Kaiser Permanente 2021 Comprehensive Formulary

(List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

This formulary was updated on 10/01/21. For more recent information or other questions, please contact the number for your Kaiser Permanente Region listed below, seven days a week, 8 a.m. to 8 p.m., or visit kp.org/seniorrx.

Kaiser Permanente Regions

CALIFORNIA REGIONS HAWAII REGION Kaiser Permanente Senior Advantage (HMO) Kaiser Permanente Senior Advantage (HMO) Member Service Contact Center Member Services 1-800-443-0815 TTY 711 1-800-805-2739 TTY 711 MID-ATLANTIC STATES REGION COLORADO REGION (District of Columbia, Maryland, Kaiser Permanente Senior Advantage (HMO) and Virginia) Member Services Kaiser Permanente Medicare Advantage (HMO) 1-800-476-2167 TTY 711 Member Services 1-888-777-5536 TTY 711 GEORGIA REGION Kaiser Permanente Senior Advantage (HMO) NORTHWEST REGION and Senior Advantage Medicare Medicaid Kaiser Permanente Senior Advantage (HMO) Plan (HMO D-SNP) Member Services Member Services 1-877-221-8221 TTY 711 1-800-232-4404 TTY 711

Y0043_N00016527_Final10_C HPMS Approved Formulary File Submission 00021410, Version 17 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us,” or “our,” it means Kaiser Permanente. When it refers to “plan” or “our plan,” it means Kaiser Permanente Senior Advantage or Kaiser Permanente Medicare Advantage, , depending upon the region in which you are enrolled.

This document includes a list of the drugs (formulary) for our plan which is current as of October 1, 2021. For an updated formulary, please visit our website at kp.org/seniorrx or call us. Contact information for your Kaiser Permanente Region, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. The formulary and pharmacy network may change at any time. You will receive notice when necessary.

What is the Kaiser Permanente adding the new generic drug, we may decide Formulary? to keep the brand name drug on our Drug List, but immediately move it to a different A formulary is a list of covered drugs selected cost-sharing tier or add new restrictions. If by Kaiser Permanente in consultation with a you are currently taking that brand name team of health care providers, which drug, we may not tell you in advance before represents the prescription therapies believed we make that change, but we will later to be a necessary part of a quality treatment provide you with information about the program. Our plan will generally cover the specific change(s) we have made. drugs listed in our formulary as long as the drug is medically necessary, the prescription • If we make such a change, you or your is filled at a Kaiser Permanente network prescriber can ask us to make an pharmacy, and other plan rules are followed. exception and continue to cover the For more information on how to fill your brand name drug for you. The notice prescriptions, please review your Evidence we provide you will also include of Coverage. information on how to request an exception, and you can also find Contact information for your Kaiser information in the section below Permanente Region, along with the date we entitled “How do I request an last updated the formulary, appears on the exception to the Kaiser Permanente front and back cover pages. Formulary?”

Can the formulary (drug list) Drugs removed from the market change? If the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe Most changes in drug coverage happen on or the drug’s manufacturer removes the drug January 1, but Kaiser Permanente may add or remove drugs on the Drug List during the from the market, we will immediately remove year, move them to different cost-sharing the drug from our formulary and provide tiers, or add new restrictions. We must follow notice to members who take the drug. Medicare rules in making these changes. Other changes

Changes that can affect you this year: We may make other changes that affect members currently taking a drug. For In the below cases, you will be affected by instance, we may add a generic drug that is coverage changes during the year: not new to market to replace a brand name drug currently on the formulary or add new New generic drugs restrictions to the brand name drug or move it to a different cost-sharing tier or both. Or we We may immediately remove a brand name may make changes based on new clinical drug on our Drug List if we are replacing it guidelines. If we remove drugs from our with a new generic drug that will appear on formulary, or add prior authorization, or move the same or lower cost sharing tier and with a drug to a higher cost-sharing tier, we must the same or fewer restrictions. Also, when notify affected members of the change at

Kaiser Permanente 2021 Comprehensive Formulary • 1

least 30 days before the change becomes we send you or Provision of Notice effective, or at the time the member requests posted at kp.org/seniorrx. a refill of the drug, at which time the member will receive a 30-day supply of the drug. How do I use the formulary? • If we make other changes, you or your prescriber can ask us to make an There are two ways to find your drug within exception and continue to cover the the formulary: brand name drug for you. The notice we provide you will include information Medical condition on how to request an exception. You can find information in the section The formulary begins on page 6. The drugs in below entitled “How do I request an this formulary are grouped into categories exception to the Kaiser Permanente depending on the type of medical conditions Formulary?” that they are used to treat. For example, drugs used to treat a heart condition are listed Changes that will not affect you if you are under the category, “Cardiovascular Drugs”. currently taking the drug. If you know what your drug is used for, look Generally, if you are taking a drug on our for the category name in the list that begins 2021 formulary that was covered at the on page 8. Then look under the category beginning of the year, we will not discontinue name for your drug. or reduce coverage of the drug during the 2021 coverage year except as described Alphabetical listing above. This means these drugs will remain available at the same cost-sharing and with If you are not sure what category to look no new restrictions for those members taking under, you should look for your drug in the them for the remainder of the coverage year. index that begins on page 76. The index You will not get direct notice this year about provides an alphabetical list of all the drugs changes that do not affect you. However, on included in this document. Preferred generic January 1 of the next year, such changes would affect you, and it is important to check and generic drugs, preferred brand-name and the Drug List for the new benefit year for any nonpreferred brand-name drugs, specialty-tier changes to drugs. drugs, and injectable vaccines are listed in the index. Look in the index and find your drug. Next to your drug, you will see the page The enclosed formulary is current as of number where you can find coverage October 1, 2021. To get updated information information. Turn to the page listed in the about the drugs covered by our plan, please index and find the name of your drug in the call us. Contact information for your Kaiser first column of the list. Permanente Region appears on the front and back cover pages. What are generic drugs? In the event of a midyear non-maintenance formulary change, Our plan covers both brand-name drugs and we will provide details in the Medicare generic drugs. A generic drug is approved by Part D Explanation of Benefits that the FDA as having the same active ingredient as the brand-name drug. Generally, generic

2 • Kaiser Permanente 2021 Comprehensive Formulary drugs cost less than brand-name drugs. Cost • Prior Authorization: Our plan may sharing for preferred generic drugs may be require you or your network provider to different than for generic drugs. Please see get prior authorization for certain your Evidence of Coverage for more drugs. This means that you will need information. to get approval from our plan before you fill your prescriptions. If you don’t What are brand-name drugs? get approval, we may not cover the drug. Brand-name drugs are manufactured and sold by the pharmaceutical company that Note: If your prescription has more than originally researched and developed the drug. one refill remaining, you can only get one When the patent on a brand-name drug refill at a time, unless authorized because expires, other pharmaceutical companies you will be away from our service area for may manufacture and sell an FDA-approved an extended period of time. generic version of the drug with the same active ingredient(s) at lower prices. Cost For certain drugs, we may limit the amount of sharing for preferred brand-name drugs may an extended day supply (amounts that be different than for nonpreferred brand-name exceed a 30-day supply) that you can drugs. Please see your Evidence of receive. Also, if there is a shortage in the Coverage for more information. marketplace, we may fill your prescription for a limited quantity. What are specialty-tier drugs? You can find out if your drug has any Specialty-tier drugs are very high-cost drugs additional requirements or limits by looking in approved by the FDA that are on our the formulary that begins on page 6. You can formulary. also get more information about the restrictions applied to specific covered drugs What are injectable Part D by visiting our website. We have posted vaccines? online a document that explains our prior authorization restriction. You may also ask us Part D vaccines are certain injectable to send you a copy. Contact information for vaccines that are covered under Medicare your Kaiser Permanente Region, along with Part D (for example, Zostavax for shingles, the date we last updated the formulary, Adacel for Diphtheria, Tetanus, and appears on the front and back cover pages. Pertussis, which are approved by the FDA). You can ask us to make an exception to Are there any restrictions on my these restrictions or limits or for a list of other, coverage? similar drugs that may treat your health condition. See the section, “How do I request Some covered drugs may have additional an exception to the Kaiser Permanente requirements or limits on coverage. These formulary?” for information about how to requirements and limits may include: request an exception.

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What if my drug is not on the • In accord with our tiering exception process, you can ask us to cover a formulary? Part D formulary drug at a lower cost- sharing level. If approved this would If your drug is not included on this formulary lower the amount you must pay for (list of covered drugs), you should first check your drug. Note: Specialty tier (Tier 5) our Kaiser Permanente 2021 drugs are not eligible for a tier Comprehensive Formulary at exception. kp.org/seniorrx or call our plan at the number listed on the front and back cover • You can ask us to waive coverage pages for your Kaiser Permanente Region restrictions or limits on your drug. For and confirm if your drug is covered. example, if your drug requires prior authorization, you can ask us to waive If your Medicare Part D prescription drug is the prior authorization requirement for not on our Kaiser Permanente 2021 your Part D drug. Comprehensive Formulary, you have two options: Generally, we will only approve your request for an exception if the alternative drugs • You can ask your network provider to included on the plan’s formulary, the lower prescribe a similar drug that is cost-sharing drug or additional utilization included on our formulary. restrictions would not be as effective in treating your condition or would cause you to • You can ask us to make an exception have adverse medical effects. and cover your drug. See the next section for information about how to You should contact us to ask us for an initial request an exception. coverage decision for a formulary, tiering or utilization restriction exception. When you How do I request an exception to request a formulary, tiering or utilization the Kaiser Permanente Formulary? restriction exception you should submit a statement from your network provider You can ask us to make an exception to our supporting your request. Generally, we coverage rules. There are several types of must make our decision within 72 hours of exceptions that you can ask us to make. getting your prescriber’s supporting statement. You can request an expedited • You can ask us to cover a drug (fast) exception if you or your network even if it is not on our provider believe that your health could be Kaiser Permanente 2021 seriously harmed by waiting up to 72 hours Comprehensive Formulary. If for a decision. If your request to expedite is approved, this drug will be covered at granted, we must give you a decision no later a pre-determined cost-sharing level, than 24 hours after we get a supporting and you would not be able to ask us to statement from your doctor or other provide the drug at a lower cost- prescriber. sharing level. Please note: You can only request an exception for drugs that are considered

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Medicare Part D prescription drugs by the formulary or if your ability to get your drugs is Centers for Medicare & Medicaid Services limited, but you are past the first 90 days of (CMS). You cannot get an exception for drugs membership in our plan, we will cover a that are excluded under Medicare Part D. 31-day emergency supply of that drug while Please refer to your Evidence of Coverage you pursue a formulary exception. for more information about requesting exceptions, including the appeals process. For current members with level of care changes, if you enter into or are discharged from a hospital, skilled nursing facility, or What do I do before I can talk to long-term care facility to a different care my network provider about setting or home, this is what is known as a changing my drugs or requesting level of care change. When your level of care changes, you may require an additional fill of an exception? your medication. We will generally cover up to a one-month supply of your Part D drugs In some cases, you might be taking Medicare during this level of care transition period even Part D drugs that are not on our formulary. if the drug is not on our Drug List. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For more information For example, you may need a prior authorization from us before you can fill your For more detailed information about your prescription. You should talk to your network Kaiser Permanente prescription drug provider to decide if you should switch to an coverage, please review your Evidence of appropriate drug that we cover or request a Coverage and other plan materials. formulary exception so that we will cover the drug you take. While you talk to your network If you have questions about our plan, please provider to determine the right course of call us. Contact information for your action for you, we may cover your drug in Kaiser Permanente Region, along with the certain cases during the first 90 days you are date we last updated the formulary, appears a member of our plan. on the front and back cover pages.

For each of your Part D drugs that is not on If you have general questions about Medicare our formulary or if your ability to get your prescription drug coverage, please call drugs is limited, we will cover a temporary Medicare at 1-800-MEDICARE 30-day supply. If your prescription is written (1-800-633-4227) 24 hours a day/7 days a for fewer days, we’ll allow refills to provide up week. TTY users should call 1-877-486-2048. to a maximum of a 30-day supply of Or, visit http://www.medicare.gov. medication. After your first 30-day supply, we may cover an additional refill, as medically necessary. After you have used these refills, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility and you need a drug that is not on our

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Kaiser Permanente’s Formulary

The formulary below/that begins on the next page provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the index that begins on page 76.

The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., NEBUPENT) and generic drugs are listed in lower-case italics (e.g., amoxicillin).

The second column, “Drug Tier,” will indicate what tier number the drug is in: Tier 1 – Preferred generic drugs Tier 2 – Generic drugs (the tier includes some brand-name drugs) Tier 3 – Preferred brand-name drugs Tier 4 – Nonpreferred brand-name drugs (the tier includes some generic drugs) Tier 5 – Specialty-tier drugs (the tier includes both generic and brand-name drugs) Tier 6 – Injectable Part D vaccines (the tier includes brand-name drugs only)

Generally, the cost sharing you will pay for your drugs depends on your coverage stage, the type of network pharmacy where you purchase your drugs, and your drug’s cost-sharing tier on our formulary. Please refer to your Evidence of Coverage for the details about your Medicare Part D prescription drug coverage, including your cost-sharing amounts.

Note: If your coverage is through an employer-sponsored group plan (including a union or trust fund), you may have different drug benefits and cost sharing, and you may have coverage for other drugs that are not covered by Medicare Part D (non-Part D drugs). The amount you pay for non-Part D drugs does not count toward your total out-of-pocket expenditures, and if you are receiving Extra Help to pay for your Medicare Part D prescription drugs, you will not receive any Extra Help to pay for non-Part D drugs. Please check with your group benefits administrator or see your Evidence of Coverage. The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug. Certain strengths or forms of the drug may be subject to the utilization management codes listed below.

HI = Home infusion drugs may be covered under our medical benefit and obtained at home infusion pharmacies. For more information, please consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region.

LD = Limited-distribution drugs can only be obtained at certain specialty pharmacies. For more information, consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region.

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MO = Mail-order drugs. You may order prescription refills of certain medications through our mail-order service online at kp.org/refill or by phone or mobile app, which may lower your costs for a three-month supply. Please contact us at least 5 days before your refills run out. Generally, you should receive them within 3 to 5 days. If not, please contact the mail-order phone number for your Kaiser Permanente Region in the chart below or the phone number on the prescription label for assistance. Not all drugs can be mailed; restrictions and limitations apply. For more information, please visit kp.org/seniorrx or call the appropriate regional phone number below.

Region Mail-Order Contact Numbers (TTY 711)

California Kaiser Permanente Mail Order Pharmacy Northern CA – 1-888-218-6245 Monday through Friday, 8 a.m. to 8 p.m., Saturday 8 a.m. to 6 p.m., and Sunday 9 a.m. to 6 p.m. Southern CA – 1-866-206-2983 Monday through Friday, 7 a.m. to 7 p.m., Saturday, 10 a.m. to 2 p.m. Colorado Kaiser Permanente Mail Order Pharmacy 1-866-523-6059 Monday through Friday, 8 a.m. to 6 p.m. Georgia Kaiser Permanente Refill Pharmacy 770-434-2008 or toll free 1-888-662-4579 Seven days a week, 24 hours Hawaii Kaiser Permanente Mail Order Pharmacy 808-643-7979 (Oahu and neighbor islands) Monday through Friday, 8:00 a.m. to 5 p.m. Mid-Atlantic Kaiser Permanente Mid-Atlantic Automated Refill Center States 703-466-4900 or toll-free 1-800-733-6345 Monday through Friday, 7 a.m. to 6 p.m., Saturday, 8:30 a.m. to 4 p.m. Northwest Kaiser Permanente Mail Order Pharmacy 1-800-548-9809 Monday through Friday, 8 a.m. to 5:30 p.m.

NDS = Non-extended Day Supply drugs that are dispensed up to a 30-day supply to monitor for possible adverse effects and to avoid medication waste.

PA = Prior authorization medications may be covered under Medicare Part D or Medicare Part B depending on how they are administered (e.g., via infusion pump, nebulizer, or other Durable Medical Equipment device), where they are administered (at home or in a long-term care facility), and what medical condition they are administered for. Prior authorization may also apply to drugs for which treatment for the medical condition will determine if the drug is non-Part D (excluded) or covered.

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Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits azithromycin tabs ANTI-INFECTIVE AGENTS 2 MO ANTHELMINTICS 250mg, 500mg, 600mg albendazole tabs 2 NDS aztreonam solr injection 2 HI emverm chew 2 bacitracin solr 2 BAXDELA SOLR ivermectin tabs 2 4 HI INTRAVENOUS praziquantel tabs 2 MO BAXDELA TABS 4 MO ANTIBACTERIALS BICILLIN C-R 900/300 4 amikacin sulfate soln 2 SUSP amikacin sulfate soln 2 HI BICILLIN C-R SUSP 4 injection BICILLIN L-A SUSP 3 amoxicillin caps 2 cefaclor caps 2 amoxicillin chew 2 cefaclor er tb12 2 amoxicillin susr 2 cefaclor susr 2 amoxicillin tabs 2 cefadroxil caps 2 amoxicillin-pot 2 clavulanate chew cefadroxil susr 2 amoxicillin-pot cefadroxil tabs 2 2 clavulanate er tb12 cefazolin sodium solr 2 amoxicillin-pot cefazolin sodium solr 2 clavulanate susr injection 1gm, 10gm, 2 HI amoxicillin-pot 500mg 2 clavulanate tabs cefdinir caps 2 ampicillin caps 2 cefdinir susr 2 cefepime hcl solr ampicillin sodium solr 2 2 HI ampicillin sodium solr injection 1gm, 2gm 2 HI injection 1gm, 125mg cefixime caps 2 ampicillin sodium solr cefixime susr 2 2 HI intravenous cefotaxime sodium solr 2 ampicillin-sulbactam cefotetan disodium solr 2 2 HI sodium solr injection 1gm, 2gm ampicillin-sulbactam cefoxitin sodium solr 2 HI 2 HI sodium solr injection injection ampicillin-sulbactam cefoxitin sodium solr 2 HI 2 HI sodium solr intravenous intravenous 1gm, 2gm ARIKAYCE SUSP 5 PA,LD,NDS cefpodoxime proxetil 2 AUGMENTIN SUSR 3 susr AVYCAZ SOLR cefpodoxime proxetil 4 HI 2 INTRAVENOUS tabs AZITHROMYCIN PACK 3 MO cefprozil susr 2 azithromycin solr cefprozil tabs 2 2 HI intravenous ceftazidime solr injection 2 HI azithromycin susr 1gm, 2gm, 6gm 2 MO 100mg/5ml, 200mg/5ml CEFTIN SUSR 3

You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

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Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits ceftriaxone sodium solr demeclocycline hcl tabs 2 injection 1gm, 2gm, 2 HI dicloxacillin sodium caps 2 250mg, 500mg DIFICID SUSR 5 NDS ceftriaxone sodium solr 2 HI DIFICID TABS 5 NDS intravenous DORYX MPC TBEC 4 MO cefuroxime axetil tabs 2 doxy 100 solr cefuroxime sodium solr 2 HI 2 HI intravenous injection 7.5gm, 750mg doxycycline hyclate caps cefuroxime sodium solr 2 MO 2 HI 50mg, 100mg intravenous doxycycline hyclate tabs cephalexin caps 2 20mg, 75mg, 100mg, 2 MO cephalexin susr 2 150mg cephalexin tabs 2 doxycycline hyclate tbec chloramphenicol sod 2 50mg, 75mg, 100mg, 2 MO succinate solr 150mg, 200mg ciprofloxacin hcl tabs 2 doxycycline monohydrate caps ciprofloxacin in d5w soln 2 2 MO ciprofloxacin in d5w soln 50mg, 75mg, 100mg, 2 HI intravenous 150mg doxycycline ciprofloxacin susr 2 2 MO ciprofloxacin-ciproflox hcl monohydrate susr 2 er tb24 doxycycline clarithromycin er tb24 2 monohydrate tabs 50mg, 2 MO clarithromycin susr 2 75mg, 100mg, 150mg e.e.s. 400 tabs 2 clarithromycin tabs 2 ertapenem sodium solr cleocin phosphate soln 2 2 HI injection cleocin solr 2 ery-tab tbec 2 clindamycin hcl caps 2 ERYTHROCIN clindamycin palmitate hcl 2 LACTOBIONATE SOLR 2 HI solr INTRAVENOUS clindamycin phosphate 2 HI erythrocin stearate tabs 2 in d5w soln intravenous erythromycin base cpep 2 MO clindamycin phosphate 2 soln erythromycin base tabs 2 clindamycin phosphate erythromycin base tbec 2 soln injection erythromycin 2 HI 2 300mg/2ml, 600mg/4ml, ethylsuccinate susr erythromycin 900mg/6ml 2 colistimethate sodium ethylsuccinate tabs 2 HI (cba) solr injection FETROJA SOLR 5 NDS DALVANCE SOLR FIRVANQ SOLR 4 5 HI INTRAVENOUS gentamicin in saline soln 2 daptomycin solr gentamicin in saline soln 2 HI intravenous 350mg, 5 HI intravenous 500mg gentamicin sulfate soln 2 You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

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Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits gentamicin sulfate soln OXACILLIN SODIUM IN 2 HI injection DEXTROSE SOLN 3 HI imipenem-cilastatin solr INTRAVENOUS 2 HI intravenous oxacillin sodium solr 2 HI KIMYRSA SOLR 5 NDS injection 1gm, 2gm oxacillin sodium solr levofloxacin in d5w soln 2 2 HI levofloxacin in d5w soln intravenous 2 HI intravenous PENICILLIN G POT IN levofloxacin soln 2 DEXTROSE SOLN 3 HI levofloxacin soln INTRAVENOUS 2 HI penicillin g potassium intravenous 2 HI levofloxacin tabs 2 solr injection lincomycin hcl soln 2 penicillin g procaine susp 2 penicillin g sodium solr linezolid soln intravenous 2 HI 2 HI injection linezolid susr 5 NDS penicillin v potassium 2 linezolid tabs 2 NDS solr meropenem solr penicillin v potassium 2 HI 2 intravenous 1gm, 500mg tabs minocycline hcl caps piperacillin sod- 2 MO 2 50mg, 75mg, 100mg tazobactam so solr minocycline hcl er tb24 piperacillin sod- 45mg, 55mg, 65mg, 2 MO tazobactam so solr 2 HI 80mg, 90mg, 105mg, intravenous 115mg, 135mg polymyxin b sulfate solr minocycline hcl tabs 2 HI 2 MO injection 50mg, 75mg, 100mg RECARBRIO SOLR 5 NDS mondoxyne nl caps SEYSARA TABS 60mg, 2 MO 5 NDS 75mg, 100mg 100mg, 150mg morgidox caps 2 MO SIVEXTRO SOLR moxifloxacin hcl in nacl 5 HI 2 HI INTRAVENOUS soln intravenous SIVEXTRO TABS 5 NDS moxifloxacin hcl tabs 2 soloxide tbec 2 MO nafcillin sodium solr 2 streptomycin sulfate solr 5 nafcillin sodium solr 2 HI sulfadiazine tabs 2 injection sulfamethoxazole- nafcillin sodium solr 2 2 HI trimethoprim soln intravenous sulfamethoxazole- neomycin sulfate tabs 2 2 MO trimethoprim susp NUZYRA SOLR 5 HI,NDS sulfamethoxazole- 2 MO NUZYRA TABS 5 NDS trimethoprim tabs ofloxacin tabs 2 sulfasalazine tabs 2 okebo caps 2 MO sulfasalazine tbec 2 ORBACTIV SOLR 5 NDS SULFATRIM 2 MO PEDIATRIC SUSP

You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

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Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits SUPRAX CAPS 4 ANTIFUNGALS suprax chew 2 ABELCET SUSP 4 HI suprax susr 100mg/5ml, INTRAVENOUS 2 200mg/5ml AMBISOME SUSR 5 HI SUPRAX SUSR 500 INTRAVENOUS 4 MG/5ML amphotericin b solr 2 HI SYNERCID SOLR 3 intravenous caspofungin acetate solr targadox tabs 2 MO 5 HI tazicef solr injection intravenous 50mg, 70mg 2 HI 1gm, 2gm, 6gm CRESEMBA CAPS 5 NDS TEFLARO SOLR CRESEMBA SOLR 5 NDS INTRAVENOUS 400mg, 4 HI ERAXIS SOLR 600mg INTRAVENOUS 50mg, 4 HI tetracycline hcl caps 100mg 2 MO 250mg, 500mg fluconazole in sodium 2 HI TIGECYCLINE SOLR chloride soln intravenous 5 HI INTRAVENOUS fluconazole susr 2 tobramycin sulfate soln fluconazole tabs 2 injection 80mg/2ml, 2 HI flucytosine caps 250mg, 5 NDS 10mg/ml 500mg VABOMERE SOLR griseofulvin microsize 4 HI 2 INTRAVENOUS susp vancomycin hcl caps 2 griseofulvin microsize 2 vancomycin hcl solr 2 tabs VANCOMYCIN HCL griseofulvin 4 2 SOLR 250 MG ultramicrosize tabs vancomycin hcl solr itraconazole caps 2 intravenous 1gm, 10gm, 2 HI ITRACONAZOLE SOLN 5 MO 500mg ketoconazole tabs 2 VIBRAMYCIN SYRP 4 micafungin sodium solr XENLETA SOLN 5 NDS intravenous 50mg, 2 HI XENLETA TABS 5 NDS 100mg XIFAXAN TABS 200mg, NOXAFIL SUSP 5 NDS 5 NDS 550mg NOXAFIL TBEC 5 NDS XIMINO CP24 45mg, 4 MO nystatin susp 2 90mg, 135mg nystatin tabs 2 ZEMDRI SOLN POSACONAZOLE 5 HI 5 NDS INTRAVENOUS SUSP ZERBAXA SOLR 4 HI posaconazole tbec 5 NDS INTRAVENOUS terbinafine hcl tabs 2 ZITHROMAX PACK 4 MO TOLSURA CAPS 5 NDS ZOSYN SOLN 4 HI voriconazole solr INTRAVENOUS 5 HI intravenous ZYVOX SOLN 5 HI INTRAVENOUS voriconazole susr 5 You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

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Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits voriconazole tabs 2 metronidazole caps 2 metronidazole in nacl ANTIMYCOBACTERIALS 2 CAPASTAT SULFATE soln 3 metronidazole in nacl SOLR 2 HI cycloserine caps 2 soln intravenous dapsone tabs 25mg, metronidazole tabs 2 2 MO 100mg NEBUPENT SOLR 3 PA ethambutol hcl tabs nitazoxanide tabs 5 2 MO 100mg, 400mg paromomycin sulfate 2 isoniazid soln 2 caps pentamidine isethionate isoniazid syrp 2 MO 2 PA isoniazid tabs 100mg, inh 2 MO pentamidine isethionate 300mg 2 paser pack 2 MO inj PRIMAQUINE PRETOMANID TABS 3 2 PRIFTIN TABS 4 MO PHOSPHATE TABS pyrimethamine tabs 5 pyrazinamide tabs 2 MO quinine sulfate caps 2 NDS RIFABUTIN CAPS 2 MO SOLOSEC PACK 4 RIFADIN CAPS 2 MO tinidazole tabs 2 rifamate caps 2 MO rifampin caps 150mg, ANTIVIRALS 2 MO 300mg abacavir sulfate soln 2 rifampin solr intravenous 2 HI abacavir sulfate tabs 2 MO abacavir sulfate- RIFATER TABS 4 MO 2 MO SIRTURO TABS 20mg, lamivudine tabs 5 NDS abacavir-lamivudine- 100mg 2 MO TRECATOR TABS 4 MO zidovudine tabs acyclovir caps 2 MO ANTIPROTOZOALS acyclovir sodium soln ARTESUNATE SOLR 5 NDS 2 HI intravenous atovaquone susp 5 NDS acyclovir susp 2 MO atovaquone-proguanil 2 acyclovir tabs 400mg, hcl tabs 2 MO 800mg BENZNIDAZOLE TABS 4 MO adefovir dipivoxil tabs 5 NDS 12.5mg, 100mg chloroquine phosphate APTIVUS CAPS 3 MO 2 NDS tabs 250mg, 500mg APTIVUS SOLN 3 MO atazanavir sulfate caps COARTEM TABS 3 2 MO DARAPRIM TABS 5 150mg, 200mg, 300mg BARACLUDE SOLN 3 MO humatin caps 2 hydroxychloroquine BIKTARVY TABS 3 2 MO,NDS sulfate tabs CABENUVA SUER 4 IMPAVIDO CAPS 5 NDS cidofovir soln 2 KRINTAFEL TABS 3 CIMDUO TABS 2 MO mefloquine hcl tabs 2 COMPLERA TABS 3 MO You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

12 • Kaiser Permanente 2021 Comprehensive Formulary

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits CRIXIVAN CAPS ISENTRESS TABS 3 MO 3 MO 200mg, 400mg JULUCA TABS 3 MO DAKLINZA TABS 30mg, 5 PA,NDS lamivudine soln 2 MO 60mg, 90mg lamivudine tabs 100mg, 2 MO DELSTRIGO TABS 4 MO 150mg, 300mg DESCOVY TABS 3 MO lamivudine-zidovudine didanosine cpdr 200mg, 2 MO 2 MO tabs 250mg, 400mg ledipasvir-sofosbuvir 5 PA,NDS DOVATO TABS 3 MO tabs EDURANT TABS 3 MO LEXIVA SUSP 4 MO efavirenz caps 50mg, lopinavir-ritonavir soln 2 MO 2 MO 200mg lopinavir-ritonavir tabs 2 MO efavirenz tabs 2 MO MAVYRET TABS 5 PA,NDS efavirenz-emtricitab- nevirapine er tb24 2 MO 2 MO tenofovir tabs 100mg, 400mg emtricitabine caps 2 MO nevirapine susp 2 MO emtricitabine-tenofovir df 2 MO nevirapine tabs 2 MO tabs NORVIR CAPS 3 MO EMTRIVA SOLN 3 MO NORVIR PACK 4 MO entecavir tabs 0.5mg, 2 MO NORVIR SOLN 3 MO 1mg ODEFSEY TABS 3 MO EPCLUSA TABS 5 PA,NDS OLYSIO CAPS 5 PA,NDS EPIVIR HBV SOLN 3 MO oseltamivir phosphate etravirine tabs 100mg, 2 MO 2 MO caps 30mg, 45mg, 75mg 200mg oseltamivir phosphate 2 MO EVOTAZ TABS 4 MO susr famciclovir tabs 125mg, PEG-INTRON REDIPEN 2 MO 5 NDS 250mg, 500mg KIT fosamprenavir calcium 2 MO PEGASYS PROCLICK tabs SOLN 135mcg/0.5ml, 5 NDS FUZEON SOLR 3 NDS 180mcg/0.5ml ganciclovir sodium soln 2 PEGASYS SOLN ganciclovir sodium solr 2 180mcg/0.5ml, 5 NDS GENVOYA TABS 3 MO 180mcg/ml HARVONI PACK 5 PA,NDS PEGINTRON KIT 5 NDS HARVONI TABS 5 PA,NDS PIFELTRO TABS 4 MO INTELENCE TABS PLEGRIDY SOPN 5 NDS 3 MO 25mg PLEGRIDY SOSY 5 NDS INVIRASE CAPS 3 MO PLEGRIDY STARTER 5 NDS INVIRASE TABS 3 MO PACK SOPN ISENTRESS CHEW PLEGRIDY STARTER 3 MO 5 NDS 25mg, 100mg PACK SOSY ISENTRESS HD TABS 3 MO ISENTRESS PACK 3 MO You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

Kaiser Permanente 2021 Comprehensive Formulary • 13

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits PREVYMIS SOLN SYMTUZA TABS 4 MO 240mg/12ml, 5 NDS SYNAGIS SOLN 5 NDS 480mg/24ml 50mg/0.5ml, 100mg/ml PREVYMIS TABS tenofovir disoproxil 5 NDS 2 MO 240mg, 480mg fumarate tabs PREZCOBIX TABS 3 MO TIVICAY PD TBSO 3 MO PREZISTA SUSP 3 MO TIVICAY TABS 10mg, 3 MO PREZISTA TABS 75mg, 25mg, 50mg 3 MO 150mg, 600mg, 800mg TRIUMEQ TABS 3 MO RAPIVAB SOLN 5 NDS TRIZIVIR TABS 3 MO REBETOL SOLN 4 MO TYBOST TABS 3 MO RELENZA DISKHALER valacyclovir hcl tabs 3 MO 2 MO AEPB 1gm, 500mg RESCRIPTOR TABS 3 MO valganciclovir hcl solr 2 NDS 100mg, 200mg valganciclovir hcl tabs 2 NDS RETROVIR SOLN 3 MO VEMLIDY TABS 5 REYATAZ PACK 4 MO VIDEX EC CPDR 4 MO ribasphere caps 2 MO 125mg, 200mg, 400mg ribasphere ribapak (1000 2 MO VIDEX SOLR 2gm, 4gm 3 MO pack) tbpk VIEKIRA PAK TBPK 5 PA,NDS ribasphere ribapak (1200 2 MO VIEKIRA XR TB24 5 PA,NDS pack) tbpk VIRACEPT TABS 3 MO ribasphere tabs 2 MO 250mg, 625mg ribavirin caps 2 MO VIREAD POWD 3 MO ribavirin solr 2 VIREAD TABS 150mg 3 MO ribavirin tabs 2 MO VIREAD TABS 200mg, 4 MO rimantadine hcl tabs 2 MO 250mg ritonavir tabs 2 MO VOCABRIA TABS 4 MO RUKOBIA TB12 4 VOSEVI TABS 5 PA,NDS SELZENTRY SOLN 4 MO XOFLUZA (40 MG 4 MO SELZENTRY TABS DOSE) TBPK 25mg, 75mg, 150mg, 3 MO XOFLUZA (80 MG 4 MO 300mg DOSE) TBPK sofosbuvir-velpatasvir 5 PA,NDS ZEPATIER TABS 5 PA,NDS tabs ZERIT CAPS 15mg, SOVALDI PACK 150mg, 4 MO 5 PA,NDS 20mg, 30mg, 40mg 200mg zidovudine caps 2 MO SOVALDI TABS 200mg, 5 PA,NDS zidovudine syrp 2 MO 400mg zidovudine tabs 2 MO stavudine caps 15mg, 2 MO URINARY ANTI-INFECTIVES 20mg, 30mg, 40mg fosfomycin tromethamine STRIBILD TABS 3 MO 2 pack SYMFI LO TABS 2 MO ME/NAPHOS/MB/HYO1 2 SYMFI TABS 2 MO TABS You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

14 • Kaiser Permanente 2021 Comprehensive Formulary

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits methenamine hippurate levocetirizine 2 2 tabs dihydrochloride tabs METHENAMINE phenadoz supp 2 2 MANDELATE TABS phenergan soln 2 NITROFURANTOIN promethazine hcl soln 2 MACROCRYSTAL 2 promethazine hcl supp 2 CAPS promethazine hcl syrp 2 NITROFURANTOIN promethazine hcl tabs 2 MONOHYD MACRO 2 promethazine- CAPS 2 phenylephrine syrp nitrofurantoin susp 2 promethegan supp 2 PHOSPHASAL TABS 2 ryclora soln 2 trimethoprim tabs 2 MO ryvent tabs 2 URETRON D/S TABS 2 SEMPREX-D CAPS 4 URIN DS TABS 2 URYL TABS 2 ANTINEOPLASTIC AGENTS USTELL CAPS 2 ANTINEOPLASTIC AGENTS abiraterone acetate tabs UTICAP CAPS 2 5 NDS 250mg, 500mg UTIRA-C TABS 2 ABRAXANE SUSR 3 UTRONA-C TABS 2 adriamycin soln 2 ANTIHISTAMINE DRUGS adriamycin solr 2 ANTIHISTAMINE DRUGS adrucil soln 2 carbinoxamine maleate AFINITOR DISPERZ 2 5 NDS soln TBSO 2mg, 3mg, 5mg carbinoxamine maleate AFINITOR TABS 2.5mg, 2 5 NDS tabs 5mg, 7.5mg, 10mg cetirizine hcl soln 2 ALECENSA CAPS 5 NDS CLARINEX SYRP 4 ALIMTA SOLR 3 CLARINEX-D 12 HOUR 4 ALIQOPA SOLR 5 NDS TB12 ALUNBRIG TABS 30mg, clemastine fumarate tabs 2 5 NDS 90mg, 180mg cyproheptadine hcl syrp 2 ALUNBRIG TBPK 5 NDS cyproheptadine hcl tabs 2 anastrozole tabs 2 desloratadine tabs 2 ARRANON SOLN 3 desloratadine tbdp 2 ARZERRA CONC dexchlorpheniramine 2 1000mg/50ml, 5 NDS maleate soln 100mg/5ml di-phen elix 2 ASPARLAS SOLN 5 NDS diphen elix 2 AVASTIN SOLN 5 diphenhydramine hcl elix 2 AYVAKIT TABS 25mg, diphenhydramine hcl 2 50mg, 100mg, 200mg, 5 NDS soln 300mg levocetirizine 2 azacitidine susr 2 dihydrochloride soln You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

Kaiser Permanente 2021 Comprehensive Formulary • 15

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits BALVERSA TABS 3mg, CYCLOPHOSPHAMIDE 5 NDS 4mg, 5mg SOLN 1gm/5ml, 5 NDS BAVENCIO SOLN 5 NDS 500mg/2.5ml BCG VACCINE INJ 3 cyclophosphamide solr 2 BELEODAQ SOLR 5 NDS CYRAMZA SOLN BELRAPZO SOLN 5 NDS 100mg/10ml, 5 NDS BENDAMUSTINE HCL 500mg/50ml 5 NDS SOLN cytarabine (pf) soln 2 BENDEKA SOLN 5 NDS cytarabine soln 2 BESPONSA SOLR 5 NDS dacarbazine solr 2 bexarotene caps 5 NDS dactinomycin solr 2 bicalutamide tabs 2 DANYELZA SOLN 5 NDS DARZALEX FASPRO BICNU SOLR 3 5 NDS bleomycin sulfate solr 2 SOLN DARZALEX SOLN BLINCYTO SOLR 5 NDS 5 NDS 400mg/20ml, 100mg/5ml BORTEZOMIB SOLR 3 daunorubicin hcl soln 2 BOSULIF TABS 100mg, 5 NDS DAURISMO TABS 400mg, 500mg 5 NDS 25mg, 100mg BRAFTOVI CAPS 50mg, 5 NDS decitabine solr 2 75mg DOCETAXEL (NON- BRUKINSA CAPS 5 NDS ALCOHOL) SOLN 5 NDS busulfan soln 2 80mg/4ml, 160mg/8ml, CABOMETYX TABS 5 NDS 20mg/ml 20mg, 40mg, 60mg docetaxel conc 2 CALQUENCE CAPS 5 NDS docetaxel soln 2 CAPRELSA TABS 3 LD,NDS doxorubicin hcl liposomal 100mg, 300mg 2 inj carboplatin soln 2 DOXORUBICIN HCL 2 carmustine solr 2 SOLN cisplatin soln 2 doxorubicin hcl solr 2 CISPLATIN SOLR 5 NDS DROXIA CAPS 4 cladribine soln 2 ELIGARD KIT 4 clofarabine soln 2 ELLENCE SOLN 2 COMETRIQ (100 MG 5 LD,NDS ELZONRIS SOLN 5 NDS DAILY DOSE) KIT EMCYT CAPS 5 NDS COMETRIQ (140 MG 5 LD,NDS EMPLICITI SOLR DAILY DOSE) KIT 5 NDS 300mg, 400mg COMETRIQ (60 MG 5 LD,NDS ENHERTU SOLR 5 NDS DAILY DOSE) KIT COPIKTRA CAPS 15mg, epirubicin hcl soln 2 5 NDS 25mg ERBITUX SOLN 3 COTELLIC TABS 5 NDS ERIVEDGE CAPS 5 NDS CYCLOPHOSPHAMIDE ERLEADA TABS 5 NDS 2 PA CAPS 25mg, 50mg You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

16 • Kaiser Permanente 2021 Comprehensive Formulary

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits erlotinib hcl tabs 25mg, IBRANCE TABS 75mg, 5 NDS 5 NDS 100mg, 150mg 100mg, 125mg ERWINASE SOLR 5 NDS ICLUSIG TABS 10mg, 5 NDS ERWINAZE SOLR 5 NDS 15mg, 30mg, 45mg ETOPOPHOS SOLR 5 NDS IDAMYCIN PFS SOLN 2 etoposide soln 2 idarubicin hcl soln 2 everolimus tabs 2.5mg, IDHIFA TABS 50mg, 5 NDS 5 NDS 5mg, 7.5mg 100mg EVOMELA SOLR 5 NDS ifosfamide soln 2 exemestane tabs 2 IFOSFAMIDE SOLR 2 FARYDAK CAPS 10mg, imatinib mesylate tabs 2 5 LD,NDS IMBRUVICA CAPS 15mg, 20mg 5 NDS FASLODEX SOLN 5 NDS 70mg, 140mg FENSOLVI (6 MONTH) IMBRUVICA TABS 5 KIT 140mg, 280mg, 420mg, 5 NDS FIRMAGON (240 MG 560mg 4 DOSE) SOLR IMFINZI SOLN FIRMAGON SOLR 4 500mg/10ml, 5 NDS floxuridine solr 2 120mg/2.4ml fludarabine phosphate INFUGEM SOLN 5 NDS 2 soln INLYTA TABS 1mg, 5mg 5 NDS fludarabine phosphate INQOVI TABS 5 NDS 2 solr INREBIC CAPS 5 NDS fluorouracil soln 2 INTRON A SOLN flutamide caps 2 10mu/ml, 5 NDS FOTIVDA CAPS 6000000unit/ml 5 NDS INTRON A SOLR 10mu, 0.89mg, 1.34mg 5 NDS fulvestrant soln 5 NDS 18mu, 50mu GAVRETO CAPS 5 NDS IRESSA TABS 5 NDS GAZYVA SOLN 5 NDS irinotecan hcl soln 2 gemcitabine hcl soln 2 IXEMPRA KIT SOLR 5 NDS gemcitabine hcl solr 2 JAKAFI TABS 5mg, 10mg, 15mg, 20mg, 5 NDS GILOTRIF TABS 20mg, 5 NDS 25mg 30mg, 40mg HERCEPTIN HYLECTA JEMPERLI SOLN 5 5 NDS KADCYLA SOLR SOLN 5 NDS HERCEPTIN SOLR 100mg, 160mg 5 NDS KANJINTI SOLR 150mg, 150mg, 440mg 5 NDS HERZUMA SOLR 420mg 5 NDS 150mg, 420mg KEYTRUDA SOLN 5 NDS KISQALI (200 MG HEXALEN CAPS 5 NDS 5 NDS hydroxyurea caps 2 DOSE) TBPK KISQALI (400 MG IBRANCE CAPS 75mg, 5 NDS 5 NDS DOSE) TBPK 100mg, 125mg

