutic trial or intolerance Non-Diabetic Peripheral Neuropathic Pain to 1 TCA*, Tramadol*, and Cyclobenzaprine 1) Amitriptyline* 50mg QHS 2) Nortriptyline* (<65 Fibromyalgia YOA: 25mg QHS / > 65 YOA: 10mg QHS) 3) Document adequate therapeutic trial or intolerance Cyclobenzaprine* 10mg TID 4) Tramadol* 50mg BID to 1 TCA*, Tramadol*, and Cyclobenzaprine Fibromyalgia Post Herpetic Neuralgia 1) Amitriptyline* 50mg QHS 2) Nortriptyline* (<65 Document adequate therapeutic trial or intolerance YOA: 25mg QHS / > 65 YOA: 10mg QHS) 3) to 1 TCA* and Gabapentin Cyclobenzaprine* 10mg TID 4) Tramadol* 50mg BID *Not recommended in the elderly and not a required Post Herpetic Neuralgia medication for patients over 65 years old 1) Nortriptyline* (<65 YOA: 25mg QHS / > 65 YOA: 10mg QHS) 2) Gabapentin 600mg TID 3) Lidocaine 5% Ointment AAA of allodynia and localized pain

Lysteda (Tranexamic Acid) 650mg Tablet 2T TID 1) Combination Oral Contraceptive 2) Quantity Limit X5D Medroxyprogesterone 5-10mg QD 3) Norethindrone Lysteda 650mg (30 Day Supply)=30 Tablets 5mg QD Macrodantin (Nitrofurantoin Macrocrystal) 100mg UTI Prophylaxis Capsule QD-BID Nitrofurantoin Monohydrate 100mg QD UTI Treatment 1) SMZ-TMP DS BID X3D 2) Ciprofloxacin 250mg BID X3D 3) Levofloxacin 250mg QD X3D 4) Nitrofurantoin Monohydrate 100mg BID X7D Makena (Hydroxyprogesterone Caproate) 250mg/ml Preservative Free Hydroxyprogesterone 250mg/ml Alere Obstetrical Homecare Intramuscular Solution QW QW MD Line 404-316-2013 Hydroxyprogesterone compounded by PharMerica is delivered directly to patient via Alere Obstetrical Homecare Administered by Alere Obstetrical Homecare Nurse

Page 35 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Mavik (Trandolapril) 1, 2, 4mg Tablet QD 1) Lisinopril 20-40mg QD 2) Benazepril 20-40mg QD Dose Conversion 3) Enalapril 10-40mg QD 4) Captopril 25-100mg TID Trandolapril 1mg=Lisinopril 10mg / Trandolapril 5) Ramipril 2.5-20mg QD 2mg=Lisinopril 20mg / Trandolapril 4mg=Lisinopril 40mg Maxair Autohaler (Pirbuterol) 200mcg Inhalation 1) Albuterol 0.5% Inhalation Solution Q4H PRN 2) Maxair Autohaler to Proair HFA is a 1:1 Conversion Aerosol Powder Q4H PRN Albuterol 0.083% Inhalation Solution Q4H PRN 3) Proair HFA (Albuterol) 0.09mg Inhalation Aerosol Powder Q4H PRN 4) Xopenex HFA Q4H PRN NF 5) Levalbuterol 0.31-1.25mg/3ml Inhalation Solution Q4H PRN NF Maxalt (Rizatriptan) 5, 10mg Tablet PRN 1) Sumatriptan 25-100mg PRN 2) Sumatriptan 5- Quantity Limit 20mg Nasal Spray PRN 3) Naratriptan 1-2.5mg PRN Maxalt MLT 5-10mg=9 Tablets 4) Sumatriptan 6mg/ml Subcutaneous Solution PRN Naratriptan 1-2.5mg=9 Tablets 5) Maxalt MLT 5-10mg PRN NF Sumatriptan 25-100mg=9 Tablets Maxalt MLT (Rizatriptan) 5, 10mg Orally 1) Sumatriptan 25-100mg PRN 2) Sumatriptan 5- Quantity Limit Disintegrating Tablet PRN 20mg Nasal Spray PRN 3) Naratriptan 1-2.5mg PRN Maxalt MLT 5-10mg=9 Tablets 4) Sumatriptan 6mg/ml Subcutaneous Solution PRN Naratriptan 1-2.5mg=9 Tablets Sumatriptan 25-100mg=9 Tablets Maxiflor (Diflorasone Diacetate) 0.05% Ointment High Potency AAA QD-QID High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BID- QID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QD- BID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Maxivate (Betamethasone Dipropionate) 0.05% Medium Potency Lotion AAA QD-BID Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BID- QID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BID- QID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID Medrol (Methylprednisolone) 2, 8, 16, 32mg Tablet Methylprednisolone 4mg QD QD

Melanex (Hydroquinone) 3% Solution AAA BID Excluded Medication Mentax (Butenafine) 1% Cream AAA QD-BID 1) OTC Lamisil Ultra (Butenafine 1%) QD-BID 2) OTC Lotrimin AF (Clotrimazole 1%) BID 3) OTC Micatin (Miconazole 1%) BID 4) Ketoconazole 2% Cream QD

Meridia (Sibutramine) 5, 10, 15mg Capsule QD Excluded Medication (Exception: Obesity Rider) Metadate CD (Methylphenidate) 10, 20, 30, 40, 50, 1) Methylin ER 10-20mg QD 2) Adderall XR 5-30mg Document adequate therapeutic trial or intolerance 60mg Extended Release Capsule QAM QAM 3) Methylphenidate SR (generic for Concerta) to at least 3 formulary alternatives 18-54mg QAM Dose Conversion Amphetamine Salt Combo 5mg=Methylphenidate 10mg Metadate ER (Methylphenidate) 20mg Extended 1) Methylin ER 10-20mg QD 2) Adderall XR 5-30mg Document adequate therapeutic trial or intolerance Release Tablet QD QAM 3) Methylphenidate SR (generic for Concerta) to at least 3 formulary alternatives 18-54mg QAM Dose Conversion Amphetamine Salt Combo 5mg=Methylphenidate 10mg MetroGel Vaginal (Metronidazole) 0.75% Gel QD 1) Clindamycin 300mg BID 2) Metronidazole 500mg BID

Page 36 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Micardis (Telmisartan) 20, 40, 80mg Tablet QD 1) Lisinopril 10-20mg QD NOTE: If Angiotensin Dose Conversion Converting Enzyme Inhibitor allergy or Micardis 40mg=Lisinopril 10mg=Losartan 25mg / contraindication consider Angiotensin Receptor Micardis 80mg=Lisinopril 20mg=Losartan 50mg Blocker 2) Losartan 25-50mg QD 3) Valsartan 80- 160mg QD NF 4) Irbesartan 75-150mg QD NF Micardis HCT (Telmisartan/HCTZ) 40/12.5, 80/12.5, 2 Separate Medications Dose Conversion 80/25mg Tablet QD HCTZ 12.5-25mg QD AND 1) Lisinopril 10-20mg QD Micardis 40mg=Lisinopril 10mg=Losartan 25mg / NOTE: If Angiotensin Converting Enzyme Inhibitor Micardis 80mg=Lisinopril 20mg=Losartan 50mg allergy or contraindication consider Angiotensin NOTE: Consider Lisinopril/HCTZ 10/12.5, 20/12.5, Receptor Blocker 2) Losartan 25-50mg QD 3) 20/25mg or Losartan/HCTZ 50/12.5mg Valsartan 80-160mg QD NF 4) Irbesartan 75-150mg QD NF Microgestin 1/20 (20mcg Ethinyl Estradiol/1mg 1) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Document adequate therapeutic trial or intolerance Norethindrone) Tablet QD Norethindrone) QD 2) Aviane (20mcg Ethinyl to at least 3 formulary oral contraceptives Estradiol/0.1mg Levonorgestrel) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD

Micronor (Norethindrone) 0.35mg Tablet QD Nora-BE (Norethindrone) 0.35mg QD Equivalent Brand and Generic Products Micronor=Nora-BE Midamor (Amiloride) 5mg Tablet QD 1) Amiloride/HCTZ 5/50mg QD 2) Triamterene/HCTZ 37.5/25-75/50mg QD 3) Spironolactone 50-100mg Tablet QD

Mirapex ER (Pramipexole) 0.375, 0.75, 1.5, 3, Parkinson's Disease 4.5mg Extended Release Tablet QD 1) Carbidopa/Levodopa ER 25/100mg BID 2) Bromocriptine 2.5mg QD 3) Amantadine 100mg BID 4) Pramipexole 0.125-1.5mg TID 5) Ropinirole 2-8mg QD 6) Selegiline 5mg QD 7) Carbidopa/Levodopa/Entacapone 12.5/50/200mg TID 8) Ropinrole ER 2-12mg QD NF 9) Zelapar 1.25mg QD NF Restless Leg Syndrome 1) Pramipexole 0.125mg QHS 2) Ropinirole 0.25-4mg QHS Mircette (20mcg Ethinyl Estradiol/0.15mg 1) Reclipsen 0.25 (30mcg Ethinyl Estradiol/0.15 Document adequate therapeutic trial or intolerance Desogestrel x 21 days, 10mcg EE x 5 days) Tablet Desogestrel) QD 2) Microgestin Fe 1/20 (20mcg to at least 3 formulary oral contraceptives QD Ethinyl Estradiol/1mg Norethindrone) QD 3) Aviane (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel) QD

Modicon (35mcg Ethinyl Estradiol/0.5mg 1) Necon 0.5/35 (35mcg Ethinyl Estradiol/0.5mg Equivalent Brand and Generic Products Norethindrone) Tablet QD Norethindrone) QD 2) Necon 1/35 (35mcg Ethinyl Modicon=Necon 0.5/35=Brevicon Estradiol/1mg Norethindrone) QD 3) Brevicon (35mcg Document adequate therapeutic trial or intolerance Ethinyl Estradiol/0.5mg Norethindrone) QD to at least 3 formulary oral contraceptives

MonoNessa (35mcg Ethinyl Estradiol/0.25mg 1) Sprintec (35mcg Ethinyl Estradiol/0.25mg Equivalent Brand and Generic Products Norgestimate) Tablet QD Norgestimate) QD 2) Necon 1/35 (35mcg Ethinyl MonoNessa=Sprintec Estradiol/1mg Norethindrone) QD 3) Necon 0.5/35 Document adequate therapeutic trial or intolerance (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD 4) to at least 3 formulary oral contraceptives Zovia 1/35 (35mcg Ethinyl Estradiol/1mg Ethynodiol diacetate) QD 5) Brevicon (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD Monopril (Fosinopril) 10, 20, 40mg Tablet QD 1) Lisinopril 20-40mg QD 2) Benazepril 20-40mg QD Dose Conversion 3) Enalapril 10-40mg QD 4) Captopril 25-100mg TID Fosinopril 10mg=Lisinopril 10mg / Fosinopril 5) Ramipril 2.5-20mg QD 20mg=Lisinopril 20mg / Fosinopril 40mg=Lisinopril 40mg Mozobil (Plerixafor) 20mg/ml Subcutaneous Solution Mozobil is dispensed via KP Glenlake Pharmacy Criteria Restricted Medication X4D QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Multaq (Dronedarone) 400mg Tablet BID Amiodarone 200-400mg QD

Page 37 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Muse (Alprostadil) 125, 250, 500, 1000mcg Excluded Medication Intraurethral Suppository PRN (Exception: Sexual Dysfunction Rider) Myobloc (Rimabotulinumtoxin B) 2500/0.5, 5000/1, Administered in a healthcare setting by healthcare Criteria Restricted Medication 10000/2U/ml Intramuscular Solution Q12-16W providers QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Naftin (Naftifine) 1% Cream AAA QD; 1% Gel AAA 1) OTC Lamisil Ultra (Butenafine 1%) QD-BID 2) OTC BID Lotrimin AF (Clotrimazole 1%) BID 3) OTC Micatin (Miconazole 1%) BID 4) Ketoconazole 2% Cream QD

Nalfon (Fenoprofen) 200, 400mg Capsule; 600mg 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg Tablet TID-QID BID 3) Ibuprofen 400-800mg TID-QID 4) Sulindac 150-200mg BID 5) Etodolac 200-500mg BID-TID 6) Nabumetone 500-750mg BID 7) Lidocaine 5% Ointment AAA Q4H 8) Diclofenac 25-100mg BID-TID

Namenda (Memantine) 10mg/5ml Solution QD 1) Galantamine 4-12mg BID, Galantamine ER 8- Document adequate therapeutic trial or intolerance 24mg QD 2) Namenda 5-10mg BID 3) Rivastigmine to Galantamine, Aricept, Namenda, and 6mg BID 4) Aricept 5-10mg QD 5) Exelon 2mg/ml Rivastigmine Capsule or Exelon Solution Solution 3ml BID 6) Exelon 4.5-9.6mg/24hr Patch QD NF 7) Razadyne 4mg/ml 1-3 ml BID NF 8) Aricept ODT 5-10mg QD NF Naprelan CR (Naproxen Sodium) 375, 500, 750mg 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg Extended Release Tablet QD BID 3) Ibuprofen 400-800mg TID-QID 4) Sulindac 150-200mg BID 5) Etodolac 200-500mg BID-TID 6) Nabumetone 500-750mg BID 7) Lidocaine 5% Ointment AAA Q4H 8) Diclofenac 25-100mg BID-TID 9) Indomethacin 25-75mg QD-BID 10) Tolmetin 200- 600mg TID Nasacort AQ (Triamcinolone Acetonide) 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) Age Recommendations 55mcg/Actuation Nasal Spray 1-2 SPRAYS IEN QD OTC Allegra 60mg BID 4) Fluticasone 2 SPRAYS Fluticasone=4 years of age and older / IEN QD 5) Flunisolide 2 SPRAYS IEN BID 6) Flunisolide=6 years of age and older / Triamcinolone 2 SPRAYS IEN QD NF Triamcinolone=2 years of age and older Nasonex (Mometasone Furoate) 0.05mg/Actuation 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) Age Recommendations Nasal Spray 2 SPRAYS IEN QD OTC Allegra 60mg BID 4) Fluticasone 2 SPRAYS Fluticasone=4 years of age and older / IEN QD 5) Flunisolide 2 SPRAYS IEN BID 6) Flunisolide=6 years of age and older / Triamcinolone 2 SPRAYS IEN QD NF 7) Veramyst 2 Triamcinolone=2 years of age and older / SPRAYS IEN QD NF 8) QNASL 2 SPRAYS IEN QD Veramyst=2 years of age and older / QNASL=12 NF years of age and older / Nasonex=2 years of age and older Natazia (3mg Estradiol Valerate x 2 days, 2mg 1) Tri-Sprintec (35mcg Ethinyl Estradiol/0.18mg Document adequate therapeutic trial or intolerance EV/2mg Dienogest x 5 days, 2mg EV/3mg Norgestimate x 7 days, 35mcg EE/0.215mg NG x 7 to at least 3 formulary oral contraceptives Dienogest x 17 days, 1mg EV x 2 days) Tablet QD days, 35mcg EE/0.25mg NGx 7 days) QD 2) Trivora (30mcg Ethinyl Estradiol/0.05mg Levonorgestrel x 6 days, 40mcg EE/0.075mg LVNGL x 5 days, 30mcg EE/0.125mg LVNGL x 10 days) QD 3) Leena (35mcg Ethinyl Estradiol/0.5mg Norethindrone x 7 days, 35mcg EE/1mg NE x 9 days, 35mcg EE/0.5mg NE x 5 days) QD

Necon 10/11 (35mcg Ethinyl Estradiol/0.5mg 1) Necon 0.5/35 (35mcg Ethinyl Estradiol/0.5mg Document adequate therapeutic trial or intolerance Norethindrone x 10 days, 35mcg EE/1mg NE x 11 Norethindrone) QD 2) Necon 1/35 (35mcg Ethinyl to at least 3 formulary oral contraceptives days) Tablet QD Estradiol/1mg Norethindrone) QD 3) Leena (35mcg Ethinyl Estradiol/0.5mg Norethindrone x 7 days, 35mcg EE/1mg NE x 9 days, 35mcg EE/0.5mg NE x 5 days) QD 4) Brevicon (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD Neulasta (Pegfilgrastim) 6mg/0.6ml Subcutaneous Neupogen (Filgrastim) 5mg/kg/day QD 24 hours after Solution 24 hours after chemotherapy chemotherapy

Page 38 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Neupro (Rotigotine) Transdermal Patch 1, 2, 3, 4, 6, Parkinson's Disease 8mg/24hr QD 1) Carbidopa/Levodopa ER 25/100mg BID 2) Bromocriptine 2.5mg QD 3) Amantadine 100mg BID 4) Pramipexole 0.125-1.5mg TID 5) Ropinirole 2-8mg QD 6) Selegiline 5mg QD 7) Carbidopa/Levodopa/Entacapone 12.5/50/200mg TID 8) Ropinrole ER 2-12mg QD NF 9) Zelapar 1.25mg QD NF 10) Mirapex ER 0.75-4.5mg QD NF Restless Leg Syndrome 1) Pramipexole 0.125mg QHS 2) Ropinirole 0.25-4mg QHS