You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

Kaiser Permanente 2021 Comprehensive Formulary • 17

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits KISQALI (600 MG LUPRON DEPOT (3- 5 NDS 5 DOSE) TBPK MONTH) KIT KISQALI FEMARA (400 LUPRON DEPOT (4- 5 NDS 5 MG DOSE) TBPK MONTH) KIT KISQALI FEMARA (600 LUPRON DEPOT (6- 5 NDS 5 MG DOSE) TBPK MONTH) KIT KISQALI FEMARA (200 LUPRON DEPOT-PED 5 NDS 3 MG DOSE) TBPK (1-MONTH) KIT KOSELUGO CAPS LUPRON DEPOT-PED 5 NDS 4 10mg, 25mg (1-MONTH) KIT 7.5 MG KYPROLIS SOLR 10mg, LUPRON DEPOT-PED 5 NDS 4 30mg, 60mg (3-MONTH) KIT lapatinib ditosylate tabs 5 NDS LYNPARZA CAPS 5 NDS LARTRUVO SOLN LYNPARZA TABS 5 NDS 190mg/19ml, 5 NDS 100mg, 150mg 500mg/50ml LYSODREN TABS 5 NDS LENVIMA (10 MG DAILY 5 LD,NDS MARGENZA SOLN 5 NDS DOSE) CPPK MARQIBO SUSP 5 NDS LENVIMA (12 MG DAILY 5 LD,NDS MATULANE CAPS 5 NDS DOSE) CPPK megestrol acetate susp 2 LENVIMA (14 MG DAILY 5 LD,NDS megestrol acetate tabs 2 DOSE) CPPK LENVIMA (18 MG DAILY MEKINIST TABS 0.5mg, 5 LD,NDS 5 NDS DOSE) CPPK 2mg LENVIMA (20 MG DAILY MEKTOVI TABS 5 NDS 5 LD,NDS DOSE) CPPK melphalan hcl solr 2 LENVIMA (24 MG DAILY mercaptopurine tabs 2 5 LD,NDS methotrexate sodium (pf) DOSE) CPPK 2 LENVIMA (4 MG DAILY soln 5 LD,NDS methotrexate sodium DOSE) CPPK 2 LENVIMA (8 MG DAILY soln 5 LD,NDS methotrexate sodium DOSE) CPPK 2 letrozole tabs 2 solr LEUKERAN TABS 5 NDS methotrexate tabs 2 PA leuprolide acetate kit 2 mitomycin solr 2 LIBTAYO SOLN 5 NDS mitoxantrone hcl conc 2 LIPODOX 50 INJ 2 MONJUVI SOLR 5 NDS LONSURF TABS 5 NDS MUSTARGEN SOLR 3 LORBRENA TABS mutamycin solr 2 5 NDS MVASI SOLN 25mg, 100mg 5 NDS LUMAKRAS TABS 5 NDS 400mg/16ml, 100mg/4ml LUMOXITI SOLR 5 NDS MYLOTARG SOLR 5 NDS LUPANETA PACK KIT 5 NERLYNX TABS 5 NDS LUPRON DEPOT (1- NEXAVAR TABS 5 NDS 5 MONTH) KIT nilutamide tabs 5 You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

18 • Kaiser Permanente 2021 Comprehensive Formulary

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits NINLARO CAPS 2.3mg, RIABNI SOLN 5 NDS 3mg, 4mg 100mg/10ml, 5 NDS NUBEQA TABS 5 NDS 500mg/50ml RITUXAN HYCELA ODOMZO CAPS 5 NDS 5 OGIVRI SOLR 5 NDS SOLN ONIVYDE INJ 5 NDS RITUXAN SOLN 5 ONTRUZANT SOLR ROMIDEPSIN SOLN 5 NDS 5 NDS ROZLYTREK CAPS 150mg, 420mg 5 NDS ONUREG TABS 200mg, 100mg, 200mg 5 NDS RUBRACA TABS 300mg 5 NDS OPDIVO SOLN 200mg, 250mg, 300mg 100mg/10ml, 5 NDS RUXIENCE SOLN 240mg/24ml, 40mg/4ml 100mg/10ml, 5 NDS oxaliplatin soln 2 500mg/50ml oxaliplatin solr 2 RYBREVANT SOLN 5 NDS paclitaxel conc 2 RYDAPT CAPS 5 NDS PADCEV SOLR 20mg, RYLAZE SOLN 5 NDS 5 NDS SARCLISA SOLN 30mg 5 NDS paraplatin soln 2 500mg/25ml, 100mg/5ml PEMAZYRE TABS SIKLOS TABS 5 NDS 5 NDS 4.5mg, 9mg, 13.5mg SOLTAMOX SOLN 5 PEPAXTO SOLR 5 NDS SPRYCEL TABS 20mg, PERJETA SOLN 5 NDS 50mg, 70mg, 80mg, 5 NDS PHESGO SOLN 5 NDS 100mg, 140mg PIQRAY (200 MG DAILY STIVARGA TABS 5 NDS 5 NDS DOSE) TBPK sunitinib malate caps PIQRAY (250 MG DAILY 12.5mg, 25mg, 37.5mg, 5 NDS 5 NDS DOSE) TBPK 50mg PIQRAY (300 MG DAILY SUTENT CAPS 12.5mg, 5 NDS 5 NDS DOSE) TBPK 25mg, 37.5mg, 50mg POLIVY SOLR 30mg, SYLATRON KIT 600 5 NDS 4 140mg MCG POMALYST CAPS 1mg, SYLATRON KIT 5 5 NDS SYLVANT SOLR 100mg, 2mg, 3mg, 4mg 5 NDS PORTRAZZA SOLN 5 NDS 400mg POTELIGEO SOLN 5 NDS SYNRIBO SOLR 5 NDS PROLEUKIN SOLR 5 NDS TABLOID TABS 3 TABRECTA TABS PURIXAN SUSP 5 NDS 5 NDS 150mg, 200mg QINLOCK TABS 5 NDS TAFINLAR CAPS 50mg, RETEVMO CAPS 40mg, 5 NDS 5 NDS 75mg 80mg TAGRISSO TABS 40mg, REVLIMID CAPS 2.5mg, 5 NDS 80mg 5mg, 10mg, 15mg, 5 NDS TALZENNA CAPS 20mg, 25mg 5 NDS 0.25mg, 1mg You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

Kaiser Permanente 2021 Comprehensive Formulary • 19

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits tamoxifen citrate tabs 2 TRUXIMA SOLN TARCEVA TABS 25mg, 100mg/10ml, 3 NDS 5 NDS 100mg, 150mg 500mg/50ml TASIGNA CAPS 50mg, TUKYSA TABS 50mg, 5 NDS 5 NDS 150mg, 200mg 150mg TAZVERIK TABS 5 NDS TURALIO CAPS 5 NDS TECENTRIQ SOLN TYKERB TABS 5 NDS 840mg/14ml, 5 NDS UKONIQ TABS 5 NDS 1200mg/20ml UNITUXIN SOLN 5 NDS temsirolimus soln 2 valrubicin soln 2 TENIPOSIDE SOLN 3 VANTAS KIT 3 TEPADINA SOLR 5 NDS VELCADE SOLR 3 TEPMETKO TABS 5 NDS VENCLEXTA 5 NDS THALOMID CAPS STARTING PACK TBPK 50mg, 100mg, 150mg, 5 NDS VENCLEXTA TABS 4 NDS 200mg 10mg thiotepa solr 15mg, VENCLEXTA TABS 5 NDS 5 NDS 100mg 50mg, 100mg TIBSOVO TABS 5 NDS VERZENIO TABS 50mg, 5 NDS toposar soln 2 100mg, 150mg, 200mg TOPOTECAN HCL vinblastine sulfate soln 2 2 SOLN vincasar pfs soln 2 topotecan hcl solr 2 vincristine sulfate soln 2 toremifene citrate tabs 5 NDS vinorelbine tartrate soln 2 TRAZIMERA SOLR VITRAKVI CAPS 25mg, 5 NDS 5 NDS 150mg, 420mg 100mg TRELSTAR MIXJECT 5 VITRAKVI SOLN 5 NDS SUSR VIZIMPRO TABS 15mg, 5 NDS tretinoin caps 5 NDS 30mg, 45mg trexall tabs 5mg, 7.5mg, 2 PA VOTRIENT TABS 5 NDS 10mg, 15mg VYXEOS SUSR 5 NDS TRISENOX SOLN XALKORI CAPS 200mg, 3 NDS 5 NDS 10mg/10ml 250mg TRISENOX SOLN 5 NDS XATMEP SOLN 4 PA,NDS TRODELVY SOLR 5 NDS XOSPATA TABS 5 NDS TRUSELTIQ (100MG 5 NDS XPOVIO (100 MG ONCE DAILY DOSE) CPPK WEEKLY) TBPK 20mg, 5 NDS TRUSELTIQ (125MG 5 NDS 50mg DAILY DOSE) CPPK XPOVIO (40 MG ONCE TRUSELTIQ (50MG 5 NDS WEEKLY) TBPK 20mg, 5 NDS DAILY DOSE) CPPK 40mg TRUSELTIQ (75MG 5 NDS XPOVIO (40 MG TWICE DAILY DOSE) CPPK WEEKLY) TBPK 20mg, 5 NDS 40mg

You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

20 • Kaiser Permanente 2021 Comprehensive Formulary

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits XPOVIO (60 MG ONCE dicyclomine hcl soln 2 MO WEEKLY) TBPK 20mg, 5 NDS dicyclomine hcl tabs 2 MO 60mg DUAKLIR PRESSAIR XPOVIO (60 MG TWICE 5 NDS 5 NDS AEPB WEEKLY) TBPK glycate tabs 2 XPOVIO (80 MG ONCE glycopyrrolate pf sosy 2 WEEKLY) TBPK 20mg, 5 NDS glycopyrrolate soln 2 40mg glycopyrrolate tabs 1mg, XPOVIO (80 MG TWICE 2 MO 5 NDS 2mg WEEKLY) TBPK INCRUSE ELLIPTA XTANDI CAPS 5 NDS 4 MO AEPB XTANDI TABS 40mg, ipratropium bromide soln 5 NDS 1 PA,MO 80mg 0.02% YERVOY SOLN 3 ipratropium bromide soln 2 MO YONDELIS SOLR 5 NDS 0.03%, 0.06% YONSA TABS 5 NDS LONHALA MAGNAIR ZALTRAP SOLN 5 NDS 5 NDS REFILL KIT SOLN 100mg/4ml, 200mg/8ml methscopolamine ZEJULA CAPS 5 NDS bromide tabs 2.5mg, 2 MO ZELBORAF TABS 5 NDS 5mg propantheline bromide ZEPZELCA SOLR 5 NDS 2 MO ZIRABEV SOLN tabs 5 NDS SPIRIVA HANDIHALER 400mg/16ml, 100mg/4ml 4 MO ZOLINZA CAPS 5 NDS CAPS ZYDELIG TABS 100mg, SPIRIVA RESPIMAT 5 NDS 3 MO 150mg AERS 2.5mcg/act SPIRIVA RESPIMAT ZYKADIA CAPS 5 NDS 4 MO ZYKADIA TABS 5 NDS AERS STIOLTO RESPIMAT ZYNLONTA SOLR 5 NDS 3 MO AERS ZYTIGA TABS 5 NDS YUPELRI SOLN 5 PA,NDS AUTONOMIC DRUGS AUTONOMIC DRUGS, MISCELLANEOUS ANTICHOLINERGIC AGENTS CHANTIX CONTINUING 3 MO ANORO ELLIPTA AEPB 4 MO MONTH PAK TABS ATROPINE SULFATE CHANTIX STARTING 2 3 MO SOLN MONTH PAK TABS ATROPINE SULFATE CHANTIX TABS 0.5mg, 2 3 MO SOSY 1mg ATROVENT HFA AERS 3 MO NICOTROL INHA 3 MO BEVESPI 4 MO NICOTROL NS SOLN 4 MO AEROSPHERE AERO PARASYMPATHOMIMETIC (CHOLINERGIC) chlordiazepoxide- 2 AGENTS clidinium caps bethanechol chloride CUVPOSA SOLN 3 MO tabs 5mg, 10mg, 25mg, 2 MO dicyclomine hcl caps 2 MO 50mg You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

Kaiser Permanente 2021 Comprehensive Formulary • 21

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits CEVIMELINE HCL cyclobenzaprine hcl tabs 2 MO 2 PA CAPS 5mg, 7.5mg, 10mg donepezil hcl tabs 5mg, dantrolene sodium caps 2 2 MO 10mg, 23mg dantrolene sodium solr 2 donepezil hcl tbdp 5mg, 2 MO fexmid tabs 2 PA 10mg lorzone tabs 375mg, 2 NDS galantamine 750mg hydrobromide er cp24 2 MO metaxall tabs 2 8mg, 16mg, 24mg metaxalone tabs 2 galantamine 2 MO methocarbamol soln 2 hydrobromide soln galantamine methocarbamol tabs 2 orphenadrine citrate er hydrobromide tabs 4mg, 2 MO 2 8mg, 12mg tb12 GUANIDINE HCL TABS 4 MO orphenadrine citrate soln 2 MESTINON SOLN 2 MO revonto solr 2 pilocarpine hcl tabs 5mg, succinylcholine chloride 2 MO 2 7.5mg soln pyridostigmine bromide tizanidine hcl caps 2 2 MO er tbcr tizanidine hcl tabs 2 pyridostigmine bromide vanadom tabs 2 PA,NDS 2 MO soln SYMPATHOLYTIC (ADRENERGIC BLOCKING) pyridostigmine bromide AGENTS 2 MO tabs 30mg, 60mg alfuzosin hcl er tb24 2 MO REGONOL SOLN 3 dihydroergotamine 2 NDS rivastigmine pt24 mesylate soln 4.6mg/24hr, 9.5mg/24hr, 2 MO ergoloid mesylates tabs 2 MO 13.3mg/24hr ergomar subl 2 rivastigmine tartrate caps phenoxybenzamine hcl 2 MO 5 NDS 1.5mg, 3mg, 4.5mg, 6mg caps urecholine tabs 5mg, 2 MO silodosin caps 4mg, 8mg 2 MO 10mg, 25mg, 50mg tamsulosin hcl caps 2 MO SKELETAL MUSCLE RELAXANTS SYMPATHOMIMETIC (ADRENERGIC) AGENTS baclofen soln 2 ADVAIR HFA AERO 3 MO baclofen tabs 5mg, albuterol sulfate er tb12 2 MO 2 MO 10mg, 20mg 4mg, 8mg carisoprodol tabs 2 PA,NDS albuterol sulfate hfa aers 2 MO,NDS 250mg, 350mg albuterol sulfate nebu 1 PA,MO carisoprodol-aspirin tabs 2 PA,NDS 0.083%, 2.5mg/0.5ml carisoprodol-aspirin- albuterol sulfate nebu 2 PA,NDS 2 PA,MO codeine tabs 0.63mg/3ml, 1.25mg/3ml chlorzoxazone tabs 2 NDS albuterol sulfate syrp 2 MO 375mg, 500mg, 750mg albuterol sulfate tabs cyclobenzaprine hcl er 2 MO 2 PA 2mg, 4mg cp24 15mg, 30mg

You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

22 • Kaiser Permanente 2021 Comprehensive Formulary

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits ARCAPTA NEOHALER STRIVERDI RESPIMAT 4 MO 3 MO CAPS AERS arformoterol tartrate terbutaline sulfate soln 2 5 PA,MO,NDS nebu terbutaline sulfate tabs 2 MO BROVANA NEBU 5 PA,MO,NDS 2.5mg, 5mg COMBIVENT tizanidine hcl caps 2 3 MO RESPIMAT AERS VENTOLIN HFA AERS 2 MO,NDS dobutamine hcl soln 2 BLOOD FORMATION, COAGULATION, AND DOBUTAMINE IN D5W 2 THROMBOSIS SOLN BLOOD FORMATION MODIFIERS dopamine hcl soln 2 ADAKVEO SOLN 5 NDS DOPAMINE IN D5W BERINERT KIT 2 5 HI SOLN INTRAVENOUS droxidopa caps 4 FIRAZYR SOLN 5 NDS epinephrine 2 icatibant acetate soln 5 NDS (anaphylaxis) soln OXBRYTA TABS 5 NDS epinephrine soaj 2 RUCONEST SOLR 5 HI EPINEPHRINE SOSY 2 INTRAVENOUS EPIPEN 2-PAK SOAJ 2 sajazir soln 5 NDS EPIPEN JR 2-PAK 2 COAGULANTS AND ANTICOAGULANTS SOAJ aminocaproic acid soln 2 MO formoterol fumarate 4 PA,MO aminocaproic acid tabs nebu 2 MO 500mg, 1000mg ipratropium-albuterol 2 PA,MO anagrelide hcl caps soln 2 MO 0.5mg, 1mg isoproterenol hcl soln 2 argatroban soln 2 levalbuterol hcl nebu aspirin-dipyridamole er 1.25mg/0.5ml, 2 MO 2 PA,MO cp12 0.31mg/3ml, BEVYXXA CAPS 40mg, 0.63mg/3ml, 1.25mg/3ml 4 MO 80mg levalbuterol tartrate aero 2 MO BRILINTA TABS 60mg, metaproterenol sulfate 3 MO 2 MO 90mg syrp cilostazol tabs 50mg, metaproterenol sulfate 2 MO 2 MO 100mg tabs 10mg, 20mg clopidogrel bisulfate tabs midodrine hcl tabs 2 MO 2 MO 75mg, 300mg 2.5mg, 5mg, 10mg ELIQUIS TABS 4 MO norepinephrine bitartrate 2 enoxaparin sodium soln soln 30mg/0.3ml, phenylephrine hcl soln 2 40mg/0.4ml, PROAIR RESPICLICK 60mg/0.6ml, 4 MO 2 NDS AEPB 80mg/0.8ml, SEREVENT DISKUS 3 MO 120mg/0.8ml, AEPB 300mg/3ml, 100mg/ml, 150mg/ml You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

Kaiser Permanente 2021 Comprehensive Formulary • 23

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits eptifibatide soln 2 tranexamic acid tabs 2 MO fondaparinux sodium warfarin sodium tabs 2 NDS soln 2.5mg/0.5ml 1mg, 2mg, 2.5mg, 3mg, 1 MO fondaparinux sodium 4mg, 5mg, 6mg, 10mg soln 5mg/0.4ml, XARELTO STARTER 5 NDS 4 MO 7.5mg/0.6ml, PACK TBPK 10mg/0.8ml XARELTO TABS 2.5mg, 4 MO FRAGMIN SOLN 10mg, 15mg, 20mg 2500unit/0.2ml, ZONTIVITY TABS 4 MO 5000unit/0.2ml, HEMATOPOIETIC AGENTS 7500unit/0.3ml, ARANESP (ALBUMIN 12500unit/0.5ml, 4 NDS FREE) SOLN 25mcg/ml, 4 PA,NDS 15000unit/0.6ml, 40mcg/ml 95000unit/3.8ml, ARANESP (ALBUMIN 10000unit/ml, FREE) SOLN 60mcg/ml, 5 PA,NDS 18000unt/0.72ml 100mcg/ml, 200mcg/ml, heparin (porcine) in nacl 2 300mcg/ml soln ARANESP (ALBUMIN HEPARIN SOD FREE) SOSY (PORCINE) IN D5W 2 25mcg/0.42ml, 4 PA,NDS SOLN 10mcg/0.4ml, heparin sodium (porcine) 2 PA 40mcg/0.4ml pf soln ARANESP (ALBUMIN heparin sodium (porcine) FREE) SOSY soln 1000unit/ml, 60mcg/0.3ml, 5000unit/ml, 2 PA 150mcg/0.3ml, 5 PA,NDS 10000unit/ml, 200mcg/0.4ml, 20000unit/ml 100mcg/0.5ml, jantoven tabs 1mg, 2mg, 300mcg/0.6ml, 2.5mg, 3mg, 4mg, 5mg, 1 MO 500mcg/ml 6mg, 7.5mg, 10mg CABLIVI KIT 5 NDS LOVENOX SOLN DOPTELET TABS 5 NDS 30mg/0.3ml, EPOGEN SOLN 40mg/0.4ml, 2000unit/ml, 3000unit/ml, 60mg/0.6ml, 2 NDS 4000unit/ml, 4 PA,NDS 80mg/0.8ml, 10000unit/ml, 120mg/0.8ml, 20000unit/ml 300mg/3ml, 100mg/ml, FULPHILA SOSY 5 NDS 150mg/ml GRANIX SOLN pentoxifylline er tbcr 2 MO 480mcg/1.6ml, 5 NDS PRADAXA CAPS 75mg 3 300mcg/ml PRADAXA CAPS 3 MO GRANIX SOSY 110mg, 150mg 300mcg/0.5ml, 5 NDS prasugrel hcl tabs 5mg, 2 MO 480mcg/0.8ml 10mg LEUKINE SOLR 5 NDS tranexamic acid soln 2 You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

24 • Kaiser Permanente 2021 Comprehensive Formulary

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits MIRCERA SOSY TAVALISSE TABS 5 NDS 30mcg/0.3ml, 100mg, 150mg 50mcg/0.3ml, UDENYCA SOSY 5 NDS 75mcg/0.3ml, 4 PA ZARXIO SOSY 100mcg/0.3ml, 300mcg/0.5ml, 5 NDS 150mcg/0.3ml, 480mcg/0.8ml 200mcg/0.3ml ZIEXTENZO SOSY 5 NDS MULPLETA TABS 5 NDS CARDIOVASCULAR DRUGS NEULASTA ONPRO 5 NDS A-ADRENERGIC BLOCKING AGENTS PSKT CARDURA XL TB24 4 MO NEULASTA SOSY 5 NDS 4mg, 8mg NEUPOGEN SOLN DEMSER CAPS 5 NDS 480mcg/1.6ml, 5 NDS doxazosin mesylate tabs 300mcg/ml 2 MO 1mg, 2mg, 4mg, 8mg NEUPOGEN SOSY metyrosine caps 5 NDS 300mcg/0.5ml, 5 NDS prazosin hcl caps 1mg, 480mcg/0.8ml 2 MO NIVESTYM SOLN 2mg, 5mg terazosin hcl caps 1mg, 480mcg/1.6ml, 5 NDS 2 MO 300mcg/ml 2mg, 5mg, 10mg NIVESTYM SOSY ANTILIPEMIC AGENTS ALTOPREV TB24 20mg, 300mcg/0.5ml, 5 NDS 4 MO 480mcg/0.8ml 40mg, 60mg ANTARA CAPS 30mg, NPLATE SOLR 5 NDS 4 MO NYVEPRIA SOSY 5 NDS 90mg PROCRIT SOLN atorvastatin calcium tabs 2000unit/ml, 3000unit/ml, 10mg, 20mg, 40mg, 1 MO 4000unit/ml, 80mg 3 PA,NDS cholestyramine light 10000unit/ml, 2 MO 20000unit/ml, pack cholestyramine light 40000unit/ml 2 MO PROMACTA PACK powd 5 NDS 12.5mg, 25mg cholestyramine pack 2 MO PROMACTA TABS cholestyramine powd 2 MO 12.5mg, 25mg, 50mg, 5 NDS colesevelam hcl pack 2 MO 75mg colesevelam hcl tabs 2 MO REBLOZYL SOLR 5 NDS colestipol hcl gran 2 MO 25mg, 75mg colestipol hcl pack 2 MO RETACRIT SOLN colestipol hcl tabs 2 MO 20000unit/2ml, EVKEEZA SOLN 2000unit/ml, 3000unit/ml, 345mg/2.3ml, 5 NDS 4000unit/ml, 4 PA,NDS 1200mg/8ml 10000unit/ml, ezetimibe tabs 1 MO 20000unit/ml, ezetimibe-simvastatin 40000unit/ml 2 MO tabs

You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

Kaiser Permanente 2021 Comprehensive Formulary • 25

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits fenofibrate caps 50mg, REPATHA 2 MO 134mg, 150mg PUSHTRONEX 4 PA,NDS fenofibrate micronized SYSTEM SOCT caps 43mg, 67mg, 2 MO REPATHA SOSY 4 PA,NDS 130mg, 200mg REPATHA SURECLICK 4 PA,NDS fenofibrate tabs 40mg, SOAJ 48mg, 54mg, 120mg, 2 MO rosuvastatin calcium 145mg, 160mg tabs 5mg, 10mg, 20mg, 1 MO fenofibric acid cpdr 2 MO 40mg 45mg, 135mg simvastatin tabs 5mg, FENOFIBRIC ACID 4 MO 10mg, 20mg, 40mg, 1 MO TABS 35mg, 105mg 80mg FIBRICOR TABS 4 MO VASCEPA CAPS 0.5gm, 2 MO FLOLIPID SUSP 1gm 4 MO 20mg/5ml, 40mg/5ml ZYPITAMAG TABS 1mg, 4 MO fluvastatin sodium caps 2mg, 4mg 2 MO 20mg, 40mg BETA-ADRENERGIC BLOCKING AGENTS fluvastatin sodium er acebutolol hcl caps 2 MO 2 MO tb24 200mg, 400mg gemfibrozil tabs 2 MO atenolol tabs 25mg, 1 MO icosapent ethyl caps 2 MO 50mg, 100mg JUXTAPID CAPS 5mg, atenolol-chlorthalidone 2 MO 10mg, 20mg, 30mg, 5 PA,LD,NDS tabs 40mg, 60mg betaxolol hcl tabs 10mg, 2 MO KYNAMRO SOSY 5 PA,LD,NDS 20mg LIVALO TABS 1mg, bisoprolol fumarate tabs 4 MO 1 MO 2mg, 4mg 5mg, 10mg lovastatin tabs 10mg, bisoprolol- 1 MO 1 MO 20mg, 40mg hydrochlorothiazide tabs niacin er carvedilol phosphate er (antihyperlipidemic) tbcr 2 MO cp24 10mg, 20mg, 2 MO 500mg, 750mg, 1000mg 40mg, 80mg carvedilol tabs 3.125mg, niacor tabs 2 MO 1 MO omega-3-acid ethyl 6.25mg, 12.5mg, 25mg 2 MO esters caps DUTOPROL TB24 4 MO pravastatin sodium tabs ESMOLOL HCL SOLN 2 10mg, 20mg, 40mg, 1 MO esmolol hcl-sodium 2 80mg chloride soln prevalite pack 2 MO INNOPRAN XL CP24 4 MO prevalite powd 2 MO 80mg, 120mg questran light powd 2 MO labetalol hcl soln 2 labetalol hcl tabs 100mg, questran pack 2 MO 2 MO questran powd 2 MO 200mg, 300mg metoprolol succinate er tb24 25mg, 50mg, 2 MO 100mg, 200mg You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

26 • Kaiser Permanente 2021 Comprehensive Formulary

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits metoprolol tartrate soct 2 CARDIZEM LA TB24 4 MO metoprolol tartrate soln 2 cartia xt cp24 120mg, 2 MO metoprolol tartrate tabs 180mg, 240mg, 300mg 1 MO 25mg, 50mg, 100mg CONSENSI TABS 5 NDS metoprolol tartrate tabs dilt-xr cp24 120mg, 2 MO 2 MO 37.5mg, 75mg 180mg, 240mg metoprolol- diltiazem hcl er beads 2 MO hydrochlorothiazide tabs cp24 120mg, 180mg, 2 MO nadolol tabs 20mg, 240mg, 300mg, 360mg, 1 MO 40mg, 80mg 420mg nadolol- DILTIAZEM HCL ER 2 MO bendroflumethiazide tabs COATED BEADS CP24 2 MO pindolol tabs 5mg, 10mg 2 MO 120mg, 180mg, 240mg, propranolol hcl er cp24 300mg, 360mg 60mg, 80mg, 120mg, 2 MO diltiazem hcl er coated beads tb24 180mg, 160mg 2 MO propranolol hcl soln 240mg, 300mg, 360mg, 2 MO 20mg/5ml, 40mg/5ml 420mg diltiazem hcl er cp12 propranolol hcl tabs 2 MO 10mg, 20mg, 40mg, 1 MO 60mg, 90mg, 120mg diltiazem hcl er cp24 60mg, 80mg 2 MO propranolol-hctz tabs 2 MO 120mg, 180mg, 240mg sorine tabs 80mg, diltiazem hcl soln 2 2 MO 120mg, 160mg, 240mg diltiazem hcl solr 2 sotalol hcl (af) tabs diltiazem hcl tabs 30mg, 2 MO 2 MO 80mg, 120mg, 160mg 60mg, 90mg, 120mg sotalol hcl tabs 80mg, felodipine er tb24 2.5mg, 2 MO 2 MO 120mg, 160mg, 240mg 5mg, 10mg isradipine caps 2.5mg, SOTYLIZE SOLN 4 MO 2 MO timolol maleate tabs 5mg 2 MO 5mg, 10mg, 20mg matzim la tb24 180mg, CALCIUM-CHANNEL BLOCKING AGENTS 240mg, 300mg, 360mg, 2 MO amlodipine besy- 420mg 2 MO nicardipine hcl caps benazepril hcl caps 2 MO amlodipine besylate tabs 20mg, 30mg 1 MO 2.5mg, 5mg, 10mg nicardipine hcl soln 2 amlodipine besylate- nifedipine caps 10mg, 2 MO 2 MO valsartan tabs 20mg amlodipine-atorvastatin nifedipine er osmotic 2 MO tabs release tb24 30mg, 2 MO amlodipine-olmesartan 60mg, 90mg 2 MO nifedipine er tb24 30mg, tabs 2 MO amlodipine-valsartan- 60mg, 90mg 2 MO hctz tabs nimodipine caps 2 MO nisoldipine er tb24 CARDENE IV SOLN 3 2 MO 8.5mg, 17mg, 20mg, You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

Kaiser Permanente 2021 Comprehensive Formulary • 27

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits 25.5mg, 30mg, 34mg, flecainide acetate tabs 2 MO 40mg 50mg, 100mg, 150mg NYMALIZE SOLN 5 NDS ibutilide fumarate soln 2 60mg/20ml, 6mg/ml LANOXIN PEDIATRIC olmesartan-amlodipine- 3 2 MO SOLN hctz tabs LANOXIN TABS 4 MO taztia xt cp24 120mg, 62.5mcg 180mg, 240mg, 300mg, 2 MO lidocaine hcl (cardiac) pf 2 360mg sosy telmisartan-amlodipine lidocaine hcl (cardiac) 2 MO 2 tabs sosy tiadylt er cp24 120mg, LIDOCAINE IN D5W 2 180mg, 240mg, 300mg, 2 MO SOLN 360mg, 420mg mexiletine hcl caps trandolapril-verapamil hcl 2 MO 2 MO 150mg, 200mg, 250mg er tbcr milrinone lactate in 2 VERAPAMIL HCL ER dextrose soln CP24 100mg, 120mg, 2 MO milrinone lactate soln 2 180mg, 200mg, 240mg, MULTAQ TABS 4 300mg, 360mg NORPACE CR CP12 verapamil hcl er tbcr 3 MO 2 MO 100mg, 150mg 120mg, 180mg, 240mg pacerone tabs 100mg, 2 MO verapamil hcl soln 2 200mg, 400mg verapamil hcl tabs 80mg, 1 MO procainamide hcl soln 2 120mg propafenone hcl er cp12 2 MO verapamil hcl tabs 2 MO 225mg, 325mg, 425mg VERELAN CP24 4 MO propafenone hcl tabs 2 MO CARDIAC DRUGS 150mg, 225mg, 300mg adenosine soln 2 quinidine gluconate er 2 MO amiodarone hcl soln 2 tbcr amiodarone hcl tabs QUINIDINE 2 MO 3 100mg, 200mg, 400mg GLUCONATE SOLN CORLANOR TABS 5mg, quinidine sulfate tabs 4 MO 2 MO 7.5mg 200mg, 300mg digitek tabs 0.125mg, ranolazine er tb12 2 MO 2 MO 0.25mg 500mg, 1000mg digox tabs 2 VYNDAMAX CAPS 5 NDS digoxin soln inj 2 VYNDAQEL CAPS 5 NDS DIGOXIN ORAL SOLN 3 MO HYPOTENSIVE AGENTS digoxin tabs 125mcg, clonidine hcl (analgesia) 2 MO 2 250mcg soln disopyramide phosphate clonidine hcl er tb12 2 MO 2 MO caps 100mg, 150mg clonidine hcl tabs 0.1mg, 2 MO dofetilide caps 125mcg, 0.2mg, 0.3mg 2 MO 250mcg, 500mcg

You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

28 • Kaiser Permanente 2021 Comprehensive Formulary

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits clonidine ptwk ENTRESTO TABS 3 MO 0.1mg/24hr, 0.2mg/24hr, 2 MO eplerenone tabs 25mg, 2 MO 0.3mg/24hr 50mg guanfacine hcl tabs 1mg, eprosartan mesylate 2 MO 2 MO 2mg tabs hydralazine hcl soln 2 fosinopril sodium tabs 2 MO hydralazine hcl tabs 10mg, 20mg, 40mg 10mg, 25mg, 50mg, 1 MO fosinopril sodium-hctz 2 MO 100mg tabs methyldopa tabs 250mg, irbesartan tabs 75mg, 2 MO 2 MO 500mg 150mg, 300mg methyldopa- irbesartan- 2 MO 2 MO hydrochlorothiazide tabs hydrochlorothiazide tabs minoxidil tabs 2.5mg, lisinopril tabs 2.5mg, 2 MO 10mg 5mg, 10mg, 20mg, 1 MO nitropress soln 2 30mg, 40mg nitroprusside sodium lisinopril- 2 1 MO soln hydrochlorothiazide tabs losartan potassium tabs vecamyl tabs 2 NDS 1 MO RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM 25mg, 50mg, 100mg losartan potassium-hctz INHIBITORS 1 MO ALDACTAZIDE TABS 4 MO tabs aliskiren fumarate tabs moexipril hcl tabs 7.5mg, 2 MO 2 MO 150mg, 300mg 15mg benazepril hcl tabs 5mg, olmesartan medoxomil 1 MO 2 MO 10mg, 20mg, 40mg tabs 5mg, 20mg, 40mg benazepril- olmesartan medoxomil- 2 MO 2 MO hydrochlorothiazide tabs hctz tabs perindopril erbumine candesartan cilexetil 2 MO tabs 4mg, 8mg, 16mg, 2 MO tabs 2mg, 4mg, 8mg 32mg QBRELIS SOLN 4 MO candesartan cilexetil- quinapril hcl tabs 5mg, 2 MO 2 MO hctz tabs 10mg, 20mg, 40mg captopril tabs 12.5mg, quinapril- 2 MO 2 MO 25mg, 50mg, 100mg hydrochlorothiazide tabs captopril- ramipril caps 1.25mg, 2 MO 2 MO hydrochlorothiazide tabs 2.5mg, 5mg, 10mg spironolactone tabs CAROSPIR SUSP 4 MO 1 MO EDARBYCLOR TABS 4 MO 25mg, 50mg, 100mg enalapril maleate tabs spironolactone-hctz tabs 2 MO 2.5mg, 5mg, 10mg, 2 MO TEKTURNA HCT TABS 4 MO telmisartan tabs 20mg, 20mg 2 MO enalapril- 40mg, 80mg 2 MO hydrochlorothiazide tabs telmisartan-hctz tabs 2 MO trandolapril tabs 1mg, enalaprilat inj 2 2 MO 2mg, 4mg You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

Kaiser Permanente 2021 Comprehensive Formulary • 29

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits valsartan tabs 40mg, 2 MO ANALGESICS AND ANTIPYRETICS 80mg, 160mg, 320mg ABSTRAL SUBL valsartan- 100mcg, 200mcg, 2 MO 4 PA,NDS hydrochlorothiazide tabs 300mcg, 400mcg, VASODILATING AGENTS 600mcg, 800mcg acetaminophen-codeine alyq tabs 2 PA 2 NDS BIDIL TABS 4 MO #3 tabs dipyridamole tabs 25mg, acetaminophen-codeine 2 MO 2 NDS 50mg, 75mg soln acetaminophen-codeine GONITRO PACK 4 MO 2 NDS isosorbide dinitrate er tabs 2 MO tbcr allzital tabs 2 isosorbide dinitrate tabs apap-caff- 2 MO 2 NDS 5mg, 10mg, 20mg, 30mg dihydrocodeine tabs isosorbide mononitrate ARYMO ER TBEA 5 NDS 1 MO er tb24 30mg, 60mg ascomp-codeine caps 2 NDS isosorbide mononitrate BELBUCA FILM 75mcg, 2 MO er tb24 150mcg, 300mcg, 4 NDS isosorbide mononitrate 450mcg, 600mcg, 2 MO tabs 10mg, 20mg 750mcg, 900mcg benzhydrocodone- minitran pt24 0.1mg/hr, 2 0.2mg/hr, 0.4mg/hr, 2 MO acetaminophen tabs 0.6mg/hr bupap tabs 2 nitro-bid oint 2 MO buprenorphine hcl soln 2 NDS NITRO-DUR PT24 buprenorphine ptwk 3 MO 0.3mg/hr, 0.8mg/hr 5mcg/hr, 7.5mcg/hr, 2 NDS nitroglycerin pt24 10mcg/hr, 15mcg/hr, 0.1mg/hr, 0.2mg/hr, 2 MO 20mcg/hr 0.4mg/hr, 0.6mg/hr butalbital-acetaminophen 4 NDS nitroglycerin soln 2 MO caps nitroglycerin subl 0.3mg, butalbital-acetaminophen 2 MO 2 0.4mg, 0.6mg tabs butalbital-apap-caff-cod sildenafil citrate soln 2 PA,NDS 2 NDS sildenafil citrate susr 2 PA caps butalbital-apap-caffeine sildenafil citrate tabs 2 PA,MO 2 tadalafil (pah) tabs 20mg 2 PA caps butalbital-apap-caffeine tadalafil tabs 2.5mg, 5mg 2 PA 2 tabs CENTRAL NERVOUS SYSTEM AGENTS butalbital-asa-caff- 2 NDS ALCOHOL DETERRENTS codeine caps acamprosate calcium butalbital-aspirin-caffeine 2 MO 2 tbec caps antabuse tabs 250mg, butalbital-aspirin-caffeine 2 MO 2 500mg tabs disulfiram tabs 250mg, 2 MO 500mg You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

30 • Kaiser Permanente 2021 Comprehensive Formulary

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits butorphanol tartrate soln fentanyl citrate tabs 1mg/ml, 2mg/ml, 2 NDS 100mcg, 200mcg, 2 PA,NDS 10mg/ml 400mcg, 600mcg, BUTRANS PTWK 4 NDS 800mcg cataflam tabs 5 NDS fentanyl pt72 12mcg/hr, celecoxib caps 2 25mcg/hr, 37.5mcg/hr, CODEINE SULFATE 50mcg/hr, 62.5mcg/hr, 2 NDS TABS 15mg, 30mg, 2 NDS 75mcg/hr, 87.5mcg/hr, 60mg 100mcg/hr DEMEROL SOLN FENTORA TABS 25mg/0.5ml, 100mcg, 200mcg, 4 PA,NDS 4 PA,NDS 75mg/1.5ml, 100mg/2ml, 400mcg, 600mcg, 75mg/ml 800mcg diclofenac potassium fioricet caps 2 2 tabs fioricet/codeine caps 2 NDS diclofenac sodium er flurbiprofen tabs 2 2 tb24 hydrocodone bitartrate er cp12 10mg, 15mg, diclofenac sodium tbec 2 2 NDS diclofenac-misoprostol 20mg, 30mg, 40mg, 2 tbec 50mg hydrocodone- diflunisal tabs 2 2 NDS DUEXIS TABS 5 NDS acetaminophen soln DURAMORPH SOLN hydrocodone- 2 HI,NDS 2 NDS 0.5mg/ml, 1mg/ml acetaminophen tabs hydrocodone-ibuprofen dvorah tabs 2 NDS 2 NDS tabs EMBEDA CPCR 4 NDS hydromorphone hcl er endocet tabs 2 NDS tb24 8mg, 12mg, 16mg, 2 NDS esgic caps 2 32mg esgic tabs 2 hydromorphone hcl liqd 2 NDS etodolac caps 2 hydromorphone hcl pf 2 NDS etodolac er tb24 2 soln 50mg/5ml, 10mg/ml etodolac tabs 2 HYDROMORPHONE fenoprofen calcium caps 2 HCL SOLN 1mg/ml, 2 NDS fenoprofen calcium tabs 2 2mg/ml hydromorphone hcl tabs fenortho caps 2 2 NDS fentanyl citrate (pf) soct 2 NDS 2mg, 4mg, 8mg FENTANYL CITRATE ibu tabs 2 (PF) SOLN 50mcg/ml, ibudone tabs 2 NDS 2 NDS 1000mcg/20ml, ibuprofen lysine soln 2 2500mcg/50ml ibuprofen susp 2 fentanyl citrate lpop ibuprofen tabs 2 200mcg, 400mcg, 5 PA,NDS ILARIS SOLN 5 NDS 600mcg, 800mcg, indocin supp 2 1200mcg, 1600mcg INDOCIN SUSP 4 You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

Kaiser Permanente 2021 Comprehensive Formulary • 31

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits indomethacin caps 2 morphine sulfate (pf) 2 NDS INDOMETHACIN CAPS soln 4mg/ml, 10mg/ml 4 20mg MORPHINE SULFATE indomethacin er cpcr 2 (PF) SOLN 4 HI indomethacin sodium INTRAVENOUS 2 solr morphine sulfate er beads cp24 30mg, KADIAN CP24 4 NDS 2 NDS ketoprofen caps 2 45mg, 60mg, 75mg, 90mg, 120mg ketoprofen er cp24 2 morphine sulfate er cp24 ketorolac tromethamine 2 10mg, 20mg, 30mg, soln 2 NDS 40mg, 50mg, 60mg, ketorolac tromethamine 2 80mg, 100mg tabs morphine sulfate er tbcr LAZANDA SOLN 15mg, 30mg, 60mg, 2 NDS 100mcg/act, 300mcg/act, 4 PA,NDS 100mg, 200mg 400mcg/act MORPHINE SULFATE levorphanol tartrate tabs 5 NDS SOLN 10mg/5ml, 2 NDS 2mg, 3mg 20mg/5ml lodine tabs 2 MORPHINE SULFATE 4 HI,NDS lorcet hd tabs 2 NDS SOLN lorcet plus tabs 2 NDS MORPHINE SULFATE lorcet tabs 2 NDS SOLN INJECTION 4 HI lortab elix 2 NDS 2mg/ml, 4mg/ml, meclofenamate sodium 10mg/ml 2 MORPHINE SULFATE caps 2 HI mefenamic acid caps 2 SOLN INTRAVENOUS morphine sulfate tabs meloxicam caps 2 2 NDS meloxicam tabs 2 15mg, 30mg meperidine hcl soln nabumetone tabs 2 50mg/5ml, 25mg/ml, 2 PA,NDS nalbuphine hcl soln 2 50mg/ml, 100mg/ml nalfon tabs 2 meperidine hcl tabs nalocet tabs 2 NDS 2 NDS 50mg, 100mg NAPRELAN TB24 4 methadone hcl conc 2 NDS naproxen sodium er tb24 2 methadone hcl intensol 2 NDS naproxen sodium tabs 2 conc naproxen susp 2 methadone hcl soln naproxen tabs 2 5mg/5ml, 10mg/5ml, 2 NDS naproxen tbec 2 10mg/ml naproxen-esomeprazole methadone hcl tabs 2 NDS 2 NDS tbec 5mg, 10mg norco tabs 2 NDS mitigo soln 2 norgesic forte tabs 2 MORPHINE SULFATE NUCYNTA ER TB12 (CONCENTRATE) 2 NDS 4 NDS SOLN 50mg, 100mg, 150mg You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

32 • Kaiser Permanente 2021 Comprehensive Formulary

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits NUCYNTA ER TB12 PIROXICAM CAPS 5 NDS 2 NDS 200mg, 250mg 10mg, 20mg NUCYNTA TABS 50mg, pregabalin er tb24 4 NDS 2 MO 75mg 82.5mg, 165mg, 330mg NUCYNTA TABS 5 NDS primlev tabs 2 NDS orphenadrine-aspirin- prolate soln 5 NDS 2 caffeine tabs prolate tabs 2 NDS orphengesic forte tabs 2 QDOLO SOLN 5 NDS oxaprozin tabs 2 relafen ds tabs 5 NDS OXAYDO TABS 5 NDS ROXYBOND TABA 5mg, 5 NDS oxycodone hcl caps 2 NDS 15mg, 30mg oxycodone hcl conc 2 NDS SALSALATE TABS 2 oxycodone hcl er t12a SUBLOCADE SOSY 10mg, 15mg, 20mg, 100mg/0.5ml, 5 NDS 2 NDS 30mg, 40mg, 60mg, 300mg/1.5ml 80mg SUBSYS LIQD 100mcg, oxycodone hcl soln 2 NDS 200mcg, 400mcg, 4 PA,NDS oxycodone hcl tabs 5mg, 600mcg, 800mcg, 10mg, 15mg, 20mg, 2 NDS 1200mcg, 1600mcg 30mg sulindac tabs 2 oxycodone- tencon tabs 2 5 NDS acetaminophen soln TIVORBEX CAPS 4 oxycodone- 2 NDS tolmetin sodium caps 2 acetaminophen tabs tolmetin sodium tabs 2 oxycodone- tramadol hcl er acetaminophen tabs 5- 5 NDS (biphasic) tb24 100mg, 2 NDS 300mg, 10-300mg 200mg, 300mg oxycodone-aspirin tabs 2 NDS tramadol hcl er cp24 oxycodone-ibuprofen 2 NDS 100mg, 150mg, 200mg, 2 NDS tabs 300mg OXYCONTIN T12A tramadol hcl er tb24 10mg, 15mg, 20mg, 2 NDS 2 NDS 100mg, 200mg, 300mg 30mg, 40mg, 60mg, tramadol hcl tabs 50mg, 2 NDS 80mg 100mg oxymorphone hcl er tb12 tramadol-acetaminophen 5mg, 7.5mg, 10mg, 2 NDS 2 NDS tabs 15mg, 20mg, 30mg, trezix caps 2 NDS 40mg tylenol with codeine #3 oxymorphone hcl tabs 2 NDS 2 NDS tabs 5mg, 10mg tylenol with codeine #4 2 NDS panlor tabs 2 NDS tabs pentazocine-naloxone 2 NDS vanatol lq soln 2 hcl tabs vicodin es tabs 2 NDS percocet tabs 2 NDS vicodin hp tabs 2 NDS phrenilin forte caps 2 vicodin tabs 2 NDS You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

Kaiser Permanente 2021 Comprehensive Formulary • 33

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits XTAMPZA ER C12A DYANAVEL XR SUER 4 NDS 9mg, 13.5mg, 18mg, 4 NDS evekeo tabs 5mg, 10mg 2 NDS 27mg, 36mg metadate er tbcr 2 NDS zebutal caps 2 methamphetamine hcl 2 PA,NDS ZIPSOR CAPS 4 tabs ZORVOLEX CAPS 4 methylphenidate hcl 2 NDS ANOREXIGENIC AGENTS AND RESPIRATORY chew 2.5mg, 5mg, 10mg AND CEREBRAL STIMULANTS methylphenidate hcl er adderall tabs 2 NDS (cd) cpcr 10mg, 20mg, 2 NDS ADDERALL XR CP24 2 NDS 30mg, 40mg, 50mg, ADZENYS ER SUER 4 NDS 60mg ADZENYS XR-ODT methylphenidate hcl er TBED 3.1mg, 6.3mg, (la) cp24 10mg, 20mg, 2 NDS 4 NDS 9.4mg, 12.5mg, 15.7mg, 30mg, 40mg, 60mg 18.8mg methylphenidate hcl er (xr) cp24 10mg, 15mg, amphetamine er suer 2 NDS 2 NDS amphetamine sulfate 20mg, 30mg, 40mg, 2 NDS tabs 5mg, 10mg 50mg, 60mg amphetamine- methylphenidate hcl er 2 NDS dextroamphet er cp24 tb24 18mg, 27mg, 36mg, 2 NDS 54mg amphetamine- 2 NDS dextroamphetamine tabs methylphenidate hcl er tbcr 10mg, 18mg, 20mg, armodafinil tabs 50mg, 2 NDS 2 PA 27mg, 36mg, 54mg, 150mg, 200mg, 250mg 72mg caffeine citrate soln 2 methylphenidate hcl soln 2 NDS COTEMPLA XR-ODT 5mg/5ml, 10mg/5ml TBED 8.6mg, 17.3mg, 4 NDS methylphenidate hcl tabs 25.9mg 2 NDS 5mg, 10mg, 20mg DAYTRANA PTCH modafinil tabs 100mg, 10mg/9hr, 15mg/9hr, 4 NDS 2 PA,NDS 200mg 20mg/9hr, 30mg/9hr MYDAYIS CP24 4 NDS dexmethylphenidate hcl er cp24 5mg, 10mg, procentra soln 2 NDS 2 NDS QUILLICHEW ER CHER 15mg, 20mg, 25mg, 4 NDS 30mg, 35mg, 40mg 20mg, 30mg, 40mg dexmethylphenidate hcl QUILLIVANT XR SRER 4 NDS 2 NDS tabs 2.5mg, 5mg, 10mg relexxii tbcr 2 NDS SUNOSI TABS 75mg, dextroamphetamine 4 NDS sulfate er cp24 5mg, 2 NDS 150mg 10mg, 15mg VYVANSE CAPS 10mg, dextroamphetamine 20mg, 30mg, 40mg, 3 NDS 2 NDS sulfate soln 50mg, 60mg, 70mg dextroamphetamine VYVANSE CHEW 10mg, sulfate tabs 5mg, 10mg, 2 NDS 20mg, 30mg, 40mg, 4 NDS 15mg, 20mg, 30mg 50mg, 60mg

You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

34 • Kaiser Permanente 2021 Comprehensive Formulary

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits WAKIX TABS 4.45mg, divalproex sodium er 5 NDS 2 MO 17.8mg tb24 250mg, 500mg zenzedi tabs 2.5mg, divalproex sodium tbec 2 MO 5mg, 7.5mg, 10mg, 2 NDS 125mg, 250mg, 500mg 15mg, 20mg, 30mg ELEPSIA XR TB24 5 NDS ANTICONVULSANTS 1000mg, 1500mg APTIOM TABS 200mg, EPIDIOLEX SOLN 5 PA,NDS 5 MO 400mg, 600mg, 800mg epitol tabs 2 MO BANZEL SUSP 5 ethosuximide caps 2 MO BANZEL TABS 200mg, 5 NDS ethosuximide soln 2 MO 400mg felbamate susp 5 MO BRIVIACT SOLN 5 NDS felbamate tabs 400mg, 2 MO BRIVIACT TABS 10mg, 600mg 25mg, 50mg, 75mg, 5 NDS FINTEPLA SOLN 5 NDS 100mg fosphenytoin sodium 2 carbamazepine chew 2 MO soln carbamazepine er cp12 2 MO FYCOMPA SUSP 5 NDS 100mg, 200mg, 300mg FYCOMPA TABS 4 carbamazepine er tb12 gabapentin caps 100mg, 2 MO 2 MO 100mg, 200mg, 400mg 400mg carbamazepine susp 2 MO gabapentin soln 2 MO carbamazepine tabs 2 MO gabapentin tabs 600mg, 2 MO CELONTIN CAPS 3 MO 800mg clobazam susp 2 MO HORIZANT TBCR 4 MO clobazam tabs 10mg, 300mg, 600mg 2 MO 20mg LAMICTAL XR KIT 4 MO clonazepam tabs 0.5mg, lamotrigine chew 5mg, 2 NDS 2 MO 1mg, 2mg 25mg clonazepam tbdp lamotrigine er tb24 0.125mg, 0.25mg, 2 NDS 25mg, 50mg, 100mg, 2 MO 0.5mg, 1mg, 2mg 200mg, 250mg, 300mg DIACOMIT CAPS 5 NDS lamotrigine kit 2 MO 250mg, 500mg lamotrigine starter kit- DIACOMIT PACK 2 MO 5 NDS blue kit 250mg, 500mg lamotrigine starter kit- DIASTAT ACUDIAL GEL 2 MO 2 NDS green kit 10mg, 20mg lamotrigine starter kit- DIASTAT PEDIATRIC 2 MO 2 NDS orange kit GEL lamotrigine tabs 25mg, diazepam gel 2.5mg, 2 MO 2 NDS 100mg, 150mg, 200mg 10mg, 20mg lamotrigine tbdp 25mg, dilantin caps 30mg, 2 MO 2 MO 50mg, 100mg, 200mg 100mg levetiracetam er tb24 2 MO dilantin infatabs chew 2 MO 500mg, 750mg divalproex sodium csdr 2 MO You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

Kaiser Permanente 2021 Comprehensive Formulary • 35

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits levetiracetam in nacl subvenite starter kit-blue 2 2 MO soln kit levetiracetam soln 2 MO subvenite starter kit- 2 MO levetiracetam tabs green kit subvenite starter kit- 250mg, 500mg, 750mg, 2 MO 2 MO 1000mg orange kit subvenite tabs 25mg, magnesium sulfate soln 2 2 MO magnesium sulfate soln 100mg, 150mg, 200mg 2 HI injection 50% SYMPAZAN FILM 5mg 4 SYMPAZAN FILM 10mg, MAGNESIUM SULFATE 5 SOLN INTRAVENOUS 20mg 40gm/1000ml, 3 HI tiagabine hcl tabs 2mg, 2 MO 4gm/100ml, 4mg, 12mg, 16mg 20gm/500ml, 2gm/50ml topiramate cpsp 15mg, 2 MO NAYZILAM SOLN 5 NDS 25mg oxcarbazepine susp 2 MO topiramate er cs24 oxcarbazepine tabs 25mg, 50mg, 100mg, 2 MO 2 MO 150mg, 300mg, 600mg 150mg, 200mg OXTELLAR XR TB24 topiramate tabs 25mg, 4 MO 2 MO 150mg, 300mg, 600mg 50mg, 100mg, 200mg PEGANONE TABS 4 MO TROKENDI XR CP24 phenytek caps 200mg, 25mg, 50mg, 100mg, 4 MO 2 MO 300mg 200mg phenytoin chew 2 MO valproate sodium soln 2 phenytoin sodium valproic acid caps 2 MO extended caps 100mg, 2 MO valproic acid soln 2 MO VALTOCO 10 MG DOSE 200mg, 300mg 5 NDS phenytoin sodium soln 2 LIQD VALTOCO 15 MG DOSE phenytoin susp 2 MO 5 NDS pregabalin caps 25mg, LQPK 50mg, 75mg, 100mg, VALTOCO 20 MG DOSE 2 MO 5 NDS 150mg, 200mg, 225mg, LQPK VALTOCO 5 MG DOSE 300mg 5 NDS pregabalin soln 2 MO LIQD primidone tabs 50mg, vigabatrin pack 5 LD,NDS 2 MO 250mg vigabatrin tabs 5 NDS roweepra tabs 500mg, vigadrone pack 2 LD,NDS 2 MO 750mg, 1000mg VIMPAT SOLN 4 roweepra xr tb24 500mg, VIMPAT TABS 4 MO 2 MO 750mg XCOPRI (250 MG DAILY 5 NDS rufinamide susp 5 DOSE) TBPK rufinamide tabs 200mg, XCOPRI (350 MG DAILY 5 NDS 5 NDS 400mg DOSE) TBPK SPRITAM TB3D 250mg, XCOPRI TABS 50mg, 4 NDS 4 500mg, 750mg, 1000mg 100mg, 150mg You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

36 • Kaiser Permanente 2021 Comprehensive Formulary

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits XCOPRI TABS 200 MG 5 NDS zolmitriptan tbdp 2 XCOPRI TBPK 14 x 12.5 ZOMIG SOLN 4 4 MG & 14 X 25 MG ANTIPARKINSONIAN AGENTS XCOPRI TBPK 5 NDS amantadine hcl caps 2 MO zarontin soln 2 MO amantadine hcl syrp 2 MO zonisamide caps 25mg, 2 MO amantadine hcl tabs 2 MO 50mg, 100mg APOKYN SOCT 5 NDS ANTIMIGRAINE AGENTS benztropine mesylate 2 AJOVY SOAJ 4 soln AJOVY SOSY 4 benztropine mesylate 2 MO almotriptan malate tabs 2 tabs 0.5mg, 1mg, 2mg cafergot tabs 2 bromocriptine mesylate 2 MO eletriptan hydrobromide caps 2 bromocriptine mesylate tabs 2 MO EMGALITY (300 MG tabs 5 NDS DOSE) SOSY cabergoline tabs 2 MO EMGALITY SOAJ 4 carbidopa tabs 2 MO EMGALITY SOSY 4 carbidopa-levodopa er 2 MO ergotamine-caffeine tabs 2 tbcr frovatriptan succinate carbidopa-levodopa tabs 2 MO 2 tabs carbidopa-levodopa tbdp 2 MO naratriptan hcl tabs 2 carbidopa-levodopa- 2 MO NURTEC TBDP 5 NDS entacapone tabs ONZETRA XSAIL EXHP 4 DUOPA SUSP 4 LD EMSAM PT24 6mg/24hr, rizatriptan benzoate tabs 2 5 NDS rizatriptan benzoate tbdp 2 9mg/24hr, 12mg/24hr sumatriptan soln 2 entacapone tabs 2 MO sumatriptan succinate INBRIJA CAPS 5 NDS 2 refill soct KYNMOBI FILM 10mg, sumatriptan succinate 15mg, 20mg, 25mg, 5 NDS 2 soaj 30mg sumatriptan succinate pramipexole 2 soln dihydrochloride er tb24 sumatriptan succinate 0.375mg, 0.75mg, 2 MO 2 sosy 1.5mg, 2.25mg, 3mg, sumatriptan succinate 3.75mg, 4.5mg 2 tabs pramipexole TOSYMRA SOLN 4 dihydrochloride tabs 0.125mg, 0.25mg, 2 MO UBRELVY TABS 50mg, 5 NDS 0.5mg, 0.75mg, 1mg, 100mg 1.5mg ZEMBRACE 4 rasagiline mesylate tabs SYMTOUCH SOAJ 2 MO 0.5mg, 1mg zolmitriptan soln 2 zolmitriptan tabs 2 You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

Kaiser Permanente 2021 Comprehensive Formulary • 37

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits ropinirole hcl er tb24 flurazepam hcl caps 2 NDS 2mg, 4mg, 6mg, 8mg, 2 MO 15mg, 30mg 12mg HETLIOZ CAPS 5 PA,NDS ropinirole hcl tabs HETLIOZ LQ SUSP 5 NDS 0.25mg, 0.5mg, 1mg, 2 MO hydroxyzine hcl soln 2 2mg, 3mg, 4mg, 5mg hydroxyzine hcl syrp 2 RYTARY CPCR 4 MO hydroxyzine hcl tabs 2 selegiline hcl caps 2 MO hydroxyzine pamoate 2 selegiline hcl tabs 2 MO caps tolcapone tabs 2 MO lorazepam intensol conc 2 NDS trihexyphenidyl hcl soln 2 MO LORAZEPAM SOLN trihexyphenidyl hcl tabs 2 NDS 2 MO 4mg/ml, 2mg/ml 2mg, 5mg lorazepam tabs 0.5mg, 2 NDS ZELAPAR TBDP 5 MO 1mg, 2mg ANXIOLYTICS, SEDATIVES, AND HYPNOTICS meprobamate tabs 2 alprazolam er tb24 midazolam hcl (pf) soln 2 2 NDS 0.5mg, 1mg, 2mg, 3mg midazolam hcl soln 2 alprazolam intensol conc 2 NDS midazolam hcl syrp 2 alprazolam tabs 0.25mg, 2 NDS nembutal soln 2 0.5mg, 1mg, 2mg oxazepam caps 10mg, alprazolam tbdp 0.25mg, 2 NDS 2 NDS 15mg, 30mg 0.5mg, 1mg, 2mg pentobarbital sodium 2 BELSOMRA TABS 4 soln buspirone hcl tabs 5mg, 1 PHENOBARBITAL ELIX 2 10mg PHENOBARBITAL buspirone hcl tabs 2 2 SODIUM SOLN 7.5mg, 15mg, 30mg PHENOBARBITAL chlordiazepoxide hcl 2 2 NDS TABS caps 5mg, 10mg, 25mg ramelteon tabs 2 clorazepate dipotassium ROZEREM TABS 4 tabs 3.75mg, 7.5mg, 2 NDS seconal caps 2 15mg TEMAZEPAM CAPS diazepam conc 2 NDS 15mg, 22.5mg, 30mg, 2 NDS diazepam soln 5mg/5ml, 2 NDS 7.5mg 5mg/ml triazolam tabs 0.125mg, diazepam tabs 2mg, 2 NDS 2 NDS 0.25mg 5mg, 10mg zaleplon caps 5mg, 2 NDS droperidol soln 2 10mg EDLUAR SUBL 5mg, zolpidem tartrate er tbcr 4 NDS 2 NDS 10mg 6.25mg, 12.5mg estazolam tabs 1mg, zolpidem tartrate subl 2 NDS 2 NDS 2mg 1.75mg, 3.5mg eszopiclone tabs 1mg, zolpidem tartrate tabs 2 NDS 2 NDS 2mg, 3mg 5mg, 10mg

You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

38 • Kaiser Permanente 2021 Comprehensive Formulary

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits CENTRAL NERVOUS SYSTEM AGENTS, BETASERON KIT 5 NDS MISCELLANEOUS dalfampridine er tb12 2 MO atomoxetine hcl caps dimethyl fumarate cpdr 2 10mg, 18mg, 25mg, dimethyl fumarate starter 2 MO 2 40mg, 60mg, 80mg, pack misc 100mg EXTAVIA KIT 2 NDS AUSTEDO TABS 6mg, GILENYA CAPS 5 LD,NDS 5 NDS 9mg, 12mg 0.25mg, 0.5mg EXSERVAN FILM 5 NDS glatiramer acetate sosy 5 NDS flumazenil soln 2 20mg/ml, 40mg/ml guanfacine hcl er tb24 glatopa sosy 20mg/ml, 2 MO 2 NDS 1mg, 2mg, 3mg, 4mg 40mg/ml INGREZZA CAPS 40mg, 5 NDS LEMTRADA SOLN 5 NDS 60mg, 80mg MAYZENT STARTER 5 NDS INGREZZA CPPK 5 NDS PACK TBPK memantine hcl er cp24 2 MAYZENT TABS 5 NDS memantine hcl soln 2 MO 0.25mg, 2mg memantine hcl tabs 5mg, 2 MO OCREVUS SOLN 5 10mg PLEGRIDY SOSY 5 NDS NAMENDA XR PONVORY STARTER 4 MO 5 NDS TITRATION PACK CP24 PACK TBPK NOURIANZ TABS 20mg, 5 NDS PONVORY TABS 5 NDS 40mg REBIF REBIDOSE NUEDEXTA CAPS 3 PA,NDS SOAJ 22mcg/0.5ml, 5 NDS RADICAVA SOLN 5 NDS 44mcg/0.5ml riluzole tabs 2 MO,NDS REBIF REBIDOSE 5 NDS SAVELLA TABS TITRATION PACK SOAJ 12.5mg, 25mg, 50mg, 4 MO REBIF SOSY 100mg 22mcg/0.5ml, 5 NDS SAVELLA TITRATION 44mcg/0.5ml 4 MO PACK MISC REBIF TITRATION 5 NDS tetrabenazine tabs PACK SOSY 5 NDS 12.5mg, 25mg TECFIDERA CPDR 5 NDS TIGLUTIK SUSP 5 NDS 120mg, 240mg XYREM SOLN 5 LD,NDS TECFIDERA MISC 5 NDS TYSABRI CONC XYWAV SOLN 5 NDS 5 HI MULTIPLE SCLEROSIS AGENTS INTRAVENOUS AUBAGIO TABS 7mg, ZEPOSIA 7-DAY 5 PA,NDS 5 NDS 14mg STARTER PACK CPPK AVONEX KIT 5 NDS ZEPOSIA CAPS 5 NDS ZEPOSIA STARTER KIT AVONEX PEN AJKT 5 NDS 5 NDS CPPK AVONEX PREFILLED 5 NDS PSKT ZINBRYTA SOSY 5 LD,NDS BAFIERTAM CPDR 5 NDS OPIATE ANTAGONISTS BUNAVAIL FILM 4 NDS You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

Kaiser Permanente 2021 Comprehensive Formulary • 39

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits buprenorphine hcl subl ARISTADA INITIO 2 NDS 5 NDS 2mg, 8mg PRSY buprenorphine hcl- ARISTADA PRSY 2 NDS naloxone hcl film 441mg/1.6ml, buprenorphine hcl- 662mg/2.4ml, 5 NDS 2 NDS naloxone hcl subl 882mg/3.2ml, LUCEMYRA TABS 5 NDS 1064mg/3.9ml asenapine maleate subl naloxone hcl soaj 2 NDS 2 MO naloxone hcl soct 2 2.5mg, 5mg, 10mg bupropion hcl er naloxone hcl soln 2 2 MO (smoking det) tb12 naloxone hcl sosy 2 bupropion hcl er (sr) tb12 2 MO naltrexone hcl tabs 2 100mg, 150mg, 200mg NARCAN LIQD 3 bupropion hcl er (xl) tb24 2 MO VIVITROL SUSR 5 NDS 150mg, 300mg, 450mg ZUBSOLV SUBL 4 NDS bupropion hcl tabs 2 MO PSYCHOTHERAPEUTIC AGENTS 75mg, 100mg ABILIFY MAINTENA CAPLYTA CAPS 5 NDS 5 NDS PRSY 300mg, 400mg chlordiazepoxide- 2 ABILIFY MAINTENA amitriptyline tabs 5 NDS SRER 300mg, 400mg chlorpromazine hcl soln 2 ABILIFY MYCITE chlorpromazine hcl tabs MAINTENANCE KIT 5 NDS 10mg, 25mg, 50mg, 2 MO TABS 2mg, 5mg, 10mg, 100mg, 200mg 15mg, 20mg, 30mg citalopram hydrobromide 2 MO ABILIFY MYCITE soln STARTER KIT TABS citalopram hydrobromide 5 NDS 1 MO 2mg, 5mg, 10mg, 15mg, tabs 10mg, 20mg, 40mg 20mg, 30mg clomipramine hcl caps 2 MO ABILIFY MYCITE TABS 25mg, 50mg, 75mg 2mg, 5mg, 10mg, 15mg, 5 NDS clozapine tabs 25mg, 2 NDS 20mg, 30mg 50mg, 100mg, 200mg amitriptyline hcl tabs clozapine tbdp 12.5mg, 10mg, 25mg, 50mg, 2 MO 25mg, 100mg, 150mg, 2 NDS 75mg, 100mg, 150mg 200mg amoxapine tabs 25mg, 2 MO compro supp 2 MO 50mg, 100mg, 150mg desipramine hcl tabs APLENZIN TB24 174mg, 4 MO 10mg, 25mg, 50mg, 2 MO 348mg, 522mg 75mg, 100mg, 150mg aripiprazole soln 2 MO DESVENLAFAXINE ER 4 MO aripiprazole tabs 2mg, TB24 50mg, 100mg 5mg, 10mg, 15mg, 2 MO desvenlafaxine succinate 20mg, 30mg er tb24 25mg, 50mg, 2 MO aripiprazole tbdp 10mg, 5 MO 100mg 15mg

You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

40 • Kaiser Permanente 2021 Comprehensive Formulary

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits doxepin hcl caps 10mg, fluvoxamine maleate 25mg, 50mg, 75mg, 2 MO tabs 25mg, 50mg, 2 MO 100mg, 150mg 100mg doxepin hcl conc 2 MO GEODON SOLR 3 doxepin hcl tabs 3mg, haloperidol decanoate 2 MO 2 6mg soln DRIZALMA SPRINKLE haloperidol lactate conc 2 MO 4 CSDR haloperidol lactate soln 2 duloxetine hcl cpep haloperidol tabs 0.5mg, 20mg, 30mg, 40mg, 2 MO 1mg, 2mg, 5mg, 10mg, 2 MO 60mg 20mg EQUETRO CP12 imipramine hcl tabs 4 MO 2 MO 100mg, 200mg, 300mg 10mg, 25mg, 50mg escitalopram oxalate 2 MO imipramine pamoate soln caps 75mg, 100mg, 2 MO escitalopram oxalate 2 MO 125mg, 150mg tabs 5mg, 10mg, 20mg INVEGA SUSTENNA 4 NDS FANAPT TABS 1mg, SUSY 39mg/0.25ml 2mg, 4mg, 6mg, 8mg, 5 NDS INVEGA SUSTENNA 10mg, 12mg SUSY 78mg/0.5ml, FANAPT TITRATION 5 NDS 4 MO 117mg/0.75ml, PACK TABS 234mg/1.5ml, 156mg/ml FETZIMA CP24 20mg, 4 MO INVEGA TRINZA SUSY 40mg, 80mg, 120mg 273mg/0.875ml, FETZIMA TITRATION 4 MO 410mg/1.315ml, 5 NDS C4PK 546mg/1.75ml, fluoxetine hcl (pmdd) 2 MO 819mg/2.625ml tabs 10mg, 20mg KHEDEZLA TB24 50mg, fluoxetine hcl caps 4 MO 1 MO 100mg 10mg, 20mg, 40mg LATUDA TABS 20mg, fluoxetine hcl cpdr 2 MO 40mg, 60mg, 80mg, 5 NDS fluoxetine hcl soln 2 MO 120mg fluoxetine hcl tabs 10mg, LITHIUM CARBONATE 2 MO 20mg, 60mg CAPS 300mg, 150mg, 2 MO fluphenazine decanoate 600mg 2 lithium carbonate er tbcr soln 2 MO fluphenazine hcl conc 2 MO 300mg, 450mg fluphenazine hcl elix 2 MO lithium carbonate tabs 2 MO fluphenazine hcl soln 2 LITHIUM SOLN 3 MO fluphenazine hcl tabs loxapine succinate caps 2 MO 2 MO 1mg, 2.5mg, 5mg, 10mg 5mg, 10mg, 25mg, 50mg fluvoxamine maleate er maprotiline hcl tabs 2 MO 2 MO cp24 100mg, 150mg 25mg, 50mg, 75mg MARPLAN TABS 4 MO mirtazapine tabs 7.5mg, 2 MO 15mg, 30mg, 45mg You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

Kaiser Permanente 2021 Comprehensive Formulary • 41

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits mirtazapine tbdp 15mg, prochlorperazine 2 MO 2 30mg, 45mg edisylate soln molindone hcl tabs 5mg, prochlorperazine 2 MO 2 10mg, 25mg maleate tabs nefazodone hcl tabs prochlorperazine supp 2 MO 50mg, 100mg, 150mg, 2 MO protriptyline hcl tabs 2 MO 200mg, 250mg 5mg, 10mg nortriptyline hcl caps quetiapine fumarate er 10mg, 25mg, 50mg, 2 MO tb24 50mg, 150mg, 2 MO 75mg 200mg, 300mg, 400mg nortriptyline hcl soln 2 MO quetiapine fumarate tabs NUPLAZID CAPS 5 NDS 25mg, 50mg, 100mg, 2 MO NUPLAZID TABS 10mg, 200mg, 300mg, 400mg 5 NDS 17mg REXULTI TABS 0.25mg, olanzapine solr 2 0.5mg, 1mg, 2mg, 3mg, 5 NDS olanzapine tabs 2.5mg, 4mg RISPERDAL CONSTA 5mg, 7.5mg, 10mg, 2 MO 4 NDS 15mg, 20mg SRER 12.5mg, 25mg olanzapine tbdp 5mg, RISPERDAL CONSTA 2 MO 5 NDS 10mg, 15mg, 20mg SRER 37.5mg, 50mg olanzapine-fluoxetine hcl risperidone soln 2 MO 2 MO caps risperidone tabs 0.25mg, PALIPERIDONE ER 0.5mg, 1mg, 2mg, 3mg, 2 MO TB24 1.5mg, 3mg, 6mg, 2 MO 4mg 9mg risperidone tbdp 0.25mg, paroxetine hcl er tb24 0.5mg, 1mg, 2mg, 3mg, 2 MO 2 MO 12.5mg, 25mg, 37.5mg 4mg paroxetine hcl tabs SAPHRIS SUBL 2.5mg, 1 MO 5 NDS 10mg, 20mg 5mg, 10mg paroxetine hcl tabs SECUADO PT24 2 MO 30mg, 40mg 3.8mg/24hr, 5.7mg/24hr, 5 NDS paroxetine mesylate 7.6mg/24hr 2 MO caps sertraline hcl conc 2 MO sertraline hcl tabs 25mg, PAXIL SUSP 4 MO 2 MO perphenazine tabs 2mg, 50mg, 100mg 2 MO 4mg, 8mg, 16mg SILENOR TABS 4 perphenazine- SPRAVATO (56 MG 2 MO 5 NDS amitriptyline tabs DOSE) SOPK PERSERIS PRSY 90mg, SPRAVATO (84 MG 5 NDS 5 NDS 120mg DOSE) SOPK PEXEVA TABS 10mg, thioridazine hcl tabs 4 MO 20mg, 30mg, 40mg 10mg, 25mg, 50mg, 2 MO phenelzine sulfate tabs 2 MO 100mg thiothixene caps 1mg, pimozide tabs 1mg, 2mg 2 MO 2 MO 2mg, 5mg, 10mg

You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

42 • Kaiser Permanente 2021 Comprehensive Formulary

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits tofranil tabs 10mg, BD INSULIN SYRINGE 2 MO 2 MO 25mg, 50mg U/F MISC tranylcypromine sulfate BD PEN NEEDLE 2 MO 2 MO tabs ORIGINAL U/F MISC trazodone hcl tabs CURITY GAUZE PADS 2 MO 1 MO 50mg, 100mg, 150mg OMNIPOD STARTER 5 NDS trazodone hcl tabs 2 MO KIT trifluoperazine hcl tabs ELECTROLYTIC, CALORIC, AND WATER 2 MO 1mg, 2mg, 5mg, 10mg BALANCE trimipramine maleate ACIDIFYING AND ALKALINIZING AGENTS caps 25mg, 50mg, 2 MO POT & SOD CIT-CIT AC 2 100mg SOLN TRINTELLIX TABS 5mg, potassium citrate er tbcr 4 MO 2 MO 10mg, 20mg 15meq, 540mg, 1080mg venlafaxine hcl er cp24 SODIUM ACETATE 2 MO 2 37.5mg, 75mg, 150mg SOLN venlafaxine hcl er tb24 SODIUM 2 37.5mg, 75mg, 150mg, 2 MO BICARBONATE SOLN 225mg SODIUM LACTATE 4 HI venlafaxine hcl tabs SOLN INTRAVENOUS 25mg, 37.5mg, 50mg, 2 MO TRICITRATES SOLN 2 75mg, 100mg AMMONIA DETOXICANTS VERSACLOZ SUSP 4 CARBAGLU TABS 5 LD VIIBRYD STARTER 4 MO constulose soln 2 MO PACK KIT VIIBRYD TABS 10mg, enulose soln 2 MO 4 MO 20mg, 40mg generlac soln 2 MO VRAYLAR CAPS 1.5mg, kristalose pack 10gm, 5 NDS 2 MO 3mg, 4.5mg, 6mg 20gm lactulose VRAYLAR CPPK 4 NDS 2 MO ziprasidone hcl caps encephalopathy soln 20mg, 40mg, 60mg, 2 MO lactulose pack 2 MO 80mg lactulose soln 2 MO ziprasidone mesylate LITHOSTAT TABS 5 MO 2 solr RAVICTI LIQD 5 NDS ZYPREXA RELPREVV sod benz-sod phenylacet 4 2 SUSR soln sodium phenylbutyrate DIABETIC SUPPLIES 5 NDS DIABETIC SUPPLIES powd sodium phenylbutyrate ALCOHOL PREP PADS 2 MO 5 NDS BD INSULIN SYR tabs 2 MO ULTRAFINE II MISC CALORIC AGENTS BD INSULIN SYRINGE AMINOSYN-PF SOLN 2 MO 4 HI MISC INTRAVENOUS

You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

Kaiser Permanente 2021 Comprehensive Formulary • 43

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits CLINIMIX E/DEXTROSE clinisol sf soln 2 HI (2.75/10) SOLN 3 HI intravenous INTRAVENOUS DEXTROSE SOLN 2 CLINIMIX E/DEXTROSE dextrose soln 2 HI (2.75/5) SOLN 3 HI intravenous 5%, 10% INTRAVENOUS FREAMINE HBC SOLN 4 HI CLINIMIX E/DEXTROSE INTRAVENOUS (4.25/10) SOLN 3 HI HEPATAMINE SOLN 4 HI INTRAVENOUS INTRAVENOUS CLINIMIX E/DEXTROSE INTRALIPID EMUL (4.25/25) SOLN 3 HI INTRAVENOUS 2 HI INTRAVENOUS 20gm/100ml CLINIMIX E/DEXTROSE INTRALIPID EMUL 4 HI (4.25/5) SOLN 3 HI INTRAVENOUS INTRAVENOUS N-ACETYL-L-CYSTEINE 2 MO CLINIMIX E/DEXTROSE CAPS (5/15) SOLN 3 HI NEPHRAMINE SOLN 3 HI INTRAVENOUS INTRAVENOUS CLINIMIX E/DEXTROSE NUTRILIPID EMUL 2 HI (5/20) SOLN 3 HI INTRAVENOUS INTRAVENOUS plenamine soln 2 HI CLINIMIX E/DEXTROSE intravenous (5/25) SOLN 3 HI premasol soln 2 HI INTRAVENOUS intravenous CLINIMIX/DEXTROSE PROCALAMINE SOLN 3 HI (2.75/5) SOLN 3 HI INTRAVENOUS INTRAVENOUS PROSOL SOLN 4 HI CLINIMIX/DEXTROSE INTRAVENOUS (4.25/10) SOLN 3 HI TRAVASOL SOLN 2 HI INTRAVENOUS INTRAVENOUS CLINIMIX/DEXTROSE TROPHAMINE SOLN 3 HI (4.25/20) SOLN 3 HI INTRAVENOUS INTRAVENOUS DIURETICS CLINIMIX/DEXTROSE AMILORIDE HCL TABS 2 MO (4.25/5) SOLN 3 HI amiloride- INTRAVENOUS 1 MO hydrochlorothiazide tabs CLINIMIX/DEXTROSE (5/15) SOLN 3 HI bumetanide soln 2 bumetanide tabs 0.5mg, INTRAVENOUS 2 MO CLINIMIX/DEXTROSE 1mg, 2mg chlorothiazide sodium (5/20) SOLN 3 HI 2 INTRAVENOUS solr chlorothiazide tabs CLINIMIX/DEXTROSE 2 MO (5/25) SOLN 3 HI 250mg, 500mg chlorthalidone tabs INTRAVENOUS 2 MO 25mg, 50mg

You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

44 • Kaiser Permanente 2021 Comprehensive Formulary

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits DIURIL SUSP 3 MO sodium polystyrene 2 MO ethacrynic acid tabs 4 MO sulfonate powd furosemide soln 8mg/ml, sodium polystyrene 2 MO 2 MO 10mg/ml sulfonate susp furosemide soln injection 2 HI sps susp 2 MO FUROSEMIDE TABS VELPHORO CHEW 5 NDS 1 MO VELTASSA PACK 40mg, 80mg, 20mg 5 NDS hydrochlorothiazide caps 2 MO 8.4gm, 16.8gm, 25.2gm hydrochlorothiazide tabs REPLACEMENT PREPARATIONS 1 MO 12.5mg, 25mg, 50mg calcium acetate (phos 2 MO indapamide tabs binder) caps 1 MO 1.25mg, 2.5mg calcium acetate (phos 2 MO JYNARQUE TABS binder) tabs 5 NDS 15mg, 30mg CALCIUM JYNARQUE TBPK 5 NDS GLUCONATE-NACL 2 MANNITOL SOLN 2 SOLN methyclothiazide tabs 2 MO DEXTROSE IN metolazone tabs 2.5mg, LACTATED RINGERS 2 2 MO 5mg, 10mg SOLN DEXTROSE-NACL OSMITROL SOLN 2 2 HI SOLN INTRAVENOUS SAMSCA TABS 15mg 5 NDS DEXTROSE 10%/NACL TOLVAPTAN TABS 5 NDS 0.2% ; DEXTROSE 3 HI 30mg, 15mg 10%/NACL 0.45% torsemide tabs 5mg, 2 MO DEXTROSE 5%/NACL 10mg, 20mg, 100mg 4 HI 0.225% triamterene caps 50mg, 2 MO IONOSOL-MB IN D5W 100mg 4 HI SOLN INTRAVENOUS triamterene-hctz caps 2 MO ISOLYTE-P IN D5W 4 HI triamterene-hctz tabs 1 MO SOLN INTRAVENOUS ION-REMOVING AGENTS ISOLYTE-S SOLN 4 HI AURYXIA TABS 5 PA,MO,NDS INTRAVENOUS FOSRENOL PACK K-TAB TBCR 2 MO 5 NDS 750mg, 1000mg KCL IN DEXTROSE- kionex susp 2 MO NACL SOLN 2 HI lanthanum carbonate INTRAVENOUS chew 500mg, 750mg, 2 MO KCL IN DEXTROSE- 1000mg NACL SOLN 3 HI LOKELMA PACK 5gm, INTRAVENOUS 40-5- 4 MO 10gm 0.9 MEQ sevelamer carbonate KCL IN DEXTROSE- 2 MO pack 0.8gm, 2.4gm NACL SOLN 4 HI sevelamer carbonate INTRAVENOUS 20-5- 2 MO tabs 0.33 MEQ sevelamer hcl tabs 2 MO 400mg, 800mg You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

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Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits KCL-LACTATED POTASSIUM RINGERS-D5W SOLN 3 HI CHLORIDE SOLN INTRAVENOUS INTRAVENOUS 2 HI KLOR-CON 10 TBCR 2 MO 2meq/ml, 10meq/100ml, klor-con m10 tbcr 2 MO 20meq/100ml, klor-con m15 tbcr 2 MO 40meq/100ml POTASSIUM klor-con m20 tbcr 2 MO 2 PHOSPHATES SOLN klor-con pack 2 MO POTASSIUM klor-con sprinkle cpcr 2 MO PHOSPHATES(66 MEQ 2 8meq, 10meq K) SOLN KLOR-CON TBCR 2 MO RINGERS SOLN 2 LACTATED RINGERS 2 SODIUM CHLORIDE SOLN 2 (PF) SOLN magnesium sulfate in 2 SODIUM CHLORIDE d5w soln 2 SOLN NORMOSOL-M IN D5W 4 HI SODIUM CHLORIDE SOLN INTRAVENOUS 2 HI SOLN INJECTION NORMOSOL-R IN D5W 4 HI SODIUM CHLORIDE SOLN INTRAVENOUS SOLN INTRAVENOUS 2 HI NORMOSOL-R SOLN 4 HI 0.45%, 0.9%, 3%, 5% INTRAVENOUS SODIUM PHOSPHATES 2 PHOSLYRA SOLN 3 MO SOLN PLASMA-LYTE 148 TPN ELECTROLYTES 3 HI 2 HI SOLN INTRAVENOUS CONC INTRAVENOUS PLASMA-LYTE A SOLN 3 HI URICOSURIC AGENTS INTRAVENOUS colchicine-probenecid POTASSIUM ACETATE 2 MO 2 tabs SOLN probenecid tabs 2 MO potassium chloride crys 2 MO er tbcr 10meq, 20meq ENZYMES potassium chloride er ENZYMES 2 MO cpcr 8meq, 10meq ADAGEN SOLN 3 POTASSIUM ALDURAZYME SOLN 3 CHLORIDE ER TBCR 2 MO CERDELGA CAPS 5 NDS 8meq, 10meq, 20meq CEREZYME SOLR 5 NDS POTASSIUM CREON CPEP 3 MO CHLORIDE IN 2 HI ELAPRASE SOLN 5 NDS DEXTROSE SOLN ELELYSO SOLR 5 NDS INTRAVENOUS potassium chloride in ELITEK SOLR 3 2 HI FABRAZYME SOLR nacl soln intravenous 5 NDS potassium chloride pack 2 MO 5mg, 35mg potassium chloride soln KANUMA SOLN 5 NDS 2 MO 10%, 20% LUMIZYME SOLR 5 NDS miglustat caps 5 NDS

You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

46 • Kaiser Permanente 2021 Comprehensive Formulary

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits NAGLAZYME SOLN 5 NDS moxifloxacin hcl (2x day) 2 NEXVIAZYME SOLR 5 NDS soln PALYNZIQ SOSY moxifloxacin hcl soln 2 2.5mg/0.5ml, 5 NDS NATACYN SUSP 3 10mg/0.5ml, 20mg/ml neo-polycin oint 2 PANCREAZE CPEP 4 MO neomycin-bacitracin zn- 2 PERTZYE CPEP 4 MO polymyx oint neomycin-polymyxin- PULMOZYME SOLN 5 PA,NDS 2 REVCOVI SOLN 5 NDS gramicidin soln STRENSIQ SOLN ofloxacin soln 2 18mg/0.45ml, OTOVEL SOLN 4 5 LD,NDS 28mg/0.7ml, paroex soln 2 80mg/0.8ml, 40mg/ml periogard soln 2 SUCRAID SOLN 5 LD polycin oint 2 VIMIZIM SOLN 5 NDS polymyxin b-trimethoprim 2 VIOKACE TABS 4 MO soln sulfacetamide sodium VPRIV SOLR 5 NDS 2 ZENPEP CPEP 3 MO oint sulfacetamide sodium EYE, EAR, NOSE, AND THROAT (EENT) 2 PREPARATIONS soln ANTI-INFECTIVES tobramycin soln 2 AZASITE SOLN 4 TOBREX OINT 3 bacitracin oint 2 trifluridine soln 2 bacitracin-polymyxin b ZIRGAN GEL 4 2 oint ANTI-INFLAMMATORY AGENTS BESIVANCE SUSP 4 ACUVAIL SOLN 4 MO bleph-10 soln 2 ALREX SUSP 4 MO bacitra-neomycin- CETRAXAL SOLN 4 2 MO chlorhexidine gluconate polymyxin-hc oint 2 soln blephamide s.o.p. oint 2 MO CILOXAN OINT 3 BLEPHAMIDE SUSP 3 MO ciprofloxacin hcl soln bromfenac sodium 2 2 MO (ophth) (once-daily) soln CIPROFLOXACIN HCL BROMSITE SOLN 4 MO 4 SOLN (OTIC) CEQUA SOLN 3 CIPROFLOXACIN- CIPRO HC SUSP 4 MO FLUOCINOLONE PF 4 CIPRODEX SUSP 3 MO SOLN ciprofloxacin- 2 MO erythromycin oint 2 dexamethasone susp gatifloxacin soln 2 COLY-MYCIN S SUSP 3 MO gentak oint 2 DERMOTIC OIL 2 MO gentamicin sulfate soln 2 dexamethasone sodium 2 MO levofloxacin soln 2 phosphate soln MOXEZA SOLN 4 diclofenac sodium soln 2 MO You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

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Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits DUREZOL EMUL 4 MO prednisolone sodium 2 MO flac oil 2 MO phosphate soln FLAREX SUSP 4 MO PROLENSA SOLN 4 MO flunisolide soln 2 MO RESTASIS EMUL 4 MO fluocinolone acetonide RETISERT IMPL 5 2 MO sulfacetamide- oil 2 MO fluorometholone susp 2 MO prednisolone soln flurbiprofen sodium soln 2 MO TOBRADEX OINT 3 MO fluticasone propionate TOBRADEX ST SUSP 4 MO 2 MO tobramycin- susp 2 MO FML FORTE SUSP 3 MO dexamethasone susp FML OINT 3 MO XHANCE EXHU 4 MO HYDROCORTISONE- XIIDRA SOLN 4 2 MO ACETIC ACID SOLN YUTIQ IMPL 5 ILEVRO SUSP 4 MO ZETONNA AERS 4 MO ILUVIEN IMPL 5 ZYLET SUSP 4 MO INVELTYS SUSP 4 MO ANTIALLERGIC AGENTS ketorolac tromethamine 2 MO ALOCRIL SOLN 4 MO soln 0.4%, 0.5% ALOMIDE SOLN 4 MO LOTEMAX GEL 2 MO azelastine hcl soln 2 MO LOTEMAX OINT 4 MO 0.05%, 0.1%, 0.15% LOTEMAX SUSP 4 MO azelastine-fluticasone 2 MO loteprednol etabonate susp 2 MO susp bepotastine besilate soln 2 MO MAXIDEX SUSP 4 MO cromolyn sodium soln 2 MO mometasone furoate 2 MO epinastine hcl soln 2 MO susp LASTACAFT SOLN 4 MO neo-polycin hc oint 2 MO olopatadine hcl soln neomycin-polymyxin- 2 MO 2 MO 0.1%, 0.2%, 0.6% dexameth oint ANTIGLAUCOMA AGENTS neomycin-polymyxin- 2 MO acetazolamide er cp12 2 MO dexameth susp acetazolamide sodium neomycin-polymyxin-hc 2 2 MO solr soln acetazolamide tabs neomycin-polymyxin-hc 2 MO 2 MO 125mg, 250mg susp ALPHAGAN P SOLN 4 MO NEVANAC SUSP 4 MO betaxolol hcl soln 2 MO OMNARIS SUSP 4 MO BETIMOL SOLN 0.25%, 4 MO PRED MILD SUSP 3 MO 0.5% PRED-G S.O.P. OINT 3 MO BETOPTIC-S SUSP 4 MO PRED-G SUSP 3 MO bimatoprost soln 2 MO prednisolone acetate 2 MO BRIMONIDINE susp TARTRATE SOLN 0.2%, 2 MO 0.15% You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