Nevanac (Nepafenac) 0.1% Ophthalmic Suspension 1) Diclofenac 0.1% 1GTT QID 2) Ketorolac 0.5% 1 1 GTT TID GTT QID 3) Prednisolone 1% 1-2 GTTS BID-QID 4) Fluorometholone 0.1% 1-2 GTTS BID-QID 5) Dexamethasone 0.1% 1-2 GTTS BID-QID 6) Ketorolac 0.4% 1 GTT QID 7) Flurbiprofen 0.03% 1 GTT QID NF 8) Vexol 1% 1-2 GTT QID NF 9) Bromfenac 0.09% 1 GTT QD-BID NF 10) Lotemax 0.5% 1-2 GTT QID NF Nexavar (Sorafenib) 200mg Tablet 2T BID 1) Torisel 25mg IV QW 2) Sutent 50mg QD NOTE: 4 Sutent preferred when initiating therapy weeks on then 2 weeks off FDA approved for treatment of advanced renal cell cancer (RCC) or unresectable hepatocellular cancer (HCC) Nexium (Esomeprazole) 20, 40mg Capsule QD-BID 1) Pantoprazole 40mg QD 2) OTC Omeprazole 20mg Excluded Medication QD 3) OTC Zegerid 20/1100mg QD 4) OTC Prevacid 15mg QD Niaspan (Niacin) 500, 750, 1000mg Extended OTC Slo-Niacin 500mg QD (Titrate to 2000mg/day as Release Tablet QD tolerated using .PITTTSLONIACIN) Nitro-Dur (Nitroglycerin) 0.1, 0.2, 0.3, 0.4, 0.6, 1) Minitran 0.1-0.6mg/hr Patch Apply 12-14 hours 0.8mg/hr Transdermal Patch then remove 10-12 hours 2) Nitro-Dur 0.8mg/hr Patch Apply 12-14 hours then remove 10-12 hours Apply 12-14 hours then remove 10-12 hours Nordette (30mcg Ethinyl Estradiol/0.15mg 1) Reclipsen (30mcg Ethinyl Estradiol/0.15mg Equivalent Brand and Generic Products Levonorgestrel) Tablet QD Desogestrel) QD 2) Levora (30mcg Ethinyl Nordette=Levora Estradiol/0.15mg Levonorgestrel) QD 3) Microgestin Document adequate therapeutic trial or intolerance Fe 1.5/30 (30mcg Ethinyl Estradioll/1.5mg to at least 3 formulary oral contraceptives Norethindrone) QD Norflex (Orphenadrine Citrate) 100mg Extended 1) Cyclobenzaprine 10mg TID 2) Chlorzoxazone 250- Release Tablet BID 500mg TID 3) Carisoprodol 350mg TID 4) Tizanidine 4mg TID 5) Methocarbamol 500-750mg QID 6) Baclofen 10-20mg TID Norgesic (Orphenadrine Citrate/Aspirin/Caffeine) 2 Separate Medications 25/385/30mg Tablet TID-QID OTC Aspirin 325mg TID-QID AND 1) Cyclobenzaprine 10mg TID 2) Chlorzoxazone 250- 500mg TID 3) Carisoprodol 350mg TID 4) Tizanidine 4mg TID 5) Methocarbamol 500-750mg QID 6) Baclofen 10-20mg TID Noritate (Metronidazole) 1% Cream AAA QD Metronidazole 0.75% Cream, Gel AAA BID Noroxin (Norfloxacin) 400mg Tablet BID Prostatitis 1) SMZ-TMP DS BID X14D 2) Ciprofloxacin 500mg BID X14D Urinary Tract Infection 1) SMZ-TMP DS BID X3D 2) Ciprofloxacin 250mg BID X3D 3) Levofloxacin 250mg QD X3D 4) Nitrofurantoin Monohydrate 100mg BID X7D NovoLog (Insulin Aspart) 100U/ml Subcutaneous Novolin R (Insulin Regular) SC 30 minutes AC NovoLog to Novolin R is a 1:1 Conversion Solution SC 5-10 minutes AC Document a) member with DM1 b) adequate therapeutic trial or intolerance (Persistent hypoglycemia) to Novolin R c) member using NovoLog via Insulin Pump d) member using Humulin R (Insulin Regular) 500U/ml e) Isolated post-prandial hyperglycemia despite titration and A1c within 0.5% of goal

Page 39 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

NovoLog 70/30 (Insulin Aspart Protamine/Insulin Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes Dose Conversion Aspart) 100U/ml Injection Solution SC 15 minutes AC OR NovoLog 70/30 20U=Novolin 70/30 20U=Novolin N AC 2 Separate Medications (NPH) 14U+Novolin R (Insulin Regular) 6U Novolin N (NPH) SC 15-30 minutes AC AND 1) Insulin Administration Device Novolin R (Insulin Regular) SC 30 minutes AC 2) Document a) member is unable to accurately draw NovoLog (Insulin Aspart) SC 5-10 minutes AC NF up insulin due to upper extremity amputation, visual impairment, young age, Parkinson's Disease, Rheumatoid Arthritis b) member administers doses < 5U c) school or day care requires insulin cartridge device for insulin administration while member is outside of primary caretaker's care

NovoLog FlexPen (Insulin Aspart) 100U/ml Injection 1) Novolin R (Insulin Regular) SC 30 minutes AC 2) Adjust based on patient response Solution SC 15 minutes AC NovoLog (Insulin Aspart) SC 5-10 minutes AC NF Insulin Administration Device Document a) member is unable to accurately draw up insulin due to upper extremity amputation, visual impairment, young age, Parkinson's Disease, Rheumatoid Arthritis b) member administers doses < 5U c) school or day care requires insulin cartridge device for insulin administration while member is outside of primary caretaker's care

Noxafil (Posaconazole) 40mg/ml Suspension 200mg Voriconazole 200mg BID NF TID

Nucynta (Tapentadol Hydrochloride) 50, 75, 100mg 1) Oxycodone/Acetaminophen 5/325-10/325mg Q6H Tablet Q6-8H 2) Morphine 15-30mg Q4H 3) Hydromorphone 2-8mg Q4-6H 4) Oxycodone 5-30mg Q4-6H 5) Morphine Solution 20mg/ml 0.5-1.5ml Q4H 6) Meperidine 50- 150mg Q3-4H Nucynta ER (Tapentadol Hydrochloride) 50, 100, 1) Morphine ER 60-100mg BID 2) Fentanyl 25- Dose Conversion 150, 200, 250mg Extended Release Tablet BID 100mcg/hr Q72H 3) Butrans 5-20mcg/hr QW NF Morphine 30mg=Butrans 5mcg/hr=Tapentadol 200mg / Morphine 90mg=Fentanyl 25mcg/hr Document adequate therapeutic trial or intolerance to Morphine ER and Fentanyl Nuedexta (Dextromethorphan 1) Amitriptyline 50-75mg QD 2) Citalopram 10-30mg Hydrobromide/Quinidine Sulfate) 20/10mg Capsule QD 3) Nortriptyline 50-100mg QD 4) Imipramine 10- BID 20mg QD Nuquin HP (Hydroquinone) 4% Cream, Gel AAA BID Excluded Medication

NuvaRing (15mcg Ethinyl Estradiol/0.12mg 1) Aviane (20mcg Ethinyl Estradiol/0.1mg Document adequate therapeutic trial or intolerance Etonogestrel) Vaginal Insert Insert for 3 weeks and Levonorgestrel) QD 2) Microgestin Fe 1/20 (20mcg to at least 3 formulary oral contraceptives remove for 1 week Ethinyl Estradiol/1mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD

Nuvigil (Armodafinil) 50, 150, 250mg Tablet QAM Narcolepsy Dose Conversion 1) OTC Caffeine 100-200mg Q3-4H 2) Methylin 10- Modafinil 50mg=Nuvigil 50mg / 60mg Divided BID-TID 3) Adderall 5-60mg Divided Modafinil100mg=Nuvigil 150mg 0.5T / Modafinil dose 4) Dextroamphetamine CR 5-60mg QD 200mg=Nuvigil 250mg 0.5T / Modafinil Obstructive Sleep Apnea 300mg=Nuvigil 250mg Modafinil 100-200mg QAM NF Ocella (30mcg Ethinyl Estradiol/3mg Drospirenone) 1) Reclipsen (30mcg Ethinyl Estradiol/0.15mg Document adequate therapeutic trial or intolerance Tablet QD Desogestrel) QD 2) Microgestin Fe 1.5/30 (30mcg to at least 3 formulary oral contraceptives Ethinyl Estradiol/1.5mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD

Ocufen (Flurbiprofen) 0.03% Ophthalmic Solution 1 1) Diclofenac 0.1% 1GTT QID 2) Ketorolac 0.5% 1 GTT QID GTT QID 3) Prednisolone 1% 1-2 GTTS BID-QID 4) Fluorometholone 0.1% 1-2 GTTS BID-QID 5) Dexamethasone 0.1% 1-2 GTTS BID-QID 6) Ketorolac 0.4% 1 GTT QID

Page 40 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Ocupress (Carteolol) 1% Ophthalmic Solution 1 GTT 1) Timolol 0.25-0.5% 1 GTT QD-BID 2) Levobunolol BID 0.25-0.5% 1-2 GTT QD-BID 3) Betaxolol 0.5% 1-2 GTT BID Oforta (Fludarabine) 10mg Tablet 40mg/m2 QD X5D Fludara 25mg/m2 X5D Q28D NF Q28D Ogestrel (50mcg Ethinyl Estradiol/0.5mg Norgestrel) 1) Zovia 1/50 (50mcg Ethinyl Estradiol/1mg Tablet QD Ethynodiol Diacetate) QD 2) Necon 1/50 (50mcg Mestranol/1mg Norethindrone) QD Oleptro (Trazodone) 150, 300mg Extended Release 1) Fluoxetine 20-40mg QD 2) Citalopram 20-40mg Dose Conversion Tablet QPM QD 3) Sertraline 50-100mg QD 4) Paroxetine 10- Oleptro 150mg=Trazodone 150mg 0.5T BID / 40mg QD 5) Trazodone 150-400mg QD 6) Oleptro 300mg=Trazodone 150mg BID Escitalopram 10-20mg QD 7) Mirtazapine 45mg QHS 8) Fluvoxamine 50-300mg QD NF 9) Mirtazapine ODT 15-45mg QD NF Olux (Clobetasol Propionate) 0.05% Foam AAA BID Very High Potency Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID

Omnaris (Ciclesonide) 50mcg/Actuation Nasal Spray 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) Age Recommendations 2 SPRAYS IEN QD OTC Allegra 60mg BID 4) Fluticasone 2 SPRAYS Fluticasone=4 years of age and older / IEN QD 5) Flunisolide 2 SPRAYS IEN BID 6) Flunisolide=6 years of age and older / Triamcinolone 2 SPRAYS IEN QD NF 7) Veramyst 2 Triamcinolone=2 years of age and older / SPRAYS IEN QD NF 8) QNASL 2 SPRAYS IEN QD Veramyst=2 years of age and older / QNASL=12 NF 9) Nasonex 2 SPRAYS IEN QD NF 10) Zetonna 1 years of age and older / Nasonex=2 years of age SPRAY IEN QD NF and older / Zetonna=12 years of age and older / Omnaris=6 years of age and older Omnicef (Cefdinir) 300mg Capsule BID 3rd 1) Cefdinir 125mg/5ml-250mg/5ml 7mg/kg BID 3rd Generation Generation Omnitrope (Somatropin) 5/1.5, 10/1.5mg/ml Criteria Restricted Medication Subcutaneous Solution QW QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Onglyza (Saxagliptin) 2.5, 5mg Tablet QD 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin Criteria Restricted Medication 500-1000mg (Maximum 2550mg QD) 3) Metformin QRM approval required prior to being dispensed for ER 500-750mg (Maximum 2000mg QD) 4) Novolin R Commercial, Multi-Choice, Self-Funded, and Triple (Insulin Regular) SC 30 minutes AC 5) Novolin N Tier members. (NPH) SC 15-30 minutes AC 6) Novolin 70/30 Provider must call 404-364-7320 (Option 2) to (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog initiate review by QRM department. (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos 15mg (Maximum 45mg QD)

Opana (Oxymorphone Hydrochloride) 5, 10mg 1) Oxycodone/Acetaminophen 5/325-10/325mg Q6H Tablet Q4-6H 2) Morphine 15-30mg Q4H 3) Hydromorphone 2-8mg Q4-6H 4) Oxycodone 5-30mg Q4-6H 5) Morphine Solution 20mg/ml 0.5-1.5ml Q4H 6) Meperidine 50- 150mg Q3-4H Opana ER (Oxymorphone Hydrochloride) 5, 7.5, 10, 1) Morphine ER 60-100mg BID 2) Fentanyl 25- Dose Conversion 15, 20, 30, 40mg Extended Release Tablet BID 100mcg/hr Q72H 3) Butrans 5-20mcg/hr QW NF 4) Morphine 30mg=Butrans 5mcg/hr=Oxymorphone Nucynta ER 50-250mg BID NF 5) Avinza 30-120mg 10mg=Tapentadol 200mg / Morphine QD NF 90mg=Fentanyl 25mcg/hr Document adequate therapeutic trial or intolerance to Morphine ER and Fentanyl

Page 41 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Optivar (Azelastine) 0.05% Ophthalmic Solution 1 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q3- GTT BID 4 HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID 4) Crolom 4% 1-2 GTTS Q4-6 HOURS NF 5) Emadine 0.05% 1 GTT QID NF 6) Alocril 2% 1-2 GTTS BID NF

Oracea (Doxycycline) 40mg Extended Release 1) Doxycycline 50–200mg QD 2) Minocycline Oracea 40mg=Doxycyline 30mg Immediate Release Capsule QD 50–200mg QD 3) Metronidazole 0.75% Cream, Gel + Doxycycline 10mg Delayed Release AAA BID Orap (Pimozide) 1, 2mg Tablet QD 1) Clonidine 0.1-0.3mg QD 2) Risperidone 1-3mg QD 3) Guanfacine 1-3mg QD 4) Haloperidol 1-4mg QD 5) Ziprasidone 20-80mg QD Ortho-Cept 28 (30mcg Ethinyl Estradiol/0.15mg 1) Reclipsen (30mcg Ethinyl Estradiol/0.15mg Equivalent Brand and Generic Products Desogestrel) Tablet QD Desogestrel) QD 2) Microgestin Fe 1.5/30 (30mcg Ortho-Cept=Reclipsen Ethinyl Estradioll/1.5mg Norethindrone) QD 3) Levora Document adequate therapeutic trial or intolerance (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD to at least 3 formulary oral contraceptives

Ortho-Cyclen (35mcg Ethinyl Estradiol/0.25mg 1) Sprintec (35mcg Ethinyl Estradiol/0.25mg Equivalent Brand and Generic Products Norgestimate) Tablet QD Norgestimate) QD 2) Necon 1/35 (35mcg Ethinyl Ortho-Cyclen=Sprintec Estradiol/1mg Norethindrone) QD 3) Necon 0.5/35 Document adequate therapeutic trial or intolerance (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD 4) to at least 3 formulary oral contraceptives Zovia 1/35 (35mcg Ethinyl Estradiol/1mg Ethynodiol diacetate) QD 5) Brevicon (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD Ortho Evra (20mcg Ethinyl Estradiol/0.15mg 1) Sprintec (35mcg Ethinyl Estradiol/0.25mg Document adequate therapeutic trial or intolerance Norelgestromin) Transdermal Patch Apply QW Norgestimate) QD 2) Aviane (20mcg Ethinyl to at least 3 formulary oral contraceptives Estradiol/0.1mg Levonorgestrel) QD 3) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) QD Ortho-Novum 1/35 (35mcg Ethinyl Estradiol/1mg 1) Sprintec (35mcg Ethinyl Estradiol/0.25mg Equivalent Brand and Generic Products Norethindrone) Tablet QD Norgestimate) QD 2) Necon 1/35 (35mcg Ethinyl Ortho-Novum 1/35=Necon 1/35 Estradiol/1mg Norethindrone) QD 3) Necon 0.5/35 Document adequate therapeutic trial or intolerance (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD 4) to at least 3 formulary oral contraceptives Zovia 1/35 (35mcg Ethinyl Estradiol/1mg Ethynodiol diacetate) QD 5) Brevicon (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD Ortho-Novum 1/50 (50mcg Mestranol/1mg 1) Necon 1/50 (50mcg Mestranol/1mg Norethindrone) Equivalent Brand and Generic Products Norethindrone) Tablet QD QD 2) Zovia 1/50 (50mcg Ethinyl Estradiol/1mg Ortho-Novum 1/50=Necon 1/50 Ethynodiol Diacetate) QD Ortho-Novum 7/7/7 (35mcg Ethinyl Estradiol/0.5mg 1) Nortrel 7/7/7 (35mcg Ethinyl Estradiol/ 0.5mg Equivalent Brand and Generic Products Norethindrone x 7 days, 35mcg EE/0.75mg NE x 7 Norethindrone x 7 days, 35mcg EE/0.75mg NE x 7 Ortho-Novum 7/7/7=Nortrel 7/7/7 days, 35mcg EE/1mg NE x 7 days) Tablet QD days, 35mcg EE/1mg NE x 7 days) QD 2) Tri- Document adequate therapeutic trial or intolerance Sprintec (35mcg Ethinyl Estradiol/0.18mg to at least 3 formulary oral contraceptives Norgestimate x 7 days, 35mcg EE/0.215mg NG x 7 days, 35mcg EE/0.25mg NGx 7 days) QD 3) Trivora (30mcg Ethinyl Estradiol/0.05mg Levonorgestrel x 6 days, 40mcg EE/0.075mg LVNGL x 5 days, 30mcg EE/0.125mg LVNGL x 10 days) QD 4) Leena (35mcg Ethinyl Estradiol/0.5mg Norethindrone x 7 days, 35mcg EE/1mg NE x 9 days, 35mcg EE/0.5mg NE x 5 days) QD

Ortho-Novum 10/11 (35mcg Ethinyl Estradiol/0.5mg 1) Necon 0.5/35 (35mcg Ethinyl Estradiol/0.5mg Equivalent Brand and Generic Products Norethindrone x 10 days, 35mcg EE/1mg NE x Norethindrone) QD 2) Necon 1/35 (35mcg Ethinyl Ortho-Novum 10/11=Necon 10/11 11days) Tablet QD Estradiol/1mg Norethindrone) QD 3) Leena (35mcg Ethinyl Estradiol/0.5mg Norethindrone x 7 days, 35mcg EE/1mg NE x 9 days, 35mcg EE/0.5mg NE x 5 days) QD 4) Brevicon (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD

Page 42 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Ortho Tri-Cyclen (35mcg Ethinyl Estradiol/0.18mg 1) Tri-Sprintec (35mcg Ethinyl Estradiol/0.18mg Equivalent Brand and Generic Products Norgestimate x 7 days, 35mcg EE/0.215mg NG x 7 Norgestimate x 7 days, 35mcg EE/0.215mg NG x 7 Ortho Tri-Cyclen=Tri-Sprintec days, 35mcg EE/0.25mg NG x 7 days) Tablet QD days, 35mcg EE/0.25mg NGx 7 days) QD 2) Sprintec Document adequate therapeutic trial or intolerance (35mcg Ethinyl Estradiol/0.25mg Norgestimate) to at least 3 formulary oral contraceptives Tablet QD 3) Trivora (30mcg Ethinyl Estradiol/0.05mg Levonorgestrel x 6 days, 40mcg EE/0.075mg LVNGL x 5 days, 30mcg EE/0.125mg LVNGL x 10 days) QD 4) Leena (35mcg Ethinyl Estradiol/0.5mg Norethindrone x 7 days, 35mcg EE/1mg NE x 9 days, 35mcg EE/0.5mg NE x 5 days) QD

Ortho Tri-Cyclen Lo (25mcg Ethinyl 1) Tri-Sprintec (35mcg Ethinyl Estradiol/0.18mg Document adequate therapeutic trial or intolerance Estradiol/0.18mg Norgestimate x 7 days, 25mcg Norgestimate x 7 days, 35mcg EE/0.215mg NG x 7 to at least 3 formulary oral contraceptives EE/0.215mg NG x 7 days, 25mcg EE/ 0.25mg NG x days, 35mcg EE/0.25mg NGx 7 days) QD 2) Sprintec 7 days) Tablet QD (35mcg Ethinyl Estradiol/0.25mg Norgestimate) Tablet QD 3) Aviane (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel) QD 4) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) QD

Orudis (Ketoprofen) 50, 75mg Capsule TID-QID 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg BID 3) Ibuprofen 400-800mg TID-QID 4) Sulindac 150-200mg BID 5) Etodolac 200-500mg BID-TID 6) Nabumetone 500-750mg BID 7) Lidocaine 5% Ointment AAA Q4H 8) Diclofenac 25-100mg BID-TID

Oruvail (Ketoprofen) 150, 200mg Extended Release 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg Capsule QD BID 3) Ibuprofen 400-800mg TID-QID 4) Sulindac 150-200mg BID 5) Etodolac 200-500mg BID-TID

Ovcon 35 (35mcg Ethinyl Estradiol/0.4mg 1) Sprintec (35mcg Ethinyl Estradiol/0.25mg Document adequate therapeutic trial or intolerance Norethindrone) Tablet QD Norgestimate) QD 2) Necon 1/35 (35mcg Ethinyl to at least 3 formulary oral contraceptives Estradiol/1mg Norethindrone) QD 3) Necon 0.5/35 (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD 4) Zovia 1/35 (35mcg Ethinyl Estradiol/1mg Ethynodiol diacetate) QD 5) Brevicon (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD Ovcon 50 (50mcg Ethinyl Estradiol/1mg 1) Zovia 1/50 (50mcg Ethinyl Estradiol/1mg Norethindrone) Tablet QD Ethynodiol Diacetate) QD 2) Necon 1/50 (50mcg Mestranol/1mg Norethindrone) QD Ovide (Malathion) 0.5% Lotion Apply to scalp, 1) OTC Nix (Permethrin 1%) 2) OTC Rid, Pronto Plus Apply to scalp, Leave on for 10 minutes, Rinse, Shampoo hair after 8-12 hours, Repeat application if (Pyrethrins 0.33%/Piperonyl Butoxide 4%) 3) OTC Repeat application if lice present 7 days after initial lice present 7 days after initial treatment Cetaphil Cleanser Lotion 4) Malathion 0.5% Lotion treatment NF Oxistat (Oxiconazole) 1% Cream, Lotion BID 1) OTC Lamisil Ultra (Butenafine 1%) QD-BID 2) OTC Lotrimin AF (Clotrimazole 1%) BID 3) OTC Micatin (Miconazole 1%) BID 4) Ketoconazole 2% Cream QD

Oxycontin (Oxycodone Hydrochloride) 10, 15, 20, 1) Morphine ER 60-100mg BID 2) Fentanyl 25- Quantity Limit 30, 40, 60, 80mg Extended Release Tablet QD-BID 100mcg/hr Q72H 3) Butrans 5-20mcg/hr QW NF 4) Oxycontin 10-80mg (30 Day Supply)=60 Tablets Nucynta ER 50-250mg BID NF 5) Avinza 30-120mg Dose Conversion QD NF 6) Opana ER 5-40mg BID NF Morphine 30mg=Butrans 5mcg/hr=Oxycodone 20mg=Oxymorphone 10mg=Tapentadol 200mg / Morphine 90mg=Fentanyl 25mcg/hr Document adequate therapeutic trial or intolerance to Morphine ER and Fentanyl

Page 43 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Pamine (Methscopolamine) 2.5mg Tablet BID Allergic Rhinitis 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) OTC Allegra 60mg BID 4) Fluticasone 2 SPRAYS IEN QD 5) Flunisolide 2 SPRAYS IEN BID 6) Ipratropium 0.03-0.06% 2 SPRAYS IEN BID-QID NF Peptic Ulcer 1) Pantoprazole 40mg QD 2) OTC Omeprazole 20mg QD 3) OTC Zegerid 20/1100mg QD 4) OTC Prevacid 15mg QD

Pancreaze (Pancrelipase) 4200, 10500, 16800, 1) Pancrelipase 5 Unit 10000 Lipase Units/kg QD 2) 21000 Unit Delayed Release Capsule 10000 Lipase Zenpep 5-20 Unit 10000 Lipase Units/kg QD Units/kg QD Pandel (Hydrocortisone Probutate) 0.1% Cream Medium Potency AAA QD-BID Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BID- QID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BID- QID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID Panretin (Alitretinoin) 0.1% Gel AAA BID-QID Document a) AIDS-related Kaposi's Sarcoma b) less than 10 new Kaposi's Sarcoma lesions in the prior month c) adequate therapeutic trial or intolerance to cryotherapy Parlodel (Bromocriptine) 5mg Capsule QD-BID Bromocritpine 2.5mg QD-BID Pataday (Olopatadine) 0.2% Ophthalmic Solution 1 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q3- GTT QD 4 HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID 4) Crolom 4% 1-2 GTTS Q4-6 HOURS NF 5) Emadine 0.05% 1 GTT QID NF 6) Alocril 2% 1-2 GTTS BID NF 7) Optivar 0.05% 1 GTT BID NF 8) Alomide 0.1% 1-2 GTTS QID NF 9) Lastacaft 0.25% 1 GTT QD NF

Patanase (Olopatadine Hydrochloride) 0.6% Nasal 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) Document adequate therapeutic trial or intolerance Spray 2 SPRAYS IEN BID OTC Allegra 60mg BID 4) Fluticasone 2 SPRAYS to Claritin, Zyrtec, or Allegra, at least 1 Nasal IEN QD 5) Flunisolide 2 SPRAYS IEN BID 6) Steroid, and Azelastine Azelastine 2 SPRAYS IEN BID NF Patanol (Olopatadine) 0.1% Ophthalmic Solution 1 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q3- GTT BID 4 HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID 4) Crolom 4% 1-2 GTTS Q4-6 HOURS NF 5) Emadine 0.05% 1 GTT QID NF 6) Alocril 2% 1-2 GTTS BID NF 7) Optivar 0.05% 1 GTT BID NF 8) Alomide 0.1% 1-2 GTTS QID NF 9) Lastacaft 0.25% 1 GTT QD NF 10) Pataday 0.2% 1 GTT QD NF 11) Alrex 0.2% 1 GTT QID NF

Paxil CR (Paroxetine) 12.5, 25, 37.5mg Extended 1) Fluoxetine 20-40mg QD 2) Citalopram 20-40mg Document adequate therapeutic trial or intolerance Release Tablet QD QD 3) Sertraline 50-100mg QD 4) Paroxetine 10- to at least 3 SSRIs 40mg QD 5) Escitalopram 10-20mg QD 6) Mirtazapine 45mg QHS 7) Fluvoxamine 50-300mg QD NF Pediapred (Prednisolone Sodium Phosphate) Prednisolone Sodium Phosphate 15mg/5ml 5-60mg 5mg/5ml Solution 5-60mg QD QD Penlac (Ciclopirox) 8% Solution QD Thymol/Isopropyl Alcohol 4/99% Solution QD KPGA Approved Compound Finger Onychomycosis Document positive fungal culture prior to approval of one 6 week treatment Toe Onychomycosis Document a) positive fungal culture b) DM or Vascular Disease prior to approval one 12 week treatment

Page 44 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Pennsaid (Voltaren) 1.5% Topical Solution Apply 10 1) OTC Aspercreme AAA BID-QID 2) Meloxicam 7.5- GTTS QID 15mg QD 3) Naproxen 250-550mg BID 4) Ibuprofen 400-800mg TID-QID 5) Sulindac 150-200mg BID 6) Etodolac 200-500mg BID-TID 7) Nabumetone 500- 750mg BID 8) Lidocaine 5% Ointment AAA Q4H 9) Diclofenac 25-100mg BID-TID

Pepcid (Famotidine) 40mg Tablet QD-BID 1) OTC Famotidine 10-20mg QD-BID 2) OTC Excluded Medication Ranitidine 75-150mg QD-BID 3) Cimetidine 400- 800mg QD-BID Percocet (Oxycodone/Acetaminophen) 7.5/325, Oxycodone/Acetaminophen 5/325-10/325mg Q6H 7.5/500, 10/650mg Tablet Q6H OR 2 Separate Medications OTC Acetaminophen 325-650mg Q6H AND Oxycodone 5-10mg Q6H Periostat (Doxycycline) 20mg Tablet BID 1) Doxycycline Hyclate 50-100mg BID 2) Minocycline 50-100mg BID Phendiet (Phendimetrazine) 35mg Tablet BID-TID Excluded Medication (Exception: Obesity Rider) Poly-Pred (Neomycin/Polymyxin/Prednisolone) 1) Neomycin/Polymyxin/Hydrocortisone 1% Ophthalmic Solution 1-2 GTTS Q4 HOURS Suspension 1-2 GTTS Q4 HOURS 2) Neomycin/Polymyxin/Dexamethasone 0.1% Suspension 1-2 GTTS Q4 HOURS 3) Tobramycin/Dexamethasone 0.3/0.1% 1-2 GTTS Q4- 6 HOURS Ponstel (Mefenamic Acid) 250mg Capsule QID 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg BID 3) Ibuprofen 400-800mg TID-QID 4) Sulindac 150-200mg BID 5) Etodolac 200-500mg BID-TID 6) Nabumetone 500-750mg BID 7) Lidocaine 5% Ointment AAA Q4H 8) Diclofenac 25-100mg BID-TID 9) Indomethacin 25-75mg QD-BID 10) Tolmetin 200- 600mg TID Portia (30mcg Ethinyl Estradiol/0.15 Levonorgestrel) 1) Reclipsen (30mcg Ethinyl Estradiol/0.15 Equivalent Brand and Generic Products Tablet QD Desogestrel) Tablet QD 2) Levora (30mcg Ethinyl Portia=Levora Estradiol/0.15mg Levonorgestrel) Tablet QD 3) Document adequate therapeutic trial or intolerance Microgestin Fe 1.5/30 (30mcg Ethinyl Estradiol/1.5mg to at least 3 formulary oral contraceptives Norethindrone) QD Pradaxa (Dabigatran) 75, 150mg Capsule 150mg Warfarin 1-10mg QD (Tiitrate to target INR) Document inclusion of: BID a) Irreversible atrial fibrillation If CHADS2 Score=1 b) Identified as an anticoagulation candidate (not ASA) c) Uninterrupted Warfarin therapy for at least 22 weeks d) TTR < 54% If CHADS2 Score≥2 b) Uninterrupted Warfarin therapy for at least 22 weeks c) TTR < 54% AND exclusion of: a) CHADS2 Score=0 b) TTR ≥ 67% c) History of heart valve disorder d) Severe, disabling stroke within the last 6 months e) Stroke within the previous 14 days f) Increased risk for bleeding g) CrCl<30mL/min h) Active liver disease i) Active infective endocarditis j) Anemia or thrombocytopenia k) Malignancy l) Reversible causes of atrial fibrillation m) Pregnancy n) Women of childbearing potential who refuse to use a form of contraception o) Contraindication to warfarin treatment p) Need for anticoagulant treatment of disorders other than atrial fibrillation

Page 45 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Pramosone (Hydrocortisone Acetate/Pramoxine) 1) OTC Hydrocortisone 0.5-1% Cream, Ointment 1/1% Cream, Lotion, Ointment QD-BID AAA BID-QID 2) OTC Prax 1% Cream, Lotion AAA BID-QID 3) Hydrocortisone 2.5% Cream, Lotion, Ointment AAA BID-QID 4) Hydrocortisone 25mg Suppository BID 5) Hydrocortisone 100mg/60ml Enema QD-BID 6) Proctofoam-HC 1/1% QD-BID

Prandin (Repaglinide) 0.5, 1mg Tablet TID-QID 1) Glipizide 5-15mg QD 2) Glyburide 2.5-10mg QD Adjust based on patient response Glipizide preferred if 65 years of age and older due to prolonged half life of Glyburide Prandin (Repaglinide) 2mg Tablet TID-QID 1) Glipizide 10-20mg BID 2) Glyburide 7.5-10mg BID Adjust based on patient response Glipizide preferred if 65 years of age and older due to prolonged half life of Glyburide Premarin (Conjugated Estrogen) 0.3, 0.45, 0.625, Vasomotor Symtoms Adjust to the lowest dose needed to control 0.9, 1.25, 2.5mg Tablet QD 1) Estradiol QD 2) Climara Patch 0.025-0.1mg/24hr symptoms based on patient response Apply weekly Dose Conversion Vaginal/Vulvar Atrophy Premarin 0.3mg=Estradiol 0.5mg / Premarin 1) Estradiol QD 2) Climara Patch 0.025-0.1mg/24hr 0.45mg=Estradiol 0.75mg / Premarin Apply weekly 3) Premarin Vaginal 1gm Apply three 0.625mg=Estradiol 1mg / Premarin 0.9mg=Estradiol times a week 4) Vagifem 10mcg Insert twice weekly 1.5mg / Premarin 1.25mg=Estradiol 2mg / Premarin 5) Estring 2mg Insert for 90 days 2.5mg=No Formulary Alternative

Premphase (Conjugated 2 Separate Medications Dose Conversion Estrogen/Medroxyprogesterone) 0.625/5mg Tablet Day 1-14: Estradiol 1mg QD Day 15-28: Estradiol Premarin 0.625mg=Estradiol 1mg Day 1-14: Conjugated Estrogen QD Day 15-28: 1mg QD AND Medroxyprogesterone 5mg QD Conjugated Estrogen/Medroxyprogesterone QD