48 • Kaiser Permanente 2021 Comprehensive Formulary

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits brinzolamide susp 2 MO IOPIDINE SOLN 3 MO carteolol hcl soln 2 MO LACRISERT INST 3 MO COMBIGAN SOLN 4 MO LUCENTIS SOLN dorzolamide hcl soln 2 MO 0.3mg/0.05ml, 5 NDS dorzolamide hcl-timolol 0.5mg/0.05ml 2 mal pf soln LUCENTIS SOSY dorzolamide hcl-timolol 0.3mg/0.05ml, 5 NDS 2 MO mal soln 0.5mg/0.05ml DURYSTA IMPL 5 NDS OXERVATE SOLN 5 NDS PHENYLEPHRINE HCL latanoprost soln 2 MO 2 levobunolol hcl soln 2 MO SOLN LUMIGAN SOLN 4 MO RHOPRESSA SOLN 4 methazolamide tabs TEPEZZA SOLR 5 NDS 2 MO 25mg, 50mg LOCAL ANESTHETICS PHOSPHOLINE IODIDE ALTACAINE SOLN 2 3 MO SOLR lidocaine hcl soln 2 pilocarpine hcl soln 1%, lidocaine viscous hcl 2 MO 2 MO 2%, 4% soln SIMBRINZA SUSP 4 MO proparacaine hcl soln 2 MO timolol maleate pf soln 2 MO TETRACAINE HCL 2 timolol maleate solg SOLN 4 MO 0.25%, 0.5% GASTROINTESTINAL DRUGS timolol maleate soln 2 MO ANTI-INFLAMMATORY AGENTS 0.25%, 0.5% ALOSETRON HCL TIMOPTIC OCUDOSE 5 NDS 4 MO TABS 0.5mg, 1mg SOLN .25% APRISO CP24 4 MO TIMOPTIC-XE SOLG balsalazide disodium 4 MO 2 MO 0.25%, 0.5% caps TRAVATAN Z SOLN 4 MO colazal caps 2 MO travoprost (bak free) soln 2 MO DELZICOL CPDR 4 MO VYZULTA SOLN 4 MO DIPENTUM CAPS 5 NDS XELPROS EMUL 4 MO LIALDA TBEC 2 MO ZIOPTAN SOLN 4 MO mesalamine cpdr 2 MO EENT DRUGS, MISCELLANEOUS mesalamine enem 2 MO ACETIC ACID SOLN 2 MO mesalamine er cp24 2 MO ALTAFRIN SOLN 2 mesalamine supp 2 MO apraclonidine hcl soln 2 MO mesalamine tbec 1.2gm, ATROPINE SULFATE 2 MO 2 MO 800mg SOLN mesalamine-cleanser kit 2 BEOVU SOLN 5 NDS PENTASA CPCR 3 MO CYSTADROPS SOLN 5 NDS 250mg, 500mg CYSTARAN SOLN 5 ANTIDIARRHEA AGENTS EYLEA SOLN 5 diphenoxylate-atropine 2 EYLEA SOSY 5 liqd You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

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Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits diphenoxylate-atropine amoxicill-clarithro- 2 2 MO tabs lansopraz misc loperamide hcl caps 2 MO CARAFATE SUSP 3 MO MYTESI TBEC 4 MO cimetidine hcl soln 2 MO OPIUM TINC 2 cimetidine tabs 200mg, 2 MO XERMELO TABS 5 LD,NDS 300mg, 400mg, 800mg ANTIEMETICS esomeprazole AKYNZEO CAPS 3 PA magnesium cpdr 20mg, 2 MO 40mg ANZEMET TABS 50mg, 4 PA,NDS esomeprazole 100mg magnesium pack 10mg, 2 MO aprepitant caps 2 PA,NDS 20mg, 40mg BONJESTA TBCR 4 MO esomeprazole sodium 2 CESAMET CAPS 4 PA solr dimenhydrinate soln 2 ESOMEPRAZOLE doxylamine-pyridoxine 4 2 MO STRONTIUM CPDR tbec famotidine premixed soln 2 dronabinol caps 2.5mg, 2 PA famotidine soln 2 5mg, 10mg famotidine susr 2 MO EMEND SUSR 4 PA,NDS famotidine tabs 20mg, fosaprepitant 2 MO 2 40mg dimeglumine solr lansoprazole cpdr 15mg, 2 MO granisetron hcl soln 2 30mg granisetron hcl tabs 2 PA lansoprazole tbdd 15mg, 2 MO meclizine hcl tabs 2 30mg ondansetron hcl soln 2 PA misoprostol tabs 2 MO ondansetron hcl tabs 100mcg, 200mcg 2 PA 4mg, 8mg, 24mg nizatidine caps 150mg, 2 MO ondansetron tbdp 4mg, 300mg 2 PA 8mg nizatidine soln 2 MO palonosetron hcl soln 2 OMECLAMOX-PAK 4 MO palonosetron hcl sosy 2 MISC omeprazole cpdr 10mg, SANCUSO PTCH 5 NDS 2 MO scopolamine pt72 2 MO 20mg, 40mg omeprazole-sodium SYNDROS SOLN 5 PA,NDS 2 MO bicarbonate caps TRANSDERM SCOP 3 omeprazole-sodium (1.5 MG) PT72 2 MO bicarbonate pack trimethobenzamide hcl 2 PA pantoprazole sodium caps 2 MO pack VARUBI (180 MG 4 PA,NDS PANTOPRAZOLE DOSE) TBPK 2 SODIUM SOLR ZUPLENZ FILM 4mg, 4 PA pantoprazole sodium 8mg 2 MO tbec 20mg, 40mg ANTIULCER AGENTS AND ACID SUPPRESSANTS pepcid tabs 20mg, 40mg 2 MO You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

50 • Kaiser Permanente 2021 Comprehensive Formulary

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits PRILOSEC PACK metoclopramide hcl tabs 4 MO 2 MO 2.5mg, 10mg 5mg, 10mg PROTONIX PACK 3 MO metoclopramide hcl tbdp 2 MO PYLERA CAPS 5 MO,NDS 5mg, 10mg MOVANTIK TABS rabeprazole sodium cpsp 2 4 MO rabeprazole sodium tbec 2 MO 12.5mg, 25mg OCALIVA TABS 5mg, sucralfate susp 2 MO 5 LD,NDS 10mg sucralfate tabs 2 MO RELISTOR SOLN 5 NDS CATHARTICS AND LAXATIVES 8mg/0.4ml, 12mg/0.6ml gavilyte-c solr 2 MO RELISTOR TABS 5 NDS gavilyte-g solr 2 MO reltone caps 200mg, 5 NDS gavilyte-h kit 2 400mg gavilyte-n with flavor 2 MO SYMPROIC TABS 4 MO pack solr TRULANCE TABS 3 MO GOLYTELY SOLR 3 ursodiol caps 300mg 2 MO OSMOPREP TABS 4 MO URSODIOL CAPS peg 3350-kcl-na bicarb- 5 NDS 2 MO 200mg, 400mg nacl solr ursodiol tabs 250mg, peg 3350/electrolytes 2 MO 2 MO 500mg solr VIBERZI TABS 75mg, peg-3350/electrolytes 5 NDS 2 MO 100mg solr HEAVY METAL ANTAGONISTS PEG-PREP KIT 2 HEAVY METAL ANTAGONISTS PLENVU SOLR 4 MO CHEMET CAPS 5 SUPREP BOWEL PREP 4 MO clovique caps 2 NDS KIT SOLN CUPRIMINE CAPS 5 NDS trilyte solr 2 MO deferasirox granules GI DRUGS, MISCELLANEOUS pack 90mg, 180mg, 5 NDS AMITIZA CAPS 8mcg, 4 MO 360mg 24mcg deferasirox tabs 90mg, BYLVAY (PELLETS) 5 NDS 5 NDS 180mg, 360mg CPSP 200mcg, 600mcg deferasirox tbso 125mg 2 NDS BYLVAY CAPS 400mcg, deferasirox tbso 250mg, 5 NDS 5 NDS 1200mcg 500mg CHOLBAM CAPS 50mg, 5 NDS deferiprone tabs 5 NDS 250mg deferoxamine mesylate ENTYVIO SOLR 5 NDS 2 solr GATTEX KIT 5 PA,NDS DEPEN TITRATABS 5 GIMOTI SOLN 5 NDS TABS LINZESS CAPS 72mcg, EXJADE TBSO 125mg, 3 MO 5 NDS 145mcg, 290mcg 250mg, 500mg lubiprostone caps 8mcg, 2 MO FERRIPROX SOLN 5 LD,NDS 24mcg FERRIPROX TABS 5 LD,NDS metoclopramide hcl soln 2 MO 500mg, 1000mg You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

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Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits FERRIPROX TWICE-A- EMFLAZA TABS 6mg, 5 NDS 5 LD,NDS DAY TABS 18mg, 30mg, 36mg JADENU SPRINKLE fludrocortisone acetate 2 MO PACK 90mg, 180mg, 5 NDS tabs 360mg hydrocortisone tabs 2 MO JADENU TABS 90mg, 5mg, 10mg, 20mg 5 NDS 360mg INTRAROSA INST 4 penicillamine caps 2 KENALOG SUSP 3 penicillamine tabs 2 MEDROL TABS 3 MO trientine hcl caps 5 NDS methylprednisolone 2 HORMONES AND SYNTHETIC SUBSTITUTES acetate susp methylprednisolone ADRENALS 2 ALKINDI SPRINKLE sodium succ solr methylprednisolone tabs CPSP 0.5mg, 1mg, 2mg, 5 NDS 2 MO 5mg 4mg, 8mg, 16mg, 32mg betamethasone sod methylprednisolone tbpk 2 MO 2 phos & acet susp millipred dp tbpk 2 budesonide cpep 2 MO millipred tabs 2 MO ORTIKOS CP24 6mg, budesonide er tb24 5 NDS 5 NDS cortisone acetate tabs 2 MO 9mg decadron elix 2 MO prednisolone sodium decadron tabs .5mg, phosphate soln 5mg/5ml, 2 MO 2 MO .75mg 10mg/5ml, 20mg/5ml, 25mg/5ml decadron tabs 4mg, 6mg 2 PA,MO prednisolone sodium deltasone tabs 2 PA,MO phosphate tbdp 10mg, 2 MO DEPO-MEDROL SUSP 3 15mg, 30mg dexabliss tbpk 2 prednisolone soln 2 MO dexamethasone elix 2 MO prednisone intensol conc 2 PA,MO dexamethasone intensol 2 MO prednisone soln 2 PA,MO conc prednisone tabs 1mg, dexamethasone sod 2 2.5mg, 5mg, 10mg, 2 PA,MO phosphate pf soln 20mg, 50mg dexamethasone sodium 2 prednisone tbpk 2 phosphate soln PULMICORT 4 dexamethasone soln 2 FLEXHALER AEPB dexamethasone tabs RAYOS TBEC 1mg, 4 PA,MO 0.5mg, 0.75mg, 1mg, 2 PA,MO 2mg, 5mg 1.5mg, 2mg, 4mg, 6mg SOLU-CORTEF SOLR 3 dexamethasone tbpk 2 MO SOLU-MEDROL SOLR 3 dexpak 10 day tbpk 2 MO taperdex 12-day tbpk 2 dexpak 13 day tbpk 2 MO taperdex 6-day tbpk 2 MO dexpak 6 day tbpk 2 MO taperdex 7-day tbpk 2 MO dxevo 11-day tbpk 2 TRELEGY ELLIPTA 4 MO EMFLAZA SUSP 5 LD,NDS AEPB You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

52 • Kaiser Permanente 2021 Comprehensive Formulary

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits triamcinolone acetonide blisovi fe 1.5/30 tabs 2 MO 2 susp briellyn tabs 2 MO veripred 20 soln 2 MO camila tabs 2 MO ANDROGENS camrese lo tabs 2 MO ANADROL-50 TABS 5 MO caziant tabs 2 MO ANDRODERM PT24 3 MO cryselle-28 tabs 2 MO 2mg/24hr, 4mg/24hr cyclafem 1/35 tabs 2 MO AVEED SOLN 4 MO cyclafem 7/7/7 tabs 2 MO danazol caps 50mg, 2 MO cyred eq tabs 2 MO 100mg, 200mg deblitane tabs 2 MO depo-testosterone soln 2 MO 100mg/ml, 200mg/ml delyla tabs 2 MO desogestrel-ethinyl methitest tabs 2 MO 2 MO estradiol tabs methyltestosterone caps 2 MO dolishale tabs 2 MO oxandrolone tabs 2.5mg 2 MO drospiren-eth estrad- 2 MO oxandrolone tabs 5 MO,NDS levomefol tabs STRIANT MISC 4 MO drospirenone-ethinyl 2 MO testosterone cypionate estradiol tabs soln 100mg/ml, 2 MO ELLA TABS 3 MO 200mg/ml eluryng ring 2 MO testosterone enanthate 2 MO emoquette tabs 2 MO soln enpresse-28 tabs 2 MO testosterone gel 1%, 1.62%, 20.25mg/1.25gm, enskyce tabs 2 MO 25mg/2.5gm, 2 MO errin tabs 2 MO 40.5mg/2.5gm, estarylla tabs 2 MO 50mg/5gm, 10mg/act ethynodiol diac-eth 2 MO testosterone soln 2 MO estradiol tabs etonogestrel-ethinyl XYOSTED SOAJ 2 MO 50mg/0.5ml, estradiol ring 4 MO 75mg/0.5ml, falmina tabs 2 MO 100mg/0.5ml fayosim tabs 2 MO CONTRACEPTIVES femynor tabs 2 MO altavera tabs 2 MO gemmily caps 2 MO alyacen 1/35 tabs 2 MO gianvi tabs 2 MO amethia lo tabs 2 MO hailey 24 fe tabs 2 MO amethia tabs 2 MO iclevia tabs 2 MO apri tabs 2 MO incassia tabs 2 MO aranelle tabs 2 MO introvale tabs 2 MO ashlyna tabs 2 MO isibloom tabs 2 MO aubra eq tabs 2 MO jasmiel tabs 2 MO aviane tabs 2 MO JOLIVETTE TABS 2 MO balziva tabs 2 MO juleber tabs 2 MO blisovi 24 fe tabs 2 MO junel 1.5/30 tabs 2 MO You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

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Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits junel 1/20 tabs 2 MO microgestin fe 1.5/30 2 MO junel fe 1.5/30 tabs 2 MO tabs junel fe 1/20 tabs 2 MO microgestin fe 1/20 tabs 2 MO junel fe 24 tabs 2 MO mili tabs 2 MO kaitlib fe chew 2 MO MONONESSA TABS 2 MO kariva tabs 2 MO NATAZIA TABS 4 MO kelnor 1/35 tabs 2 MO necon 0.5/35 (28) tabs 2 MO kelnor 1/50 tabs 2 MO NECON 7/7/7 TABS 2 MO kurvelo tabs 2 MO nikki tabs 2 MO larin 1.5/30 tabs 2 MO nora-be tabs 2 MO norethin ace-eth estrad- larin 1/20 tabs 2 MO 2 MO larin fe 1.5/30 tabs 2 MO fe caps norethin ace-eth estrad- larin fe 1/20 tabs 2 MO 2 MO fe chew larissia tabs 2 MO norethin ace-eth estrad- 2 MO LAYOLIS FE CHEW 2 MO fe tabs leena tabs 2 MO norethin-eth estradiol-fe 2 MO lessina tabs 2 MO chew levonest tabs 2 MO norethindrone acet- 2 MO levonorg-eth estrad ethinyl est tabs 2 MO triphasic tabs norethindrone tabs 2 MO levonorgest-eth est & eth norgestim-eth estrad 2 MO 2 MO est tabs triphasic tabs levonorgest-eth estrad norgestimate-eth 2 MO 2 MO 91-day tabs estradiol tabs levonorgestrel-ethinyl 2 MO norlyroc tabs 2 MO estrad tabs nortrel 0.5/35 (28) tabs 2 MO levora 0.15/30 (28) tabs 2 MO nortrel 1/35 (21) tabs 2 MO LO LOESTRIN FE TABS 4 MO nortrel 1/35 (28) tabs 2 MO loestrin 1.5/30 (21) tabs 2 MO nortrel 7/7/7 tabs 2 MO loestrin 1/20 (21) tabs 2 MO NUVARING RING 4 MO loestrin fe 1.5/30 tabs 2 MO nylia 7/7/7 tabs 2 MO loestrin fe 1/20 tabs 2 MO nymyo tabs 2 MO loryna tabs 2 MO ocella tabs 2 MO low-ogestrel tabs 2 MO ogestrel tabs 2 MO lutera tabs 2 MO orsythia tabs 2 MO lyleq tabs 2 MO pimtrea tabs 2 MO lyza tabs 2 MO pirmella 1/35 tabs 2 MO marlissa tabs 2 MO portia-28 tabs 2 MO melodetta 24 fe chew 2 MO previfem tabs 2 MO merzee caps 2 MO reclipsen tabs 2 MO mibelas 24 fe chew 2 MO rivelsa tabs 2 MO microgestin 1.5/30 tabs 2 MO setlakin tabs 2 MO microgestin 1/20 tabs 2 MO You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

54 • Kaiser Permanente 2021 Comprehensive Formulary

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits sharobel tabs 2 MO ALOGLIPTIN- sprintec 28 tabs 2 MO METFORMIN HCL 2 MO sronyx tabs 2 MO TABS alogliptin-pioglitazone syeda tabs 2 MO 2 MO tabs tarina 24 fe tabs 2 MO APIDRA SOLN 4 PA,MO tarina fe 1/20 eq tabs 2 MO APIDRA SOLOSTAR tilia fe tabs 2 MO 4 MO SOPN tri-estarylla tabs 2 MO AVANDIA TABS 2mg, 4 MO tri-legest fe tabs 2 MO 4mg tri-lo-estarylla tabs 2 MO BAQSIMI ONE PACK 3 tri-lo-sprintec tabs 2 MO POWD tri-mili tabs 2 MO BAQSIMI TWO PACK 3 tri-nymyo tabs 2 MO POWD BYDUREON BCISE tri-previfem tabs 2 MO 4 tri-sprintec tabs 2 MO AUIJ tri-vylibra lo tabs 2 MO BYDUREON PEN 4 BYETTA 10 MCG PEN tri-vylibra tabs 2 MO 4 MO SOPN TRINESSA (28) TABS 2 MO BYETTA 5 MCG PEN 4 MO trivora (28) tabs 2 MO SOPN tydemy tabs 2 MO CYCLOSET TABS 4 MO velivet tabs 2 MO diazoxide susp 5 vestura tabs 2 MO glimepiride tabs 1mg, 1 MO vienva tabs 2 MO 2mg, 4mg vyfemla tabs 2 MO glipizide er tb24 2.5mg, 2 MO vylibra tabs 2 MO 5mg, 10mg wymzya fe chew 2 MO glipizide tabs 5mg, 10mg 1 MO xulane ptwk 2 MO glipizide-metformin hcl 2 MO zafemy ptwk 2 MO tabs GLUCAGEN HYPOKIT zarah tabs 2 MO 4 zovia 1/35e (28) tabs 2 MO SOLR glucagon emergency kit 2 DIABETIC AGENTS glyburide micronized acarbose tabs 25mg, 2 MO 2 MO tabs 1.5mg, 3mg, 6mg 50mg, 100mg glyburide tabs 1.25mg, ADMELOG SOLN 4 MO 2 MO 2.5mg, 5mg ADMELOG SOLOSTAR 4 MO glyburide-metformin tabs 2 MO SOPN GLYXAMBI TABS 4 MO AFREZZA POWD 4 MO HUMALOG JUNIOR AFREZZA POWD 8 (90) 4 MO 5 NDS KWIKPEN SOPN & 12 (90) UNIT HUMALOG KWIKPEN alogliptin benzoate tabs 2 MO SOPN 100unit/ml, 4 MO 6.25mg, 12.5mg, 25mg 200unit/ml

You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

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Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits HUMALOG MIX 50/50 LANTUS SOLN 3 MO 4 MO KWIKPEN SUPN LANTUS SOLOSTAR HUMALOG MIX 50/50 4 MO 4 MO SOPN SUSP LEVEMIR FLEXTOUCH HUMALOG MIX 75/25 4 MO 4 MO SOPN KWIKPEN SUPN LEVEMIR SOLN 4 MO HUMALOG MIX 75/25 metformin hcl er tb24 4 MO 1 MO SUSP 500mg, 750mg HUMALOG SOCT 4 MO metformin hcl tabs 1 MO HUMALOG SOLN 3 PA,MO 500mg, 850mg, 1000mg HUMULIN 70/30 miglitol tabs 25mg, 2 MO 2 MO KWIKPEN SUPN 50mg, 100mg HUMULIN 70/30 SUSP 2 MO nateglinide tabs 60mg, 2 MO HUMULIN N KWIKPEN 120mg 2 MO SUPN NOVOLIN 70/30 SUSP 4 MO HUMULIN N SUSP 2 MO NOVOLOG 70/30 HUMULIN R SOLN 2 PA,MO FLEXPEN RELION 4 MO HUMULIN R U-500 SUPN NOVOLOG FLEXPEN (CONCENTRATED) 3 MO 4 MO SOLN RELION SOPN HUMULIN R U-500 NOVOLOG FLEXPEN 3 MO 4 MO KWIKPEN SOPN SOPN INSULIN ASP PROT & NOVOLOG MIX 70/30 2 MO 4 MO ASP FLEXPEN SUPN FLEXPEN SUPN INSULIN ASPART NOVOLOG MIX 70/30 2 MO 4 MO FLEXPEN SOPN RELION SUSP INSULIN ASPART NOVOLOG MIX 70/30 2 MO 4 MO PENFILL SOCT SUSP INSULIN ASPART NOVOLOG PENFILL 2 MO 4 MO PROT & ASPART SUSP SOCT INSULIN ASPART NOVOLOG RELION 2 PA,MO 4 PA,MO SOLN SOLN INSULIN LISPRO (1 NOVOLOG SOLN 4 PA,MO 4 MO OZEMPIC (0.25 OR 0.5 UNIT DIAL) SOPN 3 MO INSULIN LISPRO SOLN 4 MO MG/DOSE) SOPN INVOKAMET TABS 4 MO OZEMPIC (1 MG/DOSE) INVOKAMET XR TB24 4 MO SOPN 2mg/1.5ml, 3 MO INVOKANA TABS 4mg/3ml 4 MO pioglitazone hcl tabs 100mg, 300mg 1 MO JARDIANCE TABS 15mg, 30mg, 45mg 3 MO pioglitazone hcl- 10mg, 25mg 2 MO glimepiride tabs JENTADUETO TABS 4 MO pioglitazone hcl- JENTADUETO XR TB24 4 MO 2 MO metformin hcl tabs KAZANO TABS 4 MO prandin tabs 1mg, 2mg 2 MO KORLYM TABS 5 LD,NDS You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

56 • Kaiser Permanente 2021 Comprehensive Formulary

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits PROGLYCEM SUSP 5 MO 0.05mg/24hr, repaglinide tabs 0.5mg, 0.075mg/24hr, 2 MO 1mg, 2mg 0.1mg/24hr repaglinide-metformin estradiol ptwk 2 MO hcl tabs 37.5mcg/24hr, SOLIQUA SOPN 4 MO 0.025mg/24hr, SYMLINPEN 120 SOPN 5 MO 0.05mg/24hr, 2 MO 0.06mg/24hr, SYMLINPEN 60 SOPN 5 MO 0.075mg/24hr, SYNJARDY TABS 4 MO 0.1mg/24hr SYNJARDY XR TB24 4 MO estradiol tabs 10mcg, tolazamide tabs 250mg, 2 MO 2 MO 0.5mg, 1mg, 2mg 500mg estradiol valerate oil 2 tolbutamide tabs 2 MO estradiol-norethindrone 2 MO TRADJENTA TABS 4 MO acet tabs VICTOZA SOPN 3 MO ESTRING RING 3 MO ESTROGENS AND ANTIESTROGENS EVAMIST SOLN 4 MO amabelz tabs 2 MO fyavolv tabs 2 MO ANGELIQ TABS 4 MO IMVEXXY CLIMARA PRO PTWK 4 MO MAINTENANCE PACK 4 MO CLIMARA PTWK INST 4mcg, 10mcg 37.5mcg/24hr, IMVEXXY STARTER 0.025mg/24hr, PACK INST 4mcg, 4 MO 0.05mg/24hr, 2 MO 10mcg 0.06mg/24hr, jinteli tabs 2 MO 0.075mg/24hr, lopreeza tabs 2 MO 0.1mg/24hr lyllana pttw COMBIPATCH PTTW 4 MO 0.025mg/24hr, DELESTROGEN OIL 4 0.0375mg/24hr, 2 MO depo-estradiol oil 2 0.05mg/24hr, DIVIGEL GEL 4 MO 0.075mg/24hr, dotti pttw 0.025mg/24hr, 0.1mg/24hr menest tabs 0.3mg, 0.0375mg/24hr, 2 MO 0.05mg/24hr, 2 MO 0.625mg, 1.25mg 0.075mg/24hr, MENOSTAR PTWK 4 MO 0.1mg/24hr mimvey lo tabs 2 MO DUAVEE TABS 4 MO mimvey tabs 2 MO ELESTRIN GEL 4 MO norethindrone-eth 2 MO estrace crea 2 MO estradiol tabs estrace tabs 0.5mg, ORIAHNN CPPK 5 NDS 2 MO 1mg, 2mg OSPHENA TABS 4 MO estradiol crea 2 MO prefest tabs 2 MO estradiol pttw PREMARIN SOLR 3 0.025mg/24hr, 2 MO 0.0375mg/24hr, You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

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Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits PREMARIN TABS DDAVP RHINAL TUBE 4 MO 0.3mg, 0.45mg, 4 MO SOLN 0.625mg, 0.9mg, 1.25mg desmopressin ace spray 2 MO PREMPHASE TABS 4 MO refrig soln desmopressin acetate PREMPRO TABS 4 MO 2 MO raloxifene hcl tabs 2 MO soln DESMOPRESSIN yuvafem tabs 2 MO 2 ACETATE SOLN GONADOTROPINS desmopressin acetate CHORIONIC 2 spray soln GONADOTROPIN 4 PA DESMOPRESSIN SOLR ACETATE TABS 0.1mg, 2 MO MYFEMBREE TABS 5 NDS 0.2mg NOVAREL SOLR NOCDURNA SUBL 4 PA 4 MO 5000unit, 10000unit 27.7mcg, 55.3mcg ORGOVYX TABS 5 NDS NOCTIVA EMUL ORILISSA TABS 150mg, 5 NDS 0.83mcg/0.1ml, 4 MO 200mg 1.66mcg/0.1ml PREGNYL SOLR 4 PA STIMATE SOLN 3 MO TRIPTODUR SRER 5 NDS SYNAREL SOLN 5 MO OXYTOCICS PROGESTINS carboprost tromethamine 2 aygestin tabs 2 MO soln CRINONE GEL 4%, 8% 4 PA,MO methergine tabs 2 DEPO-PROVERA SUSP methylergonovine 3 2 400mg/ml maleate soln DEPO-SUBQ PROVERA methylergonovine 3 2 104 SUSY maleate tabs ENDOMETRIN INST 4 PA OXYTOCIN SOLN 2 hydroxyprogesterone 2 PARATHYROID caproate oil calcitonin (salmon) soln 2 MO hydroxyprogesterone cinacalcet hcl tabs 2 2 PA,NDS caproate soln 30mg, 60mg, 90mg MAKENA SOAJ 5 NDS FORTEO SOPN 5 PA,NDS medroxyprogesterone 2 NATPARA CART acetate susp 25mcg, 50mcg, 75mcg, 5 LD,NDS medroxyprogesterone 2 100mcg acetate susy SENSIPAR TABS 30mg, 5 PA,NDS medroxyprogesterone 60mg, 90mg acetate tabs 2.5mg, 2 MO TERIPARATIDE 5 PA,NDS 5mg, 10mg (RECOMBINANT) SOPN megestrol acetate susp 2 MO TYMLOS SOPN 5 NDS norethindrone acetate 2 MO PITUITARY tabs ACTHAR GEL 5 PA,LD,NDS progesterone caps 2 MO 100mg, 200mg

You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

58 • Kaiser Permanente 2021 Comprehensive Formulary

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits progesterone oil 2 SIGNIFOR LAR SRER SOMATOTROPIN AGONISTS AND 10mg, 20mg, 30mg, 5 NDS ANTAGONISTS 40mg, 60mg BYNFEZIA PEN SOPN 5 NDS SIGNIFOR SOLN EGRIFTA SOLR 5 NDS 0.3mg/ml, 0.6mg/ml, 5 NDS EGRIFTA SV SOLR 5 NDS 0.9mg/ml SOMATULINE DEPOT GENOTROPIN 5 MINIQUICK SOLR 4 PA,NDS SOLN 0.2mg SOMAVERT SOLR GENOTROPIN 10mg, 15mg, 20mg, 5 LD,NDS MINIQUICK SOLR 25mg, 30mg 0.4mg, 0.6mg, 0.8mg, 5 PA,NDS ZOMACTON SOLR 5mg 4 PA,NDS 1mg, 1.2mg, 1.4mg, ZOMACTON SOLR 5 PA,NDS 1.6mg, 1.8mg, 2mg ZORBTIVE SOLR 5 PA,NDS GENOTROPIN SOLR THYROID AND ANTITHYROID AGENTS 5 PA,NDS 5mg, 12mg EUTHYROX TABS HUMATROPE SOLR 25mcg, 50mcg, 75mcg, 5 PA,NDS 5mg, 6mg, 12mg, 24mg 88mcg, 100mcg, 2 MO INCRELEX SOLN 5 NDS 112mcg, 125mcg, MYCAPSSA CPDR 5 NDS 137mcg, 150mcg, NORDITROPIN 175mcg, 200mcg FLEXPRO SOPN LEVO-T TABS 25mcg, 5 PA,NDS 5mg/1.5ml, 10mg/1.5ml, 50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 15mg/1.5ml, 30mg/3ml 2 MO NUTROPIN AQ NUSPIN 125mcg, 137mcg, 5 PA,NDS 10 SOPN 150mcg, 175mcg, NUTROPIN AQ NUSPIN 200mcg, 300mcg 5 PA,NDS 20 SOPN levothyroxine sodium NUTROPIN AQ NUSPIN caps 13mcg, 25mcg, 5 PA,NDS 5 SOPN 50mcg, 75mcg, 88mcg, octreotide acetate soln 2 100mcg, 112mcg, 2 MO OMNITROPE SOCT 125mcg, 137mcg, 2 PA,NDS 5mg/1.5ml, 10mg/1.5ml 150mcg, 175mcg, 200mcg OMNITROPE SOLR 2 PA,NDS LEVOTHYROXINE SAIZEN CLICK.EASY 2 5 PA,NDS SODIUM SOLR SOLR levothyroxine sodium SAIZEN SOLR 5mg, 5 PA,NDS tabs 25mcg, 50mcg, 8.8mg 75mcg, 88mcg, 100mcg, SAIZENPREP SOLR 5 PA,NDS 112mcg, 125mcg, 2 MO SANDOSTATIN LAR 137mcg, 150mcg, DEPOT KIT 10mg, 5 NDS 175mcg, 200mcg, 20mg, 30mg 300mcg SEROSTIM SOLR 4mg, 5 PA,NDS LEVOXYL TABS 25mcg, 5mg, 6mg 50mcg, 75mcg, 88mcg, 2 MO 100mcg, 112mcg, You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

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Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits 125mcg, 137mcg, levoleucovorin calcium pf 2 150mcg, 175mcg, soln 200mcg levoleucovorin calcium 2 liothyronine sodium soln 2 solr liothyronine sodium tabs VISTOGARD PACK 5 NDS 2 MO 5mcg, 25mcg, 50mcg VORAXAZE SOLR 5 NDS methimazole tabs 5mg, 2 MO ANTIGOUT AGENTS 10mg allopurinol sodium solr 2 propylthiouracil tabs 2 MO allopurinol tabs 100mg, tapazole tabs 5mg, 2 MO 2 MO 300mg 10mg COLCHICINE CAPS 2 MO THYROLAR-1 TABS 4 colchicine tabs 2 MO THYROLAR-1/2 TABS 4 febuxostat tabs 40mg, 2 MO THYROLAR-1/4 TABS 4 80mg THYROLAR-2 TABS 4 GLOPERBA SOLN 4 THYROLAR-3 TABS 4 MITIGARE CAPS 4 MO TIROSINT CAPS ULORIC TABS 40mg, 4 MO 13mcg, 25mcg, 50mcg, 80mg 75mcg, 88mcg, 100mcg, 4 MO BONE RESORPTION INHIBITORS 112mcg, 125mcg, alendronate sodium soln 2 MO 137mcg, 150mcg, alendronate sodium tabs 175mcg, 200mcg 1 MO 5mg, 10mg, 35mg, 70mg UNITHROID TABS alendronate sodium tabs 25mcg, 50mcg, 75mcg, 2 MO 40mg 88mcg, 100mcg, 112mcg, 125mcg, 2 MO BINOSTO TBEF 4 MO 137mcg, 150mcg, EVENITY SOSY 5 NDS FOSAMAX PLUS D 175mcg, 200mcg, 4 MO 300mcg TABS IBANDRONATE MISCELLANEOUS THERAPEUTIC AGENTS 2 SODIUM SOLN 5-ALPHA REDUCTASE INHIBITORS ibandronate sodium tabs 2 PA,MO dutasteride caps 2 MO pamidronate disodium dutasteride-tamsulosin 2 2 MO soln hcl caps pamidronate disodium finasteride tabs 2 MO 2 solr ANTIDOTES PROLIA SOSY 4 acetylcysteine soln 10%, 2 PA,MO risedronate sodium tabs 20% 5mg, 30mg, 35mg, 2 MO fomepizole soln 2 150mg KHAPZORY SOLR RISEDRONATE 5 NDS 2 MO 175mg, 300mg SODIUM TBEC leucovorin calcium soln 2 XGEVA SOLN 5 PA,NDS leucovorin calcium solr 2 zoledronic acid conc 2 leucovorin calcium tabs 2 MO zoledronic acid soln 2 5mg, 10mg, 15mg, 25mg You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

60 • Kaiser Permanente 2021 Comprehensive Formulary

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits DISEASE-MODIFYING ANTIRHEUMATIC KEVZARA SOSY AGENTS 150mg/1.14ml, 5 NDS ACTEMRA ACTPEN 200mg/1.14ml 5 NDS SOAJ KINERET SOSY 5 NDS ACTEMRA SOSY 5 NDS leflunomide tabs 10mg, 2 MO AVSOLA SOLR 5 NDS 20mg OLUMIANT TABS 1mg, CIMZIA KIT 5 PA,NDS 5 NDS CIMZIA PREFILLED KIT 5 PA,NDS 2mg CIMZIA STARTER KIT ORENCIA CLICKJECT 5 PA 5 NDS KIT SOAJ ENBREL MINI SOCT 5 NDS ORENCIA SOLR 5 NDS ENBREL SOLN 5 NDS ORENCIA SOSY 50mg/0.4ml, 5 NDS ENBREL SOLR 5 PA,NDS 87.5mg/0.7ml, 125mg/ml ENBREL SOSY 5 NDS OTEZLA TABS 5 PA,NDS 25mg/0.5ml, 50mg/ml ENBREL SURECLICK OTEZLA TBPK 5 PA,NDS 5 NDS SOAJ OTREXUP SOAJ 4 HUMIRA PEDIATRIC RASUVO SOAJ 3 5 NDS REMICADE SOLR CROHNS START PSKT 5 HI HUMIRA PEN PNKT INTRAVENOUS 40mg/0.4ml, 5 NDS RENFLEXIS SOLR 5 NDS 40mg/0.8ml, 80mg/0.8ml RINVOQ TB24 5 NDS HUMIRA PEN- SIMPONI ARIA SOLN 5 NDS CD/UC/HS STARTER SIMPONI SOAJ 5 NDS 5 NDS PNKT 40mg/0.8ml, 50mg/0.5ml, 100mg/ml 80mg/0.8ml SIMPONI SOSY 5 NDS HUMIRA PEN- 50mg/0.5ml, 100mg/ml PEDIATRIC UC START 5 NDS XELJANZ SOLN 5 NDS PNKT XELJANZ TABS 5mg, 5 NDS HUMIRA PEN- 10mg PS/UV/ADOL HS 5 NDS XELJANZ XR TB24 5 NDS START PNKT 11mg, 22mg HUMIRA PEN- IMMUNE SUPPRESSANTS PSOR/UVEIT STARTER 5 NDS ASTAGRAF XL CP24 PNKT 4 PA,MO 0.5mg, 1mg HUMIRA PSKT ASTAGRAF XL CP24 5 PA 10mg/0.1ml, 10mg/0.2ml, azasan tabs 75mg, 5 NDS 2 PA,MO 20mg/0.2ml, 100mg 20mg/0.4ml, azathioprine sodium solr 2 40mg/0.4ml, 40mg/0.8ml azathioprine tabs 2 PA,MO INFLECTRA SOLR BENLYSTA SOAJ 5 5 HI INTRAVENOUS BENLYSTA SOLR 5 KEVZARA SOAJ BENLYSTA SOSY 5 150mg/1.14ml, 5 NDS 200mg/1.14ml You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

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Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits cyclosporine caps 25mg, PROGRAF PACK 0.2mg 4 PA 2 PA,MO 100mg PROGRAF PACK 5 PA,NDS cyclosporine modified PROGRAF SOLN 3 PA,MO caps 25mg, 50mg, 2 PA,MO SANDIMMUNE ORAL 3 PA,MO 100mg SOLN 100mg/ml cyclosporine modified 2 PA,MO SAPHNELO SOLN 5 NDS soln sirolimus soln 5 PA cyclosporine soln 2 PA,MO sirolimus tabs 0.5mg, ENVARSUS XR TB24 2 PA,MO 4 PA,MO 1mg, 2mg 0.75mg, 1mg, 4mg tacrolimus caps 0.5mg, 2 PA,MO everolimus tabs 0.25mg 2 PA,MO 1mg, 5mg everolimus tabs 0.5mg, 5 PA UPLIZNA SOLN 5 0.75mg ZORTRESS TABS 4 PA,MO GAMIFANT SOLN 0.25mg 50mg/10ml, 5 NDS ZORTRESS TABS 5 PA 100mg/20ml, 10mg/2ml 0.5mg, 0.75mg, 1mg gengraf caps 25mg, 2 PA,MO MISCELLANEOUS THERAPEUTIC AGENTS 50mg, 100mg ACETIC ACID SOLN 2 gengraf soln 2 PA,MO ACTIMMUNE SOLN 5 LUPKYNIS CAPS 5 NDS MAVENCLAD (10 TABS) AMONDYS 45 SOLN 5 NDS 5 NDS TBPK ARCALYST SOLR 5 NDS MAVENCLAD (4 TABS) ARGYLE STERILE 5 NDS 2 TBPK WATER SOLN MAVENCLAD (5 TABS) ARTICADENT DENTAL 5 NDS 2 TBPK SOCT MAVENCLAD (6 TABS) BOTOX SOLR 100unit, 5 NDS 3 PA TBPK 200unit MAVENCLAD (7 TABS) bupivacaine hcl (pf) soln 2 5 NDS TBPK bupivacaine hcl soln 2 MAVENCLAD (8 TABS) BUPIVACAINE IN 5 NDS 2 TBPK DEXTROSE SOLN MAVENCLAD (9 TABS) bupivacaine spinal soln 2 5 NDS TBPK bupivacaine-epinephrine 2 mycophenolate mofetil (pf) soln 2 PA,MO caps bupivacaine-epinephrine 2 mycophenolate mofetil soln 2 hcl solr CARNITOR SOLN 2 PA,MO mycophenolate mofetil 5 PA,MO CARNITOR TABS 2 PA,MO susr chloroprocaine hcl (pf) mycophenolate mofetil 2 2 PA,MO soln tabs CINRYZE SOLR mycophenolate sodium 5 HI 2 PA,MO INTRAVENOUS tbec 180mg, 360mg citanest plain dental soln 2 NULOJIX SOLR 5 NDS COSELA SOLR 5 NDS

You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

62 • Kaiser Permanente 2021 Comprehensive Formulary

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits CRYSVITA SOLN LUDENT CHEW 2 MO 10mg/ml, 20mg/ml, 5 NDS 0.25mg, 0.5mg, 1mg 30mg/ml mesna soln 2 CYSTADANE POWD 5 LD,NDS MESNEX TABS 5 NDS CYSTAGON CAPS 3 LD,NDS MYALEPT SOLR 5 NDS 50mg, 150mg NAFRINSE CHEW 2 MO dexrazoxane hcl solr 2 NAFRINSE DROPS DYSPORT SOLR 2 MO 4 PA SOLN 300unit, 500unit nitisinone caps 2mg, 2 NDS EASYGEL GEL 2 5mg, 10mg ELMIRON CAPS 5 NITYR TABS 2mg, 5mg, 5 NDS EMPAVELI SOLN 5 NDS 10mg ENDARI PACK 5 NDS NULIBRY SOLR 5 NDS ENSPRYNG SOSY 5 NDS ODACTRA SUBL 4 EVRYSDI SOLR 5 NDS ONPATTRO SOLN 5 NDS EXONDYS 51 SOLN ORALAIR SUBL 4 MO 5 NDS 500mg/10ml, 100mg/2ml ORFADIN CAPS 5 LD,NDS FIRDAPSE TABS 5 NDS ORFADIN SUSP 5 LD,NDS FLUORITAB CHEW ORLADEYO CAPS 2 MO 5 NDS 0.25mg, 0.5mg, 1mg 110mg, 150mg FLUORITAB SOLN 2 MO OXLUMO SOLN 5 GALAFOLD CAPS 5 NDS PALFORZIA (12 MG 5 NDS GIVLAARI SOLN 5 NDS DAILY DOSE) CSPK PALFORZIA (120 MG GRASTEK SUBL 3 MO 5 NDS HAEGARDA SOLR DAILY DOSE) CSPK 5 NDS PALFORZIA (160 MG 2000unit, 3000unit 5 NDS ISTURISA TABS 1mg, DAILY DOSE) CSPK 5 NDS PALFORZIA (20 MG 5mg, 10mg 5 NDS KESIMPTA SOAJ 5 NDS DAILY DOSE) CSPK PALFORZIA (200 MG KEVEYIS TABS 5 NDS 5 NDS KUVAN PACK 100mg, DAILY DOSE) CSPK 5 NDS PALFORZIA (240 MG 500mg 5 NDS KUVAN TABS 5 NDS DAILY DOSE) CSPK PALFORZIA (3 MG LACTATED RINGERS 5 NDS 2 DAILY DOSE) CSPK SOLN PALFORZIA (300 MG levocarnitine soln 2 PA,MO 5 NDS MAINTENANCE) PACK LEVOCARNITINE TABS 2 PA,MO PALFORZIA (300 MG 5 NDS lidocaine hcl (pf) soln 2 TITRATION) PACK lidocaine hcl soln 2 PALFORZIA (40 MG lidocaine in dextrose 5 NDS 2 DAILY DOSE) CSPK soln PALFORZIA (6 MG lidocaine-epinephrine 5 NDS 2 DAILY DOSE) CSPK soln PALFORZIA (80 MG 5 NDS DAILY DOSE) CSPK You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