Prempro (Conjugated 2 Separate Medications Adjust to the lowest dose needed to control Estrogen/Medroxyprogesterone) 0.3/1.5, Vasomotor Symtoms symptoms based on patient response 0.45/1.5mg, 0.625/2.5, 0.625/5mg Tablet QD 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.025- Dose Conversion 0.1mg/24hr Apply weekly AND 1) Premarin 0.3mg=Estradiol 0.5mg / Premarin Medroxyprogesterone 2.5-5mg QD 2) Nora-BE 0.45mg=Estradiol 0.75mg / Premarin 0.35mg QD 3) Norethindrone 5mg QD 0.625mg=Estradiol 1mg Vaginal/Vulvar Atrophy 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.025- 0.1mg/24hr Apply weekly 3) Premarin Vaginal 1gm Apply three times a week 4) Vagifem 10mcg Insert twice weekly 5) Estring 2mg Insert for 90 days AND 1) Medroxyprogesterone 2.5-5mg QD 2) Nora-BE 0.35mg QD 3) Norethindrone 5mg QD

Prenatal Vitamins (Citranatal DHA, Generet, Prenate OTC Natures Best Prenatal QD Excluded Medication Elite) QD Available OTC Prevacid (Lansoprazole) 15, 30mg Capsule QD-BID 1) Pantoprazole 40mg QD 2) OTC Omeprazole 20mg Excluded Medication QD 3) OTC Zegerid 20/1100mg QD 4) OTC Prevacid 15mg QD Prevacid Solutab (Lansoprazole) 15, 30mg Orally 1) Pantoprazole 40mg QD 2) OTC Omeprazole 20mg Excluded Medication Disintegrating Tablet QD-BID QD 3) Omeprazole 2mg/ml Liquid 10ml QD 4) Lansoprazole 3mg/ml Liquid 10ml QD 5) OTC Zegerid 20/1100mg QD 6) OTC Prevacid 15mg QD Prevpac (Lansoprazole, Amoxicillin, Clarithromycin) 3 Separate Medications Dispense Antibiotics for copays and purchase OTC 30mg Delayed Release Capsule BID, 500mg OTC Omeprazole 20mg BID AND Clarithromycin Omeprazole Capsule 2C BID, 500mg Tablet BID X14D 500mg BID AND Amoxicillin 500mg 2C BID NOTE: If Penicillin allergy or contraindication consider Metronidazole 500mg BID Prilosec (Omeprazole) 10, 20mg Capsule QD-TID 1) Pantoprazole 40mg QD 2) OTC Omeprazole 20mg Excluded Medication QD Pristiq (Desvenlafaxine) 50,100mg Tablet QD 1) Fluoxetine 20-40mg QD 2) Citalopram 20-40mg Document adequate therapeutic trial or intolerance QD 3) Sertraline 50-100mg QD 4) Paroxetine 10- to 2 SSRIs and Venlafaxine 40mg QD 5) Escitalopram 10-20mg QD 6) Bupropion SR/XL 300mg QD 7) Venlafaxine ER 75-225mg QD

Proamatine (Midodrine) 2.5, 5, 10mg Tablet TID Fludrocortisone 0.1-0.2mg QD

Page 46 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Procardia (NIfedipine) 10, 20mg Tablet TID Nifedipine ER 30-60mg QD Proctosol HC (Hydrocortisone) 2.5% Cream AAA Hydrocortisone 2.5% Cream, Lotion, Ointment AAA BID-QID BID-QID Prodigy Glucometer and Test Strips One Touch Ultra 2 Glucometer and One Touch Ultra Document member is unable to accurately use One Test Strips Touch Ultra 2 Glucometer and One Touch Ultra Test Strips due to visual impairment Prolia (Denosumab) 60mg/ml Subcutaneous Administered in a healthcare setting by healthcare Solution Q6M providers 1) Alendronate 10mg QD 2) Alendronate 70mg QW 3) Fortical 200IU QD Alternate nostrils 4) Ibandronate 150mg QM NF 5) Actonel 5mg QD NF 6) Actonel 150mg QM NF 7) Evista 60mg QD 8) Actonel 35mg QW NF Promacta (Eltrombopag Olamine) 25, 50, 75mg Prescribing Physician must call Promacta Cares KP CA Specialty Pharmacy Tablet QD Distribution Program 877-9-PROMACTA MD Line 650-301-5799 / Patient Line 1-877-404- Promacta is delivered directly to patient via KP CA 5777 / Fax Line 650-301-5790 Specialty Pharmacy Prometrium (Progesterone) 100, 200mg Tablet QD 1) Medroxyprogesterone 2.5-5mg QD 2) Nora-BE 0.35mg QD 3) Norethindrone 5mg QD Propecia (Finasteride) 1mg Tablet QD OTC Rogaine (Minoxidil) BID Excluded Medication Prosom (Estazolam) 1, 2mg Tablet QHS 1) Temazepam 15mg QHS 2) Lorazepam 0.5mg QHS Document adequate therapeutic trial or intolerance 3) Oxazepam 10-30mg QHS 4) Trazodone 50-100mg to Trazodone, Zolpidem, and at least 1 QHS 5) Zolpidem 5-10mg QHS Benzodiazepine Protonix (Pantoprazole) 20, 40mg Tablet QD-BID Pantoprazole 40mg QD Excluded Medication Protopic (Tacrolimus) 0.03, 0.1% Ointment AAA Atopic Dermatitis Protopic preferred over Elidel if Vitiligo BID Elidel 1% Cream AAA BID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BID- QID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BID- QID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QD- BID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID Proventil HFA (Albuterol) 0.09mg Inhalation Aerosol Proair HFA (Albuterol) 0.09mg Inhalation Aerosol Proventil HFA to Proair HFA is a 1:1 Conversion Powder Q4H PRN Powder Q4H PRN Provigil (Modafinil) 100, 200mg Tablet QAM Narcolepsy Dose Conversion 1) OTC Caffeine 100-200mg Q3-4H 2) Methylin 10- Modafinil 50mg=Nuvigil 50mg / 60mg Divided BID-TID 3) Adderall 5-60mg Divided Modafinil100mg=Nuvigil 150mg 0.5T / Modafinil dose 4) Dextroamphetamine CR 5-60mg QD 200mg=Nuvigil 250mg 0.5T / Modafinil Obstructive Sleep Apnea 300mg=Nuvigil 250mg 1) Modafinil 100-200mg QAM NF 2) Nuvigil 50- 250mg QAM NF Prozac Weekly (Fluoxetine) 90mg Delayed Release 1) Fluoxetine 20-40mg QD 2) Citalopram 20-40mg Document adequate therapeutic trial or intolerance Capsule QW QD 3) Sertraline 50-100mg QD 4) Paroxetine 10- to at least 3 SSRIs 40mg QD 5) Escitalopram 10-20mg QD 6) Mirtazapine 45mg QHS 7) Fluvoxamine 50-300mg QD NF 8) Paxil CR 12.5-37.5mg QD NF 9) Viibryd 10- 40mg QD NF

Page 47 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Psorcon (Diflorasone Diacetate) 0.05% Cream AAA High Potency QD-QID High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BID- QID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QD- BID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Psorcon (Diflorasone Diacetate) 0.05% Ointment Very High Potency AAA QD-QID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID

Pulmicort Flexhaler (Budesonide) 90, 180mcg 1) Qvar 40-80mcg 1-2 PUFFS QD-BID 2) Flovent Document adequate trial or intolerance to Qvar Inhalation Powder 2 PUFFS BID HFA 44mcg 2 PUFFS BID NOTE: Flovent HFA 80mcg 2 PUFFS BID and Asmanex 220mcg 2 44mcg for patients 4-11 years of age 3) Asmanex PUFFS QD within the past 3 months 110-220mcg 1-2 PUFFS QD Pulmicort is the preferred Inhaled Corticosteroid during pregnancy Dose Conversion Pulmicort Flexhaler 90mcg 2 PUFFS BID=Qvar 80mcg 1PUFF BID=Flovent 44mcg 2 PUFFS BID

Pulmicort 180mcg 2 PUFFS BID=Qvar 80mcg 2 PUFFS BID=Asmanex 220mcg 2 PUFFS QD

Pylera (Tetracycline 3 Separate Medications Dispense Antibiotics for copays and purchase OTC Hydrochloride/Metronidazole/Bismuth Subcitrate OTC Omeprazole 20mg BID AND Clarithromycin Omeprazole Potassium) 125/125/140mg Capsule 3C QID with 500mg BID AND Amoxicillin 500mg 2C BID NOTE: If OTC Omeprazole 20mg BID X10D Penicillin allergy or contraindication consider Metronidazole 500mg BID QNASL (Beclomethasone Dipropionate) 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) Age Recommendations 80mcg/Actuation Nasal Aerosol Liquid 2 SPRAYS OTC Allegra 60mg BID 4) Fluticasone 2 SPRAYS Fluticasone=4 years of age and older / IEN QD IEN QD 5) Flunisolide 2 SPRAYS IEN BID 6) Flunisolide=6 years of age and older / Triamcinolone 2 SPRAYS IEN QD NF 7) Veramyst 2 Triamcinolone=2 years of age and older / SPRAYS IEN QD NF Veramyst=2 years of age and older / QNASL=12 years of age and older Qsymia (Phentermine/Topiramate) 3.75/23, 7.5/46, Excluded Medication 11.25/69, 15/92mg Extended Release Capsule QD (Exception: Obesity Rider)

Quixin (Levofloxacin) 0.5% Ophthalmic Solution 1-2 1) Ofloxacin 0.3% Solution 1-2 GTTS QID 2) GTTS Q4H Ciprofloxacin 0.3% Solution 1-2 GTTS Q4HS NF 3) Sodium Sulfacetamide 10% Solution 1-3 GTTS Q2- 3H 4) Gentamicin 0.3% Solution 1-2 GTTS QID 5) Erythromycin 0.5% Ointment APPLY RIBBON Q4H 6) Vigamox Solution 0.5% 1 GTT BID NF 7) Ciloxan 0.3% Ointment APPLY RIBBON BID-TID NF 8) Zymaxid 0.5% Solution 1 GTT QID

Qutenza (Capsaicin) 8% Patch Apply up to 4 1) OTC LMX 4 (Lidocaine 4% Cream) AAA QID 2) Qutenza is only indicated for postherpetic neuralgia patches for 60 mintues every 3 months OTC Axsain cream (Lidocaine 4%/Capsaicin 0.25% Cream) AAA QID 3) Lidocaine 2% Gel AAA QID 4) Lidocaine 5% Ointment AAA 5G QID

Page 48 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Ranexa (Ranolazine) 500, 1000mg Extended 1) Atenolol 50-100mg QD 2) Nitroglycerin CR 6.5mg Document adequate trial or intolerance to Beta Release Tablet BID BID-TID 3) Isosorbide Mononitrate ER 30-60mg QD Blocker (NOTE: If Beta Blocker allergy or 4) Isosorbide Dinitrate 5-40mg TID 5) Metoprolol contraindication consider Verapamil ER or Diltiazem Tartrate 50-100mg BID 6) Verapamil SR 240mg QD ER) and Long-Acting Nitrate (NOTE: If patient is 7) Diltiazem ER 240mg QD 8) Nifedipine ER 30- hypertensive consider Nifedipine ER) 690mg QD Rapaflo (Silodosin) 4, 8mg Capsule QD 1) Doxazosin 1-8mg QD 2) Terazosin 1-10mg QD 3) Tamsulosin 0.4mg QD 4) Alfuzosin ER 10mg QD NF

Razadyne (Galantamine) 4mg/ml Solution 3ml BID 1) Galantamine 4-12mg BID, Galantamine ER 8- Document adequate therapeutic trial or intolerance 24mg QD 2) Namenda 5-10mg BID 3) Rivastigmine to Galantamine, Aricept, Namenda, and Exelon 6mg BID 4) Aricept 5-10mg QD 5) Exelon 2mg/ml Capsule or Solution Solution 3ml BID 6) Exelon 4.5-9.6mg/24hr Patch QD NF Rectiv (Nitroglycerin) 0.4% Ointment Apply intra- Nitroglycerin 0.2% Ointment Apply intra-anally Q12H KPGA Approved Compound anally Q12H Relpax (Eletriptan) 20, 40mg Tablet PRN 1) Sumatriptan 25-100mg PRN 2) Sumatriptan 5- Quantity Limit 20mg Nasal Spray PRN 3) Naratriptan 1-2.5mg PRN Maxalt MLT 5-10mg=9 Tablets 4) Sumatriptan 6mg/ml Subcutaneous Solution PRN Naratriptan 1-2.5mg=9 Tablets 5) Maxalt MLT 5-10mg PRN NF 6) Zomig 5mg PRN Relpax 20-40mg=6 Tablets NF 7) Zomig 2.5mg PRN NF Sumatriptan 25-100mg=9 Tablets Zomig 2.5mg=6 Tablets Zomig 5mg=3 Tablets Remeron Soltab (Mirtazapine) 15, 30, 45mg Orally 1) Fluoxetine 20-40mg QD 2) Citalopram 20-40mg Document adequate therapeutic trial or intolerance Disintegrating Tablet QD QD 3) Sertraline 50-100mg QD 4) Paroxetine 10- to at least 3 SSRIs 40mg QD 5) Escitalopram 10-20mg QD 6) Mirtazapine 45mg QHS 7) Fluvoxamine 50-300mg QD NF 8) Mirtazapine ODT 15-45mg QD NF Remicade (Infliximab) 100mg Intravenous Powder 1) Humira 40mg QOW 2) Enbrel 50mg QW KP Dermatology, GI, or Rheumatology for Solution 5mg/kg Q8W Contact CU Infusion Center 770-431-4367 or SW Infusion Center 770-603-3663 Network Dermatology, GI, or Rheumatology Contact Provider Relations 404-364-4934 Renal Vitamins (Nephrocaps, Nephronex, OTC Full Spectrum B with Vitamin C QD Excluded Medication Nephrotrans) QD Available OTC Renova (Tretinoin) 0.02, 0.05% Cream AAA QHS Retin-A 0.025-0.1% Cream, Gel AAA QHS Excluded Medication for patients > 36 YOA Renvela (Sevelamer Carbonate) 0.8, 2.4gm/Packet 1) Phoslyra 667mg/5ml 15ml with meals 2) Eliphos Powder for Suspension 1 Packet with meals 667mg 3C with meals 3) Renvela 800mg 3T with meals Requip XL (Ropinirole) 2, 4, 6, 8, 12mg Extended Parkinson's Disease Release Tablet QD 1) Carbidopa/Levodopa ER 25/100mg BID 2) Bromocriptine 2.5mg QD 3) Amantadine 100mg BID 4) Pramipexole 0.125-1.5mg TID 5) Ropinirole 2-8mg QD 6) Selegiline 5mg QD 7) Carbidopa/Levodopa/Entacapone 12.5/50/200mg TID 8) Ropinrole ER 2-12mg QD NF Restless Leg Syndrome 1) Pramipexole 0.125mg QHS 2) Ropinirole 0.25-4mg QHS Restoril (Temazepam) 7.5, 22.5mg Capsule QHS Temazepam 15, 30mg QHS Retin-A Micro (Tretinoin) 0.04, 0.1% Gel AAA QHS Retin-A 0.025-0.1% Cream, Gel AAA QHS Excluded Medication for patients > 36 YOA

Revatio (Sildenafil) 20mg Tablet TID Pulmonary Hypertension 1) Viagra 50mg 0.5T TID 2) Cialis 20mg 2T QD 3) Adcirca 20mg 2T QD Revlimid (Lenalidomide) 5, 10, 15, 25mg Capsule Prescribing Physician must call RevAssist Program KP CA Specialty Pharmacy QD 888-423-5436 MD Line 650-301-5799 / Patient Line 1-877-404- Revlimid is delivered directly to patient via KP CA 5777 / Fax Line 650-301-5790 Specialty Pharmacy

Page 49 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Rhinocort Aqua (Budesonide) 0.032mg/Actuation 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) Age Recommendations Nasal Spray 2 SPRAYS IEN BID OTC Allegra 60mg BID 4) Fluticasone 2 SPRAYS Fluticasone=4 years of age and older / IEN QD 5) Flunisolide 2 SPRAYS IEN BID 6) Flunisolide=6 years of age and older / Triamcinolone 2 SPRAYS IEN QD NF 7) Veramyst 2 Triamcinolone=2 years of age and older / SPRAYS IEN QD NF 8) QNASL 2 SPRAYS IEN QD Veramyst=2 years of age and older / QNASL=12 NF 9) Nasonex 2 SPRAYS IEN QD NF 10) Zetonna 1 years of age and older / Nasonex=2 years of age SPRAY IEN QD NF 11) Omnaris 2 SPRAYS IEN QD and older / Zetonna=12 years of age and older / NF Omnaris=6 years of age and older / Rhinocort Aqua=6 years of age and older Riomet (Metformin) 500mg/5ml Solution QD-BID 1) Metformin 500-1000mg (Maximum 2550mg QD) 2) Adjust based on patient response Metformin ER 500-750mg (Maximum 2000mg QD)

Ritalin LA (Methylphenidate) 10, 20, 30, 40mg 1) Methylin ER 10-20mg QD 2) Adderall XR 5-30mg Document adequate therapeutic trial or intolerance Extended Release Capsule QAM QAM 3) Methylphenidate SR (generic for Concerta) to at least 3 formulary alternatives 18-54mg QAM Dose Conversion Amphetamine Salt Combo 5mg=Methylphenidate 10mg Rozerem (Ramelteon) 8mg Tablet QHS 1) Trazodone 50-100mg QHS 2) Temazepam 15- Document adequate therapeutic trial or intolerance 30mg QHS 3) Zolpidem 5-10mg QHS 4) Zaleplon 5- to Trazodone, Zolpidem, and at least 1 10mg QHS 5) Ambien CR 6.25-12.5mg QHS NF Benzodiazepine Sabril (Vigabatrin) 500mg Tablet BID Precribing Physician must call SHARE Distribution Criteria Restricted Medication Program 888-45-SHARE QRM approval required prior to being dispensed for Sabril is delivered directly to patient via CuraScript Commercial, Multi-Choice, Self-Funded, and Triple Specialty Pharmacy Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Salagen (Pilocarpine) 5mg Tablet TID-QID Pilocarpine 0.5, 1, 2, 3, 4, 6% Ophthalmic Solution 5- Ophthalmic Solution may be administered orally 10 GTTS PO TID Samsca (Tolvaptan) 15, 30mg Tablet QD 1) OTC Sodium Chloride 1gm QD 2) Demeclocycline Quantity Limit 300mg BID-TID NF Samsca 15-30mg=10 Tablets Sanctura (Trospium) 20mg Tablet BID 1) Oxybutinin 5mg BID-TID 2) Oxybutynin XL 5-15mg QD 3) Oxytrol 3.9mg/day Patch Apply twice weekly 4) Trospium 20mg BID NF Sanctura XR (Trospium) 60mg Extended Release 1) Oxybutinin 5mg BID-TID 2) Oxybutynin XL 5-15mg Capsule QD QD 3) Oxytrol 3.9mg/day Patch Apply twice weekly 4) Trospium 20mg BID NF 5) Tolterodine 1-2mg BID NF 6) Toviaz 4-8mg QD NF 7) Enablex 7.5-15mg QD NF 8) Detrol LA 2-4mg QD NF 9) Vesicare 5-10mg QD NF 10) Trospium XR 60mg QD NF

Sancuso (Granisetron) 3.1mg/24hr Transdermal 1) Metoclopramide 1-2mg/kg 30 minutes prior to Patch Apply 24-48 hours prior to chemotherapy chemotherapy 2) Prochlorperazine 5-10mg Q6H 3) Dexamethasone 20mg 30 minutes prior to chemotherapy 4) Ondansetron 4-8mg 30 minutes prior to chemotherapy 5) Ondansetron 4-8mg ODT 30 minutes prior to chemotherapy 6) Transderm Scop 1.5mg Apply Q72H NF 7) Granisetron 2mg 1 hour prior to chemotherapy NF Sandostatin (Octreotide) 50, 100, 200, 500, Document Acromegaly, Metastatic carcinoid tumor, 1000mcg/ml Injection Solution TID or Vasoactive intestinal peptide secreting tumor

Sandostatin LAR Depot (Octreotide) 10, 20, 30mg Octreotide 50mcg TID NF Document Acromegaly, Metastatic carcinoid tumor, Intramuscular Powder for Suspension Q4W or Vasoactive intestinal peptide secreting tumor

Santyl (Collagenase) 250U/gm Ointment AAA QD Urea 40% Cream AAA BID

Saphris (Asenapine) 5, 10mg Sublingual Tablet BID 1) Risperidone 4mg QD 2) Haloperidol 0.5-5mg BID- TID 3) Thiothixene 2mg TID 4) Quetiapine 400- 800mg QD 5) Ziprasidone 20-80mg BID 6) Olanzapine 10mg QD 7) Olanzapine ODT 10mg QD 8) Latuda 40-80mg QD NF 9) Abilify 10-15mg QD

Page 50 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Sarafem (Fluoxetine) 10mg Capsule; 10, 15, 20mg 1) Fluoxetine 20-40mg QD 2) Citalopram 20-40mg Document adequate therapeutic trial or intolerance Tablet QD QD 3) Sertraline 50-100mg QD 4) Paroxetine 10- to at least 3 SSRIs 40mg QD 5) Escitalopram 10-20mg QD 6) Mirtazapine 45mg QHS 7) Fluvoxamine 50-300mg QD NF 8) Paxil CR 12.5-37.5mg QD NF 9) Viibryd 10- 40mg QD NF Savella (Milnacipran) 12.5, 25, 50, 100mg Tablet 1) Amitriptyline* 50mg QHS 2) Nortriptyline* (<65 Document adequate therapeutic trial or intolerance BID YOA: 25mg QHS / > 65 YOA: 10mg QHS) 3) to 1 TCA*, Tramadol*, and Cyclobenzaprine Cyclobenzaprine* 10mg TID 4) Tramadol* 50mg BID *Not recommended in the elderly and not a required medication for patients over 65 years old

Seasonale (30mcg Ethinyl Estradiol/0.15mg 1) Levora (30mcg Ethinyl Estradiol/0.15mg Equivalent Brand and Generic Products Levonorgestrel x 84 days) Tablet QD Levonorgestrel) QD 2) Jolessa (30mcg Ethinyl Seasonale=Jolessa=Quasense Estradiol/0.15mg Levonorgestrel x 84 days) QD NF Levora Dose Recommendation 3) Quasense (30mcg Ethinyl Estradiol/0.15mg Day 1-84: Take 1 active tablet QD (Discard placebo Levonorgestrel x 84 days) QD NF tablets from first 3 packets) Day 85-91: Take 1 placebo tablet QD Seasonique (30mcg Ethinyl Estradiol/0.15mg 1) Levora (30mcg Ethinyl Estradiol/0.15mg Equivalent Brand and Generic Products Levonorgestrel x 84 days, 10mcg EE x 7 days) Levonorgestrel) QD 2) Jolessa (30mcg Ethinyl Seasonique=Amethia Tablet QD Estradiol/0.15mg Levonorgestrel x 84 days) QD NF Levora Dose Recommendation 3) Amethia Lo (20mcg Ethinyl Estradiol/0.1mg Day 1-84: Take 1 active tablet QD (Discard placebo Levonorgestrel x 84 days, 10mcg EE x 7 days) QD tablets from first 3 packets) NF 4) Amethia (30mcg Ethinyl Estradiol/0.15mg Day 85-91: Take 1 placebo tablet QD Levonorgestrel x 84 days, 10mcg EE x 7 days) QD NF Serzone (Nefazodone) 50, 100, 150, 200, 250mg 1) Fluoxetine 20-40mg QD 2) Citalopram 20-40mg Tablet BID QD 3) Sertraline 50-100mg QD 4) Paroxetine 10- 40mg QD 5) Escitalopram 10-20mg QD 6) Mirtazapine 45mg QHS 7) Fluvoxamine 50-300mg QD NF Silenor (Doxepin) 3, 6mg Tablet QHS 1) Trazodone 50-100mg QHS 2) Temazepam 15- Document adequate therapeutic trial or intolerance 30mg QHS 3) Zolpidem 5-10mg QHS 4) Zaleplon 5- to Trazodone, Zolpidem, and at least 1 10mg QHS 5) Ambien CR 6.25-12.5mg QHS NF 6) Benzodiazepine Rozerem 8mg QHS NF 7) Lunesta 1-3mg QHS NF

Simponi (Golimumab) 50mg/0.5ml Subcutaneous 1) Humira 40mg QOW 2) Enbrel 50mg QW 3) Document adequate therapeutic trial or intolerance Solution Q4W Remicade 5mg/kg Q8W NF to Humira, Enbrel, and Remicade Remicade Infusion KP Rheumatology Contact CU Infusion Center 770-431-4367 or SW Infusion Center 770-603-3663 Network Rheumatology Contact Provider Relations 404-364-4934 Skelaxin (Metaxalone) 400, 800mg Tablet TID-QID 1) Cyclobenzaprine 10mg TID 2) Chlorzoxazone 250- 500mg TID 3) Carisoprodol 350mg TID 4) Tizanidine 4mg TID 5) Methocarbamol 500-750mg QID 6) Baclofen 10-20mg TID Sklice (Ivermectin) 0.5% Lotion Apply 1 tube to dry 1) OTC Nix (Permethrin 1%) 2) OTC Rid, Pronto Plus Apply to scalp, Leave on for 10 minutes, Rinse, hair and scalp, Leave on for 10 minutes, Rinse (Pyrethrins 0.33%/Piperonyl Butoxide 4%) 3) OTC Repeat application if lice present 7 days after initial Cetaphil Cleanser Lotion 4) Malathion 0.5% Lotion treatment NF Solage (Mequinol/Tretinoin) 2/0.01% Cream AAA Excluded Medication BID Solaquin Forte (Hydroquinone) 4% Cream AAA BID Excluded Medication

Solodyn (Minocycline) 45, 55, 65, 80, 90, 105, 115, 1) Doxycycline Hyclate 50-100mg BID 2) Minocycline Dose Conversion 135mg Extended Release Tablet QD 50-100mg BID Solodyn 45mg QD=Minocycline 50mg QD / Solodyn 135mg=Minocycline 100mg QD

Page 51 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Soma Compound (Carisoprodol/Aspirin) 200/325mg 2 Separate Medications Tablet QID OTC Aspirin 325mg TID-QID AND 1) Cyclobenzaprine 10mg TID 2) Chlorzoxazone 250- 500mg TID 3) Carisoprodol 350mg TID 4) Tizanidine 4mg TID 5) Methocarbamol 500-750mg QID 6) Baclofen 10-20mg TID Somatuline Depot (Lanreotide) 120/0.5, 90/0.3, Octreotide 50mcg TID NF Document Acromegaly, Metastatic carcinoid tumor, 60/0.2mg/ml Subcutaneous Solution Q4W or Vasoactive intestinal peptide secreting tumor

Soriatane (Acitretin) 10, 17.5, 22.5, 25mg Capsule 1) Vectical 3mcg/gm (Calcitriol) AAA BID 2) QD Calcipotriene 0.005% Solution AAA QD-BID NF 3) Tazorac 0.05, 0.1% Cream, Gel AAA QHS NF 4) Calcipotriene 0.005% Ointment AAA QD-BID NF 5) Taclonex 0.005/0.064% Ointment, Suspension AAA QD NF OR Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID

Spectazole (Econazole) 1% Cream AAA QD-BID 1) OTC Lamisil Ultra (Butenafine 1%) QD-BID 2) OTC Lotrimin AF (Clotrimazole 1%) BID 3) OTC Micatin (Miconazole 1%) BID 4) Ketoconazole 2% Cream QD

Sprix (Ketorolac) 15.75mg/Actuation Nasal Spray 1 1) Sumatriptan 25-100mg PRN 2) Sumatriptan 5- Quantity Limit SPRAY IEN Q6-8H 20mg Nasal Spray PRN 3) Naratriptan 1-2.5mg PRN Axert 6.25-12.5mg=6 Tablets 4) Sumatriptan 6mg/ml Subcutaneous Solution PRN Frova 2.5mg=9 Tablets 5) Maxalt MLT 5-10mg PRN NF 6) Zomig 5mg PRN Maxalt MLT 5-10mg=9 Tablets NF 7) Zomig 2.5mg PRN NF 8) Relpax 20-40mg PRN Naratriptan 1-2.5mg=9 Tablets NF 9) Axert 6.25-12.5mg PRN NF 10) Treximet Relpax 20-40mg=6 Tablets 500/85mg PRN NF Sumatriptan 25-100mg=9 Tablets Treximet 500/85mg=9 Tablets Zomig 2.5mg=6 Tablets Zomig 5mg=3 Tablets Stadol (Butorphanol) 10mg/ml Nasal Spray 1 Migraine Treatment Quantity Limit SPRAY IN 1 NOSTRIL Q3-4H PRN 1) Sumatriptan 25-100mg PRN 2) Sumatriptan 5- Naratriptan 1-2.5mg=9 Tablets 20mg Nasal Spray PRN 3) Naratriptan 1-2.5mg PRN Sumatriptan 25-100mg=9 Tablets 4) Sumatriptan 6mg/ml Subcutaneous Solution PRN Pain 1) Oxycodone/Acetaminophen 5/325-10/325mg Q6H 2) Morphine 15-30mg Q4H 3) Hydromorphone 2-8mg Q4-6H 4) Oxycodone 5-30mg Q4-6H 5) Morphine Solution 20mg/ml 0.5-1.5ml Q4H 6) Meperidine 50- 150mg Q3-4H

Starlix (Nateglinide) 60, 120mg Tablet TID 1) Glipizide 5-15mg QD 2) Glyburide 2.5-10mg QD Adjust based on patient response Glipizide preferred if 65 years of age and older due to prolonged half life of Glyburide

Page 52 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Stavzor (Valproic Acid) 125, 250, 500mg Delayed Epilepsy Release Capsule BID-TID 1) Lamotrigine 100-200mg BID 2) Carbamazepine 800-1600mg QD 3) Topiramate 200mg BID 4) Phenytoin 100mg TID 5) Levetiracetam 500-1500mg BID 6) Gabapentin 300-600mg TID 7) Levetiracetam ER 1000mg QD 8) Divalproex 250-500mg TID Migraine Prophylaxis 1) Amitriptyline 10-25mg QHS 2) Propranolol 20- 40mg BID-TID 3) Topiramate 25-100mg QHS 4) Divalproex 250-1000mg BID 5) Propranolol ER 80mg QD NF 6) Divalproex ER 500-1000mg QD

Staxyn (Vardenafil) 10mg Orally Disintegrating Excluded Medication Tablet PRN (Exception: Sexual Dysfunction Rider) Stelara (Ustekinumab) 90mg/ml, 45mg/0.5ml 1) Humira 40mg QOW 2) Enbrel 50mg QW Document adequate therapeutic trial or intolerance Subcutaneous Solution Q12W to Humira and Enbrel Stendra (Avanafil) 50, 100, 200mg Tablet PRN Excluded Medication (Exception: Sexual Dysfunction Rider) Stivarga (Regorafenib) 40mg Tablet QD FDA approved for treatment of metastatic colorectal cancer Strattera (Atomoxetine) 10, 18, 25, 40, 60, 80, 1) Clonidine 0.1mg QD-TID 2) Guanfacine 1-4mg QD Document adequate therapeutic trial or intolerance 100mg Capsule QD 3) Methylphenidate 5-20mg BID-TID 4) Amphetamine to at least 3 formulary alternatives Salt Combo 5-30mg QD-BID 5) Dexmethylphenidate 2.5-10mg BID NF 6) Adderall XR 5-30mg QAM 7) Dextroamphetamine CR 5-15mg QD-BID 8) Dextroamphetamine 5-10mg QD-TID 9) Methylphenidate SR (generic for Concerta) 10-54mg QAM Stribild 2 Separate Medications (Cobicistat/Elvitegravir/Emtricitabine/Tenofovir Isentress (Raltegravir Potassium) 400mg BID AND Disoproxil Fumarate) 150/150/200/300mg Tablet QD Truvada (Emtricitabine/Tenofovir Disoproxil Fumarate 200/300mg) QD Stromectol (Ivermectin) 3mg Tablet 3mg Single Scabies dose Permethrim 5% Cream Apply from head to toe, Wash off after 8-14 hours, Repeat application if live mites present 7 days after initial treatment Tissue Nematodes Albenza 400mg Single dose Suboxone (Buprenorphine/Naloxone) 2/0.5, 8/2mg Buprenorpine/Naloxone 2/0.5-8/2mg QD Sublingual Film QD Sular (Nisoldipine) 8.5, 10, 17, 20, 25.5, 34, 40mg 1) Amlodipine 5-10mg QD 2) Verapamil SR 180- Dose Conversion Extended Release Tablet QD 240mg BID 3) Diltiazem ER 240-360mg QD 4) Nislodipine 10mg=Nifedipine ER 30mg / Nislodipine Nifedipine ER 30-60mg QD 5) Felodipine 2.5-20mg 20mg=Nifedipine ER 60mg / Nislodipine QD 40mg=Nifedipine ER 90mg Supartz (Hyaluronate Sodium) 25mg/2.5ml Injection Administered in a healthcare setting by healthcare Criteria Restricted Medication Solution QW providers QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Suprax (Cefixime) 100mg/5ml, 200mg/5ml Powder 1) Cefdinir 125mg/5ml-250mg/5ml 7mg/kg BID 3rd for Suspension; 400mg Tablet QD 3rd Generation Generation 2) Pediazole (Erythromycin Ethylsuccinate/Sulfisoxazole) 50mg/kg divided TID- QID Sylatron (Peginterferon Alfa-2b) 296, 444, 888mcg 1) Pegasys 180mcg QW 2) PEG-Intron 150mcg QW Subcutaneous Powder for Solution 1.5mcg/kg QW