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Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits PALFORZIA INITIAL THYROGEN SOLR 4 5 NDS ESCALATION CSPK tiopronin tabs 5 NDS PHYSIOLYTE SOLN 2 TIS-U-SOL SOLN 2 PHYSIOSOL 2 ULTOMIRIS SOLN 5 IRRIGATION SOLN VILTEPSO SOLN 5 NDS polocaine soln 2 VUMERITY (STARTER) 5 NDS polocaine-mpf soln 2 CPDR PROCYSBI CPDR 5 NDS VUMERITY CPDR 5 NDS 25mg, 75mg VYONDYS 53 SOLN 5 NDS PROCYSBI PACK 5 NDS WATER FOR 75mg, 300mg IRRIGATION, STERILE 2 REZUROCK TABS 5 NDS SOLN RIDAURA CAPS 5 MO XEOMIN SOLR 50unit, 4 PA RIMSO-50 SOLN 3 100unit RINGERS IRRIGATION 2 XEOMIN SOLR 5 PA,NDS SOLN XURIDEN PACK 5 NDS ropivacaine hcl soln 2 xylocaine dental soln 2 RUZURGI TABS 5 NDS ZOKINVY CAPS 50mg, 5 NDS sapropterin 75mg dihydrochloride pack 5 NDS RESPIRATORY TRACT AGENTS 100mg, 500mg ANTI-INFLAMMATORY AGENTS sapropterin 5 NDS CINQAIR SOLN 5 NDS dihydrochloride tabs SENSORCAINE SOLN 2 cromolyn sodium conc 2 MO sensorcaine-mpf soln 2 cromolyn sodium nebu 2 PA,MO sensorcaine- DUPIXENT SOPN 2 mpf/epinephrine soln 200mg/1.14ml, 5 PA,NDS 300mg/2ml sensorcaine/epinephrine 2 soln DUPIXENT SOSY 200mg/1.14ml, 5 PA,NDS SODIUM CHLORIDE 2 MO 300mg/2ml SOLN SODIUM FLUORIDE FASENRA PEN SOAJ 5 NDS CHEW 0.25mg, 0.5mg, 2 MO FASENRA SOSY 5 PA montelukast sodium 1mg 1 MO SODIUM FLUORIDE chew 4mg, 5mg 2 MO montelukast sodium SOLN 2 MO SODIUM FLUORIDE pack 4 MO TABS montelukast sodium tabs 1 MO STERILE WATER FOR NUCALA SOAJ 5 PA,NDS 2 IRRIGATION SOLN NUCALA SOLR 5 PA,NDS TAKHZYRO SOLN 5 NDS NUCALA SOSY 5 PA,NDS TEGSEDI SOSY 5 NDS zafirlukast tabs 10mg, 2 MO THIOLA EC TBEC 20mg 5 NDS 100mg, 300mg zileuton er tb12 5 NDS THIOLA TABS 5 NDS CYSTIC FIBROSIS You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

64 • Kaiser Permanente 2021 Comprehensive Formulary

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits BETHKIS NEBU 5 PA budesonide susp CAYSTON SOLR 5 LD,NDS 0.25mg/2ml, 0.5mg/2ml, 2 PA,MO KALYDECO PACK 1mg/2ml 5 PA,NDS budesonide-formoterol 25mg, 50mg, 75mg 4 KALYDECO TABS 5 PA,NDS fumarate aero DALIRESP TABS KITABIS PAK NEBU 5 PA 4 MO 250mcg, 500mcg ORKAMBI PACK 5 NDS DULERA AERO 4 MO ORKAMBI TABS 5 NDS FLOVENT DISKUS SYMDEKO TBPK 5 NDS AEPB 50mcg/blist, 4 MO TOBI PODHALER CAPS 5 100mcg/blist, tobramycin nebu 5 PA 250mcg/blist 300mg/4ml, 300mg/5ml FLOVENT HFA AERO 3 MO TRIKAFTA TBPK 5 LD,NDS 44mcg/act PULMONARY FIBROSIS FLOVENT HFA AERO 4 MO ESBRIET CAPS 5 PA,NDS 110mcg/act, 220mcg/act ESBRIET TABS 267mg, fluticasone-salmeterol 5 PA,NDS 2 MO 801mg aepb OFEV CAPS 100mg, GLASSIA SOLN 5 NDS 5 HI 150mg INTRAVENOUS PROLASTIN-C SOLN RESPIRATORY AGENTS, MISCELLANEOUS 5 HI ALVESCO AERS INTRAVENOUS 3 MO PROLASTIN-C SOLR 80mcg/act, 160mcg/act 5 HI ARALAST NP SOLR INTRAVENOUS INTRAVENOUS 500mg, 5 HI SYMBICORT AERO 3 1000mg wixela inhub aepb 2 ARNUITY ELLIPTA XOLAIR SOLR 5 PA,NDS AEPB 50mcg/act, 4 MO XOLAIR SOSY 5 PA,NDS 100mcg/act, 200mcg/act 75mg/0.5ml, 150mg/ml ASMANEX (120 ZEMAIRA SOLR 5 HI METERED DOSES) 3 MO INTRAVENOUS AEPB VASODILATING AGENTS ASMANEX (30 ADEMPAS TABS 0.5mg, 5 PA,NDS METERED DOSES) 3 MO 1mg, 1.5mg, 2mg, 2.5mg AEPB 110mcg/inh ambrisentan tabs 2 ASMANEX (30 bosentan tabs 2 METERED DOSES) 4 MO epoprostenol sodium solr 2 AEPB LETAIRIS TABS 5mg, ASMANEX (60 5 NDS METERED DOSES) 3 MO 10mg ORENITRAM TBCR AEPB 4 LD,NDS ASMANEX HFA AERO 0.125mg 3 MO 100mcg/act, 200mcg/act ORENITRAM TBCR 0.25mg, 1mg, 2.5mg, 5 LD,NDS BRONCHITOL CAPS 5 NDS 5mg

You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

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Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits TRACLEER TABS INTRAVENOUS 5gm, 5 NDS 62.5mg, 125mg 10gm GAMMAGARD SOLN TRACLEER TBSO 5 NDS 3 HI treprostinil soln INJECTION 20mg/20ml, 50mg/20ml, GAMMAKED SOLN 5 PA,LD,NDS 3 HI 100mg/20ml, INJECTION 200mg/20ml GAMMAPLEX SOLN TYVASO REFILL SOLN 4 PA,LD INTRAVENOUS 3 HI TYVASO SOLN 4 PA,LD 10gm/200ml TYVASO STARTER GAMMAPLEX SOLN 4 PA,LD INTRAVENOUS SOLN 4 HI UPTRAVI SOLR 5 NDS 10gm/100ml, 20gm/200ml, 5gm/50ml UPTRAVI TABS 200mcg, 400mcg, GAMUNEX-C SOLN 600mcg, 800mcg, 5 NDS INJECTION 1000mcg, 1200mcg, 10gm/100ml, 1gm/10ml, 3 HI 1400mcg, 1600mcg 20gm/200ml, 2.5gm/25ml, 5gm/50ml UPTRAVI TBPK 5 NDS HYPERHEP B SOLN 3 VENTAVIS SOLN 5 PA,LD,NDS 10mcg/ml, 20mcg/ml HYPERRAB S/D SOLN 3 SERUMS, TOXOIDS, AND VACCINES HYQVIA KIT 5 PA,NDS IMOGAM RABIES-HT SERUMS 3 SOLN ASCENIV SOLN 5 NDS KEDRAB SOLN 3 BIVIGAM SOLN 3 HI NABI-HB SOLN 3 10gm/100ml OCTAGAM SOLN BIVIGAM SOLN 4 HI INTRAVENOUS 5gm/50ml 3 HI 5gm/100ml, 1gm/20ml, CUTAQUIG SOLN 2gm/20ml, 25gm/500ml 1.65gm/10ml, 2gm/12ml, 5 PA,NDS PANZYGA SOLN 3.3gm/20ml, 4gm/24ml, INTRAVENOUS 8gm/48ml, 1gm/6ml 10gm/100ml, 1gm/10ml, CYTOGAM INJ 3 5 HI 20gm/200ml, FLEBOGAMMA DIF 2.5gm/25ml, SOLN INTRAVENOUS 30gm/300ml, 5gm/50ml 5gm/100ml, PRIVIGEN SOLN 3 HI 10gm/100ml, INTRAVENOUS 0.5gm/10ml, 3 HI VARIZIG SOLN 6 10gm/200ml, 20gm/200ml, XEMBIFY SOLN SUBCUTANEOUS 20gm/400ml, 5 HI 2.5gm/50ml, 5gm/50ml 2gm/10ml, 4gm/20ml, 10gm/50ml, 1gm/5ml GAMASTAN INJ 3 PA GAMMAGARD S/D TOXOIDS 3 HI DIPHTHERIA-TETANUS LESS IGA SOLR 6 TOXOIDS DT SUSP

You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

66 • Kaiser Permanente 2021 Comprehensive Formulary

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits KINRIX SUSP 6 ZOSTAVAX SUSR 6 QUADRACEL SUSP 6 SKIN AND MUCOUS MEMBRANE AGENTS TDVAX SUSP 6 ANTI-INFECTIVES (SKIN AND MUCOUS TENIVAC INJ 6 MEMBRANE) VACCINES acyclovir oint 2 ACTHIB SOLR 6 AKTIPAK PACK 4 MO ADACEL SUSP 6 AVC VAGINAL CREA 3 BACTROBAN NASAL BEXSERO SUSY 6 4 BOOSTRIX SUSP 6 OINT BENZEPRO CREAMY DAPTACEL SUSP 6 2 WASH LIQD ENGERIX-B SUSP 6 PA BENZEPRO FOAMING 10mcg/0.5ml, 20mcg/ml 2 CLOTHS MISC GARDASIL 9 SUSP 6 BENZOYL PEROXIDE 5 NDS GARDASIL 9 SUSY 6 GEL HAVRIX SUSP 6 benzoyl peroxide- 2 MO HEPLISAV-B SOLN 6 PA erythromycin gel HIBERIX SOLR 6 ciclopirox gel 2 IMOVAX RABIES INJ 6 ciclopirox olamine crea 2 INFANRIX SUSP 6 ciclopirox olamine susp 2 IPOL INJ 6 ciclopirox sham 2 IXIARO SUSP 6 ciclopirox soln 2 M-M-R II SOLR 6 CLEOCIN SUPP 4 MENACTRA INJ 6 clindacin-p swab 2 MO MENQUADFI INJ 6 clindamycin phos- 2 MO MENVEO SOLR 6 benzoyl perox gel clindamycin phosphate PEDIARIX SUSP 6 2 PEDVAX HIB SUSP 6 crea clindamycin phosphate PROQUAD SUSR 6 2 MO RABAVERT SUSR 6 foam clindamycin phosphate RECOMBIVAX HB 2 MO SUSP 5mcg/0.5ml, 6 PA gel clindamycin phosphate 10mcg/ml, 40mcg/ml 2 MO lotn ROTARIX SUSR 4 clindamycin phosphate ROTATEQ SOLN 4 2 MO soln SHINGRIX SUSR 6 clindamycin phosphate 2 MO TRUMENBA SUSY 6 swab TWINRIX SUSY 6 CLINDESSE CREA 4 TYPHIM VI SOLN 6 clotrimazole crea 2 VAQTA SUSP 6 clotrimazole soln 2 VARIVAX INJ 6 clotrimazole troc 2 VAXCHORA SUSR 3 clotrimazole- 2 YF-VAX INJ 6 betamethasone crea

You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

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Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits clotrimazole- nyamyc powd 2 2 betamethasone lotn nystatin crea 2 crotan lotn 2 nystatin oint 2 DENAVIR CREA 5 nystatin powd 2 econazole nitrate crea 2 nystop powd 2 ERTACZO CREA 4 ORAVIG TABS 4 ery pads 2 MO ovide lotn 2 erythromycin gel 2 MO oxiconazole nitrate crea 2 erythromycin pads 2 MO OXISTAT LOTN 4 erythromycin soln 2 MO permethrin crea 2 EURAX CREA 4 PR BENZOYL 2 EXELDERM CREA 4 PEROXIDE WASH LIQD EXELDERM SOLN 4 selenium sulfide lotn 2 gentamicin sulfate crea 2 SELENIUM SULFIDE 2 gentamicin sulfate oint 2 SHAM SILVER SULFADIAZINE gynazole-1 crea 2 2 ivermectin crea 2 CREA ivermectin lotn 2 SKLICE LOTN 4 ketoconazole crea 2 SODIUM SULFACETAMIDE 2 ketoconazole foam 2 SHAM ketoconazole sham 2 SODIUM ketodan foam 2 SULFACETAMIDE 2 lindane sham 2 WASH LIQD LULICONAZOLE CREA 4 SPINOSAD SUSP 4 LUZU CREA 4 SSD CREA 2 mafenide acetate pack 2 sulfacetamide sodium 2 MO malathion lotn 2 (acne) lotn SULFACETAMIDE MENTAX CREA 4 2 metronidazole crea 2 SODIUM GEL SULFACETAMIDE metronidazole gel 2 2 metronidazole lotn 2 SODIUM LIQD SULFAMYLON CREA 3 miconazole 3 supp 2 miconazole-zinc oxide- tavaborole soln 2 2 petrolat oint terconazole crea 2 mupirocin calcium crea 2 terconazole supp 2 mupirocin oint 2 VANDAZOLE GEL 2 naftifine hcl crea 2 XEPI CREA 4 MO naftifine hcl gel 2 XERESE CREA 4 NAFTIN GEL 4 ANTI-INFLAMMATORY AGENTS (SKIN AND NATROBA SUSP 4 MUCOUS MEMBRANE) neomycin-polymyxin b ala scalp lotn 2 MO 2 gu soln ala-cort crea 1%, 2.5% 2 MO

You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

68 • Kaiser Permanente 2021 Comprehensive Formulary

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits alclometasone clobetasol propionate e 2 MO 2 MO dipropionate crea crea alclometasone clobetasol propionate 2 MO 2 dipropionate oint emulsion foam amcinonide crea 2 MO clobetasol propionate 2 MO amcinonide lotn 2 MO foam amcinonide oint 2 MO clobetasol propionate gel 2 MO clobetasol propionate anusol-hc crea 2 MO 2 MO apexicon e crea 2 MO liqd benzoyl perox- clobetasol propionate 2 2 MO hydrocortisone lotn lotn BENZOYL PEROXIDE clobetasol propionate 5 NDS 2 MO FORTE- HC LOTN oint clobetasol propionate beser lotn 2 MO 2 MO sham betamethasone 2 MO clobetasol propionate dipropionate aug crea 2 MO soln betamethasone 2 MO dipropionate aug gel CLOBEX SHAM 2 MO betamethasone CLOBEX SPRAY LIQD 2 MO 2 MO clocortolone pivalate dipropionate aug lotn 2 MO betamethasone crea 2 MO clocortolone pivalate dipropionate aug oint 2 MO betamethasone pump crea 2 MO dipropionate crea clodan sham 2 MO betamethasone colocort enem 2 MO 2 MO dipropionate lotn CORDRAN TAPE 3 MO BETAMETHASONE CORTISPORIN CREA 3 MO 2 MO DIPROPIONATE OINT CORTISPORIN OINT 3 MO betamethasone valerate 2 MO DESONATE GEL 4 MO crea desonide crea 2 MO betamethasone valerate 2 MO desonide gel 2 MO foam desonide lotn 2 MO BETAMETHASONE 2 MO VALERATE LOTN desonide oint 2 MO BETAMETHASONE desowen lotn 2 MO 2 MO desoximetasone crea VALERATE OINT 2 MO BRYHALI LOTN 4 MO 0.05%, 0.25% calcipotriene-betameth desoximetasone gel 2 MO 2 MO,NDS diprop oint desoximetasone liqd 2 MO calcipotriene-betameth desoximetasone oint 5 NDS 2 MO diprop susp 0.05%, 0.25% CAPEX SHAM 3 MO desrx gel 2 MO clobetasol propionate diclofenac sodium gel 2 2 MO crea 1%, 3%

You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

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Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits diflorasone diacetate hydrocortisone butyrate 2 MO 2 MO crea crea diflorasone diacetate oint 2 MO hydrocortisone butyrate 2 MO DUOBRII LOTN 4 MO lotn HYDROCORTISONE ENSTILAR FOAM 5 NDS 2 MO epifoam foam 2 BUTYRATE OINT fluocinolone acetonide hydrocortisone butyrate 2 2 MO body oil soln fluocinolone acetonide hydrocortisone crea 1%, 2 MO 2 MO crea 0.01%, 0.025% 2.5% fluocinolone acetonide hydrocortisone enem 2 MO 2 MO oint hydrocortisone lotn 2 MO fluocinolone acetonide hydrocortisone oint 1%, 2 MO 2 MO scalp oil 2.5% fluocinolone acetonide hydrocortisone valerate 2 MO 2 MO soln crea hydrocortisone valerate fluocinonide crea 2 MO 2 MO fluocinonide emulsified oint 2 MO base crea LEXETTE FOAM 5 NDS FLUOCINONIDE GEL 2 MO micort-hc crea 2 MO mometasone furoate fluocinonide oint 2 MO 2 MO fluocinonide soln 2 MO crea flurandrenolide crea 2 MO mometasone furoate oint 2 MO mometasone furoate flurandrenolide lotn 2 MO 2 MO soln flurandrenolide oint 2 MO neo-synalar crea 2 MO fluticasone propionate 2 MO crea nolix crea 2 fluticasone propionate nolix lotn 2 MO 2 MO nystatin-triamcinolone lotn 2 MO fluticasone propionate crea 2 MO nystatin-triamcinolone oint 2 MO halcinonide crea 2 MO oint halobetasol propionate oralone pste 2 MO 2 MO crea PANDEL CREA 4 MO HALOBETASOL prednicarbate crea 2 MO 5 NDS PROPIONATE FOAM prednicarbate oint 2 MO halobetasol propionate procto-med hc crea 2 MO 2 MO oint procto-pak crea 2 MO HALOG CREA 4 MO proctosol hc crea 2 MO HALOG OINT 4 MO proctozone-hc crea 2 MO hydrocortisone (perianal) 2 MO psorcon crea 2 MO crea 1%, 2.5% TACLONEX SUSP 5 NDS hydrocortisone butyr lipo topicort crea 0.05%, 2 2 MO base crea 0.25%

You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

70 • Kaiser Permanente 2021 Comprehensive Formulary

Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits topicort gel 2 MO lidocaine-tetracaine crea 2 PA topicort oint 2 MO LIDOCORT CREA 2 tovet foam 2 MO lidopin crea 2 triamcinolone acetonide LIDOZION LOTN 2 2 MO aers phenazo tabs 2 triamcinolone acetonide PHENAZOPYRIDINE 2 crea 0.025%, 0.1%, 2 MO HCL TABS 0.5% PRAMOX GEL 2 triamcinolone acetonide 2 MO proctofoam hc foam 2 lotn 0.025%, 0.1% texacort soln 2 MO triamcinolone acetonide TOPEX TOPICAL oint 0.025%, 0.05%, 2 MO 2 ANESTHETIC AERO 0.1%, 0.5% ZERUVIA PTCH 2 triamcinolone acetonide 2 MO pste ZIONODIL 100 LOTN 2 trianex oint 2 MO ZIONODIL LOTN 2 triderm crea 0.1%, 0.5% 2 MO CELL STIMULANTS AND PROLIFERANTS tritocin oint 2 MO ALTRENO LOTN 4 PA,MO UCERIS FOAM 4 MO AVITA CREA 2 PA,MO ULTRAVATE LOTN 5 NDS AVITA GEL 2 PA,MO VANOXIDE-HC LOTN 2 KEPIVANCE SOLR 5 NDS ANTIPRURITICS AND LOCAL ANESTHETICS PANRETIN GEL 5 NDS RETIN-A CREA 0.025%, ANA-LEX KIT 2 2 PA,MO 0.05%, 0.1% doxepin hcl crea 2 MO RETIN-A GEL 0.01%, glydo prsy 2 MO 2 PA,MO 0.025% hydrocortisone ace- RETIN-A MICRO GEL 2 MO 2 PA,MO pramoxine crea 0.04%, 0.1% LIDO-SORB LOTN 2 RETIN-A MICRO PUMP 2 PA,MO LIDOCAINE HCL CREA 2 GEL 0.04%, 0.1% lidocaine hcl lotn 2 RETIN-A MICRO PUMP 4 PA,MO lidocaine hcl soln 2 PA GEL 0.08% lidocaine hcl RETIN-A MICRO PUMP 2 MO 5 PA,NDS urethral/mucosal gel GEL lidocaine hcl 2 MO TARGRETIN GEL 5 PA,NDS urethral/mucosal prsy tretinoin crea 0.025%, 2 PA,MO lidocaine oint 2 PA,MO 0.05%, 0.1% lidocaine ptch 2 PA,MO tretinoin gel 0.01%, 2 PA,MO LIDOCAINE- 0.025%, 0.05% HYDROCORT 2 tretinoin microsphere gel 2 PA,MO (PERIANAL) CREA 0.04%, 0.1% LIDOCAINE- tretinoin microsphere 2 PA,MO HYDROCORTISONE 2 pump gel 0.04%, 0.1% ACE KIT SKIN AND MUCOUS MEMBRANE AGENTS, lidocaine-prilocaine crea 2 PA,MO MISCELLANEOUS You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

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Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits ABSORICA CAPS COSENTYX 4 NDS 25mg, 35mg SENSOREADY PEN 5 NDS ABSORICA LD CAPS SOAJ 5 NDS 8mg, 16mg, 24mg, 32mg COSENTYX SOSY 5 NDS accutane caps 10mg, 75mg/0.5ml, 150mg/ml 2 NDS 20mg, 30mg, 40mg DAPSONE GEL 7.5%, 2 MO acitretin caps 10mg, 5% 2 NDS 17.5mg, 25mg DIFFERIN CREA 2 MO ADAPALENE CREA 2 MO DIFFERIN LOTN 4 MO adapalene gel 0.1%, 2 MO EPIDUO FORTE GEL 4 MO 0.3% FABIOR FOAM 4 PA,MO adapalene pads 2 MO FINACEA FOAM 4 MO adapalene soln 5 NDS fluorouracil crea 5% 2 MO adapalene-benzoyl 2 MO fluorouracil crea .5% 5 peroxide gel fluorouracil soln 2%, 5% 2 MO ADAPALENE-BENZOYL 5 NDS ILUMYA SOSY 5 PA PEROXIDE PADS imiquimod crea 3.75%, ammonium lactate crea 2 MO 2 MO 5% ammonium lactate lotn 2 MO IMIQUIMOD PUMP amnesteem caps 10mg, 2 MO 2 NDS CREA 20mg, 40mg isotretinoin caps 10mg, AVAR CLEANSER 2 NDS 2 20mg, 30mg, 40mg EMUL keralyt sham 2 AVAR-E EMOLLIENT 2 KLISYRI OINT 5 NDS CREA LACTIC ACID LOTN 2 AVAR-E GREEN CREA 2 methoxsalen rapid caps 5 MO azelaic acid gel 2 MO myorisan caps 10mg, AZELEX CREA 3 MO 2 NDS 20mg, 30mg, 40mg BP 10-1 EMUL 2 ORACEA CPDR 2 calcipotriene crea 2 MO pimecrolimus crea 2 MO calcipotriene oint 2 MO podofilox soln 2 MO calcipotriene soln 2 MO RECTIV OINT 4 MO calcitrene oint 2 MO REGRANEX GEL 5 NDS CALCITRIOL OINT 4 MO RYNODERM CREA 5 NDS CARAC CREA 5 SALEX SHAM 2 CEROVEL LOTN 2 SALICYLIC ACID CREA 2 claravis caps 10mg, 2 NDS SALICYLIC ACID ER 20mg, 30mg, 40mg 2 SOLN CONDYLOX GEL 4 MO SALICYLIC ACID FOAM 2 COSENTYX (300 MG 5 NDS SALICYLIC ACID GEL 2 DOSE) SOSY COSENTYX SALICYLIC ACID LIQD 2 SENSOREADY (300 5 NDS SALICYLIC ACID SHAM 2 SALICYLIC ACID WART MG) SOAJ 2 REMOVER LIQD You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

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Drug Requirements/ Drug Requirements/ Drug Name Drug Name Tier Limits Tier Limits SALICYLIC ACID- TOLAK CREA 4 2 CLEANSER KIT TREMFYA SOPN 5 SALIMEZ CREA 2 TREMFYA SOSY 5 SANTYL OINT 3 MO UMECTA MOUSSE 2 SILIQ SOSY 5 NDS FOAM SKYRIZI (150 MG UREA CREA 39% 2 5 DOSE) PSKT UREA LOTN 40% 2 SKYRIZI PEN SOAJ 5 UREA-C40 LOTN 2 SKYRIZI SOSY 5 uredeb crea 2 SORILUX FOAM 4 MO VALCHLOR GEL 5 NDS SSS 10-5 CREA 2 VECTICAL OINT 2 MO STELARA SOLN VEREGEN OINT 4 MO 45mg/0.5ml, 5 PA WYNZORA CREA 5 NDS 130mg/26ml XUREA CREA 2 STELARA SOSY 5 PA zenatane caps 10mg, 45mg/0.5ml, 90mg/ml 2 NDS 20mg, 30mg, 40mg SULFACETAMIDE ZYCLARA PUMP CREA 4 MO SODIUM-SULFUR 2 CREA SMOOTH MUSCLE RELAXANTS SULFACETAMIDE SMOOTH MUSCLE RELAXANTS SODIUM-SULFUR 2 aminophylline soln 2 EMUL darifenacin SULFACETAMIDE hydrobromide er tb24 2 MO 2 SODIUM-SULFUR LIQD 7.5mg, 15mg SULFACETAMIDE elixophyllin elix 2 SODIUM-SULFUR 2 flavoxate hcl tabs 2 MO LOTN MYRBETRIQ TB24 4 MO SULFACETAMIDE 25mg, 50mg SODIUM-SULFUR 2 oxybutynin chloride er 2 MO PADS tb24 5mg, 10mg, 15mg SULFACETAMIDE oxybutynin chloride syrp 2 MO SODIUM-SULFUR 2 oxybutynin chloride tabs 2 MO SUSP solifenacin succinate SULFACLEANSE 8/4 2 MO 2 tabs 5mg, 10mg SUSP theo-24 cp24 100mg, 2 MO sulfamez wash emul 2 200mg, 300mg, 400mg TACROLIMUS OINT 2 MO theophylline er tb12 0.1%, 0.03% 100mg, 200mg, 300mg, 2 MO TALTZ SOAJ 5 NDS 450mg TALTZ SOSY 5 NDS theophylline er tb24 2 MO tazarotene crea 2 PA,MO 400mg, 600mg tazarotene foam 4 PA,MO theophylline soln 2 MO TAZORAC CREA 4 PA,MO tolterodine tartrate er 2 MO TAZORAC GEL 0.05%, cp24 2mg, 4mg 4 PA,MO 0.1% tolterodine tartrate tabs 2 MO You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

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Drug Requirements/ Drug Name Tier Limits trospium chloride er 2 MO cp24 trospium chloride tabs 2 MO VITAMINS VITAMINS ADC/F (0.5MG/ML) 2 MO SOLN calcitriol caps 0.25mcg, 2 PA,MO 0.5mcg calcitriol soln 2 PA,MO doxercalciferol caps 2 PA,MO 0.5mcg, 1mcg, 2.5mcg DOXERCALCIFEROL 2 SOLN MULTI- VITAMIN/FLUORIDE/IR 2 MO ON SOLN MULTI- VITAMIN/FLUORIDE 2 MO SOLN MULTIVITAMIN/FLUORI 2 MO DE CHEW MVC-FLUORIDE CHEW 2 MO paricalcitol caps 1mcg, 2 PA,MO 2mcg, 4mcg PARICALCITOL SOLN 2 PRENATAL TABS 4 MO RAYALDEE CPCR 5 NDS TRI- VITAMIN/FLUORIDE 2 MO SOLN TRI-VITE/FLUORIDE 2 MO SOLN VITAMINS ACD- 2 MO FLUORIDE SOLN VP-PNV-DHA CAPS 4 MO

You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.

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The information in the Requirements/Limits column you need an urgent refill, please contact the mail- tells you if our plan has any special requirements order phone number for your Kaiser Permanente for coverage of your drug. Certain strengths or Region in the chart on page 7 or the phone number forms of the drug may be subject to the utilization on the prescription label for assistance. Not all management codes listed below. drugs can be mailed; restrictions and limitations apply. For more information, please visit HI = Home infusion drugs may be covered under kp.org/seniorrx or call the appropriate regional our medical benefit and obtained at home infusion phone number on page 7. pharmacies. For more information, please consult your pharmacy directory or call our plan at the NDS = Non-extended Day Supply drugs that are number listed on the front and back cover pages for dispensed up to a 30-day supply to monitor for your Kaiser Permanente Region. possible adverse effects and to avoid medication waste. LD = Limited-distribution drugs can only be PA = Prior authorization medications may be obtained at certain specialty pharmacies. For more covered under Medicare Part D or Medicare Part B information, consult your pharmacy directory or call depending on how they are administered (e.g., via our plan at the number listed on the front and back infusion pump, nebulizer, or other Durable Medical cover pages for your Kaiser Permanente Region. Equipment device), where they are administered

(at home or in a long-term care facility), and what MO = Mail-order drugs. You may order prescription medical condition they are administered for. Prior refills of certain medications through our mail-order authorization may also apply to drugs for which service online at kp.org/refill or by phone or treatment for the medical condition will determine if mobile app, which may lower your costs for a the drug is non-Part D (excluded) or covered. three-month supply. Please contact us at least 5 days before your refills run out. Generally, you should receive them within 3 to 5 days. If not and

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Index of Drugs

A acyclovir caps ...... 12 acyclovir oint ...... 67 abacavir sulfate soln ...... 12 acyclovir sodium soln intravenous ...... 12 abacavir sulfate tabs ...... 12 acyclovir susp ...... 12 abacavir sulfate-lamivudine tabs ...... 12 acyclovir tabs 400mg, 800mg ...... 12 abacavir-lamivudine-zidovudine tabs ...... 12 ADACEL SUSP ...... 67 ABELCET SUSP INTRAVENOUS ...... 11 ADAGEN SOLN ...... 46 ABILIFY MAINTENA PRSY 300mg, 400mg ADAKVEO SOLN ...... 23 ...... 40 ADAPALENE CREA ...... 72 ABILIFY MAINTENA SRER 300mg, 400mg adapalene gel 0.1%, 0.3% ...... 72 ...... 40 adapalene pads ...... 72 ABILIFY MYCITE MAINTENANCE KIT adapalene soln ...... 72 TABS 2mg, 5mg, 10mg, 15mg, 20mg, adapalene-benzoyl peroxide gel ...... 72 30mg ...... 40 ADAPALENE-BENZOYL PEROXIDE PADS ABILIFY MYCITE STARTER KIT TABS ...... 72 2mg, 5mg, 10mg, 15mg, 20mg, 30mg .. 40 ADC/F (0.5MG/ML) SOLN ...... 74 ABILIFY MYCITE TABS 2mg, 5mg, 10mg, adderall tabs ...... 34 15mg, 20mg, 30mg ...... 40 ADDERALL XR CP24 ...... 34 abiraterone acetate tabs 250mg, 500mg .. 15 adefovir dipivoxil tabs ...... 12 ABRAXANE SUSR ...... 15 ADEMPAS TABS 0.5mg, 1mg, 1.5mg, 2mg, ABSORICA CAPS 25mg, 35mg ...... 72 2.5mg ...... 65 ABSORICA LD CAPS 8mg, 16mg, 24mg, adenosine soln ...... 28 32mg ...... 72 ADMELOG SOLN ...... 55 ABSTRAL SUBL 100mcg, 200mcg, ADMELOG SOLOSTAR SOPN ...... 55 300mcg, 400mcg, 600mcg, 800mcg ..... 30 adriamycin soln ...... 15 acamprosate calcium tbec ...... 30 adriamycin solr ...... 15 acarbose tabs 25mg, 50mg, 100mg ...... 55 adrucil soln...... 15 accutane caps 10mg, 20mg, 30mg, 40mg 72 ADVAIR HFA AERO ...... 22 acebutolol hcl caps 200mg, 400mg ...... 26 ADZENYS ER SUER ...... 34 acetaminophen-codeine #3 tabs ...... 30 ADZENYS XR-ODT TBED 3.1mg, 6.3mg, acetaminophen-codeine soln ...... 30 9.4mg, 12.5mg, 15.7mg, 18.8mg ...... 34 acetaminophen-codeine tabs ...... 30 AFINITOR DISPERZ TBSO 2mg, 3mg, 5mg acetazolamide er cp12 ...... 48 ...... 15 acetazolamide sodium solr ...... 48 AFINITOR TABS 2.5mg, 5mg, 7.5mg, 10mg acetazolamide tabs 125mg, 250mg ...... 48 ...... 15 ACETIC ACID SOLN ...... 49, 62 AFREZZA POWD ...... 55 acetylcysteine soln 10%, 20% ...... 60 AFREZZA POWD 8 (90) & 12 (90) UNIT . 55 acitretin caps 10mg, 17.5mg, 25mg ...... 72 AJOVY SOAJ ...... 37 ACTEMRA ACTPEN SOAJ ...... 61 AJOVY SOSY ...... 37 ACTEMRA SOSY ...... 61 AKTIPAK PACK ...... 67 ACTHAR GEL ...... 58 AKYNZEO CAPS ...... 50 ACTHIB SOLR ...... 67 ala scalp lotn ...... 68 ACTIMMUNE SOLN ...... 62 ala-cort crea 1%, 2.5% ...... 68 ACUVAIL SOLN ...... 47

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albendazole ...... 118 ALTOPREV TB24 20mg, 40mg, 60mg ..... 25 albendazole tabs ...... 8 ALTRENO LOTN ...... 71 albuterol sulfate er tb12 4mg, 8mg ...... 22 ALUNBRIG TABS 30mg, 90mg, 180mg ... 15 albuterol sulfate hfa aers ...... 22 ALUNBRIG TBPK ...... 15 albuterol sulfate nebu 0.083%, 2.5mg/0.5ml ALVESCO AERS 80mcg/act, 160mcg/act 65 ...... 22 alyacen 1/35 tabs ...... 53 albuterol sulfate nebu 0.63mg/3ml, alyq tabs ...... 30 1.25mg/3ml ...... 22 amabelz tabs ...... 57 albuterol sulfate syrp ...... 22 amantadine hcl caps ...... 37 albuterol sulfate tabs 2mg, 4mg ...... 22 amantadine hcl syrp ...... 37 alclometasone dipropionate crea ...... 69 amantadine hcl tabs ...... 37 alclometasone dipropionate oint ...... 69 AMBISOME SUSR INTRAVENOUS ...... 11 ALCOHOL PREP PADS ...... 43 ambrisentan tabs ...... 65 ALDACTAZIDE TABS...... 29 amcinonide crea ...... 69 ALDURAZYME SOLN ...... 46 amcinonide lotn ...... 69 ALECENSA CAPS ...... 15 amcinonide oint ...... 69 alendronate sodium soln ...... 60 amethia lo tabs ...... 53 alendronate sodium tabs 40mg ...... 60 amethia tabs ...... 53 alendronate sodium tabs 5mg, 10mg, amikacin sulfate soln ...... 8 35mg, 70mg ...... 60 amikacin sulfate soln injection ...... 8 alfuzosin hcl er tb24 ...... 22 AMILORIDE HCL TABS ...... 44 ALIMTA SOLR ...... 15 amiloride-hydrochlorothiazide tabs ...... 44 ALIQOPA SOLR ...... 15 aminocaproic acid soln ...... 23 aliskiren fumarate tabs 150mg, 300mg .... 29 aminocaproic acid tabs 500mg, 1000mg .. 23 ALKINDI SPRINKLE CPSP 0.5mg, 1mg, aminophylline soln ...... 73 2mg, 5mg ...... 52 AMINOSYN-PF SOLN INTRAVENOUS ... 43 allopurinol sodium solr ...... 60 amiodarone hcl soln ...... 28 allopurinol tabs 100mg, 300mg ...... 60 amiodarone hcl tabs 100mg, 200mg, allzital tabs ...... 30 400mg ...... 28 almotriptan malate tabs ...... 37 AMITIZA CAPS 8mcg, 24mcg ...... 51 ALOCRIL SOLN ...... 48 amitriptyline hcl tabs 10mg, 25mg, 50mg, alogliptin benzoate tabs 6.25mg, 12.5mg, 75mg, 100mg, 150mg ...... 40 25mg ...... 55 amlodipine besy-benazepril hcl caps ...... 27 ALOGLIPTIN-METFORMIN HCL TABS ... 55 amlodipine besylate tabs 2.5mg, 5mg, alogliptin-pioglitazone tabs ...... 55 10mg ...... 27 ALOMIDE SOLN ...... 48 amlodipine besylate-valsartan tabs ...... 27 ALOSETRON HCL TABS 0.5mg, 1mg ..... 49 amlodipine-atorvastatin tabs ...... 27 ALPHAGAN P SOLN ...... 48 amlodipine-olmesartan tabs ...... 27 alprazolam er tb24 0.5mg, 1mg, 2mg, 3mg amlodipine-valsartan-hctz tabs ...... 27 ...... 38 ammonium lactate crea ...... 72 alprazolam intensol conc ...... 38 ammonium lactate lotn ...... 72 alprazolam tabs 0.25mg, 0.5mg, 1mg, 2mg amnesteem caps 10mg, 20mg, 40mg ...... 72 ...... 38 AMONDYS 45 SOLN ...... 62 alprazolam tbdp 0.25mg, 0.5mg, 1mg, 2mg amoxapine tabs 25mg, 50mg, 100mg, ...... 38 150mg ...... 40 ALREX SUSP ...... 47 amoxicill-clarithro-lansopraz misc ...... 50 ALTACAINE SOLN ...... 49 amoxicillin caps ...... 8 ALTAFRIN SOLN ...... 49 amoxicillin chew ...... 8 altavera tabs ...... 53 amoxicillin susr ...... 8

Kaiser Permanente 2021 Comprehensive Formulary • 77 amoxicillin tabs ...... 8 ARANESP (ALBUMIN FREE) SOLN amoxicillin-pot clavulanate chew ...... 8 25mcg/ml, 40mcg/ml ...... 24 amoxicillin-pot clavulanate er tb12 ...... 8 ARANESP (ALBUMIN FREE) SOLN amoxicillin-pot clavulanate susr ...... 8 60mcg/ml, 100mcg/ml, 200mcg/ml, amoxicillin-pot clavulanate tabs ...... 8 300mcg/ml ...... 24 amphetamine er suer ...... 34 ARANESP (ALBUMIN FREE) SOSY amphetamine sulfate tabs 5mg, 10mg ..... 34 25mcg/0.42ml, 10mcg/0.4ml, amphetamine-dextroamphet er cp24 ...... 34 40mcg/0.4ml ...... 24 amphetamine-dextroamphetamine tabs ... 34 ARANESP (ALBUMIN FREE) SOSY amphotericin b solr intravenous ...... 11 60mcg/0.3ml, 150mcg/0.3ml, ampicillin caps ...... 8 200mcg/0.4ml, 100mcg/0.5ml, ampicillin sodium solr...... 8 300mcg/0.6ml, 500mcg/ml ...... 24 ampicillin sodium solr injection 1gm, 125mg ARCALYST SOLR ...... 62 ...... 8 ARCAPTA NEOHALER CAPS ...... 23 ampicillin sodium solr intravenous ...... 8 arformoterol tartrate nebu ...... 23 ampicillin-sulbactam sodium solr ...... 8 argatroban soln ...... 23 ampicillin-sulbactam sodium solr injection .. 8 ARGYLE STERILE WATER SOLN ...... 62 ampicillin-sulbactam sodium solr ARIKAYCE SUSP ...... 8 intravenous ...... 8 aripiprazole soln ...... 40 ANADROL-50 TABS ...... 53 aripiprazole tabs 2mg, 5mg, 10mg, 15mg, anagrelide hcl caps 0.5mg, 1mg ...... 23 20mg, 30mg ...... 40 ANA-LEX KIT ...... 71 aripiprazole tbdp 10mg, 15mg ...... 40 anastrozole tabs ...... 15 ARISTADA INITIO PRSY ...... 40 ANDRODERM PT24 2mg/24hr, 4mg/24hr ARISTADA PRSY 441mg/1.6ml, ...... 53 662mg/2.4ml, 882mg/3.2ml, ANGELIQ TABS ...... 57 1064mg/3.9ml ...... 40 ANORO ELLIPTA AEPB ...... 21 armodafinil tabs 50mg, 150mg, 200mg, antabuse tabs 250mg, 500mg ...... 30 250mg ...... 34 ANTARA CAPS 30mg, 90mg ...... 25 ARNUITY ELLIPTA AEPB 50mcg/act, anusol-hc crea ...... 69 100mcg/act, 200mcg/act ...... 65 ANZEMET TABS 50mg, 100mg ...... 50 ARRANON SOLN ...... 15 apap-caff-dihydrocodeine tabs ...... 30 ARTESUNATE SOLR ...... 12 apexicon e crea ...... 69 ARTICADENT DENTAL SOCT ...... 62 APIDRA SOLN ...... 55 ARYMO ER TBEA ...... 30 APIDRA SOLOSTAR SOPN ...... 55 ARZERRA CONC 1000mg/50ml, APLENZIN TB24 174mg, 348mg, 522mg 40 100mg/5ml ...... 15 APOKYN SOCT ...... 37 ASCENIV SOLN ...... 66 apraclonidine hcl soln ...... 49 ascomp-codeine caps ...... 30 aprepitant caps ...... 50 asenapine maleate subl 2.5mg, 5mg, 10mg apri tabs ...... 53 ...... 40 APRISO CP24 ...... 49 ashlyna tabs ...... 53 APTIOM TABS 200mg, 400mg, 600mg, ASMANEX (120 METERED DOSES) AEPB 800mg ...... 35 ...... 65 APTIVUS CAPS ...... 12 ASMANEX (30 METERED DOSES) AEPB APTIVUS SOLN ...... 12 ...... 65 ARALAST NP SOLR INTRAVENOUS ASMANEX (30 METERED DOSES) AEPB 500mg, 1000mg ...... 65 110mcg/inh ...... 65 aranelle tabs ...... 53 ASMANEX (60 METERED DOSES) AEPB ...... 65

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ASMANEX HFA AERO 100mcg/act, azelastine-fluticasone susp ...... 48 200mcg/act ...... 65 AZELEX CREA ...... 72 ASPARLAS SOLN ...... 15 AZITHROMYCIN PACK ...... 8 aspirin-dipyridamole er cp12 ...... 23 azithromycin solr intravenous ...... 8 ASTAGRAF XL CP24 ...... 61 azithromycin susr 100mg/5ml, 200mg/5ml . 8 ASTAGRAF XL CP24 0.5mg, 1mg ...... 61 azithromycin tabs 250mg, 500mg, 600mg . 8 atazanavir sulfate caps 150mg, 200mg, aztreonam solr injection ...... 8 300mg ...... 12 atenolol tabs 25mg, 50mg, 100mg ...... 26 B atenolol-chlorthalidone tabs ...... 26 bacitracin oint ...... 47 atomoxetine hcl caps 10mg, 18mg, 25mg, bacitracin solr ...... 8 40mg, 60mg, 80mg, 100mg ...... 39 bacitracin-polymyxin b oint ...... 47 atorvastatin calcium tabs 10mg, 20mg, bacitra-neomycin-polymyxin-hc oint ...... 47 40mg, 80mg ...... 25 baclofen soln ...... 22 atovaquone susp ...... 12 baclofen tabs 5mg, 10mg, 20mg ...... 22 atovaquone-proguanil hcl tabs ...... 12 BACTROBAN NASAL OINT ...... 67 ATROPINE SULFATE SOLN ...... 21, 49 BAFIERTAM CPDR ...... 39 ATROPINE SULFATE SOSY ...... 21 balsalazide disodium caps ...... 49 ATROVENT HFA AERS ...... 21 BALVERSA TABS 3mg, 4mg, 5mg ...... 16 AUBAGIO TABS 7mg, 14mg ...... 39 balziva tabs ...... 53 aubra eq tabs ...... 53 BANZEL SUSP ...... 35 AUGMENTIN SUSR ...... 8 BANZEL TABS 200mg, 400mg ...... 35 AURYXIA TABS ...... 45 BAQSIMI ONE PACK POWD ...... 55 AUSTEDO TABS 6mg, 9mg, 12mg ...... 39 BAQSIMI TWO PACK POWD ...... 55 AVANDIA TABS 2mg, 4mg ...... 55 BARACLUDE SOLN ...... 12 AVAR CLEANSER EMUL ...... 72 BAVENCIO SOLN ...... 16 AVAR-E EMOLLIENT CREA ...... 72 BAXDELA SOLR INTRAVENOUS ...... 8 AVAR-E GREEN CREA ...... 72 BAXDELA TABS ...... 8 AVASTIN SOLN ...... 15 BCG VACCINE INJ ...... 16 AVC VAGINAL CREA ...... 67 BD INSULIN SYR ULTRAFINE II MISC ... 43 AVEED SOLN ...... 53 BD INSULIN SYRINGE MISC ...... 43 aviane tabs ...... 53 BD INSULIN SYRINGE U/F MISC ...... 43 AVITA CREA ...... 71 BD PEN NEEDLE ORIGINAL U/F MISC .. 43 AVITA GEL ...... 71 BELBUCA FILM 75mcg, 150mcg, 300mcg, AVONEX KIT ...... 39 450mcg, 600mcg, 750mcg, 900mcg ..... 30 AVONEX PEN AJKT...... 39 BELEODAQ SOLR ...... 16 AVONEX PREFILLED PSKT ...... 39 BELRAPZO SOLN ...... 16 AVSOLA SOLR ...... 61 BELSOMRA TABS ...... 38 AVYCAZ SOLR INTRAVENOUS ...... 8 benazepril hcl tabs 5mg, 10mg, 20mg, aygestin tabs ...... 58 40mg ...... 29 AYVAKIT TABS 25mg, 50mg, 100mg, benazepril-hydrochlorothiazide tabs ...... 29 200mg, 300mg ...... 15 BENDAMUSTINE HCL SOLN ...... 16 azacitidine susr ...... 15 BENDEKA SOLN ...... 16 azasan tabs 75mg, 100mg ...... 61 BENLYSTA SOAJ ...... 61 AZASITE SOLN ...... 47 BENLYSTA SOLR ...... 61 azathioprine sodium solr ...... 61 BENLYSTA SOSY ...... 61 azathioprine tabs ...... 61 BENZEPRO CREAMY WASH LIQD ...... 67 azelaic acid gel ...... 72 BENZEPRO FOAMING CLOTHS MISC .. 67 azelastine hcl soln 0.05%, 0.1%, 0.15% ... 48 benzhydrocodone-acetaminophen tabs ... 30