Page 53 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Symbicort (Budesonide/Formoterol) 1) Qvar 40-80mcg 1-2 PUFFS QD-BID 2) Flovent Document adequate trial or intolerance to Qvar 80/4.5, 160/4.5mcg Inhalation Aerosol Liquid 2 HFA 44mcg 2 PUFFS BID NOTE: Flovent HFA 80mcg 2 PUFFS BID or Asmanex 220mcg 2 PUFFS PUFFS BID 44mcg for patients 4-11 years of age 3) Asmanex QD within the past 3 months 110-220mcg 1-2 PUFFS QD 4) Dulera 100/5mcg 2 *Patients should have prescription for a Short- PUFFS BID NF Acting Beta 2 Agonist (e.g. Proair) for asthma exacerbations Dose Conversion Symbicort 80/4.5mcg 2 PUFFS BID=Albuterol Q4H PRN + Qvar 80mcg 1PUFF BID =Albuterol Q4H PRN + Flovent 44mcg 2 PUFFS BID

Symbicort 160/4.5mcg 2 PUFFS BID=Albuterol Q4H PRN + Qvar 80mcg 2 PUFFS BID=Albuterol Q4H PRN + Asmanex 220mcg 2 PUFFS QD=Dulera 100/5mcg 2 PUFFS BID NF Symbyax (Fluoxetine/Olanzapine) 25/3, 25/6, 25/12, 2 Separate Medications 50/6, 50/12mg Capsule QD Fluoxetine 20-40mg QD AND Olanzapine 2.5-15mg QD Symlin (Pramlintide) 0.6mg/ml Subcutaneous DM1 Criteria Restricted Medication Solution AC 1) Novolin R (Insulin Regular) SC 30 minutes AC 2) QRM approval required prior to being dispensed for Novolin N (NPH) SC 15-30 minutes AC 3) Novolin Commercial, Multi-Choice, Self-Funded, and Triple 70/30 (NPH/Insulin Regular) SC 30 minutes AC 4) Tier members. NovoLog (Insulin Aspart) SC 5-10 minutes AC Provider must call 404-364-7320 (Option 2) to DM2 initiate review by QRM department. 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin 500-1000mg (Maximum 2550mg QD) 3) Metformin ER 500-750mg (Maximum 2000mg QD) 4) Novolin R (Insulin Regular) SC 30 minutes AC 5) Novolin N (NPH) SC 15-30 minutes AC 6) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos 15mg (Maximum 45mg QD)

Synagis (Palivizumab) 50/0.5, 100mg/ml Administered in a healthcare setting by healthcare Contact GW Synagis Clinic 770-931-6010 Intramuscular Solution 15mg/kg QM providers Synalar (Fluocinolone) 0.01% Cream AAA BID-QID Low Potency Low Potency 1) Betamethasone Valerate 0.1% Lotion AAA QD-BID 2) Desonide 0.05% Cream, Ointment AAA BID-TID 3) Fluocinolone Acetonide 0.01% Solution AAA QD 4) Derma-Smoothe/FS 0.01% Oil AAA QD Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BID- QID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID

Synalar (Fluocinolone Acetonide) 0.025% Cream Medium Potency AAA BID-QID Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BID- QID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BID- QID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID

Page 54 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Synalar (Fluocinolone Acetonide) 0.025% Ointment Medium-High Potency AAA BID-QID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BID- QID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BID- QID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QD- BID Synthroid (Levothyroxine) 0.025, 0.05, 0.075, 0.088, Levothroid 0.025-0.3mg QD Synthroid to Levothroid is a 1:1 Conversion 0.1, 0.112, 0.125, 0.137, 0.15, 0.175, 0.2, 0.3mg Tablet QD Synvisc (Hylan Polymers A and B) 8mg/ml Injection Administered in a healthcare setting by healthcare Criteria Restricted Medication Solution QW providers QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Taclonex (Calcipotriene/Betamethasone 2 Separate Medications Dipropionate) 0.005/0.064% 1) Vectical 3mcg/gm (Calcitriol) AAA BID 2) Ointment, Suspension AAA QD Very High Potency Calcipotriene 0.005% Solution AAA QD-BID NF 3) Tazorac 0.05, 0.1% Cream, Gel AAA QHS NF 4) Calcipotriene 0.005% Ointment AAA QD-BID NF AND Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID

Talwin NX (Pentazocine/Naloxone) 50/0.5mg Tablet 1) Tramadol 50mg Q4-6H PRN 2) Q3-4H Hydrocodone/Acetaminophen 5/325mg Q4-6H 3) Codeine/APAP 15/300, 30/300, 60/300mg Q4H Tarceva (Erlotinib) 25, 100, 150mg Tablet QD 1) Platinum-based Chemotherapy 2) Docetaxel FDA approved for locally advanced or metastatic 75mg/m2 IV Q21D nonsmall cell lung cancer (NSCLC) failed at least one Chemotherapy Tarka (Trandolapril/Verapamil) 1/240, 2/180, 2/240, 2 Separate Medications Dose Conversion 4/240mg Tablet QD-BID Lisinopril QD AND Verapamil SR 180-240mg QD-BID Trandolapril 1mg=Lisinopril 10mg / Trandolapril 2mg=Lisinopril 20mg / Trandolapril 4mg=Lisinopril 40mg Tasigna (Nilotinib) 150, 200mg Capsule 400mg BID Sprycel 100-180mg QD

Page 55 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Tazorac (Tazarotene) 0.05, 0.1% Cream, Gel AAA Acne Excluded medication for patients > 36 YOA QHS 1) Retin-A 0.025-0.1% Cream, Gel AAA QHS Psoriasis 1) Vectical 3mcg/gm (Calcitriol) AAA BID 2) Calcipotriene 0.005% Solution AAA QD-BID NF OR Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID

Tegretol-XR (Carbamazepine) 100, 200, 400mg Carbatrol 100, 200, 300mg BID Tegretol-XR to Carbatrol is a 1:1 Conversion Extended Release Tablet BID Tekamlo (Aliskiren/Amlodipine) 150/5, 150/10, 2 Separate Medications Document adequate therapeutic trial or intolerance 300/5, 300/10mg Tablet QD Amlodipine 5-10mg QD AND to maximum tolerated doses of at least 4 Blood Renin-Angiotensin System/Diuretic Pressure medications 1) Lisinopril/HCTZ 10/12.5, 20/12.5, 20/25mg QD NOTE: If Angiotensin Converting Enzyme Inhibitor allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan/HCTZ 50/12.5, 100/12.5, 100/25mg QD Beta Blocker Metoprolol 100-450mg QD Tekturna (Aliskiren) 150, 300mg Tablet QD Renin-Angiotensin System/Diuretic Document adequate therapeutic trial or intolerance 1) Lisinopril/HCTZ 10/12.5, 20/12.5, 20/25mg QD to maximum tolerated doses of at least 3 Blood NOTE: If Angiotensin Converting Enzyme Inhibitor Pressure medications allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan/HCTZ 50/12.5, 100/12.5, 100/25mg QD Calcium Channel Blocker Amlodipine 5-10mg QD Beta Blocker Metoprolol 100-450mg QD Tekturna HCT (Aliskiren/HCTZ) 150/12.5, 150/25, Renin-Angiotensin System/Diuretic Document adequate therapeutic trial or intolerance 300/12.5, 300/25mg Tablet QD 1) Lisinopril/HCTZ 10/12.5, 20/12.5, 20/25mg QD to maximum tolerated doses of at least 4 Blood NOTE: If Angiotensin Converting Enzyme Inhibitor Pressure medications allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan/HCTZ 50/12.5, 100/12.5, 100/25mg QD Calcium Channel Blocker Amlodipine 5-10mg QD Beta Blocker Metoprolol 100-450mg QD Temovate E (Clobetasol Propionate) 0.05% Very High Potency Emollient Cream AAA BID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID

Tenex (Guanfacine) 1, 2mg Tablet QHS Guanfacine 1mg QHS

Page 56 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Terazol (Terconazole) 0.4, 0.8% Cream; 80mg 1) OTC Mycelex (Clotrimazole 1%) QHS 2) OTC Vaginal Suppository QHS Monistat (Miconazole) QHS 3) OTC Vagistat (Tioconazole 6.5%) QHS 4) Fluconazole 150mg QD

Testim 1% (Testosterone) 50mg/5gm Gel Apply 1) Testosterone Cypionate 200mg/ml IM Q2-4W 2) QAM Androderm Patch 2-4mg/24hr Apply QPM 3) AndroGel Pump 1.62% Apply 2 pumps QAM NF 4) AndrogGel Pump 1% Apply 4 pumps QAM NF 5) AndroGel 1% (25mg/2.5gm-50mg/5gm) Apply QAM NF Thyroid (Thyroid) 1/4(15mg), 1/2(30mg), 1(60mg), Levothroid QD Dose Conversion 1&1/2(90mg), 2(120mg), 3(180mg), 4(240mg), Thyroid 15mg=Levothroid 25mcg / Thyroid 5(300mg) Grain Tablet QD 30mg=Levothroid 50mcg / Thyroid 60mg =Levothroid 100mcg / Thyroid 90mg =Levothroid 150mcg / Thyroid 120mg =Levothroid 200mcg / Thyroid 180mg =Levothroid 300mcg / Thyroid 240mg =Levothroid 400mcg / Thyroid 300mg =Levothroid 500mcg Ticlid (Ticlopidine) 250mg Tablet BID (CVA/CABG) 1) Clopidogrel 75mg QD (CVA/CABG) 2) Aggrenox 25/200mg BID (CVA) Tikosyn (Dofetilide) 125, 250, 500mcg Capsule BID Prescribing Physician must call Tikosyn Education Distribution Program 877-TIKOSYN Timoptic-XE (Timolol) 0.25, 0.5% Ophthalmic Gel- 1) Timolol 0.25-0.5% 1 GTT QD-BID 2) Levobunolol Forming Solution 1 GTT QD 0.25-0.5% 1-2 GTT QD-BID 3) Betaxolol 0.5% 1-2 GTT BID Tindamax (Tinidazole) 250, 500mg Tablet 2gm Bacterial Vaginosis Single dose 1) Metronidazole 500mg BID X7D 2) Clindamycin 300mg BID X7D Giardiasis Metronidazole 250mg TID X5-7D Trichomoniasis Metronidazole 500mg BID X7D Tirosint (Levothyroxine) 13, 25, 50, 75, 88, 100, 112, Levothroid 0.025-0.15mg QD Tirosint to Levothroid is a 1:1 Conversion 125, 137, 150mcg Liquid Filled Capsule QAM

TOBI (Tobramycin) 300mg/5ml Inhalation Solution Document cystic fibrosis patient requiring treatment BID of Pseudomonas aeruginosa TobraDex ST (Tobramycin/Dexamethasone) Tobramycin/Dexamethasone 0.3/0.1% 1-2 GTTS Q4- 0.3/0.05% Ophthalmic Suspension 1-2 GTTS Q4-6 6 HOURS HOURS Topamax (Topiramate) 15, 25mg Capsule; 25, 50, Epilepsy 100, 200mg Tablet QD-BID 1) Lamotrigine 100-200mg BID 2) Carbamazepine 800-1600mg QD 3) Topiramate 200mg BID 4) Phenytoin 100mg TID 5) Levetiracetam 500-1500mg BID 6) Gabapentin 300-600mg TID 7) Levetiracetam ER 1000mg QD 8) Divalproex 250-500mg TID Migraine Prophylaxis 1) Amitriptyline 10-25mg QHS 2) Propranolol 20- 40mg BID-TID 3) Topiramate 25-100mg QHS 4) Divalproex 250-1000mg BID 5) Propranolol ER 80mg QD NF 6) Divalproex ER 500-1000mg QD

Page 57 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Topicort (Desoximetasone) 0.05% Gel; 0.25% Very High Potency Cream, Ointment AAA BID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID

Topicort LP (Desoximetasone) 0.05% Cream AAA High Potency BID High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BID- QID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QD- BID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Toradol (Ketorolac) 10mg Tablet Q4-6H X5D 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg Black Box Warning BID 3) Ibuprofen 400-800mg TID-QID 4) Sulindac Ketorolac is only indicated for short-term (up to 5 150-200mg BID 5) Etodolac 200-500mg BID-TID 6) days) management of moderatley severe acute Nabumetone 500-750mg BID 7) Lidocaine 5% pain. Ketorolac is not indicated for minor or chronic Ointment AAA Q4H painful conditions. Toviaz (Fesoterodine) 4, 8mg Extended 1) Oxybutinin 5mg BID-TID 2) Oxybutynin XL 5-15mg ReleaseTablet QD QD 3) Oxytrol 3.9mg/day Patch Apply twice weekly 4) Trospium 20mg BID NF 5) Tolterodine 1-2mg BID NF

Tradjenta (Linagliptin) 5mg Tablet QD 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin Criteria Restricted Medication 500-1000mg (Maximum 2550mg QD) 3) Metformin QRM approval required prior to being dispensed for ER 500-750mg (Maximum 2000mg QD) 4) Novolin R Commercial, Multi-Choice, Self-Funded, and Triple (Insulin Regular) SC 30 minutes AC 5) Novolin N Tier members. (NPH) SC 15-30 minutes AC 6) Novolin 70/30 Provider must call 404-364-7320 (Option 2) to (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog initiate review by QRM department. (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos 15mg (Maximum 45mg QD)

Transderm Scop (Scopolamine) 1.5mg Transdermal Vertigo Excluded Medication for Travel Patch Apply Q72H 1) OTC Benadryl (Diphenhydramine) 25-50mg Q4-6H 2) OTC Dramamine (Dimenhydrinate) 50mg Q4-6H 3) OTC Antivert (Meclizine) 25-50mg QD-QID 4) OTC Bonine (Cyclizine) 50mg Q4-6H 5) Clonazepam 0.5mg TID 6) Diazepam 5mg BID-QID 7) Lorazepam 1-2mg TID 8) Promethazine 25mg Q6H Sialorrhea 1) Benztropine 2mg TID-QID 2) Trihexphenidyl 2mg TID 3) Trihexphenidyl 0.4mg/ml NF 4) Glycopyrrolate 1mg TID-QID 5) Atrovent 1-2 PUFFS TID

Tranxene-SD (Clorazepate) 11.25, 22.5mg 1) Clonazepam 0.25-0.5mg BID 2) Alprazolam 0.25- Dose Conversion Extended Release Tablet QD 0.5mg TID 3) Diazepam 2-10mg BID-QID 4) Tranxene-SD 11.25mg QD=Clorazepate 3.75mg Lorazepam 1mg BID-TID 5) Clorazepate 3.75-15mg TID / Tranxene-SD 22.5mg QD=Clorazepate 7.5mg TID 6) Chlordiazepoxide 5-10mg TID-QID 7) TID Oxazepam 10-15mg TID-QID Travatan Z (Travoprost) 0.004% Ophthalmic 1) Latanoprost 0.005% 1 GTT QPM Solution 1 GTT QPM

Page 58 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Treximet (Naproxen/Sumatriptan) 500/85mg Tablet 2 Separate Medications Quantity Limit PRN Naproxen 500mg AND 1) Sumatriptan 25-100mg Axert 6.25-12.5mg=6 Tablets PRN 2) Sumatriptan 5-20mg Nasal Spray PRN 3) Maxalt MLT 5-10mg=9 Tablets Naratriptan 1-2.5mg PRN 4) Sumatriptan 6mg/ml Naratriptan 1-2.5mg=9 Tablets Subcutaneous Solution PRN 5) Maxalt MLT 5-10mg Relpax 20-40mg=6 Tablets PRN NF 6) Zomig 5mg PRN NF 7) Zomig 2.5mg PRN Sumatriptan 25-100mg=9 Tablets NF 8) Relpax 20-40mg PRN NF 9) Axert 6.25-12.5mg Treximet 500/85mg=9 Tablets PRN NF Zomig 2.5mg=6 Tablets Zomig 5mg=3 Tablets Triaz (Benzoyl Peroxide) 3, 6, 9% Gel; 6% Foaming 1) OTC Benzoyl Peroxide 2.5-10% AAA QD 2) OTC Excluded Medication Cloth; 3, 6, 9% Pad QD-BID Benzoyl Peroxide 5-10% Liquid AAA QD-BID Tribenzor 3 Separate Medications Dose Conversion (Amlodipine/Hydrochlorothiazide/Olmesartan) Amlodipine 5-10mg QD AND HCTZ 12.5-25mg QD 1) Benicar 20mg=Lisinopril 20mg=Losartan 50mg / 5/12.5/20, 5/12.5/40, 10/12.5/40, 5/25/40, Lisinopril 20-40mg QD NOTE: If Angiotensin Benicar 40mg=Lisinopril 40mg= Losartan 100mg 10/25/40mg Tablet QD Converting Enzyme Inhibitor allergy or NOTE: Consider Lisinopril/HCTZ 20/12.5mg or contraindication consider Angiotensin Receptor Losartan/HCTZ 50/12.5, 100/12.5, 100/25mg Blocker 2) Losartan 50-100mg QD 3) Valsartan 160- 320mg QD NF 4) Irbesartan 150-300mg QD NF