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BENZNIDAZOLE TABS 12.5mg, 100mg .. 12 bisoprolol fumarate tabs 5mg, 10mg ...... 26 benzoyl perox-hydrocortisone lotn ...... 69 bisoprolol-hydrochlorothiazide tabs ...... 26 BENZOYL PEROXIDE FORTE- HC LOTN BIVIGAM SOLN 10gm/100ml ...... 66 ...... 69 BIVIGAM SOLN 5gm/50ml ...... 66 BENZOYL PEROXIDE GEL ...... 67 bleomycin sulfate solr ...... 16 benzoyl peroxide-erythromycin gel ...... 67 bleph-10 soln ...... 47 benztropine mesylate soln ...... 37 blephamide s.o.p. oint ...... 47 benztropine mesylate tabs 0.5mg, 1mg, BLEPHAMIDE SUSP ...... 47 2mg ...... 37 BLINCYTO SOLR ...... 16 BEOVU SOLN ...... 49 blisovi 24 fe tabs ...... 53 bepotastine besilate soln ...... 48 blisovi fe 1.5/30 tabs ...... 53 BERINERT KIT INTRAVENOUS ...... 23 BONJESTA TBCR ...... 50 beser lotn ...... 69 BOOSTRIX SUSP ...... 67 BESIVANCE SUSP ...... 47 BORTEZOMIB SOLR ...... 16 BESPONSA SOLR ...... 16 bosentan tabs ...... 65 betamethasone dipropionate aug crea ..... 69 BOSULIF TABS 100mg, 400mg, 500mg .. 16 betamethasone dipropionate aug gel ...... 69 BOTOX SOLR 100unit, 200unit ...... 62 betamethasone dipropionate aug lotn ...... 69 BP 10-1 EMUL ...... 72 betamethasone dipropionate aug oint ...... 69 BRAFTOVI CAPS 50mg, 75mg ...... 16 betamethasone dipropionate crea ...... 69 briellyn tabs ...... 53 betamethasone dipropionate lotn ...... 69 BRILINTA TABS 60mg, 90mg ...... 23 BETAMETHASONE DIPROPIONATE OINT BRIMONIDINE TARTRATE SOLN 0.2%, ...... 69 0.15% ...... 48 betamethasone sod phos & acet susp ..... 52 brinzolamide susp ...... 49 betamethasone valerate crea ...... 69 BRIVIACT SOLN ...... 35 betamethasone valerate foam ...... 69 BRIVIACT TABS 10mg, 25mg, 50mg, BETAMETHASONE VALERATE LOTN ... 69 75mg, 100mg ...... 35 BETAMETHASONE VALERATE OINT .... 69 bromfenac sodium (once-daily) soln...... 47 BETASERON KIT ...... 39 bromocriptine mesylate caps ...... 37 betaxolol hcl soln ...... 48 bromocriptine mesylate tabs ...... 37 betaxolol hcl tabs 10mg, 20mg ...... 26 BROMSITE SOLN ...... 47 bethanechol chloride tabs 5mg, 10mg, BRONCHITOL CAPS ...... 65 25mg, 50mg ...... 21 BROVANA NEBU ...... 23 BETHKIS NEBU ...... 65 BRUKINSA CAPS ...... 16 BETIMOL SOLN 0.25%, 0.5% ...... 48 BRYHALI LOTN ...... 69 BETOPTIC-S SUSP ...... 48 budesonide cpep ...... 52 BEVESPI AEROSPHERE AERO ...... 21 budesonide er tb24 ...... 52 BEVYXXA CAPS 40mg, 80mg ...... 23 budesonide susp 0.25mg/2ml, 0.5mg/2ml, bexarotene caps ...... 16 1mg/2ml ...... 65 BEXSERO SUSY ...... 67 budesonide-formoterol fumarate aero ...... 65 bicalutamide tabs ...... 16 bumetanide soln ...... 44 BICILLIN C-R 900/300 SUSP ...... 8 bumetanide tabs 0.5mg, 1mg, 2mg ...... 44 BICILLIN C-R SUSP ...... 8 BUNAVAIL FILM ...... 39 BICILLIN L-A SUSP ...... 8 bupap tabs ...... 30 BICNU SOLR ...... 16 bupivacaine hcl (pf) soln ...... 62 BIDIL TABS ...... 30 bupivacaine hcl soln ...... 62 BIKTARVY TABS ...... 12 BUPIVACAINE IN DEXTROSE SOLN ..... 62 bimatoprost soln ...... 48 bupivacaine spinal soln ...... 62 BINOSTO TBEF ...... 60 bupivacaine-epinephrine (pf) soln ...... 62

80 • Kaiser Permanente 2021 Comprehensive Formulary

bupivacaine-epinephrine soln ...... 62 calcitrene oint ...... 72 buprenorphine hcl soln ...... 30 calcitriol caps 0.25mcg, 0.5mcg ...... 74 buprenorphine hcl subl 2mg, 8mg ...... 40 CALCITRIOL OINT ...... 72 buprenorphine hcl-naloxone hcl film ...... 40 calcitriol soln ...... 74 buprenorphine hcl-naloxone hcl subl ...... 40 calcium acetate (phos binder) caps ...... 45 buprenorphine ptwk 5mcg/hr, 7.5mcg/hr, calcium acetate (phos binder) tabs...... 45 10mcg/hr, 15mcg/hr, 20mcg/hr ...... 30 CALCIUM GLUCONATE-NACL SOLN .... 45 bupropion hcl er (smoking det) tb12 ...... 40 CALQUENCE CAPS ...... 16 bupropion hcl er (sr) tb12 100mg, 150mg, camila tabs...... 53 200mg ...... 40 camrese lo tabs ...... 53 bupropion hcl er (xl) tb24 150mg, 300mg, candesartan cilexetil tabs 4mg, 8mg, 16mg, 450mg ...... 40 32mg ...... 29 bupropion hcl tabs 75mg, 100mg ...... 40 candesartan cilexetil-hctz tabs ...... 29 buspirone hcl tabs 5mg, 10mg ...... 38 CAPASTAT SULFATE SOLR ...... 12 buspirone hcl tabs 7.5mg, 15mg, 30mg ... 38 CAPEX SHAM ...... 69 busulfan soln ...... 16 CAPLYTA CAPS ...... 40 butalbital-acetaminophen caps ...... 30 CAPRELSA TABS 100mg, 300mg ...... 16 butalbital-acetaminophen tabs ...... 30 captopril tabs 12.5mg, 25mg, 50mg, 100mg butalbital-apap-caff-cod caps ...... 30 ...... 29 butalbital-apap-caffeine caps ...... 30 captopril-hydrochlorothiazide tabs ...... 29 butalbital-apap-caffeine tabs ...... 30 CARAC CREA ...... 72 butalbital-asa-caff-codeine caps ...... 30 CARAFATE SUSP ...... 50 butalbital-aspirin-caffeine caps ...... 30 CARBAGLU TABS ...... 43 butalbital-aspirin-caffeine tabs ...... 30 carbamazepine chew ...... 35 butorphanol tartrate soln 1mg/ml, 2mg/ml, carbamazepine er cp12 100mg, 200mg, 10mg/ml ...... 31 300mg ...... 35 BUTRANS PTWK ...... 31 carbamazepine er tb12 100mg, 200mg, BYDUREON BCISE AUIJ ...... 55 400mg ...... 35 BYDUREON PEN ...... 55 carbamazepine susp ...... 35 BYETTA 10 MCG PEN SOPN ...... 55 carbamazepine tabs ...... 35 BYETTA 5 MCG PEN SOPN ...... 55 carbidopa tabs ...... 37 BYLVAY (PELLETS) CPSP 200mcg, carbidopa-levodopa er tbcr ...... 37 600mcg ...... 51 carbidopa-levodopa tabs ...... 37 BYLVAY CAPS 400mcg, 1200mcg ...... 51 carbidopa-levodopa tbdp ...... 37 BYNFEZIA PEN SOPN...... 59 carbidopa-levodopa-entacapone tabs ...... 37 carbinoxamine maleate soln ...... 15 C carbinoxamine maleate tabs ...... 15 CABENUVA SUER ...... 12 carboplatin soln ...... 16 cabergoline tabs ...... 37 carboprost tromethamine soln ...... 58 CABLIVI KIT ...... 24 CARDENE IV SOLN ...... 27 CABOMETYX TABS 20mg, 40mg, 60mg . 16 CARDIZEM LA TB24 ...... 27 cafergot tabs ...... 37 CARDURA XL TB24 4mg, 8mg ...... 25 caffeine citrate soln ...... 34 carisoprodol tabs 250mg, 350mg ...... 22 calcipotriene crea ...... 72 carisoprodol-aspirin tabs ...... 22 calcipotriene oint ...... 72 carisoprodol-aspirin-codeine tabs ...... 22 calcipotriene soln ...... 72 carmustine solr ...... 16 calcipotriene-betameth diprop oint ...... 69 CARNITOR SOLN ...... 62 calcipotriene-betameth diprop susp ...... 69 CARNITOR TABS ...... 62 calcitonin (salmon) soln ...... 58 CAROSPIR SUSP ...... 29

Kaiser Permanente 2021 Comprehensive Formulary • 81 carteolol hcl soln ...... 49 CEQUA SOLN ...... 47 cartia xt cp24 120mg, 180mg, 240mg, CERDELGA CAPS ...... 46 300mg ...... 27 CEREZYME SOLR ...... 46 carvedilol phosphate er cp24 10mg, 20mg, CEROVEL LOTN ...... 72 40mg, 80mg ...... 26 CESAMET CAPS ...... 50 carvedilol tabs 3.125mg, 6.25mg, 12.5mg, cetirizine hcl soln ...... 15 25mg ...... 26 CETRAXAL SOLN ...... 47 caspofungin acetate solr intravenous 50mg, CEVIMELINE HCL CAPS ...... 22 70mg ...... 11 CHANTIX CONTINUING MONTH PAK cataflam tabs ...... 31 TABS ...... 21 CAYSTON SOLR ...... 65 CHANTIX STARTING MONTH PAK TABS caziant tabs ...... 53 ...... 21 cefaclor caps ...... 8 CHANTIX TABS 0.5mg, 1mg ...... 21 cefaclor er tb12 ...... 8 CHEMET CAPS ...... 51 cefaclor susr ...... 8 chloramphenicol sod succinate solr ...... 9 cefadroxil caps ...... 8 chlordiazepoxide hcl caps 5mg, 10mg, cefadroxil susr ...... 8 25mg ...... 38 cefadroxil tabs ...... 8 chlordiazepoxide-amitriptyline tabs ...... 40 cefazolin sodium solr ...... 8 chlordiazepoxide-clidinium caps ...... 21 cefazolin sodium solr injection 1gm, 10gm, chlorhexidine gluconate soln ...... 47 500mg ...... 8 chloroprocaine hcl (pf) soln ...... 62 cefdinir caps ...... 8 chloroquine phosphate tabs 250mg, 500mg cefdinir susr ...... 8 ...... 12 cefepime hcl solr injection 1gm, 2gm ...... 8 chlorothiazide sodium solr ...... 44 cefixime caps ...... 8 chlorothiazide tabs 250mg, 500mg...... 44 cefixime susr ...... 8 chlorpromazine hcl soln ...... 40 cefotaxime sodium solr ...... 8 chlorpromazine hcl tabs 10mg, 25mg, cefotetan disodium solr injection 1gm, 2gm 8 50mg, 100mg, 200mg ...... 40 cefoxitin sodium solr injection ...... 8 chlorthalidone tabs 25mg, 50mg ...... 44 cefoxitin sodium solr intravenous 1gm, 2gm chlorzoxazone tabs 375mg, 500mg, 750mg ...... 8 ...... 22 cefpodoxime proxetil susr ...... 8 CHOLBAM CAPS 50mg, 250mg ...... 51 cefpodoxime proxetil tabs ...... 8 cholestyramine light pack ...... 25 cefprozil susr ...... 8 cholestyramine light powd ...... 25 cefprozil tabs ...... 8 cholestyramine pack ...... 25 ceftazidime solr injection 1gm, 2gm, 6gm .. 8 cholestyramine powd ...... 25 CEFTIN SUSR ...... 8 CHORIONIC GONADOTROPIN SOLR .... 58 ceftriaxone sodium solr injection 1gm, 2gm, ciclopirox gel ...... 67 250mg, 500mg ...... 9 ciclopirox olamine crea ...... 67 ceftriaxone sodium solr intravenous ...... 9 ciclopirox olamine susp ...... 67 cefuroxime axetil tabs ...... 9 ciclopirox sham ...... 67 cefuroxime sodium solr injection 7.5gm, ciclopirox soln ...... 67 750mg ...... 9 cidofovir soln ...... 12 cefuroxime sodium solr intravenous ...... 9 cilostazol tabs 50mg, 100mg ...... 23 celecoxib caps ...... 31 CILOXAN OINT ...... 47 CELONTIN CAPS ...... 35 CIMDUO TABS ...... 12 cephalexin caps ...... 9 cimetidine hcl soln ...... 50 cephalexin susr ...... 9 cimetidine tabs 200mg, 300mg, 400mg, cephalexin tabs ...... 9 800mg ...... 50

82 • Kaiser Permanente 2021 Comprehensive Formulary

CIMZIA KIT ...... 61 clindamycin phosphate lotn ...... 67 CIMZIA PREFILLED KIT ...... 61 clindamycin phosphate soln ...... 9, 67 CIMZIA STARTER KIT KIT ...... 61 clindamycin phosphate soln injection cinacalcet hcl tabs 30mg, 60mg, 90mg .... 58 300mg/2ml, 600mg/4ml, 900mg/6ml ...... 9 CINQAIR SOLN ...... 64 clindamycin phosphate swab ...... 67 CINRYZE SOLR INTRAVENOUS ...... 62 CLINDESSE CREA ...... 67 CIPRO HC SUSP ...... 47 CLINIMIX E/DEXTROSE (2.75/10) SOLN CIPRODEX SUSP ...... 47 INTRAVENOUS ...... 44 ciprofloxacin hcl soln (ophth) ...... 47 CLINIMIX E/DEXTROSE (2.75/5) SOLN CIPROFLOXACIN HCL SOLN (OTIC) ..... 47 INTRAVENOUS ...... 44 ciprofloxacin hcl tabs ...... 9 CLINIMIX E/DEXTROSE (4.25/10) SOLN ciprofloxacin in d5w soln ...... 9 INTRAVENOUS ...... 44 ciprofloxacin in d5w soln intravenous ...... 9 CLINIMIX E/DEXTROSE (4.25/25) SOLN ciprofloxacin susr ...... 9 INTRAVENOUS ...... 44 ciprofloxacin-ciproflox hcl er tb24 ...... 9 CLINIMIX E/DEXTROSE (4.25/5) SOLN ciprofloxacin-dexamethasone susp ...... 47 INTRAVENOUS ...... 44 CIPROFLOXACIN-FLUOCINOLONE PF CLINIMIX E/DEXTROSE (5/15) SOLN SOLN ...... 47 INTRAVENOUS ...... 44 cisplatin soln ...... 16 CLINIMIX E/DEXTROSE (5/20) SOLN CISPLATIN SOLR ...... 16 INTRAVENOUS ...... 44 citalopram hydrobromide soln ...... 40 CLINIMIX E/DEXTROSE (5/25) SOLN citalopram hydrobromide tabs 10mg, 20mg, INTRAVENOUS ...... 44 40mg ...... 40 CLINIMIX/DEXTROSE (2.75/5) SOLN citanest plain dental soln ...... 62 INTRAVENOUS ...... 44 cladribine soln ...... 16 CLINIMIX/DEXTROSE (4.25/10) SOLN claravis caps 10mg, 20mg, 30mg, 40mg .. 72 INTRAVENOUS ...... 44 CLARINEX SYRP ...... 15 CLINIMIX/DEXTROSE (4.25/20) SOLN CLARINEX-D 12 HOUR TB12 ...... 15 INTRAVENOUS ...... 44 clarithromycin er tb24 ...... 9 CLINIMIX/DEXTROSE (4.25/5) SOLN clarithromycin susr ...... 9 INTRAVENOUS ...... 44 clarithromycin tabs ...... 9 CLINIMIX/DEXTROSE (5/15) SOLN clemastine fumarate tabs ...... 15 INTRAVENOUS ...... 44 cleocin phosphate soln ...... 9 CLINIMIX/DEXTROSE (5/20) SOLN cleocin solr ...... 9 INTRAVENOUS ...... 44 CLEOCIN SUPP ...... 67 CLINIMIX/DEXTROSE (5/25) SOLN CLIMARA PRO PTWK...... 57 INTRAVENOUS ...... 44 CLIMARA PTWK 37.5mcg/24hr, clinisol sf soln intravenous ...... 44 0.025mg/24hr, 0.05mg/24hr, clobazam susp ...... 35 0.06mg/24hr, 0.075mg/24hr, 0.1mg/24hr clobazam tabs 10mg, 20mg ...... 35 ...... 57 clobetasol propionate crea ...... 69 clindacin-p swab ...... 67 clobetasol propionate e crea ...... 69 clindamycin hcl caps ...... 9 clobetasol propionate emulsion foam ...... 69 clindamycin palmitate hcl solr ...... 9 clobetasol propionate foam ...... 69 clindamycin phos-benzoyl perox gel ...... 67 clobetasol propionate gel ...... 69 clindamycin phosphate crea ...... 67 clobetasol propionate liqd ...... 69 clindamycin phosphate foam ...... 67 clobetasol propionate lotn ...... 69 clindamycin phosphate gel ...... 67 clobetasol propionate oint ...... 69 clindamycin phosphate in d5w soln clobetasol propionate sham ...... 69 intravenous ...... 9 clobetasol propionate soln ...... 69

Kaiser Permanente 2021 Comprehensive Formulary • 83

CLOBEX SHAM ...... 69 COMETRIQ (60 MG DAILY DOSE) KIT ... 16 CLOBEX SPRAY LIQD ...... 69 COMPLERA TABS ...... 12 clocortolone pivalate crea ...... 69 compro supp ...... 40 clocortolone pivalate pump crea ...... 69 CONDYLOX GEL ...... 72 clodan sham ...... 69 CONSENSI TABS ...... 27 clofarabine soln ...... 16 constulose soln ...... 43 clomipramine hcl caps 25mg, 50mg, 75mg COPIKTRA CAPS 15mg, 25mg ...... 16 ...... 40 CORDRAN TAPE ...... 69 clonazepam tabs 0.5mg, 1mg, 2mg ...... 35 CORLANOR TABS 5mg, 7.5mg ...... 28 clonazepam tbdp 0.125mg, 0.25mg, 0.5mg, cortisone acetate tabs ...... 52 1mg, 2mg ...... 35 CORTISPORIN CREA ...... 69 clonidine hcl (analgesia) soln ...... 28 CORTISPORIN OINT ...... 69 clonidine hcl er tb12 ...... 28 COSELA SOLR ...... 62 clonidine hcl tabs 0.1mg, 0.2mg, 0.3mg ... 28 COSENTYX (300 MG DOSE) SOSY ...... 72 clonidine ptwk 0.1mg/24hr, 0.2mg/24hr, COSENTYX SENSOREADY (300 MG) 0.3mg/24hr ...... 29 SOAJ ...... 72 clopidogrel bisulfate tabs 75mg, 300mg ... 23 COSENTYX SENSOREADY PEN SOAJ . 72 clorazepate dipotassium tabs 3.75mg, COSENTYX SOSY 75mg/0.5ml, 150mg/ml 7.5mg, 15mg ...... 38 ...... 72 clotrimazole crea ...... 67 COTELLIC TABS ...... 16 clotrimazole soln ...... 67 COTEMPLA XR-ODT TBED 8.6mg, clotrimazole troc ...... 67 17.3mg, 25.9mg ...... 34 clotrimazole-betamethasone crea ...... 67 CREON CPEP ...... 46 clotrimazole-betamethasone lotn ...... 68 CRESEMBA CAPS ...... 11 clovique caps ...... 51 CRESEMBA SOLR ...... 11 clozapine tabs 25mg, 50mg, 100mg, 200mg CRINONE GEL 4%, 8% ...... 58 ...... 40 CRIXIVAN CAPS 200mg, 400mg ...... 13 clozapine tbdp 12.5mg, 25mg, 100mg, cromolyn sodium conc ...... 64 150mg, 200mg ...... 40 cromolyn sodium nebu ...... 64 COARTEM TABS ...... 12 cromolyn sodium soln ...... 48 CODEINE SULFATE TABS 15mg, 30mg, crotan lotn ...... 68 60mg ...... 31 cryselle-28 tabs ...... 53 colazal caps ...... 49 CRYSVITA SOLN 10mg/ml, 20mg/ml, COLCHICINE CAPS ...... 60 30mg/ml ...... 63 colchicine tabs ...... 60 CUPRIMINE CAPS ...... 51 colchicine-probenecid tabs ...... 46 CURITY GAUZE PADS ...... 43 colesevelam hcl pack ...... 25 CUTAQUIG SOLN 1.65gm/10ml, 2gm/12ml, colesevelam hcl tabs ...... 25 3.3gm/20ml, 4gm/24ml, 8gm/48ml, colestipol hcl gran ...... 25 1gm/6ml ...... 66 colestipol hcl pack...... 25 CUVPOSA SOLN ...... 21 colestipol hcl tabs ...... 25 cyclafem 1/35 tabs ...... 53 colistimethate sodium (cba) solr injection ... 9 cyclafem 7/7/7 tabs ...... 53 colocort enem ...... 69 cyclobenzaprine hcl er cp24 15mg, 30mg 22 COLY-MYCIN S SUSP ...... 47 cyclobenzaprine hcl tabs 5mg, 7.5mg, COMBIGAN SOLN ...... 49 10mg ...... 22 COMBIPATCH PTTW...... 57 CYCLOPHOSPHAMIDE CAPS 25mg, COMBIVENT RESPIMAT AERS ...... 23 50mg ...... 16 COMETRIQ (100 MG DAILY DOSE) KIT . 16 CYCLOPHOSPHAMIDE SOLN 1gm/5ml, COMETRIQ (140 MG DAILY DOSE) KIT . 16 500mg/2.5ml ...... 16

84 • Kaiser Permanente 2021 Comprehensive Formulary

cyclophosphamide solr ...... 16 decadron elix ...... 52 cycloserine caps ...... 12 decadron tabs .5mg, .75mg ...... 52 CYCLOSET TABS ...... 55 decadron tabs 4mg, 6mg ...... 52 cyclosporine caps 25mg, 100mg ...... 62 decitabine solr ...... 16 cyclosporine modified caps 25mg, 50mg, deferasirox granules pack 90mg, 180mg, 100mg ...... 62 360mg ...... 51 cyclosporine modified soln ...... 62 deferasirox tabs 90mg, 180mg, 360mg .... 51 cyclosporine soln ...... 62 deferasirox tbso 125mg ...... 51 cyproheptadine hcl syrp ...... 15 deferasirox tbso 250mg, 500mg ...... 51 cyproheptadine hcl tabs ...... 15 deferiprone tabs ...... 51 CYRAMZA SOLN 100mg/10ml, deferoxamine mesylate solr ...... 51 500mg/50ml ...... 16 DELESTROGEN OIL ...... 57 cyred eq tabs ...... 53 DELSTRIGO TABS ...... 13 CYSTADANE POWD...... 63 deltasone tabs ...... 52 CYSTADROPS SOLN ...... 49 delyla tabs...... 53 CYSTAGON CAPS 50mg, 150mg ...... 63 DELZICOL CPDR ...... 49 CYSTARAN SOLN ...... 49 demeclocycline hcl tabs ...... 9 cytarabine (pf) soln ...... 16 DEMEROL SOLN 25mg/0.5ml, 75mg/1.5ml, cytarabine soln ...... 16 100mg/2ml, 75mg/ml ...... 31 CYTOGAM INJ ...... 66 DEMSER CAPS ...... 25 DENAVIR CREA ...... 68 D DEPEN TITRATABS TABS ...... 51 dacarbazine solr ...... 16 depo-estradiol oil ...... 57 dactinomycin solr ...... 16 DEPO-MEDROL SUSP ...... 52 DAKLINZA TABS 30mg, 60mg, 90mg ...... 13 DEPO-PROVERA SUSP 400mg/ml ...... 58 dalfampridine er tb12 ...... 39 DEPO-SUBQ PROVERA 104 SUSY...... 58 DALIRESP TABS 250mcg, 500mcg ...... 65 depo-testosterone soln 100mg/ml, DALVANCE SOLR INTRAVENOUS ...... 9 200mg/ml ...... 53 danazol caps 50mg, 100mg, 200mg ...... 53 DERMOTIC OIL ...... 47 dantrolene sodium caps ...... 22 DESCOVY TABS ...... 13 dantrolene sodium solr ...... 22 desipramine hcl tabs 10mg, 25mg, 50mg, DANYELZA SOLN ...... 16 75mg, 100mg, 150mg ...... 40 DAPSONE GEL 7.5%, 5% ...... 72 desloratadine tabs ...... 15 dapsone tabs 25mg, 100mg ...... 12 desloratadine tbdp ...... 15 DAPTACEL SUSP ...... 67 desmopressin ace spray refrig soln ...... 58 daptomycin solr intravenous 350mg, 500mg desmopressin acetate ...... 9 soln ...... 58 DARAPRIM TABS ...... 12 DESMOPRESSIN ACETATE SOLN ...... 58 darifenacin hydrobromide er tb24 7.5mg, desmopressin acetate spray soln ...... 58 15mg ...... 73 DESMOPRESSIN ACETATE TABS 0.1mg, DARZALEX FASPRO SOLN ...... 16 0.2mg ...... 58 DARZALEX SOLN 400mg/20ml, 100mg/5ml desogestrel-ethinyl estradiol tabs ...... 53 ...... 16 DESONATE GEL ...... 69 daunorubicin hcl soln ...... 16 desonide crea ...... 69 DAURISMO TABS 25mg, 100mg ...... 16 desonide gel ...... 69 DAYTRANA PTCH 10mg/9hr, 15mg/9hr, desonide lotn ...... 69 20mg/9hr, 30mg/9hr ...... 34 desonide oint ...... 69 DDAVP RHINAL TUBE SOLN ...... 58 desowen lotn ...... 69 deblitane tabs ...... 53 desoximetasone crea 0.05%, 0.25% ...... 69

Kaiser Permanente 2021 Comprehensive Formulary • 85 desoximetasone gel ...... 69 diazoxide susp ...... 55 desoximetasone liqd ...... 69 diclofenac potassium tabs ...... 31 desoximetasone oint 0.05%, 0.25% ...... 69 diclofenac sodium er tb24 ...... 31 desrx gel ...... 69 diclofenac sodium gel 1%, 3% ...... 69 DESVENLAFAXINE ER TB24 50mg, diclofenac sodium soln ...... 48 100mg ...... 40 diclofenac sodium tbec ...... 31 desvenlafaxine succinate er tb24 25mg, diclofenac-misoprostol tbec ...... 31 50mg, 100mg ...... 40 dicloxacillin sodium caps ...... 9 dexabliss tbpk ...... 52 dicyclomine hcl caps ...... 21 dexamethasone elix ...... 52 dicyclomine hcl soln ...... 21 dexamethasone intensol conc ...... 52 dicyclomine hcl tabs ...... 21 dexamethasone sod phosphate pf soln .... 52 didanosine cpdr 200mg, 250mg, 400mg .. 13 dexamethasone sodium phosphate soln . 47, DIFFERIN CREA ...... 72 52 DIFFERIN LOTN ...... 72 dexamethasone soln...... 52 DIFICID SUSR ...... 9 dexamethasone tabs 0.5mg, 0.75mg, 1mg, DIFICID TABS ...... 9 1.5mg, 2mg, 4mg, 6mg ...... 52 diflorasone diacetate crea ...... 70 dexamethasone tbpk ...... 52 diflorasone diacetate oint ...... 70 dexchlorpheniramine maleate soln ...... 15 diflunisal tabs ...... 31 dexmethylphenidate hcl er cp24 5mg, digitek tabs 0.125mg, 0.25mg ...... 28 10mg, 15mg, 20mg, 25mg, 30mg, 35mg, digox tabs ...... 28 40mg ...... 34 DIGOXIN ORAL SOLN ...... 28 dexmethylphenidate hcl tabs 2.5mg, 5mg, digoxin soln inj ...... 28 10mg ...... 34 digoxin tabs 125mcg, 250mcg ...... 28 dexpak 10 day tbpk ...... 52 dihydroergotamine mesylate soln ...... 22 dexpak 13 day tbpk ...... 52 dilantin caps 30mg, 100mg ...... 35 dexpak 6 day tbpk...... 52 dilantin infatabs chew ...... 35 dexrazoxane hcl solr ...... 63 diltiazem hcl er beads cp24 120mg, 180mg, dextroamphetamine sulfate er cp24 5mg, 240mg, 300mg, 360mg, 420mg ...... 27 10mg, 15mg ...... 34 DILTIAZEM HCL ER COATED BEADS dextroamphetamine sulfate soln ...... 34 CP24 120mg, 180mg, 240mg, 300mg, dextroamphetamine sulfate tabs 5mg, 360mg ...... 27 10mg, 15mg, 20mg, 30mg ...... 34 diltiazem hcl er coated beads tb24 180mg, DEXTROSE 10%/NACL 0.2% ...... 45 240mg, 300mg, 360mg, 420mg ...... 27 DEXTROSE 5%/NACL 0.225% ...... 45 diltiazem hcl er cp12 60mg, 90mg, 120mg DEXTROSE IN LACTATED RINGERS ...... 27 SOLN ...... 45 diltiazem hcl er cp24 120mg, 180mg, DEXTROSE SOLN ...... 44 240mg ...... 27 dextrose soln intravenous 5%, 10% ...... 44 diltiazem hcl soln ...... 27 DEXTROSE-NACL SOLN INTRAVENOUS diltiazem hcl solr ...... 27 ...... 45 diltiazem hcl tabs 30mg, 60mg, 90mg, DIACOMIT CAPS 250mg, 500mg ...... 35 120mg ...... 27 DIACOMIT PACK 250mg, 500mg ...... 35 dilt-xr cp24 120mg, 180mg, 240mg ...... 27 DIASTAT ACUDIAL GEL 10mg, 20mg .... 35 dimenhydrinate soln ...... 50 DIASTAT PEDIATRIC GEL ...... 35 dimethyl fumarate cpdr ...... 39 diazepam conc ...... 38 dimethyl fumarate starter pack misc ...... 39 diazepam gel 2.5mg, 10mg, 20mg ...... 35 DIPENTUM CAPS ...... 49 diazepam soln 5mg/5ml, 5mg/ml ...... 38 diphen elix...... 15 diazepam tabs 2mg, 5mg, 10mg ...... 38 di-phen elix ...... 15

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diphenhydramine hcl elix ...... 15 DOXORUBICIN HCL SOLN ...... 16 diphenhydramine hcl soln ...... 15 doxorubicin hcl solr ...... 16 diphenoxylate-atropine liqd ...... 49 doxy 100 solr intravenous ...... 9 diphenoxylate-atropine tabs ...... 50 doxycycline hyclate caps 50mg, 100mg ..... 9 DIPHTHERIA-TETANUS TOXOIDS DT doxycycline hyclate tabs 20mg, 75mg, SUSP ...... 66 100mg, 150mg ...... 9 dipyridamole tabs 25mg, 50mg, 75mg ..... 30 doxycycline hyclate tbec 50mg, 75mg, disopyramide phosphate caps 100mg, 100mg, 150mg, 200mg ...... 9 150mg ...... 28 doxycycline monohydrate caps 50mg, disulfiram tabs 250mg, 500mg ...... 30 75mg, 100mg, 150mg ...... 9 DIURIL SUSP ...... 45 doxycycline monohydrate susr ...... 9 divalproex sodium csdr ...... 35 doxycycline monohydrate tabs 50mg, divalproex sodium er tb24 250mg, 500mg 35 75mg, 100mg, 150mg ...... 9 divalproex sodium tbec 125mg, 250mg, doxylamine-pyridoxine tbec ...... 50 500mg ...... 35 DRIZALMA SPRINKLE CSDR ...... 41 DIVIGEL GEL ...... 57 dronabinol caps 2.5mg, 5mg, 10mg ...... 50 dobutamine hcl soln ...... 23 droperidol soln ...... 38 DOBUTAMINE IN D5W SOLN ...... 23 drospiren-eth estrad-levomefol tabs ...... 53 DOCETAXEL (NON-ALCOHOL) SOLN drospirenone-ethinyl estradiol tabs...... 53 80mg/4ml, 160mg/8ml, 20mg/ml ...... 16 DROXIA CAPS ...... 16 docetaxel conc ...... 16 droxidopa caps ...... 23 docetaxel soln ...... 16 DUAKLIR PRESSAIR AEPB ...... 21 dofetilide caps 125mcg, 250mcg, 500mcg DUAVEE TABS ...... 57 ...... 28 DUEXIS TABS ...... 31 dolishale tabs ...... 53 DULERA AERO ...... 65 donepezil hcl tabs 5mg, 10mg, 23mg ...... 22 duloxetine hcl cpep 20mg, 30mg, 40mg, donepezil hcl tbdp 5mg, 10mg ...... 22 60mg ...... 41 dopamine hcl soln ...... 23 DUOBRII LOTN ...... 70 DOPAMINE IN D5W SOLN ...... 23 DUOPA SUSP ...... 37 DOPTELET TABS ...... 24 DUPIXENT SOPN 200mg/1.14ml, DORYX MPC TBEC ...... 9 300mg/2ml ...... 64 dorzolamide hcl soln ...... 49 DUPIXENT SOSY 200mg/1.14ml, dorzolamide hcl-timolol mal pf soln ...... 49 300mg/2ml ...... 64 dorzolamide hcl-timolol mal soln ...... 49 DURAMORPH SOLN 0.5mg/ml, 1mg/ml . 31 dotti pttw 0.025mg/24hr, 0.0375mg/24hr, DUREZOL EMUL ...... 48 0.05mg/24hr, 0.075mg/24hr, 0.1mg/24hr DURYSTA IMPL ...... 49 ...... 57 dutasteride caps ...... 60 DOVATO TABS ...... 13 dutasteride-tamsulosin hcl caps ...... 60 doxazosin mesylate tabs 1mg, 2mg, 4mg, DUTOPROL TB24 ...... 26 8mg ...... 25 dvorah tabs ...... 31 doxepin hcl caps 10mg, 25mg, 50mg, dxevo 11-day tbpk ...... 52 75mg, 100mg, 150mg ...... 41 DYANAVEL XR SUER ...... 34 doxepin hcl conc ...... 41 DYSPORT SOLR 300unit, 500unit ...... 63 doxepin hcl crea ...... 71 doxepin hcl tabs 3mg, 6mg ...... 41 E doxercalciferol caps 0.5mcg, 1mcg, 2.5mcg e.e.s. 400 tabs ...... 9 ...... 74 EASYGEL GEL ...... 63 DOXERCALCIFEROL SOLN ...... 74 econazole nitrate crea ...... 68 doxorubicin hcl liposomal inj ...... 16 EDARBYCLOR TABS ...... 29

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EDLUAR SUBL 5mg, 10mg ...... 38 endocet tabs ...... 31 EDURANT TABS ...... 13 ENDOMETRIN INST ...... 58 efavirenz caps 50mg, 200mg ...... 13 ENGERIX-B SUSP 10mcg/0.5ml, 20mcg/ml efavirenz tabs ...... 13 ...... 67 efavirenz-emtricitab-tenofovir tabs ...... 13 ENHERTU SOLR ...... 16 EGRIFTA SOLR ...... 59 enoxaparin sodium soln 30mg/0.3ml, EGRIFTA SV SOLR...... 59 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml, ELAPRASE SOLN ...... 46 120mg/0.8ml, 300mg/3ml, 100mg/ml, ELELYSO SOLR ...... 46 150mg/ml ...... 23 ELEPSIA XR TB24 1000mg, 1500mg ...... 35 enpresse-28 tabs ...... 53 ELESTRIN GEL ...... 57 enskyce tabs ...... 53 eletriptan hydrobromide tabs ...... 37 ENSPRYNG SOSY ...... 63 ELIGARD KIT ...... 16 ENSTILAR FOAM ...... 70 ELIQUIS TABS ...... 23 entacapone tabs ...... 37 ELITEK SOLR ...... 46 entecavir tabs 0.5mg, 1mg ...... 13 elixophyllin elix ...... 73 ENTRESTO TABS ...... 29 ELLA TABS ...... 53 ENTYVIO SOLR ...... 51 ELLENCE SOLN ...... 16 enulose soln ...... 43 ELMIRON CAPS ...... 63 ENVARSUS XR TB24 0.75mg, 1mg, 4mg62 eluryng ring ...... 53 EPCLUSA TABS ...... 13 ELZONRIS SOLN ...... 16 EPIDIOLEX SOLN ...... 35 EMBEDA CPCR ...... 31 EPIDUO FORTE GEL ...... 72 EMCYT CAPS ...... 16 epifoam foam ...... 70 EMEND SUSR ...... 50 epinastine hcl soln ...... 48 EMFLAZA SUSP ...... 52 epinephrine (anaphylaxis) soln ...... 23 EMFLAZA TABS 6mg, 18mg, 30mg, 36mg epinephrine soaj ...... 23 ...... 52 EPINEPHRINE SOSY ...... 23 EMGALITY (300 MG DOSE) SOSY ...... 37 EPIPEN 2-PAK SOAJ ...... 23 EMGALITY SOAJ ...... 37 EPIPEN JR 2-PAK SOAJ ...... 23 EMGALITY SOSY ...... 37 epirubicin hcl soln ...... 16 emoquette tabs ...... 53 epitol tabs ...... 35 EMPAVELI SOLN ...... 63 EPIVIR HBV SOLN ...... 13 EMPLICITI SOLR 300mg, 400mg ...... 16 eplerenone tabs 25mg, 50mg ...... 29 EMSAM PT24 6mg/24hr, 9mg/24hr, EPOGEN SOLN 2000unit/ml, 3000unit/ml, 12mg/24hr ...... 37 4000unit/ml, 10000unit/ml, 20000unit/ml emtricitabine caps ...... 13 ...... 24 emtricitabine-tenofovir df tabs ...... 13 epoprostenol sodium solr ...... 65 EMTRIVA SOLN ...... 13 eprosartan mesylate tabs ...... 29 emverm chew ...... 8 eptifibatide soln ...... 24 enalapril maleate tabs 2.5mg, 5mg, 10mg, EQUETRO CP12 100mg, 200mg, 300mg 41 20mg ...... 29 ERAXIS SOLR INTRAVENOUS 50mg, enalaprilat inj ...... 29 100mg ...... 11 enalapril-hydrochlorothiazide tabs ...... 29 ERBITUX SOLN ...... 16 ENBREL MINI SOCT ...... 61 ergoloid mesylates tabs ...... 22 ENBREL SOLN ...... 61 ergomar subl ...... 22 ENBREL SOLR ...... 61 ergotamine-caffeine tabs ...... 37 ENBREL SOSY 25mg/0.5ml, 50mg/ml ..... 61 ERIVEDGE CAPS ...... 16 ENBREL SURECLICK SOAJ ...... 61 ERLEADA TABS ...... 16 ENDARI PACK ...... 63 erlotinib hcl tabs 25mg, 100mg, 150mg ... 17

88 • Kaiser Permanente 2021 Comprehensive Formulary

errin tabs ...... 53 eszopiclone tabs 1mg, 2mg, 3mg ...... 38 ERTACZO CREA ...... 68 ethacrynic acid tabs ...... 45 ertapenem sodium solr injection ...... 9 ethambutol hcl tabs 100mg, 400mg ...... 12 ERWINASE SOLR ...... 17 ethosuximide caps ...... 35 ERWINAZE SOLR ...... 17 ethosuximide soln ...... 35 ery pads ...... 68 ethynodiol diac-eth estradiol tabs ...... 53 ery-tab tbec ...... 9 etodolac caps ...... 31 ERYTHROCIN LACTOBIONATE SOLR etodolac er tb24 ...... 31 INTRAVENOUS ...... 9 etodolac tabs ...... 31 erythrocin stearate tabs ...... 9 etonogestrel-ethinyl estradiol ring ...... 53 erythromycin base cpep ...... 9 ETOPOPHOS SOLR ...... 17 erythromycin base tabs ...... 9 etoposide soln ...... 17 erythromycin base tbec ...... 9 etravirine tabs 100mg, 200mg ...... 13 erythromycin ethylsuccinate susr ...... 9 EURAX CREA ...... 68 erythromycin ethylsuccinate tabs ...... 9 EUTHYROX TABS 25mcg, 50mcg, 75mcg, erythromycin gel ...... 68 88mcg, 100mcg, 112mcg, 125mcg, erythromycin oint ...... 47 137mcg, 150mcg, 175mcg, 200mcg ..... 59 erythromycin pads ...... 68 EVAMIST SOLN ...... 57 erythromycin soln ...... 68 evekeo tabs 5mg, 10mg ...... 34 ESBRIET CAPS ...... 65 EVENITY SOSY ...... 60 ESBRIET TABS 267mg, 801mg ...... 65 everolimus tabs 0.25mg ...... 62 escitalopram oxalate soln ...... 41 everolimus tabs 0.5mg, 0.75mg ...... 62 escitalopram oxalate tabs 5mg, 10mg, everolimus tabs 2.5mg, 5mg, 7.5mg ...... 17 20mg ...... 41 EVKEEZA SOLN 345mg/2.3ml, esgic caps ...... 31 1200mg/8ml ...... 25 esgic tabs ...... 31 EVOMELA SOLR ...... 17 ESMOLOL HCL SOLN ...... 26 EVOTAZ TABS ...... 13 esmolol hcl-sodium chloride soln ...... 26 EVRYSDI SOLR ...... 63 esomeprazole magnesium cpdr 20mg, EXELDERM CREA ...... 68 40mg ...... 50 EXELDERM SOLN ...... 68 esomeprazole magnesium pack 10mg, exemestane tabs ...... 17 20mg, 40mg ...... 50 EXJADE TBSO 125mg, 250mg, 500mg ... 51 esomeprazole sodium solr ...... 50 EXONDYS 51 SOLN 500mg/10ml, ESOMEPRAZOLE STRONTIUM CPDR .. 50 100mg/2ml ...... 63 estarylla tabs ...... 53 EXSERVAN FILM ...... 39 estazolam tabs 1mg, 2mg ...... 38 EXTAVIA KIT ...... 39 estrace crea ...... 57 EYLEA SOLN ...... 49 estrace tabs 0.5mg, 1mg, 2mg ...... 57 EYLEA SOSY ...... 49 estradiol crea ...... 57 ezetimibe tabs ...... 25 estradiol pttw 0.025mg/24hr, ezetimibe-simvastatin tabs ...... 25 0.0375mg/24hr, 0.05mg/24hr, 0.075mg/24hr, 0.1mg/24hr ...... 57 F estradiol ptwk 37.5mcg/24hr, 0.025mg/24hr, FABIOR FOAM ...... 72 0.05mg/24hr, 0.06mg/24hr, FABRAZYME SOLR 5mg, 35mg ...... 46 0.075mg/24hr, 0.1mg/24hr ...... 57 falmina tabs ...... 53 estradiol tabs 10mcg, 0.5mg, 1mg, 2mg .. 57 famciclovir tabs 125mg, 250mg, 500mg ... 13 estradiol valerate oil ...... 57 famotidine premixed soln ...... 50 estradiol-norethindrone acet tabs ...... 57 famotidine soln ...... 50 ESTRING RING ...... 57 famotidine susr ...... 50