Tricor (Fenofibrate) 48, 145, 160mg Tablet QD 1) Gemfibrozil 600mg BID 2) Fenofibrate 54-160mg Dose Conversion Tricor QD 48mg=Fenofibrate 54mg / Tricor 145,160mg=Fenofibrate 160mg Fenofibrate preferred if current statin therapy Gemfibrozil preferred if reduced renal function Trileptal (Oxcarbazepine) 300mg/5ml Suspension; 1) Lamotrigine 100-200mg BID 2) Carbamazepine 150, 300, 600mg Tablet BID 800-1600mg QD 3) Topiramate 200mg BID 4) Phenytoin 100mg TID 5) Levetiracetam 500-1500mg BID 6) Zonisamide 100mg TID NF 7) Gabapentin 300- 600mg TID 8) Levetiracetam ER 1000mg QD 9) Oxcarbazepine 600mg BID NF Trilipix (Fenofibric Acid) 45, 135mg Capsule QD 1) Gemfibrozil 600mg BID 2) Fenofibrate 54-160mg Dose Conversion QD Trilipix 45mg=Fenofibrate 54mg / Trilipix 135mg=Fenofibrate 160mg Fenofibric Acid is the active metabolite of Fenofibrate Fenofibrate preferred if current statin therapy Gemfibrozil preferred if reduced renal function Tri-Luma (Fluocinolone/Hydroquinone/Tretinoin) Excluded Medication 0.01/4/0.05% Cream AAA BID Triphasil (30mcg Ethinyl Estradiol/0.05mg 1) Tri-Sprintec (35mcg Ethinyl Estradiol/0.18mg Equivalent Brand and Generic Products Levonorgestrel x 6 days, 40mcg EE/0.075mg Norgestimate x 7 days, 35mcg EE/0.215mg NG x 7 Triphasil=Trivora LVNGL x 5 days, 30mcg EE/0.125mg LVNGL x 10 days, 35mcg EE/0.25mg NGx 7 days) QD 2) Trivora Document adequate therapeutic trial or intolerance days) Tablet QD (30mcg Ethinyl Estradiol/0.05mg Levonorgestrel x 6 to at least 3 formulary oral contraceptives days, 40mcg EE/0.075mg LVNGL x 5 days, 30mcg EE/0.125mg LVNGL x 10 days) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD 4) Leena (35mcg Ethinyl Estradiol/0.5mg Norethindrone x 7 days, 35mcg EE/1mg NE x 9 days, 35mcg EE/0.5mg NE x 5 days) QD

Tudorza Pressair (Aclidinium Bromide) 1) Ipratropium 0.02% Inhalation Solution QID 2) 400mcg/Actuation Inhalation Aerosol Powder 1 Aminophylline 100-200mg BID-TID 3) Proair HFA PUFF BID (Albuterol) 0.09mg Inhalation Aerosol Powder Q4H PRN 4) Theophylline 100-300 TID-QID 5) Albuterol 0.5% Inhalation Solution QID 6) Combivent Respimat (Albuterol Sulfate/Ipratropium Bromide) 100/20mcg/Actuation Inhalation Spray QID 7) Spiriva 18mcg QD

Page 59 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Tussionex Pennkinetic (Hydrocodone 1) Cheratussin AC (Codeine/Guaifenesin) Bitartrate/Chlorpheniramine Maleate) 10mg/8mg/5ml 10mg/100mg/5ml Q4-6H PRN 2) Extended-Release Suspension Q12H Promethazine/Codeine 6.25mg/10mg/5ml Q4-6H PRN 3) Hydrocodone Bitartrate/Homatropine Methylbromide 5/1.5mg Q4-6H PRN 4) Promethazine VC/Codeine (Promethazine/Codeine/Phenylephrine) 6.25mg/10mg/5mg/5ml Q4-6H PRN 5) Benzonatate 100-200mg TID PRN 6) Hydrocodone Bitartrate/Homatropine Methylbromide 5mg/1.5mg/5ml Syrup 5ml Q4-6H PRN NF

Tysabri (Natalizumab) 20mg/ml Solution 300mg Precribing Physician must call TOUCH Prescribing Criteria Restricted Medication Q4W Program 800-456-2255 (Option 2) QRM approval required prior to being dispensed for Tysabri is delivered directly to MD office via Tysabri Commercial, Multi-Choice, Self-Funded, and Triple Direct Tier members. Administered in a healthcare setting by healthcare Provider must call 404-364-7320 (Option 2) to providers initiate review by QRM department. U-Cort (Hydrocortisone/Urea) 1/10% Cream AAA Lowest Potency BID-QID Lowest Potency 1) OTC Hydrocortisone 0.5-1% Cream, Ointment AAA BID-QID 2) Hydrocortisone 2.5% Cream, Lotion, Ointment AAA BID-QID Low Potency 1) Betamethasone Valerate 0.1% Lotion AAA QD-BID 2) Desonide 0.05% Cream, Ointment AAA BID-TID 3) Fluocinolone Acetonide 0.01% Solution AAA QD 4) Derma-Smoothe/FS 0.01% Oil AAA QD

Ulesfia (Benzyl Alcohol) 5% Lotion Apply to scalp, 1) OTC Nix (Permethrin 1%) 2) OTC Rid, Pronto Plus Apply to scalp, Leave on for 10 minutes, Rinse, Leave on for 10 minutes, Rinse, Repeat application (Pyrethrins 0.33%/Piperonyl Butoxide 4%) 3) OTC Repeat application if lice present 7 days after initial if lice present 7 days after initial treatment Cetaphil Cleanser Lotion treatment

Uloric (Febuxostat) 40, 80mg Tablet QD Allopurinol 300mg BID Document adequate therapeutic trial or intolerance to maximum tolerated dose of Allopurinol

Ultracet (Acetaminopen/Tramadol) 325/37.5mg 2 Separate Medications Tablet Q4-6H PRN OTC Acetaminophen 325mg Q4-6H PRN AND Tramadol 50mg Q4-6H PRN Ultravate (Halobetasol Propionate) 0.05% Cream, Very High Potency Ointment AAA QD-BID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID

Uniretic (Moexipril/HCTZ) 7.5/12.5, 15/25mg Tablet 2 Separate Medications Dose Conversion QD HCTZ QD AND 1) Lisinopril 10-40mg QD 2) Moexipril 7.5mg=Lisinopril 10mg / Moexipril Benazepril 20-40mg QD 3) Enalapril 10-40mg QD 4) 15mg=Lisinopril 20mg Captopril 25-100mg TID 5) Ramipril 2.5-20mg QD NOTE: Consider Lisinopril/HCTZ 10/12.5, 20/25mg

Univasc (Moexipril) 7.5, 15mg Tablet QD 1) Lisinopril 10-40mg QD 2) Benazepril 20-40mg QD Dose Conversion 3) Enalapril 10-40mg QD 4) Captopril 25-100mg TID Moexipril 7.5mg=Lisinopril 10mg / Moexipril 5) Ramipril 2.5-20mg QD 15mg=Lisinopril 20mg Uroxatral (Alfuzosin) 10mg Extended Release Tablet 1) Doxazosin 1-8mg QD 2) Terazosin 1-10mg QD 3) QD Tamsulosin 0.4mg QD 4) Alfuzosin ER 10mg QD NF

Page 60 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

UTA (Methenamine Sodium, Phosphate Monobasic, 1) OTC Azo-Standard (Phenazopyridine) 95mg TID 2) Phenyl Salicylate, Methylene Blue, Hyoscyamine Hyoscyamine SL 0.125mg 1-2T Q4H 3) Hyoscyamine Sulfate) 120/40.8/36/10/0.12mg Capsule QID 0.125mg 1-2T Q4H 4) Hyoscyamine Solution 0.125mg/ml 5-10ml Q4H 5) Elmiron 100mg TID

Valtrex (Valacyclovir) 1gm, 500mg Tablet QD-BID Genital Herpes Episodic Treatment 1) Acyclovir 200mg Q4H 2) Acyclovir 400mg TID 3) Acyclovir 800mg BID Genital Herpes Suppressive Treatment Acyclovir 400mg BID Herpes Zoster Treatment Acyclovir 800mg Q4H Vancocin (Vancomycin Hydrochloride) 125, 250mg 1) Metronidazole 500mg TID X10-14D 2) Vancomycin KPGA Approved Compound Capsule QID 50mg/ml Solution 125mg QID X10-14D

Vaniqa (Eflornithine) 13.9% Cream AAA BID Excluded Medication

Vanos (Flucinonide) 0.1% Cream AAA QD Ultra High Potency High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BID- QID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QD- BID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Vantin (Cefpodoxime) 50mg/5ml, 100mg/5ml 1) Cefdinir 125mg/5ml-250mg/5ml 7mg/kg BID 3rd Powder for Suspension; 100, 200mg Tablet BID 3rd Generation 2) Pediazole (Erythromycin Generation Ethylsuccinate/Sulfisoxazole) 50mg/kg divided TID- QID Vaseretic (Enalapril/HCTZ) 5/12.5, 10/25mg Tablet 2 Separate Medications QD Enalapril QD AND HCTZ QD Veltin (Clindamycin/Tretinoin) 1.2/0.025% Gel AAA 2 Separate Medications Excluded Medication for patients > 36 YOA QHS Clindamycin 1% Gel AAA QHS AND Retin-A 0.025% Cream, Gel AAA QHS Ventolin HFA (Albuterol) 0.09mg Inhalation Aerosol Proair HFA (Albuterol) 0.09mg Inhalation Aerosol Ventolin HFA to Proair HFA is a 1:1 Conversion Powder Q4H PRN Powder Q4H PRN Veramyst (Fluticasone Furoate) 27.5mcg/Actuation 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) Age Recommendations Nasal Spray 2 SPRAYS IEN QD OTC Allegra 60mg BID 4) Fluticasone 2 SPRAYS Fluticasone=4 years of age and older / IEN QD 5) Flunisolide 2 SPRAYS IEN BID 6) Flunisolide=6 years of age and older / Triamcinolone 2 SPRAYS IEN QD NF Triamcinolone=2 years of age and older / Veramyst=2 years of age and older Verdeso (Desonide) 0.05% Foam AAA BID Low Low Potency Potency 1) Betamethasone Valerate 0.1% Lotion AAA QD-BID 2) Desonide 0.05% Cream, Ointment AAA BID-TID 3) Fluocinolone Acetonide 0.01% Solution AAA QD 4) Derma-Smoothe/FS 0.01% Oil AAA QD Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BID- QID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID

Veregen (Sinecatechins) 15% Ointment AAA TID 1) Condylox 0.5% Gel AAA BID X3D 2) Imiquimod Document a) biopsy confirming external genical or X16W 5% Cream AAA three times a week X16W perianal warts b) adequate trial or intolerance to Condylox Gel and Imiquimod Cream prior to approval one 16 week treatment Verelan (Verapamil Hydrochloride) 360mg Extended Verapamil SR 180mg BID Release Capsule QD

Page 61 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Verelan PM (Verapamil) 100, 200, 300mg Extended Verapamil SR QD-BID Dose Conversion Release Capsule QHS Verelan PM 100mg=Verapamil SR 120mg / Verelan PM 200mg=Verapamil SR 180mg / Verelan PM 300mg=Verapamil SR 240mg Vesicare (Solifenacin) 5, 10mg Tablet QD 1) Oxybutinin 5mg BID-TID 2) Oxybutynin XL 5-15mg QD 3) Oxytrol 3.9mg/day Patch Apply twice weekly 4) Trospium 20mg BID NF 5) Tolterodine 1-2mg BID NF 6) Toviaz 4-8mg QD NF 7) Enablex 7.5-15mg QD NF 8) Detrol LA 2-4mg QD NF Vexol (Rimexolone) 1% Ophthalmic Suspension 1-2 1) Prednisolone 1% 1-2 GTTS BID-QID 2) GTT QID Fluorometholone 0.1% 1-2 GTTS BID-QID 3) Dexamethasone 0.1% 1-2 GTTS BID-QID Vfend (Voriconazole) 40mg/ml Powder for 1) Voriconazole 200mg BID NF 2) Noxafil 40mg/ml Suspension; 50, 200mg Tablet 200mg BID 200mg TID NF Viagra (Sildenafil) 25, 50, 100mg Tablet PRN Excluded Medication (Exception: Sexual Dysfunction Rider) Vicoprofen (Hydrocodone/Ibuprofen) 7.5/200mg 1) Tramadol 50mg Q4-6H 2) Tablet Q4-6H Hydrocodone/Acetaminophen 7.5/325mg Q6H 3) Oxycodone/Acetaminophen 5/325-10/325mg Q6H 4) Morphine 15-30mg Q4H 5) Oxycodone 5-30mg Q4- 6H

Victoza (Liraglutide) 6mg/ml Subcutaneous Solution 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin Criteria Restricted Medication QD 500-1000mg (Maximum 2550mg QD) 3) Metformin QRM approval required prior to being dispensed for ER 500-750mg (Maximum 2000mg QD) 4) Novolin R Commercial, Multi-Choice, Self-Funded, and Triple (Insulin Regular) SC 30 minutes AC 5) Novolin N Tier members. (NPH) SC 15-30 minutes AC 6) Novolin 70/30 Provider must call 404-364-7320 (Option 2) to (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog initiate review by QRM department. (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos 15mg (Maximum 45mg QD)

Victrelis (Boceprevir) 200mg Capsule 4T TID 2 Separate Medications No initial fill Peg-Intron 1.5mcg/kg QW AND Ribavirin 800- Document a) chronic Hepatitis C genotype 1 b) 1400mg QD prescription from Gastroenterologist or Infectious Disease Specialist c) compensated liver disease d) completion of 4 week lead-in with Interferon Alfa and Ribavirin Vigamox (Moxifloxacin) 0.5% Ophthalmic Solution 1 1) Ofloxacin 0.3% Solution 1-2 GTTS QID 2) GTT BID Ciprofloxacin 0.3% Solution 1-2 GTTS Q4HS NF 3) Sodium Sulfacetamide 10% Solution 1-3 GTTS Q2- 3H 4) Gentamicin 0.3% Solution 1-2 GTTS QID 5) Erythromycin 0.5% Ointment APPLY RIBBON Q4H

Viibryd (Vilazodone) 10, 20, 40mg Tablet QD 1) Fluoxetine 20-40mg QD 2) Citalopram 20-40mg Document adequate therapeutic trial or intolerance QD 3) Sertraline 50-100mg QD 4) Paroxetine 10- to 2 SSRIs and Venlafaxine 40mg QD 5) Escitalopram 10-20mg QD 6) Mirtazapine 45mg QHS 7) Fluvoxamine 50-300mg QD NF 8) Mirtazapine ODT 15-45mg QD NF 9) Oleptro 150-300mg QD NF 10) Venlafaxine ER 75- 225mg QD 11) Paxil CR 12.5-37.5mg QD NF Vimovo (Esomeprazole/Naproxen) 20/375, 2 Separate Medications Excluded Medication 20/500mg Delayed Release Tablet BID Naproxen 375-500mg BID AND 1) Pantoprazole 40mg QD 2) OTC Omeprazole 20mg QD 3) OTC Zegerid 20/1100mg QD 4) OTC Prevacid 15mg QD Vimpat (Lacosamide) 50, 100, 150, 200mg Tablet 1) Lamotrigine 100-200mg BID 2) Carbamazepine BID 800-1600mg QD 3) Topiramate 200mg BID 4) Phenytoin 100mg TID 5) Levetiracetam 500-1500mg BID 6) Zonisamide 100mg TID NF 7) Gabapentin 300- 600mg TID 8) Levetiracetam ER 1000mg QD 9) Oxcarbazepine 600mg BID NF 10) Divalproex 250- 500mg TID 11) Lyrica 50-200mg TID NF

Page 62 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Viokace (Pancrelipase) 10440, 20880 Unit Tablet 1) Pancrelipase 5 Unit 10000 Lipase Units/kg QD 2) 10000 Lipase Units/kg QD Zenpep 5-20 Unit 10000 Lipase Units/kg QD Viquin Forte (Hydroquinone/Sunscreen) 4% Cream Excluded Medication AAA BID Viramune XR (Nevirapine) 400mg Extended 1) Nevirapine 200mg BID 2) Viramune 50mg/5ml Release Tablet QD 20ml BID Vistaril (Hydroxyzine Pamoate) 25, 50, 100mg 1) Hydroxyzine HCl 10, 25, 50mg TID-QID 2) Vistaril to Hydroxyzine HCl is a 1:1 Conversion Capsule; 25mg/5ml Suspension TID-QID Hydroxyzine HCl 10mg/5ml Syrup TID-QID Vivactil (Protriptyline) 5, 10mg Tablet TID-QID 1) Amitriptyline 50-100mg QHS 2) Nortriptyline 25mg TID 3) Imipramine 75mg QHS 4) Clomipramine 25mg TID 5) Desipramine 100-200mg QD