Kaiser Permanente 2021 Comprehensive Formulary • 89 famotidine tabs 20mg, 40mg ...... 50 FINTEPLA SOLN ...... 35 FANAPT TABS 1mg, 2mg, 4mg, 6mg, 8mg, fioricet caps ...... 31 10mg, 12mg ...... 41 fioricet/codeine caps ...... 31 FANAPT TITRATION PACK TABS ...... 41 FIRAZYR SOLN ...... 23 FARYDAK CAPS 10mg, 15mg, 20mg ...... 17 FIRDAPSE TABS ...... 63 FASENRA PEN SOAJ ...... 64 FIRMAGON (240 MG DOSE) SOLR ...... 17 FASENRA SOSY ...... 64 FIRMAGON SOLR ...... 17 FASLODEX SOLN ...... 17 FIRVANQ SOLR ...... 9 fayosim tabs ...... 53 flac oil ...... 48 febuxostat tabs 40mg, 80mg ...... 60 FLAREX SUSP ...... 48 felbamate susp ...... 35 flavoxate hcl tabs ...... 73 felbamate tabs 400mg, 600mg ...... 35 FLEBOGAMMA DIF SOLN INTRAVENOUS felodipine er tb24 2.5mg, 5mg, 10mg ...... 27 5gm/100ml, 10gm/100ml, 0.5gm/10ml, femynor tabs ...... 53 10gm/200ml, 20gm/200ml, 20gm/400ml, fenofibrate caps 50mg, 134mg, 150mg .... 26 2.5gm/50ml, 5gm/50ml ...... 66 fenofibrate micronized caps 43mg, 67mg, flecainide acetate tabs 50mg, 100mg, 130mg, 200mg ...... 26 150mg ...... 28 fenofibrate tabs 40mg, 48mg, 54mg, FLOLIPID SUSP 20mg/5ml, 40mg/5ml .... 26 120mg, 145mg, 160mg ...... 26 FLOVENT DISKUS AEPB 50mcg/blist, fenofibric acid cpdr 45mg, 135mg ...... 26 100mcg/blist, 250mcg/blist ...... 65 FENOFIBRIC ACID TABS 35mg, 105mg . 26 FLOVENT HFA AERO 110mcg/act, fenoprofen calcium caps ...... 31 220mcg/act ...... 65 fenoprofen calcium tabs ...... 31 FLOVENT HFA AERO 44mcg/act ...... 65 fenortho caps ...... 31 floxuridine solr ...... 17 FENSOLVI (6 MONTH) KIT ...... 17 fluconazole in sodium chloride soln fentanyl citrate (pf) soct ...... 31 intravenous ...... 11 FENTANYL CITRATE (PF) SOLN fluconazole susr ...... 11 50mcg/ml, 1000mcg/20ml, fluconazole tabs ...... 11 2500mcg/50ml ...... 31 flucytosine caps 250mg, 500mg ...... 11 fentanyl citrate lpop 200mcg, 400mcg, fludarabine phosphate soln ...... 17 600mcg, 800mcg, 1200mcg, 1600mcg . 31 fludarabine phosphate solr ...... 17 fentanyl citrate tabs 100mcg, 200mcg, fludrocortisone acetate tabs ...... 52 400mcg, 600mcg, 800mcg ...... 31 flumazenil soln ...... 39 fentanyl pt72 12mcg/hr, 25mcg/hr, flunisolide soln ...... 48 37.5mcg/hr, 50mcg/hr, 62.5mcg/hr, fluocinolone acetonide body oil ...... 70 75mcg/hr, 87.5mcg/hr, 100mcg/hr ...... 31 fluocinolone acetonide crea 0.01%, 0.025% FENTORA TABS 100mcg, 200mcg, ...... 70 400mcg, 600mcg, 800mcg ...... 31 fluocinolone acetonide oil ...... 48 FERRIPROX SOLN ...... 51 fluocinolone acetonide oint ...... 70 FERRIPROX TABS 500mg, 1000mg ...... 51 fluocinolone acetonide scalp oil ...... 70 FERRIPROX TWICE-A-DAY TABS ...... 52 fluocinolone acetonide soln ...... 70 FETROJA SOLR ...... 9 fluocinonide crea ...... 70 FETZIMA CP24 20mg, 40mg, 80mg, 120mg fluocinonide emulsified base crea ...... 70 ...... 41 FLUOCINONIDE GEL ...... 70 FETZIMA TITRATION C4PK ...... 41 fluocinonide oint ...... 70 fexmid tabs ...... 22 fluocinonide soln ...... 70 FIBRICOR TABS ...... 26 FLUORITAB CHEW 0.25mg, 0.5mg, 1mg 63 FINACEA FOAM ...... 72 FLUORITAB SOLN ...... 63 finasteride tabs ...... 60 fluorometholone susp ...... 48

90 • Kaiser Permanente 2021 Comprehensive Formulary

fluorouracil crea .5% ...... 72 FOSRENOL PACK 750mg, 1000mg ...... 45 fluorouracil crea 5% ...... 72 FOTIVDA CAPS 0.89mg, 1.34mg ...... 17 fluorouracil soln ...... 17, 72 FREAMINE HBC SOLN INTRAVENOUS 44 fluorouracil soln 2%, 5% ...... 72 frovatriptan succinate tabs ...... 37 fluoxetine hcl (pmdd) tabs 10mg, 20mg ... 41 FULPHILA SOSY ...... 24 fluoxetine hcl caps 10mg, 20mg, 40mg .... 41 fulvestrant soln ...... 17 fluoxetine hcl cpdr ...... 41 furosemide soln 8mg/ml, 10mg/ml ...... 45 fluoxetine hcl soln ...... 41 furosemide soln injection ...... 45 fluoxetine hcl tabs 10mg, 20mg, 60mg ..... 41 FUROSEMIDE TABS 40mg, 80mg, 20mg45 fluphenazine decanoate soln ...... 41 FUZEON SOLR ...... 13 fluphenazine hcl conc ...... 41 fyavolv tabs ...... 57 fluphenazine hcl elix ...... 41 FYCOMPA SUSP ...... 35 fluphenazine hcl soln ...... 41 FYCOMPA TABS ...... 35 fluphenazine hcl tabs 1mg, 2.5mg, 5mg, 10mg ...... 41 G flurandrenolide crea ...... 70 gabapentin caps 100mg, 400mg ...... 35 flurandrenolide lotn ...... 70 gabapentin soln ...... 35 flurandrenolide oint ...... 70 gabapentin tabs 600mg, 800mg ...... 35 flurazepam hcl caps 15mg, 30mg ...... 38 GALAFOLD CAPS ...... 63 flurbiprofen sodium soln ...... 48 galantamine hydrobromide er cp24 8mg, flurbiprofen tabs ...... 31 16mg, 24mg ...... 22 flutamide caps ...... 17 galantamine hydrobromide soln ...... 22 fluticasone propionate crea ...... 70 galantamine hydrobromide tabs 4mg, 8mg, fluticasone propionate lotn ...... 70 12mg ...... 22 fluticasone propionate oint ...... 70 GAMASTAN INJ ...... 66 fluticasone propionate susp ...... 48 GAMIFANT SOLN 50mg/10ml, fluticasone-salmeterol aepb ...... 65 100mg/20ml, 10mg/2ml ...... 62 fluvastatin sodium caps 20mg, 40mg ...... 26 GAMMAGARD S/D LESS IGA SOLR fluvastatin sodium er tb24 ...... 26 INTRAVENOUS 5gm, 10gm ...... 66 fluvoxamine maleate er cp24 100mg, GAMMAGARD SOLN INJECTION ...... 66 150mg ...... 41 GAMMAKED SOLN INJECTION ...... 66 fluvoxamine maleate tabs 25mg, 50mg, GAMMAPLEX SOLN INTRAVENOUS 100mg ...... 41 10gm/100ml, 20gm/200ml, 5gm/50ml .. 66 FML FORTE SUSP ...... 48 GAMMAPLEX SOLN INTRAVENOUS FML OINT ...... 48 10gm/200ml ...... 66 fomepizole soln ...... 60 GAMUNEX-C SOLN INJECTION fondaparinux sodium soln 2.5mg/0.5ml .... 24 10gm/100ml, 1gm/10ml, 20gm/200ml, fondaparinux sodium soln 5mg/0.4ml, 2.5gm/25ml, 5gm/50ml ...... 66 7.5mg/0.6ml, 10mg/0.8ml ...... 24 ganciclovir sodium soln ...... 13 formoterol fumarate nebu ...... 23 ganciclovir sodium solr ...... 13 FORTEO SOPN ...... 58 GARDASIL 9 SUSP ...... 67 FOSAMAX PLUS D TABS ...... 60 GARDASIL 9 SUSY ...... 67 fosamprenavir calcium tabs ...... 13 gatifloxacin soln ...... 47 fosaprepitant dimeglumine solr ...... 50 GATTEX KIT ...... 51 fosfomycin tromethamine pack ...... 14 gavilyte-c solr ...... 51 fosinopril sodium tabs 10mg, 20mg, 40mg gavilyte-g solr ...... 51 ...... 29 gavilyte-h kit ...... 51 fosinopril sodium-hctz tabs ...... 29 gavilyte-n with flavor pack solr ...... 51 fosphenytoin sodium soln ...... 35 GAVRETO CAPS ...... 17

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GAZYVA SOLN ...... 17 GONITRO PACK ...... 30 gemcitabine hcl soln ...... 17 granisetron hcl soln ...... 50 gemcitabine hcl solr ...... 17 granisetron hcl tabs ...... 50 gemfibrozil tabs ...... 26 GRANIX SOLN 480mcg/1.6ml, 300mcg/ml gemmily caps ...... 53 ...... 24 generlac soln ...... 43 GRANIX SOSY 300mcg/0.5ml, gengraf caps 25mg, 50mg, 100mg ...... 62 480mcg/0.8ml ...... 24 gengraf soln ...... 62 GRASTEK SUBL ...... 63 GENOTROPIN MINIQUICK SOLR 0.2mg 59 griseofulvin microsize susp ...... 11 GENOTROPIN MINIQUICK SOLR 0.4mg, griseofulvin microsize tabs ...... 11 0.6mg, 0.8mg, 1mg, 1.2mg, 1.4mg, griseofulvin ultramicrosize tabs ...... 11 1.6mg, 1.8mg, 2mg ...... 59 guanfacine hcl er tb24 1mg, 2mg, 3mg, GENOTROPIN SOLR 5mg, 12mg ...... 59 4mg ...... 39 gentak oint ...... 47 guanfacine hcl tabs 1mg, 2mg ...... 29 gentamicin in saline soln ...... 9 GUANIDINE HCL TABS ...... 22 gentamicin in saline soln intravenous ...... 9 gynazole-1 crea ...... 68 gentamicin sulfate crea ...... 68 gentamicin sulfate oint ...... 68 H gentamicin sulfate soln ...... 9, 10, 47 HAEGARDA SOLR 2000unit, 3000unit .... 63 gentamicin sulfate soln injection ...... 10 hailey 24 fe tabs ...... 53 GENVOYA TABS ...... 13 halcinonide crea ...... 70 GEODON SOLR ...... 41 halobetasol propionate crea ...... 70 gianvi tabs ...... 53 HALOBETASOL PROPIONATE FOAM ... 70 GILENYA CAPS 0.25mg, 0.5mg ...... 39 halobetasol propionate oint ...... 70 GILOTRIF TABS 20mg, 30mg, 40mg ...... 17 HALOG CREA ...... 70 GIMOTI SOLN ...... 51 HALOG OINT ...... 70 GIVLAARI SOLN ...... 63 haloperidol decanoate soln ...... 41 GLASSIA SOLN INTRAVENOUS ...... 65 haloperidol lactate conc ...... 41 glatiramer acetate sosy 20mg/ml, 40mg/ml haloperidol lactate soln ...... 41 ...... 39 haloperidol tabs 0.5mg, 1mg, 2mg, 5mg, glatopa sosy 20mg/ml, 40mg/ml ...... 39 10mg, 20mg ...... 41 glimepiride tabs 1mg, 2mg, 4mg ...... 55 HARVONI PACK ...... 13 glipizide er tb24 2.5mg, 5mg, 10mg ...... 55 HARVONI TABS ...... 13 glipizide tabs 5mg, 10mg ...... 55 HAVRIX SUSP ...... 67 glipizide-metformin hcl tabs ...... 55 heparin (porcine) in nacl soln ...... 24 GLOPERBA SOLN ...... 60 HEPARIN SOD (PORCINE) IN D5W SOLN GLUCAGEN HYPOKIT SOLR ...... 55 ...... 24 glucagon emergency kit ...... 55 heparin sodium (porcine) pf soln ...... 24 glyburide micronized tabs 1.5mg, 3mg, 6mg heparin sodium (porcine) soln 1000unit/ml, ...... 55 5000unit/ml, 10000unit/ml, 20000unit/ml glyburide tabs 1.25mg, 2.5mg, 5mg ...... 55 ...... 24 glyburide-metformin tabs ...... 55 HEPATAMINE SOLN INTRAVENOUS .... 44 glycate tabs ...... 21 HEPLISAV-B SOLN ...... 67 glycopyrrolate pf sosy ...... 21 HERCEPTIN HYLECTA SOLN ...... 17 glycopyrrolate soln ...... 21 HERCEPTIN SOLR 150mg, 440mg ...... 17 glycopyrrolate tabs 1mg, 2mg ...... 21 HERZUMA SOLR 150mg, 420mg ...... 17 glydo prsy ...... 71 HETLIOZ CAPS ...... 38 GLYXAMBI TABS ...... 55 HETLIOZ LQ SUSP ...... 38 GOLYTELY SOLR ...... 51 HEXALEN CAPS ...... 17

92 • Kaiser Permanente 2021 Comprehensive Formulary

HIBERIX SOLR ...... 67 hydrocortisone ace-pramoxine crea ...... 71 HORIZANT TBCR 300mg, 600mg ...... 35 hydrocortisone butyr lipo base crea ...... 70 HUMALOG JUNIOR KWIKPEN SOPN .... 55 hydrocortisone butyrate crea ...... 70 HUMALOG KWIKPEN SOPN 100unit/ml, hydrocortisone butyrate lotn ...... 70 200unit/ml ...... 55 HYDROCORTISONE BUTYRATE OINT . 70 HUMALOG MIX 50/50 KWIKPEN SUPN . 56 hydrocortisone butyrate soln ...... 70 HUMALOG MIX 50/50 SUSP ...... 56 hydrocortisone crea 1%, 2.5% ...... 70 HUMALOG MIX 75/25 KWIKPEN SUPN . 56 hydrocortisone enem ...... 70 HUMALOG MIX 75/25 SUSP ...... 56 hydrocortisone lotn ...... 70 HUMALOG SOCT ...... 56 hydrocortisone oint 1%, 2.5% ...... 70 HUMALOG SOLN ...... 56 hydrocortisone tabs 5mg, 10mg, 20mg .... 52 humatin caps ...... 12 hydrocortisone valerate crea ...... 70 HUMATROPE SOLR 5mg, 6mg, 12mg, hydrocortisone valerate oint ...... 70 24mg ...... 59 HYDROCORTISONE-ACETIC ACID SOLN HUMIRA PEDIATRIC CROHNS START ...... 48 PSKT ...... 61 hydromorphone hcl er tb24 8mg, 12mg, HUMIRA PEN PNKT 40mg/0.4ml, 16mg, 32mg ...... 31 40mg/0.8ml, 80mg/0.8ml ...... 61 hydromorphone hcl liqd ...... 31 HUMIRA PEN-CD/UC/HS STARTER PNKT hydromorphone hcl pf soln 50mg/5ml, 40mg/0.8ml, 80mg/0.8ml ...... 61 10mg/ml ...... 31 HUMIRA PEN-PEDIATRIC UC START HYDROMORPHONE HCL SOLN 1mg/ml, PNKT ...... 61 2mg/ml ...... 31 HUMIRA PEN-PS/UV/ADOL HS START hydromorphone hcl tabs 2mg, 4mg, 8mg . 31 PNKT ...... 61 hydroxychloroquine sulfate tabs ...... 12 HUMIRA PEN-PSOR/UVEIT STARTER hydroxyprogesterone caproate oil ...... 58 PNKT ...... 61 hydroxyprogesterone caproate soln ...... 58 HUMIRA PSKT 10mg/0.1ml, 10mg/0.2ml, hydroxyurea caps ...... 17 20mg/0.2ml, 20mg/0.4ml, 40mg/0.4ml, hydroxyzine hcl soln ...... 38 40mg/0.8ml ...... 61 hydroxyzine hcl syrp ...... 38 HUMULIN 70/30 KWIKPEN SUPN ...... 56 hydroxyzine hcl tabs ...... 38 HUMULIN 70/30 SUSP ...... 56 hydroxyzine pamoate caps ...... 38 HUMULIN N KWIKPEN SUPN ...... 56 HYPERHEP B SOLN ...... 66 HUMULIN N SUSP ...... 56 HYPERRAB S/D SOLN ...... 66 HUMULIN R SOLN ...... 56 HYQVIA KIT ...... 66 HUMULIN R U-500 (CONCENTRATED) SOLN ...... 56 I HUMULIN R U-500 KWIKPEN SOPN ...... 56 IBANDRONATE SODIUM SOLN ...... 60 hydralazine hcl soln ...... 29 ibandronate sodium tabs ...... 60 hydralazine hcl tabs 10mg, 25mg, 50mg, IBRANCE CAPS 75mg, 100mg, 125mg ... 17 100mg ...... 29 IBRANCE TABS 75mg, 100mg, 125mg ... 17 hydrochlorothiazide caps ...... 45 ibu tabs ...... 31 hydrochlorothiazide tabs 12.5mg, 25mg, ibudone tabs ...... 31 50mg ...... 45 ibuprofen lysine soln ...... 31 hydrocodone bitartrate er cp12 10mg, ibuprofen susp ...... 31 15mg, 20mg, 30mg, 40mg, 50mg ...... 31 ibuprofen tabs ...... 31 hydrocodone-acetaminophen soln ...... 31 ibutilide fumarate soln ...... 28 hydrocodone-acetaminophen tabs ...... 31 icatibant acetate soln ...... 23 hydrocodone-ibuprofen tabs ...... 31 iclevia tabs ...... 53 hydrocortisone (perianal) crea 1%, 2.5% . 70

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ICLUSIG TABS 10mg, 15mg, 30mg, 45mg INQOVI TABS ...... 17 ...... 17 INREBIC CAPS ...... 17 icosapent ethyl caps ...... 26 INSULIN ASP PROT & ASP FLEXPEN IDAMYCIN PFS SOLN ...... 17 SUPN ...... 56 idarubicin hcl soln ...... 17 INSULIN ASPART FLEXPEN SOPN ...... 56 IDHIFA TABS 50mg, 100mg ...... 17 INSULIN ASPART PENFILL SOCT ...... 56 ifosfamide soln ...... 17 INSULIN ASPART PROT & ASPART SUSP IFOSFAMIDE SOLR ...... 17 ...... 56 ILARIS SOLN ...... 31 INSULIN ASPART SOLN ...... 56 ILEVRO SUSP ...... 48 INSULIN LISPRO (1 UNIT DIAL) SOPN .. 56 ILUMYA SOSY ...... 72 INSULIN LISPRO SOLN ...... 56 ILUVIEN IMPL ...... 48 INTELENCE TABS 25mg ...... 13 imatinib mesylate tabs ...... 17 INTRALIPID EMUL INTRAVENOUS ...... 44 IMBRUVICA CAPS 70mg, 140mg ...... 17 INTRALIPID EMUL INTRAVENOUS IMBRUVICA TABS 140mg, 280mg, 420mg, 20gm/100ml ...... 44 560mg ...... 17 INTRAROSA INST ...... 52 IMFINZI SOLN 500mg/10ml, 120mg/2.4ml INTRON A SOLN 10mu/ml, 6000000unit/ml ...... 17 ...... 17 imipenem-cilastatin solr intravenous ...... 10 INTRON A SOLR 10mu, 18mu, 50mu...... 17 imipramine hcl tabs 10mg, 25mg, 50mg ... 41 introvale tabs ...... 53 imipramine pamoate caps 75mg, 100mg, INVEGA SUSTENNA SUSY 39mg/0.25ml 125mg, 150mg ...... 41 ...... 41 imiquimod crea 3.75%, 5% ...... 72 INVEGA SUSTENNA SUSY 78mg/0.5ml, IMIQUIMOD PUMP CREA ...... 72 117mg/0.75ml, 234mg/1.5ml, 156mg/ml IMOGAM RABIES-HT SOLN ...... 66 ...... 41 IMOVAX RABIES INJ ...... 67 INVEGA TRINZA SUSY 273mg/0.875ml, IMPAVIDO CAPS ...... 12 410mg/1.315ml, 546mg/1.75ml, IMVEXXY MAINTENANCE PACK INST 819mg/2.625ml ...... 41 4mcg, 10mcg ...... 57 INVELTYS SUSP ...... 48 IMVEXXY STARTER PACK INST 4mcg, INVIRASE CAPS ...... 13 10mcg ...... 57 INVIRASE TABS ...... 13 INBRIJA CAPS ...... 37 INVOKAMET TABS ...... 56 incassia tabs ...... 53 INVOKAMET XR TB24 ...... 56 INCRELEX SOLN ...... 59 INVOKANA TABS 100mg, 300mg ...... 56 INCRUSE ELLIPTA AEPB ...... 21 IONOSOL-MB IN D5W SOLN indapamide tabs 1.25mg, 2.5mg ...... 45 INTRAVENOUS ...... 45 indocin supp ...... 31 IOPIDINE SOLN ...... 49 INDOCIN SUSP ...... 31 IPOL INJ ...... 67 indomethacin caps ...... 32 ipratropium bromide soln 0.02% ...... 21 INDOMETHACIN CAPS 20mg ...... 32 ipratropium bromide soln 0.03%, 0.06% .. 21 indomethacin er cpcr ...... 32 ipratropium-albuterol soln ...... 23 indomethacin sodium solr ...... 32 irbesartan tabs 75mg, 150mg, 300mg ...... 29 INFANRIX SUSP ...... 67 irbesartan-hydrochlorothiazide tabs ...... 29 INFLECTRA SOLR INTRAVENOUS ...... 61 IRESSA TABS ...... 17 INFUGEM SOLN ...... 17 irinotecan hcl soln ...... 17 INGREZZA CAPS 40mg, 60mg, 80mg ..... 39 ISENTRESS CHEW 25mg, 100mg ...... 13 INGREZZA CPPK ...... 39 ISENTRESS HD TABS ...... 13 INLYTA TABS 1mg, 5mg ...... 17 ISENTRESS PACK ...... 13 INNOPRAN XL CP24 80mg, 120mg ...... 26 ISENTRESS TABS ...... 13

94 • Kaiser Permanente 2021 Comprehensive Formulary

isibloom tabs ...... 53 JUXTAPID CAPS 5mg, 10mg, 20mg, 30mg, ISOLYTE-P IN D5W SOLN INTRAVENOUS 40mg, 60mg ...... 26 ...... 45 JYNARQUE TABS 15mg, 30mg ...... 45 ISOLYTE-S SOLN INTRAVENOUS ...... 45 JYNARQUE TBPK ...... 45 isoniazid soln ...... 12 isoniazid syrp ...... 12 K isoniazid tabs 100mg, 300mg ...... 12 KADCYLA SOLR 100mg, 160mg ...... 17 isoproterenol hcl soln ...... 23 KADIAN CP24 ...... 32 isosorbide dinitrate er tbcr ...... 30 kaitlib fe chew ...... 54 isosorbide dinitrate tabs 5mg, 10mg, 20mg, KALYDECO PACK 25mg, 50mg, 75mg ... 65 30mg ...... 30 KALYDECO TABS ...... 65 isosorbide mononitrate er tb24 ...... 30 KANJINTI SOLR 150mg, 420mg ...... 17 isosorbide mononitrate er tb24 30mg, 60mg KANUMA SOLN ...... 46 ...... 30 kariva tabs ...... 54 isosorbide mononitrate tabs 10mg, 20mg 30 KAZANO TABS ...... 56 isotretinoin caps 10mg, 20mg, 30mg, 40mg KCL IN DEXTROSE-NACL SOLN ...... 72 INTRAVENOUS ...... 45 isradipine caps 2.5mg, 5mg ...... 27 KCL IN DEXTROSE-NACL SOLN ISTURISA TABS 1mg, 5mg, 10mg ...... 63 INTRAVENOUS 20-5-0.33 MEQ ...... 45 itraconazole caps ...... 11 KCL IN DEXTROSE-NACL SOLN ITRACONAZOLE SOLN ...... 11 INTRAVENOUS 40-5-0.9 MEQ ...... 45 ivermectin crea ...... 68 KCL-LACTATED RINGERS-D5W SOLN ivermectin lotn ...... 68 INTRAVENOUS ...... 46 ivermectin tabs ...... 8 KEDRAB SOLN ...... 66 IXEMPRA KIT SOLR ...... 17 kelnor 1/35 tabs ...... 54 IXIARO SUSP ...... 67 kelnor 1/50 tabs ...... 54 KENALOG SUSP ...... 52

J KEPIVANCE SOLR ...... 71 JADENU SPRINKLE PACK 90mg, 180mg, keralyt sham ...... 72 360mg ...... 52 KESIMPTA SOAJ ...... 63 JADENU TABS 90mg, 360mg ...... 52 ketoconazole crea ...... 68 JAKAFI TABS 5mg, 10mg, 15mg, 20mg, ketoconazole foam ...... 68 25mg ...... 17 ketoconazole sham ...... 68 jantoven tabs 1mg, 2mg, 2.5mg, 3mg, 4mg, ketoconazole tabs ...... 11 5mg, 6mg, 7.5mg, 10mg ...... 24 ketodan foam ...... 68 JARDIANCE TABS 10mg, 25mg ...... 56 ketoprofen caps ...... 32 jasmiel tabs ...... 53 ketoprofen er cp24 ...... 32 JEMPERLI SOLN ...... 17 ketorolac tromethamine soln ...... 32, 48 JENTADUETO TABS ...... 56 ketorolac tromethamine soln 0.4%, 0.5% . 48 JENTADUETO XR TB24 ...... 56 ketorolac tromethamine tabs ...... 32 jinteli tabs ...... 57 KEVEYIS TABS ...... 63 JOLIVETTE TABS ...... 53 KEVZARA SOAJ 150mg/1.14ml, juleber tabs ...... 53 200mg/1.14ml ...... 61 JULUCA TABS ...... 13 KEVZARA SOSY 150mg/1.14ml, junel 1.5/30 tabs ...... 53 200mg/1.14ml ...... 61 junel 1/20 tabs ...... 54 KEYTRUDA SOLN ...... 17 junel fe 1.5/30 tabs ...... 54 KHAPZORY SOLR 175mg, 300mg ...... 60 junel fe 1/20 tabs ...... 54 KHEDEZLA TB24 50mg, 100mg ...... 41 junel fe 24 tabs ...... 54 KIMYRSA SOLR ...... 10

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KINERET SOSY ...... 61 lamotrigine er tb24 25mg, 50mg, 100mg, KINRIX SUSP ...... 67 200mg, 250mg, 300mg ...... 35 kionex susp ...... 45 lamotrigine kit ...... 35 KISQALI (200 MG DOSE) TBPK ...... 17 lamotrigine starter kit-blue kit ...... 35 KISQALI (400 MG DOSE) TBPK ...... 17 lamotrigine starter kit-green kit ...... 35 KISQALI (600 MG DOSE) TBPK ...... 18 lamotrigine starter kit-orange kit ...... 35 KISQALI FEMARA (200 MG DOSE) TBPK lamotrigine tabs 25mg, 100mg, 150mg, ...... 18 200mg ...... 35 KISQALI FEMARA (400 MG DOSE) TBPK lamotrigine tbdp 25mg, 50mg, 100mg, ...... 18 200mg ...... 35 KISQALI FEMARA (600 MG DOSE) TBPK LANOXIN PEDIATRIC SOLN ...... 28 ...... 18 LANOXIN TABS 62.5mcg ...... 28 KITABIS PAK NEBU ...... 65 lansoprazole cpdr 15mg, 30mg ...... 50 KLISYRI OINT ...... 72 lansoprazole tbdd 15mg, 30mg ...... 50 KLOR-CON 10 TBCR ...... 46 lanthanum carbonate chew 500mg, 750mg, klor-con m10 tbcr ...... 46 1000mg ...... 45 klor-con m15 tbcr ...... 46 LANTUS SOLN ...... 56 klor-con m20 tbcr ...... 46 LANTUS SOLOSTAR SOPN ...... 56 klor-con pack ...... 46 lapatinib ditosylate tabs ...... 18 klor-con sprinkle cpcr 8meq, 10meq ...... 46 larin 1.5/30 tabs ...... 54 KLOR-CON TBCR ...... 46 larin 1/20 tabs ...... 54 KORLYM TABS ...... 56 larin fe 1.5/30 tabs ...... 54 KOSELUGO CAPS 10mg, 25mg ...... 18 larin fe 1/20 tabs ...... 54 KRINTAFEL TABS ...... 12 larissia tabs ...... 54 kristalose pack 10gm, 20gm ...... 43 LARTRUVO SOLN 190mg/19ml, K-TAB TBCR ...... 45 500mg/50ml ...... 18 kurvelo tabs ...... 54 LASTACAFT SOLN ...... 48 KUVAN PACK 100mg, 500mg ...... 63 latanoprost soln ...... 49 KUVAN TABS ...... 63 LATUDA TABS 20mg, 40mg, 60mg, 80mg, KYNAMRO SOSY ...... 26 120mg ...... 41 KYNMOBI FILM 10mg, 15mg, 20mg, 25mg, LAYOLIS FE CHEW ...... 54 30mg ...... 37 LAZANDA SOLN 100mcg/act, 300mcg/act, KYPROLIS SOLR 10mg, 30mg, 60mg ..... 18 400mcg/act ...... 32 ledipasvir-sofosbuvir tabs ...... 13 L leena tabs ...... 54 labetalol hcl soln ...... 26 leflunomide tabs 10mg, 20mg ...... 61 labetalol hcl tabs 100mg, 200mg, 300mg . 26 LEMTRADA SOLN ...... 39 LACRISERT INST ...... 49 LENVIMA (10 MG DAILY DOSE) CPPK .. 18 LACTATED RINGERS SOLN ...... 46, 63 LENVIMA (12 MG DAILY DOSE) CPPK .. 18 LACTIC ACID LOTN ...... 72 LENVIMA (14 MG DAILY DOSE) CPPK .. 18 lactulose encephalopathy soln ...... 43 LENVIMA (18 MG DAILY DOSE) CPPK .. 18 lactulose pack ...... 43 LENVIMA (20 MG DAILY DOSE) CPPK .. 18 lactulose soln ...... 43 LENVIMA (24 MG DAILY DOSE) CPPK .. 18 LAMICTAL XR KIT ...... 35 LENVIMA (4 MG DAILY DOSE) CPPK .... 18 lamivudine soln ...... 13 LENVIMA (8 MG DAILY DOSE) CPPK .... 18 lamivudine tabs 100mg, 150mg, 300mg ... 13 lessina tabs ...... 54 lamivudine-zidovudine tabs ...... 13 LETAIRIS TABS 5mg, 10mg ...... 65 lamotrigine chew 5mg, 25mg ...... 35 letrozole tabs ...... 18 leucovorin calcium soln ...... 60

96 • Kaiser Permanente 2021 Comprehensive Formulary

leucovorin calcium solr ...... 60 LEVOXYL TABS 25mcg, 50mcg, 75mcg, leucovorin calcium tabs 5mg, 10mg, 15mg, 88mcg, 100mcg, 112mcg, 125mcg, 25mg ...... 60 137mcg, 150mcg, 175mcg, 200mcg ..... 59 LEUKERAN TABS ...... 18 LEXETTE FOAM ...... 70 LEUKINE SOLR ...... 24 LEXIVA SUSP ...... 13 leuprolide acetate kit ...... 18 LIALDA TBEC ...... 49 levalbuterol hcl nebu 1.25mg/0.5ml, LIBTAYO SOLN ...... 18 0.31mg/3ml, 0.63mg/3ml, 1.25mg/3ml . 23 lidocaine hcl (cardiac) pf sosy ...... 28 levalbuterol tartrate aero ...... 23 lidocaine hcl (cardiac) sosy ...... 28 LEVEMIR FLEXTOUCH SOPN ...... 56 lidocaine hcl (pf) soln ...... 63 LEVEMIR SOLN ...... 56 LIDOCAINE HCL CREA ...... 71 levetiracetam er tb24 500mg, 750mg ...... 35 lidocaine hcl lotn ...... 71 levetiracetam in nacl soln ...... 36 lidocaine hcl soln ...... 49, 63, 71 levetiracetam soln ...... 36 lidocaine hcl urethral/mucosal gel ...... 71 levetiracetam tabs 250mg, 500mg, 750mg, lidocaine hcl urethral/mucosal prsy ...... 71 1000mg ...... 36 LIDOCAINE IN D5W SOLN ...... 28 levobunolol hcl soln ...... 49 lidocaine in dextrose soln ...... 63 levocarnitine soln ...... 63 lidocaine oint ...... 71 LEVOCARNITINE TABS ...... 63 lidocaine ptch ...... 71 levocetirizine dihydrochloride soln ...... 15 lidocaine viscous hcl soln ...... 49 levocetirizine dihydrochloride tabs ...... 15 lidocaine-epinephrine soln ...... 63 levofloxacin in d5w soln ...... 10 LIDOCAINE-HYDROCORT (PERIANAL) levofloxacin in d5w soln intravenous ...... 10 CREA ...... 71 levofloxacin soln ...... 10, 47 LIDOCAINE-HYDROCORTISONE ACE KIT levofloxacin soln intravenous ...... 10 ...... 71 levofloxacin tabs ...... 10 lidocaine-prilocaine crea ...... 71 levoleucovorin calcium pf soln ...... 60 lidocaine-tetracaine crea ...... 71 levoleucovorin calcium solr ...... 60 LIDOCORT CREA ...... 71 levonest tabs ...... 54 lidopin crea ...... 71 levonorgest-eth est & eth est tabs ...... 54 LIDO-SORB LOTN ...... 71 levonorgest-eth estrad 91-day tabs ...... 54 LIDOZION LOTN ...... 71 levonorgestrel-ethinyl estrad tabs ...... 54 lincomycin hcl soln ...... 10 levonorg-eth estrad triphasic tabs ...... 54 lindane sham ...... 68 levora 0.15/30 (28) tabs ...... 54 linezolid soln intravenous ...... 10 levorphanol tartrate tabs 2mg, 3mg ...... 32 linezolid susr ...... 10 LEVO-T TABS 25mcg, 50mcg, 75mcg, linezolid tabs ...... 10 88mcg, 100mcg, 112mcg, 125mcg, LINZESS CAPS 72mcg, 145mcg, 290mcg 137mcg, 150mcg, 175mcg, 200mcg, ...... 51 300mcg ...... 59 liothyronine sodium soln ...... 60 levothyroxine sodium caps 13mcg, 25mcg, liothyronine sodium tabs 5mcg, 25mcg, 50mcg, 75mcg, 88mcg, 100mcg, 50mcg ...... 60 112mcg, 125mcg, 137mcg, 150mcg, LIPODOX 50 INJ ...... 18 175mcg, 200mcg ...... 59 lisinopril tabs 2.5mg, 5mg, 10mg, 20mg, LEVOTHYROXINE SODIUM SOLR ...... 59 30mg, 40mg ...... 29 levothyroxine sodium tabs 25mcg, 50mcg, lisinopril-hydrochlorothiazide tabs ...... 29 75mcg, 88mcg, 100mcg, 112mcg, LITHIUM CARBONATE CAPS 300mg, 125mcg, 137mcg, 150mcg, 175mcg, 150mg, 600mg ...... 41 200mcg, 300mcg ...... 59 lithium carbonate er tbcr 300mg, 450mg .. 41 lithium carbonate tabs ...... 41

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LITHIUM SOLN ...... 41 LUMIGAN SOLN ...... 49 LITHOSTAT TABS ...... 43 LUMIZYME SOLR ...... 46 LIVALO TABS 1mg, 2mg, 4mg ...... 26 LUMOXITI SOLR ...... 18 LO LOESTRIN FE TABS ...... 54 LUPANETA PACK KIT ...... 18 lodine tabs ...... 32 LUPKYNIS CAPS ...... 62 loestrin 1.5/30 (21) tabs ...... 54 LUPRON DEPOT (1-MONTH) KIT ...... 18 loestrin 1/20 (21) tabs ...... 54 LUPRON DEPOT (3-MONTH) KIT ...... 18 loestrin fe 1.5/30 tabs ...... 54 LUPRON DEPOT (4-MONTH) KIT ...... 18 loestrin fe 1/20 tabs ...... 54 LUPRON DEPOT (6-MONTH) KIT ...... 18 LOKELMA PACK 5gm, 10gm ...... 45 LUPRON DEPOT-PED (1-MONTH) KIT .. 18 LONHALA MAGNAIR REFILL KIT SOLN 21 LUPRON DEPOT-PED (1-MONTH) KIT 7.5 LONSURF TABS ...... 18 MG ...... 18 loperamide hcl caps ...... 50 LUPRON DEPOT-PED (3-MONTH) KIT .. 18 lopinavir-ritonavir soln ...... 13 lutera tabs ...... 54 lopinavir-ritonavir tabs ...... 13 LUZU CREA ...... 68 lopreeza tabs ...... 57 lyleq tabs...... 54 lorazepam intensol conc ...... 38 lyllana pttw 0.025mg/24hr, 0.0375mg/24hr, LORAZEPAM SOLN 4mg/ml, 2mg/ml ...... 38 0.05mg/24hr, 0.075mg/24hr, 0.1mg/24hr lorazepam tabs 0.5mg, 1mg, 2mg ...... 38 ...... 57 LORBRENA TABS 25mg, 100mg ...... 18 LYNPARZA CAPS ...... 18 lorcet hd tabs ...... 32 LYNPARZA TABS 100mg, 150mg ...... 18 lorcet plus tabs ...... 32 LYSODREN TABS ...... 18 lorcet tabs ...... 32 lyza tabs ...... 54 lortab elix ...... 32 loryna tabs ...... 54 M lorzone tabs 375mg, 750mg ...... 22 mafenide acetate pack ...... 68 losartan potassium tabs 25mg, 50mg, magnesium sulfate in d5w soln ...... 46 100mg ...... 29 magnesium sulfate soln ...... 36 losartan potassium-hctz tabs ...... 29 magnesium sulfate soln injection 50% ..... 36 LOTEMAX GEL ...... 48 MAGNESIUM SULFATE SOLN LOTEMAX OINT ...... 48 INTRAVENOUS 40gm/1000ml, LOTEMAX SUSP ...... 48 4gm/100ml, 20gm/500ml, 2gm/50ml .... 36 loteprednol etabonate susp ...... 48 MAKENA SOAJ ...... 58 lovastatin tabs 10mg, 20mg, 40mg ...... 26 malathion lotn ...... 68 LOVENOX SOLN 30mg/0.3ml, 40mg/0.4ml, MANNITOL SOLN ...... 45 60mg/0.6ml, 80mg/0.8ml, 120mg/0.8ml, maprotiline hcl tabs 25mg, 50mg, 75mg .. 41 300mg/3ml, 100mg/ml, 150mg/ml ...... 24 MARGENZA SOLN ...... 18 low-ogestrel tabs ...... 54 marlissa tabs ...... 54 loxapine succinate caps 5mg, 10mg, 25mg, MARPLAN TABS ...... 41 50mg ...... 41 MARQIBO SUSP ...... 18 lubiprostone caps 8mcg, 24mcg ...... 51 MATULANE CAPS ...... 18 LUCEMYRA TABS ...... 40 matzim la tb24 180mg, 240mg, 300mg, LUCENTIS SOLN 0.3mg/0.05ml, 360mg, 420mg ...... 27 0.5mg/0.05ml ...... 49 MAVENCLAD (10 TABS) TBPK ...... 62 LUCENTIS SOSY 0.3mg/0.05ml, MAVENCLAD (4 TABS) TBPK ...... 62 0.5mg/0.05ml ...... 49 MAVENCLAD (5 TABS) TBPK ...... 62 LUDENT CHEW 0.25mg, 0.5mg, 1mg ..... 63 MAVENCLAD (6 TABS) TBPK ...... 62 LULICONAZOLE CREA ...... 68 MAVENCLAD (7 TABS) TBPK ...... 62 LUMAKRAS TABS...... 18 MAVENCLAD (8 TABS) TBPK ...... 62

98 • Kaiser Permanente 2021 Comprehensive Formulary

MAVENCLAD (9 TABS) TBPK ...... 62 metadate er tbcr ...... 34 MAVYRET TABS ...... 13 metaproterenol sulfate syrp ...... 23 MAXIDEX SUSP ...... 48 metaproterenol sulfate tabs 10mg, 20mg . 23 MAYZENT STARTER PACK TBPK ...... 39 metaxall tabs ...... 22 MAYZENT TABS 0.25mg, 2mg ...... 39 metaxalone tabs ...... 22 ME/NAPHOS/MB/HYO1 TABS ...... 14 metformin hcl er tb24 500mg, 750mg ...... 56 meclizine hcl tabs ...... 50 metformin hcl tabs 500mg, 850mg, 1000mg meclofenamate sodium caps ...... 32 ...... 56 MEDROL TABS ...... 52 methadone hcl conc ...... 32 medroxyprogesterone acetate susp ...... 58 methadone hcl intensol conc ...... 32 medroxyprogesterone acetate susy ...... 58 methadone hcl soln 5mg/5ml, 10mg/5ml, medroxyprogesterone acetate tabs 2.5mg, 10mg/ml ...... 32 5mg, 10mg ...... 58 methadone hcl tabs 5mg, 10mg ...... 32 mefenamic acid caps ...... 32 methamphetamine hcl tabs ...... 34 mefloquine hcl tabs ...... 12 methazolamide tabs 25mg, 50mg ...... 49 megestrol acetate susp ...... 18, 58 methenamine hippurate tabs ...... 15 megestrol acetate tabs ...... 18 METHENAMINE MANDELATE TABS...... 15 MEKINIST TABS 0.5mg, 2mg ...... 18 methergine tabs ...... 58 MEKTOVI TABS ...... 18 methimazole tabs 5mg, 10mg ...... 60 melodetta 24 fe chew ...... 54 methitest tabs ...... 53 meloxicam caps ...... 32 methocarbamol soln ...... 22 meloxicam tabs ...... 32 methocarbamol tabs ...... 22 melphalan hcl solr ...... 18 methotrexate sodium (pf) soln ...... 18 memantine hcl er cp24 ...... 39 methotrexate sodium soln ...... 18 memantine hcl soln ...... 39 methotrexate sodium solr ...... 18 memantine hcl tabs 5mg, 10mg ...... 39 methotrexate tabs ...... 18 MENACTRA INJ ...... 67 methoxsalen rapid caps ...... 72 menest tabs 0.3mg, 0.625mg, 1.25mg ..... 57 methscopolamine bromide tabs 2.5mg, 5mg MENOSTAR PTWK ...... 57 ...... 21 MENQUADFI INJ ...... 67 methyclothiazide tabs ...... 45 MENTAX CREA ...... 68 methyldopa tabs 250mg, 500mg ...... 29 MENVEO SOLR ...... 67 methyldopa-hydrochlorothiazide tabs ...... 29 meperidine hcl soln 50mg/5ml, 25mg/ml, methylergonovine maleate soln ...... 58 50mg/ml, 100mg/ml ...... 32 methylergonovine maleate tabs ...... 58 meperidine hcl tabs 50mg, 100mg ...... 32 methylphenidate hcl chew 2.5mg, 5mg, meprobamate tabs ...... 38 10mg ...... 34 mercaptopurine tabs ...... 18 methylphenidate hcl er (cd) cpcr 10mg, meropenem solr intravenous 1gm, 500mg 20mg, 30mg, 40mg, 50mg, 60mg ...... 34 ...... 10 methylphenidate hcl er (la) cp24 10mg, merzee caps ...... 54 20mg, 30mg, 40mg, 60mg ...... 34 mesalamine cpdr ...... 49 methylphenidate hcl er (xr) cp24 10mg, mesalamine enem ...... 49 15mg, 20mg, 30mg, 40mg, 50mg, 60mg mesalamine er cp24 ...... 49 ...... 34 mesalamine supp ...... 49 methylphenidate hcl er tb24 18mg, 27mg, mesalamine tbec 1.2gm, 800mg ...... 49 36mg, 54mg ...... 34 mesalamine-cleanser kit ...... 49 methylphenidate hcl er tbcr 10mg, 18mg, mesna soln ...... 63 20mg, 27mg, 36mg, 54mg, 72mg ...... 34 MESNEX TABS ...... 63 methylphenidate hcl soln 5mg/5ml, MESTINON SOLN ...... 22 10mg/5ml ...... 34