Vivelle-DOT (Estradiol) 0.025, 0.0375, 0.05, 0.075, Vasomotor Symtoms Adjust to the lowest dose needed to control 0.1mg/24hr Transdermal Patch Apply twice weekly 1) Estradiol QD 2) Climara Patch 0.025-0.1mg/24hr symptoms based on patient response Apply weekly Vaginal/Vulvar Atrophy 1) Estradiol QD 2) Climara Patch 0.025-0.1mg/24hr Apply weekly 3) Premarin Vaginal 1gm Apply three times a week 4) Vagifem 10mcg Insert twice weekly 5) Estring 2mg Insert for 90 days

Voltaren Gel (Diclofenac Sodium) 1% Gel AAA 2- 1) OTC Aspercreme AAA BID-QID 2) Meloxicam 7.5- Lower Extremity Application 4gm QID 15mg QD 3) Naproxen 250-550mg BID 4) Ibuprofen Voltaren Gel 1% AAA 4gm QID 400-800mg TID-QID 5) Sulindac 150-200mg BID 6) Upper Extremity Application Etodolac 200-500mg BID-TID 7) Nabumetone 500- Voltaren Gel 1% AAA 2gm QID 750mg BID 8) Lidocaine 5% Ointment AAA Q4H 9) Diclofenac 25-100mg BID-TID

Votrient (Pazopanib) 200mg Tablet 4T QD 1) Torisel 25mg IV QW 2) Sutent 50mg QD NOTE: 4 Sutent preferred when initiating therapy weeks on then 2 weeks off FDA approved for treatment of advanced renal cell cancer (RCC) VPRIV (Velaglucerase Alfa) 400U Powder for 1) Zavesca 100mg TID NF 2) Cerezyme 60U/kg Q2W Solution 60U/kg QOW NF 3) Ceredase 60 U/kg Q2W NF

Vytorin (Ezetimibe/Simvastatin) 10/10, 10/20, 2 Separate Medications NOTE: Zetia 5mg (25.8%) is expected to give the 10/40mg, 10/80mg Tablet QD OTC Slo-Niacin 500mg QD (Titrate to 2000mg/day as same LDL reduction as 10mg (26%) tolerated using .PITTTSLONIACIN) AND 1) Simvastatin 10-40mg QD 2) Pravastatin 20-80mg QD 3) Atorvastatin 10-80mg QD Vyvanse (Lisdexamfetamine) 20, 30, 40, 50, 60, 1) Adderall XR 5-30mg QAM 2) Methylphenidate SR Document adequate therapeutic trial or intolerance 70mg Capsule QD (generic for Concerta) 18-54mg QAM to Adderall XR and Methylphenidate SR Dose Conversion Vyvanse 30mg=Adderall XR 10mg / Vyvanse 50mg=Adderall XR 20mg / Vyvanse 70mg=Adderall XR 30mg

Welchol (Colesevelam) 3.75gm Powder for 1) Cholestyramine 4gm 8-16gm QD 2) Suspension QD; 625mg Tablet 3T BID Cholestyramine Light 4gm 8-16gm QD 3) Colestipol 1gm 2-16gm QD Westcort (Hydrocortisone Valerate) 0.2% Cream, Medium Potency Ointment BID-TID Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BID- QID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BID- QID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID Xanax XR (Alprazolam) 0.5, 1, 2, 3mg Extended 1) Clonazepam 0.25-0.5mg BID 2) Alprazolam 0.25- Dose Conversion Release Tablet QAM 0.5mg TID 3) Diazepam 2-10mg BID-QID 4) Xanax XR 0.5mg QAM=Alprazolam 0.25mg BID / Lorazepam 1mg BID-TID 5) Clorazepate 3.75-15mg Xanax XR 1mg QAM=Alprazolam 0.25mg QID / TID 6) Chlordiazepoxide 5-10mg TID-QID 7) Xanax XR 2mg QAM=Alprazolam 0.5mg QID / Oxazepam 10-15mg TID-QID Xanax XR 3mg=Alprazolam 1mg TID

Page 63 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Xarelto (Rivaroxaban) 10, 15, 20mg Tablet QD Hip or Knee Replacement Quantity Limit Enoxaparin 40mg QD or 30mg BID Xarelto 10mg (30 Day Supply)=35 Tablets Atrial Fibrillation Atrial Fibrillation 1) Warfarin 1-10mg QD (Tiitrate to target INR) 2) Document a) Irreversible atrial fibrillation Pradaxa 150mg BID NF If CHADS2 Score=1 b) Identified as an anticoagulation candidate (not ASA) c) Uninterrupted Warfarin therapy for at least 22 weeks If CHADS2 Score≥2 b) Uninterrupted Warfarin therapy for at least 22 weeks Arixtra preferred if history of Heparin-Induced Thrombocytopenia (HIT)

Xenazine (Tetrabenazine) 12.5, 25mg Tablet BID- Criteria Restricted Medication TID QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Xenical (Orlistat) 120mg Capsule TID Excluded Medication (Exception: Obesity Rider) Xgeva (Denosumab) 120/1.7mg/ml Subcutaneous Criteria Restricted Medication Solution Q4W QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Xiaflex (Collagenase, Clostridium histolyticum) Criteria Restricted Medication 0.9mg Powder for Solution Q4W QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Xibrom (Bromfenac) 0.09% Ophthalmic Solution 1 1) Diclofenac 0.1% 1GTT QID 2) Ketorolac 0.5% 1 GTT BID GTT QID 3) Prednisolone 1% 1-2 GTTS BID-QID 4) Fluorometholone 0.1% 1-2 GTTS BID-QID 5) Dexamethasone 0.1% 1-2 GTTS BID-QID 6) Ketorolac 0.4% 1 GTT QID 7) Flurbiprofen 0.03% 1 GTT QID NF 8) Vexol 1% 1-2 GTT QID NF 9) Bromfenac 0.09% 1 GTT QD-BID NF Xifaxan (Rifaximin) 200, 550mg Tablet BID-TID Hepatic Encephalopathy Hepatic Encephalopathy Lactulose 10gm/15ml Solution 30-45ml TID-QID Xifaxan 550mg BID Traveler's Diarrhea Traveler's Diarrhea Ciprofloxacin 500mg BID Xifaxan 200mg TID X3D Xolair (Omalizumab) 150mg Subcutaneous Powder Xolair is delivered directly to MD office via CuraScript Criteria Restricted Medication for Solution Q2-4W Specialty Pharmacy QRM approval required prior to being dispensed for Administered in a healthcare setting by healthcare Commercial, Multi-Choice, Self-Funded, and Triple providers Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Xopenex (Levalbuterol Hydrochloride) 0.31mg/3ml, 1) Albuterol 0.5% Inhalation Solution Q4H PRN 2) 0.63mg/3ml, 1.25mg/3ml Inhalation Solution Q4H Albuterol 0.083% Inhalation Solution Q4H PRN 3) PRN Proair HFA (Albuterol) 0.09mg Inhalation Aerosol Powder Q4H PRN 4) Xopenex HFA Q4H PRN NF 5) Levalbuterol 0.31-1.25mg/3ml Inhalation Solution Q4H PRN NF Xopenex HFA (Levalbuterol Tartrate) 0.045mg 1) Albuterol 0.5% Inhalation Solution Q4H PRN 2) Inhalation Aerosol Powder Q4H PRN Albuterol 0.083% Inhalation Solution Q4H PRN 3) Proair HFA (Albuterol) 0.09mg Inhalation Aerosol Powder Q4H PRN Xyzal (Levocetirizine) 5mg Tablet, 0.5mg/ml Solution 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) Excluded Medication QPM OTC Allegra 60mg BID 4) Fluticasone 2 SPRAYS IEN QD 5) Flunisolide 2 SPRAYS IEN BID

Page 64 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Yasmin (30mcg Ethinyl Estradiol/3mg Drospirenone) 1) Reclipsen (30mcg Ethinyl Estradiol/0.15mg Document adequate therapeutic trial or intolerance Tablet QD Desogestrel) QD 2) Microgestin Fe 1.5/30 (30mcg to at least 3 formulary oral contraceptives Ethinyl Estradiol/1.5mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD

Yaz (20mcg Ethinyl Estradiol/3mg Drospirenone) 1) Reclipsen (30mcg Ethinyl Estradiol/0.15 Document adequate therapeutic trial or intolerance Tablet QD Desogestrel) QD 2) Microgestin Fe 1/20 (20mcg to at least 3 formulary oral contraceptives Ethinyl Estradiol/1mg Norethindrone) QD 3) Aviane (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel) QD

Zanaflex (Tizanidine) 2mg Tablet TID 1) Cyclobenzaprine 10mg TID 2) Chlorzoxazone 250- 500mg TID 3) Carisoprodol 350mg TID 4) Tizanidine 4mg 0.5T TID 5) Methocarbamol 500-750mg QID 6) Baclofen 10-20mg TID Zantac 300 (Ranitidine) 300mg Tablet QD 1) OTC Famotidine 10-20mg QD-BID 2) OTC Excluded Medication Ranitidine 75-150mg QD-BID 3) Cimetidine 400- 800mg QD-BID Zegerid (Omeprazole/Sodium Bicarbonate) 1) Pantoprazole 40mg QD 2) OTC Omeprazole 20mg Excluded Medication 40/1100mg Capsule; 20/1680, 40/1680mg Packet QD 3) Omeprazole 2mg/ml Liquid 10ml QD 4) QD Lansoprazole 3mg/ml Liquid 10ml QD 5) OTC Zegerid 20/1100mg QD 6) OTC Prevacid 15mg QD Zelapar (Selegiline) 1.25mg Orally Disintegrating 1) Carbidopa/Levodopa ER 25/100mg BID 2) Tablet QD Bromocriptine 2.5mg QD 3) Amantadine 100mg BID 4) Pramipexole 0.125-1.5mg TID 5) Ropinirole 2-8mg QD 6) Selegiline 5mg QD 7) Carbidopa/Levodopa/Entacapone 12.5/50/200mg TID 8) Ropinrole ER 2-12mg QD NF Zelboraf (Vemurafenib) 240mg Tablet 4T BID FDA approved for treatment of unresectable, Stage IIIC or metastatic, BRAF V6003 mutation positive malignant melanoma Zemplar (Paricalcitol) 1, 2, 4mcg Capsule QD Calcitriol 0.25-1mcg QD Zetia (Ezetimibe) 10mg Tablet QD Adjunctive Therapy NOTE: Zetia 5mg (25.8%) is expected to give the 1) OTC Slo-Niacin 500mg QD (Titrate to 2000mg/day same LDL reduction as 10mg (26%) as tolerated using .PITTTSLONIACIN) 2) Cholestyramine 4gm 8-16gm QD 3) Cholestyramine Light 4gm 8-16gm QD 4) Colestipol 1gm 2-16gm QD Monotherapy 1) Simvastatin 5-40mg QD 2) Pravastatin 10-80mg QD 3) Atorvastatin 10-80mg QD

Zetonna (Ciclesonide) 37mcg/Actuation Nasal 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) Age Recommendations Aerosol Liquid 1 SPRAY IEN QD OTC Allegra 60mg BID 4) Fluticasone 2 SPRAYS Fluticasone=4 years of age and older / IEN QD 5) Flunisolide 2 SPRAYS IEN BID 6) Flunisolide=6 years of age and older / Triamcinolone 2 SPRAYS IEN QD NF 7) Veramyst 2 Triamcinolone=2 years of age and older / SPRAYS IEN QD NF 8) QNASL 2 SPRAYS IEN QD Veramyst=2 years of age and older / QNASL=12 NF 9) Nasonex 2 SPRAYS IEN QD NF years of age and older / Nasonex=2 years of age and older / Zetonna=12 years of age and older

Ziana (Clindamycin/Tretinoin) 1.2/0.025% Gel AAA 2 Separate Medications Excluded Medication for patients > 36 YOA QHS Clindamycin 1% Gel AAA QHS AND Retin-A 0.025% Cream, Gel AAA QHS Zioptan (Tafluprost) 0.0015% Ophthalmic Solution 1 1) Latanoprost 0.005% 1 GTT QPM 2) Travatan Z GTT QPM 0.004% 1 GTT QPM NF 3) Lumigan 0.01-0.03% 1 GTT QPM NF Zipsor (Diclofenac Potassium) 25mg Liquid Filled 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg Capsule 2C BID-TID BID 3) Ibuprofen 400-800mg TID-QID 4) Sulindac 150-200mg BID 5) Etodolac 200-500mg BID-TID 6) Nabumetone 500-750mg BID 7) Lidocaine 5% Ointment AAA Q4H 8) Diclofenac 25-100mg BID-TID 9) Indomethacin 25-75mg QD-BID 10) Tolmetin 200- 600mg TID Zirgan (Ganciclovir) 0.15% Ophthalmic Gel 1 GTT 5 Trifluridine 1% 1 GTT Q2H until healed then 1 GTT times daily until healed then 1 GTT TID X7D Q4H X7D

Page 65 Last Updated: 11/12/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List

Zofran (Ondansetron) 4mg/5ml Solution 30 minutes 1) Ondansetron 4-8mg 30 minutes prior to prior to chemotherapy chemotherapy 2) Ondansetron 4-8mg ODT 30 minutes prior to chemotherapy Zomig (Zolmitriptan) 5mg Nasal Spray; 2.5, 5mg 1) Sumatriptan 25-100mg PRN 2) Sumatriptan 5- Quantity Limit Tablet PRN 20mg Nasal Spray PRN 3) Naratriptan 1-2.5mg PRN Maxalt MLT 5-10mg=9 Tablets 4) Sumatriptan 6mg/ml Subcutaneous Solution PRN Naratriptan 1-2.5mg=9 Tablets 5) Maxalt MLT 5-10mg PRN NF Sumatriptan 25-100mg=9 Tablets Zomig 2.5mg=6 Tablets Zomig 5mg=3 Tablets Zonegran (Zonisamide) 25, 50, 100mg Capsule QD 1) Lamotrigine 100-200mg BID 2) Carbamazepine 800-1600mg QD 3) Topiramate 200mg BID 4) Phenytoin 100mg TID 5) Levetiracetam 500-1500mg BID 6) Zonisamide 100mg TID NF Zovirax (Acyclovir) 5% Ointment AAA Q4H 1) OTC Abreva 10% Cream AAA Q4H 2) Acyclovir 400mg BID Zyban (Bupropion) 150mg Extended Release Tablet 1) OTC Nicoderm 7, 14, 21mg/day Patch Apply QD 2) BID OTC Nicorette 2, 4mg Gum Chew 3-24 QD 3) Bupropion SR 150mg QD-BID Zyflo CR (Zileuton) 600mg Extended Release Tablet 1) Montelukast 10mg QHS 2) Qvar 40-80mcg 1-2 Document adequate therapeutic trial or intolerance 2T BID PUFFS QD-BID 3) Flovent HFA 44mcg 2 PUFFS BID to Montelukast, Zafirlukast, and an Inhaled NOTE: Flovent HFA 44mcg for patients 4-11 years of Corticosteroid within the past 3 months age 4) Zafirlukast 10-20mg BID NF 5) Asmanex 110- *Patients should have prescription for a Short- 220mcg 1-2 PUFFS QD 6) Budesonide 0.25- Acting Beta 2 Agonist (e.g. Proair) for asthma 0.5mg/2ml QD-BID exacerbations Zylet (Loteprednol/Tobramycin) 0.5/0.3% 2 Separate Medications NOTE: Consider Tobramycin/Dexamethasone Ophthalmic Suspension 1-2 GTT Q4-6H Tobramycin 0.3% 1-2 GTT Q4H AND 1) Diclofenac 0.3/0.1% 1-2 GTTS Q4-6 HOURS 0.1% 1GTT QID 2) Ketorolac 0.5% 1 GTT QID 3) Prednisolone 1% 1-2 GTTS BID-QID 4) Fluorometholone 0.1% 1-2 GTTS BID-QID 5) Dexamethasone 0.1% 1-2 GTTS BID-QID 6) Ketorolac 0.4% 1 GTT QID 7) Flurbiprofen 0.03% 1 GTT QID NF 8) Vexol 1% 1-2 GTT QID NF 9) Bromfenac 0.09% 1 GTT QD-BID NF 10) Lotemax 0.5% 1-2 GTT QID NF 11) Nevanac 0.1% 1 GTT TID NF Zytiga (Abiraterone Acetate) 250mg Tablet 4T QD Docetaxel-based Chemotherapy FDA approved for treatment of castration-resistant metastatic prostate cancer who have failed Docetaxel-based Chemotherapy zzUpdated: August 19, 2011 Diana Diaz, Pharm.D. zzUpdated: October 20, 2011 Diana Diaz, Pharm.D. zzUpdated: December 21, 2011 Diana Diaz, Pharm.D. zzUpdated: February 20, 2012 Diana Diaz, Pharm.D. zzUpdated: April 24, 2012 Christine Lord, PharmD zzUpdated: June 20, 2012 Diana Diaz, Pharm.D. zzUpdated: August 17, 2012 Diana Diaz, Pharm.D. zzUpdated: October 23, 2012 Diana Diaz, Pharm.D.

Page 66 Last Updated: 11/12/2012