Kaiser Permanente 2021 Comprehensive Formulary • 99

methylphenidate hcl tabs 5mg, 10mg, 20mg milrinone lactate in dextrose soln ...... 28 ...... 34 milrinone lactate soln ...... 28 methylprednisolone acetate susp ...... 52 mimvey lo tabs ...... 57 methylprednisolone sodium succ solr ...... 52 mimvey tabs ...... 57 methylprednisolone tabs 4mg, 8mg, 16mg, minitran pt24 0.1mg/hr, 0.2mg/hr, 0.4mg/hr, 32mg ...... 52 0.6mg/hr ...... 30 methylprednisolone tbpk ...... 52 minocycline hcl caps 50mg, 75mg, 100mg methyltestosterone caps ...... 53 ...... 10 metoclopramide hcl soln ...... 51 minocycline hcl er tb24 45mg, 55mg, 65mg, metoclopramide hcl tabs 5mg, 10mg ...... 51 80mg, 90mg, 105mg, 115mg, 135mg ... 10 metoclopramide hcl tbdp 5mg, 10mg ...... 51 minocycline hcl tabs 50mg, 75mg, 100mg 10 metolazone tabs 2.5mg, 5mg, 10mg ...... 45 minoxidil tabs 2.5mg, 10mg ...... 29 metoprolol succinate er tb24 25mg, 50mg, MIRCERA SOSY 30mcg/0.3ml, 100mg, 200mg ...... 26 50mcg/0.3ml, 75mcg/0.3ml, metoprolol tartrate soct ...... 27 100mcg/0.3ml, 150mcg/0.3ml, metoprolol tartrate soln ...... 27 200mcg/0.3ml ...... 25 metoprolol tartrate tabs 25mg, 50mg, mirtazapine tabs 7.5mg, 15mg, 30mg, 100mg ...... 27 45mg ...... 41 metoprolol tartrate tabs 37.5mg, 75mg ..... 27 mirtazapine tbdp 15mg, 30mg, 45mg ...... 42 metoprolol-hydrochlorothiazide tabs ...... 27 misoprostol tabs 100mcg, 200mcg ...... 50 metronidazole caps...... 12 MITIGARE CAPS ...... 60 metronidazole crea ...... 68 mitigo soln...... 32 metronidazole gel ...... 68 mitomycin solr ...... 18 metronidazole in nacl soln ...... 12 mitoxantrone hcl conc ...... 18 metronidazole in nacl soln intravenous .... 12 M-M-R II SOLR ...... 67 metronidazole lotn ...... 68 modafinil tabs 100mg, 200mg ...... 34 metronidazole tabs ...... 12 moexipril hcl tabs 7.5mg, 15mg ...... 29 metyrosine caps ...... 25 molindone hcl tabs 5mg, 10mg, 25mg ..... 42 mexiletine hcl caps 150mg, 200mg, 250mg mometasone furoate crea ...... 70 ...... 28 mometasone furoate oint ...... 70 mibelas 24 fe chew ...... 54 mometasone furoate soln ...... 70 micafungin sodium solr intravenous 50mg, mometasone furoate susp ...... 48 100mg ...... 11 mondoxyne nl caps 75mg, 100mg...... 10 miconazole 3 supp ...... 68 MONJUVI SOLR ...... 18 miconazole-zinc oxide-petrolat oint ...... 68 MONONESSA TABS ...... 54 micort-hc crea ...... 70 montelukast sodium chew 4mg, 5mg ...... 64 microgestin 1.5/30 tabs ...... 54 montelukast sodium pack ...... 64 microgestin 1/20 tabs ...... 54 montelukast sodium tabs ...... 64 microgestin fe 1.5/30 tabs ...... 54 morgidox caps ...... 10 microgestin fe 1/20 tabs ...... 54 MORPHINE SULFATE (CONCENTRATE) midazolam hcl (pf) soln ...... 38 SOLN ...... 32 midazolam hcl soln ...... 38 morphine sulfate (pf) soln 4mg/ml, 10mg/ml midazolam hcl syrp ...... 38 ...... 32 midodrine hcl tabs 2.5mg, 5mg, 10mg ..... 23 MORPHINE SULFATE (PF) SOLN miglitol tabs 25mg, 50mg, 100mg ...... 56 INTRAVENOUS ...... 32 miglustat caps ...... 47 morphine sulfate er beads cp24 30mg, mili tabs ...... 54 45mg, 60mg, 75mg, 90mg, 120mg ...... 32 millipred dp tbpk ...... 52 millipred tabs ...... 52

100 • Kaiser Permanente 2021 Comprehensive Formulary

morphine sulfate er cp24 10mg, 20mg, N-ACETYL-L-CYSTEINE CAPS ...... 44 30mg, 40mg, 50mg, 60mg, 80mg, 100mg nadolol tabs 20mg, 40mg, 80mg ...... 27 ...... 32 nadolol-bendroflumethiazide tabs...... 27 morphine sulfate er tbcr 15mg, 30mg, nafcillin sodium solr ...... 10 60mg, 100mg, 200mg ...... 32 nafcillin sodium solr injection ...... 10 MORPHINE SULFATE SOLN ...... 32 nafcillin sodium solr intravenous ...... 10 MORPHINE SULFATE SOLN 10mg/5ml, NAFRINSE CHEW ...... 63 20mg/5ml ...... 32 NAFRINSE DROPS SOLN ...... 63 MORPHINE SULFATE SOLN INJECTION naftifine hcl crea ...... 68 2mg/ml, 4mg/ml, 10mg/ml...... 32 naftifine hcl gel ...... 68 MORPHINE SULFATE SOLN NAFTIN GEL ...... 68 INTRAVENOUS ...... 32 NAGLAZYME SOLN ...... 47 morphine sulfate tabs 15mg, 30mg ...... 32 nalbuphine hcl soln ...... 32 MOVANTIK TABS 12.5mg, 25mg ...... 51 nalfon tabs ...... 32 MOXEZA SOLN ...... 47 nalocet tabs ...... 32 moxifloxacin hcl (2x day) soln ...... 47 naloxone hcl soaj ...... 40 moxifloxacin hcl in nacl soln intravenous .. 10 naloxone hcl soct ...... 40 moxifloxacin hcl soln ...... 47 naloxone hcl soln ...... 40 moxifloxacin hcl tabs...... 10 naloxone hcl sosy ...... 40 MULPLETA TABS ...... 25 naltrexone hcl tabs ...... 40 MULTAQ TABS ...... 28 NAMENDA XR TITRATION PACK CP24 . 39 MULTIVITAMIN/FLUORIDE CHEW ...... 74 NAPRELAN TB24 ...... 32 MULTI-VITAMIN/FLUORIDE SOLN ...... 74 naproxen sodium er tb24 ...... 32 MULTI-VITAMIN/FLUORIDE/IRON SOLN naproxen sodium tabs ...... 32 ...... 74 naproxen susp ...... 32 mupirocin calcium crea ...... 68 naproxen tabs ...... 32 mupirocin oint ...... 68 naproxen tbec ...... 32 MUSTARGEN SOLR ...... 18 naproxen-esomeprazole tbec ...... 32 mutamycin solr ...... 18 naratriptan hcl tabs ...... 37 MVASI SOLN 400mg/16ml, 100mg/4ml ... 18 NARCAN LIQD ...... 40 MVC-FLUORIDE CHEW ...... 74 NATACYN SUSP ...... 47 MYALEPT SOLR ...... 63 NATAZIA TABS ...... 54 MYCAPSSA CPDR ...... 59 nateglinide tabs 60mg, 120mg ...... 56 mycophenolate mofetil caps ...... 62 NATPARA CART 25mcg, 50mcg, 75mcg, mycophenolate mofetil hcl solr ...... 62 100mcg ...... 58 mycophenolate mofetil susr ...... 62 NATROBA SUSP ...... 68 mycophenolate mofetil tabs ...... 62 NAYZILAM SOLN ...... 36 mycophenolate sodium tbec 180mg, 360mg NEBUPENT SOLR ...... 12 ...... 62 necon 0.5/35 (28) tabs ...... 54 MYDAYIS CP24 ...... 34 NECON 7/7/7 TABS ...... 54 MYFEMBREE TABS ...... 58 nefazodone hcl tabs 50mg, 100mg, 150mg, MYLOTARG SOLR ...... 18 200mg, 250mg ...... 42 myorisan caps 10mg, 20mg, 30mg, 40mg 72 nembutal soln ...... 38 MYRBETRIQ TB24 25mg, 50mg ...... 73 neomycin sulfate tabs ...... 10 MYTESI TBEC ...... 50 neomycin-bacitracin zn-polymyx oint...... 47 neomycin-polymyxin b gu soln ...... 68 N neomycin-polymyxin-dexameth oint ...... 48 NABI-HB SOLN ...... 66 neomycin-polymyxin-dexameth susp ...... 48 nabumetone tabs ...... 32 neomycin-polymyxin-gramicidin soln ...... 47

Kaiser Permanente 2021 Comprehensive Formulary • 101

neomycin-polymyxin-hc soln ...... 48 nitropress soln ...... 29 neomycin-polymyxin-hc susp ...... 48 nitroprusside sodium soln ...... 29 neo-polycin hc oint ...... 48 NITYR TABS 2mg, 5mg, 10mg ...... 63 neo-polycin oint ...... 47 NIVESTYM SOLN 480mcg/1.6ml, neo-synalar crea ...... 70 300mcg/ml ...... 25 NEPHRAMINE SOLN INTRAVENOUS .... 44 NIVESTYM SOSY 300mcg/0.5ml, NERLYNX TABS ...... 18 480mcg/0.8ml ...... 25 NEULASTA ONPRO PSKT ...... 25 nizatidine caps 150mg, 300mg ...... 50 NEULASTA SOSY ...... 25 nizatidine soln ...... 50 NEUPOGEN SOLN 480mcg/1.6ml, NOCDURNA SUBL 27.7mcg, 55.3mcg .... 58 300mcg/ml ...... 25 NOCTIVA EMUL 0.83mcg/0.1ml, NEUPOGEN SOSY 300mcg/0.5ml, 1.66mcg/0.1ml ...... 58 480mcg/0.8ml ...... 25 nolix crea ...... 70 NEVANAC SUSP ...... 48 nolix lotn ...... 70 nevirapine er tb24 100mg, 400mg ...... 13 nora-be tabs ...... 54 nevirapine susp ...... 13 norco tabs ...... 32 nevirapine tabs ...... 13 NORDITROPIN FLEXPRO SOPN NEXAVAR TABS ...... 18 5mg/1.5ml, 10mg/1.5ml, 15mg/1.5ml, NEXVIAZYME SOLR ...... 47 30mg/3ml ...... 59 niacin er (antihyperlipidemic) tbcr 500mg, norepinephrine bitartrate soln ...... 23 750mg, 1000mg ...... 26 norethin ace-eth estrad-fe caps ...... 54 niacor tabs ...... 26 norethin ace-eth estrad-fe chew ...... 54 nicardipine hcl caps 20mg, 30mg ...... 27 norethin ace-eth estrad-fe tabs ...... 54 nicardipine hcl soln ...... 27 norethindrone acetate tabs ...... 58 NICOTROL INHA ...... 21 norethindrone acet-ethinyl est tabs ...... 54 NICOTROL NS SOLN ...... 21 norethindrone tabs ...... 54 nifedipine caps 10mg, 20mg ...... 27 norethindrone-eth estradiol tabs ...... 57 nifedipine er osmotic release tb24 30mg, norethin-eth estradiol-fe chew ...... 54 60mg, 90mg ...... 27 norgesic forte tabs ...... 32 nifedipine er tb24 30mg, 60mg, 90mg ...... 27 norgestimate-eth estradiol tabs ...... 54 nikki tabs ...... 54 norgestim-eth estrad triphasic tabs ...... 54 nilutamide tabs ...... 18 norlyroc tabs ...... 54 nimodipine caps ...... 27 NORMOSOL-M IN D5W SOLN NINLARO CAPS 2.3mg, 3mg, 4mg ...... 19 INTRAVENOUS ...... 46 nisoldipine er tb24 8.5mg, 17mg, 20mg, NORMOSOL-R IN D5W SOLN 25.5mg, 30mg, 34mg, 40mg ...... 27 INTRAVENOUS ...... 46 nitazoxanide tabs ...... 12 NORMOSOL-R SOLN INTRAVENOUS ... 46 nitisinone caps 2mg, 5mg, 10mg ...... 63 NORPACE CR CP12 100mg, 150mg...... 28 nitro-bid oint ...... 30 nortrel 0.5/35 (28) tabs ...... 54 NITRO-DUR PT24 0.3mg/hr, 0.8mg/hr .... 30 nortrel 1/35 (21) tabs ...... 54 NITROFURANTOIN MACROCRYSTAL nortrel 1/35 (28) tabs ...... 54 CAPS ...... 15 nortrel 7/7/7 tabs ...... 54 NITROFURANTOIN MONOHYD MACRO nortriptyline hcl caps 10mg, 25mg, 50mg, CAPS ...... 15 75mg ...... 42 nitrofurantoin susp ...... 15 nortriptyline hcl soln ...... 42 nitroglycerin pt24 0.1mg/hr, 0.2mg/hr, NORVIR CAPS ...... 13 0.4mg/hr, 0.6mg/hr ...... 30 NORVIR PACK ...... 13 nitroglycerin soln ...... 30 NORVIR SOLN ...... 13 nitroglycerin subl 0.3mg, 0.4mg, 0.6mg .... 30 NOURIANZ TABS 20mg, 40mg ...... 39

102 • Kaiser Permanente 2021 Comprehensive Formulary

NOVAREL SOLR 5000unit, 10000unit ..... 58 NYVEPRIA SOSY ...... 25 NOVOLIN 70/30 SUSP ...... 56 NOVOLOG 70/30 FLEXPEN RELION O SUPN ...... 56 OCALIVA TABS 5mg, 10mg ...... 51 NOVOLOG FLEXPEN RELION SOPN .... 56 ocella tabs...... 54 NOVOLOG FLEXPEN SOPN ...... 56 OCREVUS SOLN ...... 39 NOVOLOG MIX 70/30 FLEXPEN SUPN .. 56 OCTAGAM SOLN INTRAVENOUS NOVOLOG MIX 70/30 RELION SUSP ..... 56 5gm/100ml, 1gm/20ml, 2gm/20ml, NOVOLOG MIX 70/30 SUSP ...... 56 25gm/500ml ...... 66 NOVOLOG PENFILL SOCT ...... 56 octreotide acetate soln ...... 59 NOVOLOG RELION SOLN ...... 56 ODACTRA SUBL ...... 63 NOVOLOG SOLN ...... 56 ODEFSEY TABS ...... 13 NOXAFIL SUSP ...... 11 ODOMZO CAPS ...... 19 NOXAFIL TBEC ...... 11 OFEV CAPS 100mg, 150mg ...... 65 NPLATE SOLR ...... 25 ofloxacin soln ...... 47 NUBEQA TABS ...... 19 ofloxacin tabs ...... 10 NUCALA SOAJ ...... 64 ogestrel tabs ...... 54 NUCALA SOLR ...... 64 OGIVRI SOLR ...... 19 NUCALA SOSY ...... 64 okebo caps ...... 10 NUCYNTA ER TB12 200mg, 250mg ...... 33 olanzapine solr ...... 42 NUCYNTA ER TB12 50mg, 100mg, 150mg olanzapine tabs 2.5mg, 5mg, 7.5mg, 10mg, ...... 32 15mg, 20mg ...... 42 NUCYNTA TABS ...... 33 olanzapine tbdp 5mg, 10mg, 15mg, 20mg NUCYNTA TABS 50mg, 75mg ...... 33 ...... 42 NUEDEXTA CAPS ...... 39 olanzapine-fluoxetine hcl caps ...... 42 NULIBRY SOLR ...... 63 olmesartan medoxomil tabs 5mg, 20mg, NULOJIX SOLR ...... 62 40mg ...... 29 NUPLAZID CAPS ...... 42 olmesartan medoxomil-hctz tabs ...... 29 NUPLAZID TABS 10mg, 17mg ...... 42 olmesartan-amlodipine-hctz tabs ...... 28 NURTEC TBDP ...... 37 olopatadine hcl soln 0.1%, 0.2%, 0.6% .... 48 NUTRILIPID EMUL INTRAVENOUS ...... 44 OLUMIANT TABS 1mg, 2mg ...... 61 NUTROPIN AQ NUSPIN 10 SOPN ...... 59 OLYSIO CAPS ...... 13 NUTROPIN AQ NUSPIN 20 SOPN ...... 59 OMECLAMOX-PAK MISC ...... 50 NUTROPIN AQ NUSPIN 5 SOPN ...... 59 omega-3-acid ethyl esters caps ...... 26 NUVARING RING ...... 54 omeprazole cpdr 10mg, 20mg, 40mg ...... 50 NUZYRA SOLR ...... 10 omeprazole-sodium bicarbonate caps...... 50 NUZYRA TABS ...... 10 omeprazole-sodium bicarbonate pack ..... 50 nyamyc powd ...... 68 OMNARIS SUSP ...... 48 nylia 7/7/7 tabs ...... 54 OMNIPOD STARTER KIT ...... 43 NYMALIZE SOLN 60mg/20ml, 6mg/ml .... 28 OMNITROPE SOCT 5mg/1.5ml, nymyo tabs ...... 54 10mg/1.5ml ...... 59 nystatin crea ...... 68 OMNITROPE SOLR ...... 59 nystatin oint ...... 68 ondansetron hcl soln ...... 50 nystatin powd ...... 68 ondansetron hcl tabs 4mg, 8mg, 24mg .... 50 nystatin susp ...... 11 ondansetron tbdp 4mg, 8mg ...... 50 nystatin tabs ...... 11 ONIVYDE INJ ...... 19 nystatin-triamcinolone crea ...... 70 ONPATTRO SOLN ...... 63 nystatin-triamcinolone oint ...... 70 ONTRUZANT SOLR 150mg, 420mg ...... 19 nystop powd ...... 68 ONUREG TABS 200mg, 300mg ...... 19

Kaiser Permanente 2021 Comprehensive Formulary • 103

ONZETRA XSAIL EXHP ...... 37 oxaprozin tabs ...... 33 OPDIVO SOLN 100mg/10ml, 240mg/24ml, OXAYDO TABS ...... 33 40mg/4ml ...... 19 oxazepam caps 10mg, 15mg, 30mg ...... 38 OPIUM TINC ...... 50 OXBRYTA TABS ...... 23 ORACEA CPDR ...... 72 oxcarbazepine susp ...... 36 ORALAIR SUBL ...... 63 oxcarbazepine tabs 150mg, 300mg, 600mg oralone pste ...... 70 ...... 36 ORAVIG TABS ...... 68 OXERVATE SOLN ...... 49 ORBACTIV SOLR ...... 10 oxiconazole nitrate crea ...... 68 ORENCIA CLICKJECT SOAJ ...... 61 OXISTAT LOTN ...... 68 ORENCIA SOLR ...... 61 OXLUMO SOLN ...... 63 ORENCIA SOSY 50mg/0.4ml, OXTELLAR XR TB24 150mg, 300mg, 87.5mg/0.7ml, 125mg/ml ...... 61 600mg ...... 36 ORENITRAM TBCR 0.125mg ...... 65 oxybutynin chloride er tb24 5mg, 10mg, ORENITRAM TBCR 0.25mg, 1mg, 2.5mg, 15mg ...... 73 5mg ...... 65 oxybutynin chloride syrp ...... 73 ORFADIN CAPS ...... 63 oxybutynin chloride tabs ...... 73 ORFADIN SUSP ...... 63 oxycodone hcl caps ...... 33 ORGOVYX TABS ...... 58 oxycodone hcl conc ...... 33 ORIAHNN CPPK ...... 57 oxycodone hcl er t12a 10mg, 15mg, 20mg, ORILISSA TABS 150mg, 200mg ...... 58 30mg, 40mg, 60mg, 80mg ...... 33 ORKAMBI PACK ...... 65 oxycodone hcl soln ...... 33 ORKAMBI TABS ...... 65 oxycodone hcl tabs 5mg, 10mg, 15mg, ORLADEYO CAPS 110mg, 150mg ...... 63 20mg, 30mg ...... 33 orphenadrine citrate er tb12 ...... 22 oxycodone-acetaminophen soln ...... 33 orphenadrine citrate soln ...... 22 oxycodone-acetaminophen tabs ...... 33 orphenadrine-aspirin-caffeine tabs ...... 33 oxycodone-acetaminophen tabs 5-300mg, orphengesic forte tabs ...... 33 10-300mg ...... 33 orsythia tabs ...... 54 oxycodone-aspirin tabs ...... 33 ORTIKOS CP24 6mg, 9mg ...... 52 oxycodone-ibuprofen tabs ...... 33 oseltamivir phosphate caps 30mg, 45mg, OXYCONTIN T12A 10mg, 15mg, 20mg, 75mg ...... 13 30mg, 40mg, 60mg, 80mg ...... 33 oseltamivir phosphate susr ...... 13 oxymorphone hcl er tb12 5mg, 7.5mg, OSMITROL SOLN ...... 45 10mg, 15mg, 20mg, 30mg, 40mg ...... 33 OSMOPREP TABS...... 51 oxymorphone hcl tabs 5mg, 10mg ...... 33 OSPHENA TABS ...... 57 OXYTOCIN SOLN ...... 58 OTEZLA TABS ...... 61 OZEMPIC (0.25 OR 0.5 MG/DOSE) SOPN OTEZLA TBPK ...... 61 ...... 56 OTOVEL SOLN ...... 47 OZEMPIC (1 MG/DOSE) SOPN 2mg/1.5ml, OTREXUP SOAJ ...... 61 4mg/3ml ...... 56 ovide lotn ...... 68 OXACILLIN SODIUM IN DEXTROSE SOLN P INTRAVENOUS ...... 10 pacerone tabs 100mg, 200mg, 400mg ..... 28 oxacillin sodium solr injection 1gm, 2gm .. 10 paclitaxel conc ...... 19 oxacillin sodium solr intravenous ...... 10 PADCEV SOLR 20mg, 30mg ...... 19 oxaliplatin soln ...... 19 PALFORZIA (12 MG DAILY DOSE) CSPK oxaliplatin solr ...... 19 ...... 63 oxandrolone tabs ...... 53 PALFORZIA (120 MG DAILY DOSE) CSPK oxandrolone tabs 2.5mg ...... 53 ...... 63

104 • Kaiser Permanente 2021 Comprehensive Formulary

PALFORZIA (160 MG DAILY DOSE) CSPK PAXIL SUSP ...... 42 ...... 63 PEDIARIX SUSP ...... 67 PALFORZIA (20 MG DAILY DOSE) CSPK PEDVAX HIB SUSP ...... 67 ...... 63 peg 3350/electrolytes solr ...... 51 PALFORZIA (200 MG DAILY DOSE) CSPK peg 3350-kcl-na bicarb-nacl solr ...... 51 ...... 63 peg-3350/electrolytes solr ...... 51 PALFORZIA (240 MG DAILY DOSE) CSPK PEGANONE TABS ...... 36 ...... 63 PEGASYS PROCLICK SOLN PALFORZIA (3 MG DAILY DOSE) CSPK 63 135mcg/0.5ml, 180mcg/0.5ml ...... 13 PALFORZIA (300 MG MAINTENANCE) PEGASYS SOLN 180mcg/0.5ml, PACK ...... 63 180mcg/ml ...... 13 PALFORZIA (300 MG TITRATION) PACK PEGINTRON KIT ...... 13 ...... 63 PEG-INTRON REDIPEN KIT ...... 13 PALFORZIA (40 MG DAILY DOSE) CSPK PEG-PREP KIT ...... 51 ...... 63 PEMAZYRE TABS 4.5mg, 9mg, 13.5mg . 19 PALFORZIA (6 MG DAILY DOSE) CSPK 63 penicillamine caps ...... 52 PALFORZIA (80 MG DAILY DOSE) CSPK penicillamine tabs ...... 52 ...... 63 PENICILLIN G POT IN DEXTROSE SOLN PALFORZIA INITIAL ESCALATION CSPK INTRAVENOUS ...... 10 ...... 64 penicillin g potassium solr injection ...... 10 PALIPERIDONE ER TB24 1.5mg, 3mg, penicillin g procaine susp ...... 10 6mg, 9mg ...... 42 penicillin g sodium solr injection ...... 10 palonosetron hcl soln ...... 50 penicillin v potassium solr ...... 10 palonosetron hcl sosy ...... 50 penicillin v potassium tabs ...... 10 PALYNZIQ SOSY 2.5mg/0.5ml, pentamidine isethionate inh ...... 12 10mg/0.5ml, 20mg/ml ...... 47 pentamidine isethionate inj ...... 12 pamidronate disodium soln ...... 60 PENTASA CPCR 250mg, 500mg ...... 49 pamidronate disodium solr ...... 60 pentazocine-naloxone hcl tabs ...... 33 PANCREAZE CPEP ...... 47 pentobarbital sodium soln ...... 38 PANDEL CREA ...... 70 pentoxifylline er tbcr ...... 24 panlor tabs ...... 33 PEPAXTO SOLR ...... 19 PANRETIN GEL ...... 71 pepcid tabs 20mg, 40mg ...... 50 pantoprazole sodium pack ...... 50 percocet tabs ...... 33 PANTOPRAZOLE SODIUM SOLR ...... 50 perindopril erbumine tabs 2mg, 4mg, 8mg pantoprazole sodium tbec 20mg, 40mg ... 50 ...... 29 PANZYGA SOLN INTRAVENOUS periogard soln ...... 47 10gm/100ml, 1gm/10ml, 20gm/200ml, PERJETA SOLN ...... 19 2.5gm/25ml, 30gm/300ml, 5gm/50ml ... 66 permethrin crea ...... 68 paraplatin soln ...... 19 perphenazine tabs 2mg, 4mg, 8mg, 16mg paricalcitol caps 1mcg, 2mcg, 4mcg ...... 74 ...... 42 PARICALCITOL SOLN ...... 74 perphenazine-amitriptyline tabs ...... 42 paroex soln ...... 47 PERSERIS PRSY 90mg, 120mg ...... 42 paromomycin sulfate caps ...... 12 PERTZYE CPEP ...... 47 paroxetine hcl er tb24 12.5mg, 25mg, PEXEVA TABS 10mg, 20mg, 30mg, 40mg 37.5mg ...... 42 ...... 42 paroxetine hcl tabs 10mg, 20mg ...... 42 phenadoz supp ...... 15 paroxetine hcl tabs 30mg, 40mg ...... 42 phenazo tabs ...... 71 paroxetine mesylate caps ...... 42 PHENAZOPYRIDINE HCL TABS ...... 71 paser pack ...... 12 phenelzine sulfate tabs ...... 42

Kaiser Permanente 2021 Comprehensive Formulary • 105

phenergan soln ...... 15 polocaine soln ...... 64 PHENOBARBITAL ELIX ...... 38 polocaine-mpf soln ...... 64 PHENOBARBITAL SODIUM SOLN ...... 38 polycin oint ...... 47 PHENOBARBITAL TABS ...... 38 polymyxin b sulfate solr injection ...... 10 phenoxybenzamine hcl caps ...... 22 polymyxin b-trimethoprim soln ...... 47 phenylephrine hcl soln ...... 23 POMALYST CAPS 1mg, 2mg, 3mg, 4mg 19 PHENYLEPHRINE HCL SOLN ...... 49 PONVORY STARTER PACK TBPK...... 39 phenytek caps 200mg, 300mg ...... 36 PONVORY TABS ...... 39 phenytoin chew ...... 36 portia-28 tabs ...... 54 phenytoin sodium extended caps 100mg, PORTRAZZA SOLN ...... 19 200mg, 300mg ...... 36 POSACONAZOLE SUSP ...... 11 phenytoin sodium soln ...... 36 posaconazole tbec ...... 11 phenytoin susp ...... 36 POT & SOD CIT-CIT AC SOLN ...... 43 PHESGO SOLN ...... 19 POTASSIUM ACETATE SOLN ...... 46 PHOSLYRA SOLN ...... 46 potassium chloride crys er tbcr 10meq, PHOSPHASAL TABS ...... 15 20meq ...... 46 PHOSPHOLINE IODIDE SOLR ...... 49 potassium chloride er cpcr 8meq, 10meq 46 phrenilin forte caps ...... 33 POTASSIUM CHLORIDE ER TBCR 8meq, PHYSIOLYTE SOLN ...... 64 10meq, 20meq ...... 46 PHYSIOSOL IRRIGATION SOLN ...... 64 POTASSIUM CHLORIDE IN DEXTROSE PIFELTRO TABS ...... 13 SOLN INTRAVENOUS ...... 46 pilocarpine hcl soln 1%, 2%, 4% ...... 49 potassium chloride in nacl soln intravenous pilocarpine hcl tabs 5mg, 7.5mg ...... 22 ...... 46 pimecrolimus crea ...... 72 potassium chloride pack ...... 46 pimozide tabs 1mg, 2mg ...... 42 potassium chloride soln 10%, 20%...... 46 pimtrea tabs ...... 54 POTASSIUM CHLORIDE SOLN pindolol tabs 5mg, 10mg ...... 27 INTRAVENOUS 2meq/ml, 10meq/100ml, pioglitazone hcl tabs 15mg, 30mg, 45mg . 56 20meq/100ml, 40meq/100ml ...... 46 pioglitazone hcl-glimepiride tabs ...... 56 potassium citrate er tbcr 15meq, 540mg, pioglitazone hcl-metformin hcl tabs ...... 56 1080mg ...... 43 piperacillin sod-tazobactam so solr ...... 10 POTASSIUM PHOSPHATES SOLN ...... 46 piperacillin sod-tazobactam so solr POTASSIUM PHOSPHATES(66 MEQ K) intravenous ...... 10 SOLN ...... 46 PIQRAY (200 MG DAILY DOSE) TBPK ... 19 POTELIGEO SOLN ...... 19 PIQRAY (250 MG DAILY DOSE) TBPK ... 19 PR BENZOYL PEROXIDE WASH LIQD .. 68 PIQRAY (300 MG DAILY DOSE) TBPK ... 19 PRADAXA CAPS 110mg, 150mg ...... 24 pirmella 1/35 tabs ...... 54 PRADAXA CAPS 75mg ...... 24 PIROXICAM CAPS 10mg, 20mg ...... 33 pramipexole dihydrochloride er tb24 PLASMA-LYTE 148 SOLN INTRAVENOUS 0.375mg, 0.75mg, 1.5mg, 2.25mg, 3mg, ...... 46 3.75mg, 4.5mg ...... 37 PLASMA-LYTE A SOLN INTRAVENOUS 46 pramipexole dihydrochloride tabs 0.125mg, PLEGRIDY SOPN ...... 13 0.25mg, 0.5mg, 0.75mg, 1mg, 1.5mg ... 37 PLEGRIDY SOSY ...... 13, 39 PRAMOX GEL ...... 71 PLEGRIDY STARTER PACK SOPN ...... 13 prandin tabs 1mg, 2mg ...... 56 PLEGRIDY STARTER PACK SOSY ...... 13 prasugrel hcl tabs 5mg, 10mg ...... 24 plenamine soln intravenous ...... 44 pravastatin sodium tabs 10mg, 20mg, PLENVU SOLR ...... 51 40mg, 80mg ...... 26 podofilox soln ...... 72 praziquantel tabs ...... 8 POLIVY SOLR 30mg, 140mg ...... 19 prazosin hcl caps 1mg, 2mg, 5mg ...... 25

106 • Kaiser Permanente 2021 Comprehensive Formulary

PRED MILD SUSP ...... 48 PRIVIGEN SOLN INTRAVENOUS ...... 66 PRED-G S.O.P. OINT...... 48 PROAIR RESPICLICK AEPB ...... 23 PRED-G SUSP ...... 48 probenecid tabs ...... 46 prednicarbate crea ...... 70 procainamide hcl soln ...... 28 prednicarbate oint ...... 70 PROCALAMINE SOLN INTRAVENOUS . 44 prednisolone acetate susp ...... 48 procentra soln ...... 34 prednisolone sodium phosphate soln . 48, 52 prochlorperazine edisylate soln ...... 42 prednisolone sodium phosphate soln prochlorperazine maleate tabs ...... 42 5mg/5ml, 10mg/5ml, 20mg/5ml, prochlorperazine supp ...... 42 25mg/5ml ...... 52 PROCRIT SOLN 2000unit/ml, 3000unit/ml, prednisolone sodium phosphate tbdp 10mg, 4000unit/ml, 10000unit/ml, 20000unit/ml, 15mg, 30mg ...... 52 40000unit/ml ...... 25 prednisolone soln ...... 52 proctofoam hc foam ...... 71 prednisone intensol conc ...... 52 procto-med hc crea ...... 70 prednisone soln ...... 52 procto-pak crea ...... 70 prednisone tabs 1mg, 2.5mg, 5mg, 10mg, proctosol hc crea ...... 70 20mg, 50mg ...... 52 proctozone-hc crea ...... 70 prednisone tbpk ...... 52 PROCYSBI CPDR 25mg, 75mg ...... 64 prefest tabs ...... 57 PROCYSBI PACK 75mg, 300mg ...... 64 pregabalin caps 25mg, 50mg, 75mg, progesterone caps 100mg, 200mg ...... 58 100mg, 150mg, 200mg, 225mg, 300mg progesterone oil ...... 59 ...... 36 PROGLYCEM SUSP ...... 57 pregabalin er tb24 82.5mg, 165mg, 330mg PROGRAF PACK ...... 62 ...... 33 PROGRAF PACK 0.2mg ...... 62 pregabalin soln ...... 36 PROGRAF SOLN ...... 62 PREGNYL SOLR ...... 58 PROLASTIN-C SOLN INTRAVENOUS.... 65 PREMARIN SOLR ...... 57 PROLASTIN-C SOLR INTRAVENOUS.... 65 PREMARIN TABS 0.3mg, 0.45mg, prolate soln ...... 33 0.625mg, 0.9mg, 1.25mg ...... 58 prolate tabs ...... 33 premasol soln intravenous ...... 44 PROLENSA SOLN ...... 48 PREMPHASE TABS ...... 58 PROLEUKIN SOLR ...... 19 PREMPRO TABS ...... 58 PROLIA SOSY ...... 60 PRENATAL TABS ...... 74 PROMACTA PACK 12.5mg, 25mg ...... 25 PRETOMANID TABS ...... 12 PROMACTA TABS 12.5mg, 25mg, 50mg, prevalite pack ...... 26 75mg ...... 25 prevalite powd ...... 26 promethazine hcl soln ...... 15 previfem tabs ...... 54 promethazine hcl supp ...... 15 PREVYMIS SOLN 240mg/12ml, promethazine hcl syrp ...... 15 480mg/24ml ...... 14 promethazine hcl tabs ...... 15 PREVYMIS TABS 240mg, 480mg ...... 14 promethazine-phenylephrine syrp ...... 15 PREZCOBIX TABS...... 14 promethegan supp ...... 15 PREZISTA SUSP ...... 14 propafenone hcl er cp12 225mg, 325mg, PREZISTA TABS 75mg, 150mg, 600mg, 425mg ...... 28 800mg ...... 14 propafenone hcl tabs 150mg, 225mg, PRIFTIN TABS ...... 12 300mg ...... 28 PRILOSEC PACK 2.5mg, 10mg ...... 51 propantheline bromide tabs ...... 21 PRIMAQUINE PHOSPHATE TABS ...... 12 proparacaine hcl soln ...... 49 primidone tabs 50mg, 250mg ...... 36 propranolol hcl er cp24 60mg, 80mg, primlev tabs ...... 33 120mg, 160mg ...... 27

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propranolol hcl soln 20mg/5ml, 40mg/5ml 27 raloxifene hcl tabs ...... 58 propranolol hcl tabs 10mg, 20mg, 40mg, ramelteon tabs ...... 38 60mg, 80mg ...... 27 ramipril caps 1.25mg, 2.5mg, 5mg, 10mg 29 propranolol-hctz tabs ...... 27 ranolazine er tb12 500mg, 1000mg ...... 28 propylthiouracil tabs ...... 60 RAPIVAB SOLN ...... 14 PROQUAD SUSR ...... 67 rasagiline mesylate tabs 0.5mg, 1mg ...... 37 PROSOL SOLN INTRAVENOUS ...... 44 RASUVO SOAJ ...... 61 PROTONIX PACK ...... 51 RAVICTI LIQD ...... 43 protriptyline hcl tabs 5mg, 10mg ...... 42 RAYALDEE CPCR ...... 74 psorcon crea ...... 70 RAYOS TBEC 1mg, 2mg, 5mg ...... 52 PULMICORT FLEXHALER AEPB ...... 52 REBETOL SOLN ...... 14 PULMOZYME SOLN ...... 47 REBIF REBIDOSE SOAJ 22mcg/0.5ml, PURIXAN SUSP ...... 19 44mcg/0.5ml ...... 39 PYLERA CAPS ...... 51 REBIF REBIDOSE TITRATION PACK pyrazinamide tabs...... 12 SOAJ ...... 39 pyridostigmine bromide er tbcr ...... 22 REBIF SOSY 22mcg/0.5ml, 44mcg/0.5ml 39 pyridostigmine bromide soln ...... 22 REBIF TITRATION PACK SOSY ...... 39 pyridostigmine bromide tabs 30mg, 60mg 22 REBLOZYL SOLR 25mg, 75mg ...... 25 pyrimethamine tabs ...... 12 RECARBRIO SOLR ...... 10 reclipsen tabs ...... 54 Q RECOMBIVAX HB SUSP 5mcg/0.5ml, QBRELIS SOLN ...... 29 10mcg/ml, 40mcg/ml ...... 67 QDOLO SOLN ...... 33 RECTIV OINT ...... 72 QINLOCK TABS ...... 19 REGONOL SOLN ...... 22 QUADRACEL SUSP...... 67 REGRANEX GEL ...... 72 questran light powd...... 26 relafen ds tabs ...... 33 questran pack ...... 26 RELENZA DISKHALER AEPB ...... 14 questran powd ...... 26 relexxii tbcr...... 34 quetiapine fumarate er tb24 50mg, 150mg, RELISTOR SOLN 8mg/0.4ml, 12mg/0.6ml 200mg, 300mg, 400mg ...... 42 ...... 51 quetiapine fumarate tabs 25mg, 50mg, RELISTOR TABS ...... 51 100mg, 200mg, 300mg, 400mg ...... 42 reltone caps 200mg, 400mg ...... 51 QUILLICHEW ER CHER 20mg, 30mg, REMICADE SOLR INTRAVENOUS ...... 61 40mg ...... 34 RENFLEXIS SOLR ...... 61 QUILLIVANT XR SRER ...... 34 repaglinide tabs 0.5mg, 1mg, 2mg ...... 57 quinapril hcl tabs 5mg, 10mg, 20mg, 40mg repaglinide-metformin hcl tabs ...... 57 ...... 29 REPATHA PUSHTRONEX SYSTEM SOCT quinapril-hydrochlorothiazide tabs ...... 29 ...... 26 quinidine gluconate er tbcr ...... 28 REPATHA SOSY ...... 26 QUINIDINE GLUCONATE SOLN ...... 28 REPATHA SURECLICK SOAJ ...... 26 quinidine sulfate tabs 200mg, 300mg ...... 28 RESCRIPTOR TABS 100mg, 200mg...... 14 quinine sulfate caps ...... 12 RESTASIS EMUL ...... 48 RETACRIT SOLN 20000unit/2ml, R 2000unit/ml, 3000unit/ml, 4000unit/ml, 10000unit/ml, 20000unit/ml, 40000unit/ml RABAVERT SUSR ...... 67 ...... 25 rabeprazole sodium cpsp ...... 51 RETEVMO CAPS 40mg, 80mg ...... 19 rabeprazole sodium tbec ...... 51 RETIN-A CREA 0.025%, 0.05%, 0.1% .... 71 RADICAVA SOLN ...... 39 RETIN-A GEL 0.01%, 0.025% ...... 71

108 • Kaiser Permanente 2021 Comprehensive Formulary

RETIN-A MICRO GEL 0.04%, 0.1% ...... 71 ritonavir tabs ...... 14 RETIN-A MICRO PUMP GEL ...... 71 RITUXAN HYCELA SOLN ...... 19 RETIN-A MICRO PUMP GEL 0.04%, 0.1% RITUXAN SOLN ...... 19 ...... 71 rivastigmine pt24 4.6mg/24hr, 9.5mg/24hr, RETIN-A MICRO PUMP GEL 0.08% ...... 71 13.3mg/24hr ...... 22 RETISERT IMPL ...... 48 rivastigmine tartrate caps 1.5mg, 3mg, RETROVIR SOLN ...... 14 4.5mg, 6mg ...... 22 REVCOVI SOLN ...... 47 rivelsa tabs...... 54 REVLIMID CAPS 2.5mg, 5mg, 10mg, rizatriptan benzoate tabs ...... 37 15mg, 20mg, 25mg ...... 19 rizatriptan benzoate tbdp ...... 37 revonto solr ...... 22 ROMIDEPSIN SOLN ...... 19 REXULTI TABS 0.25mg, 0.5mg, 1mg, 2mg, ropinirole hcl er tb24 2mg, 4mg, 6mg, 8mg, 3mg, 4mg ...... 42 12mg ...... 38 REYATAZ PACK ...... 14 ropinirole hcl tabs 0.25mg, 0.5mg, 1mg, REZUROCK TABS ...... 64 2mg, 3mg, 4mg, 5mg ...... 38 RHOPRESSA SOLN ...... 49 ropivacaine hcl soln ...... 64 RIABNI SOLN 100mg/10ml, 500mg/50ml 19 rosuvastatin calcium tabs 5mg, 10mg, ribasphere caps ...... 14 20mg, 40mg ...... 26 ribasphere ribapak (1000 pack) tbpk ...... 14 ROTARIX SUSR ...... 67 ribasphere ribapak (1200 pack) tbpk ...... 14 ROTATEQ SOLN ...... 67 ribasphere tabs ...... 14 roweepra tabs 500mg, 750mg, 1000mg ... 36 ribavirin caps ...... 14 roweepra xr tb24 500mg, 750mg ...... 36 ribavirin solr ...... 14 ROXYBOND TABA 5mg, 15mg, 30mg..... 33 ribavirin tabs ...... 14 ROZEREM TABS ...... 38 RIDAURA CAPS ...... 64 ROZLYTREK CAPS 100mg, 200mg ...... 19 RIFABUTIN CAPS ...... 12 RUBRACA TABS 200mg, 250mg, 300mg 19 RIFADIN CAPS ...... 12 RUCONEST SOLR INTRAVENOUS ...... 23 rifamate caps ...... 12 rufinamide susp ...... 36 rifampin caps 150mg, 300mg ...... 12 rufinamide tabs 200mg, 400mg ...... 36 rifampin solr intravenous ...... 12 RUKOBIA TB12 ...... 14 RIFATER TABS ...... 12 RUXIENCE SOLN 100mg/10ml, riluzole tabs ...... 39 500mg/50ml ...... 19 rimantadine hcl tabs...... 14 RUZURGI TABS ...... 64 RIMSO-50 SOLN ...... 64 RYBREVANT SOLN ...... 19 RINGERS IRRIGATION SOLN ...... 64 ryclora soln ...... 15 RINGERS SOLN ...... 46 RYDAPT CAPS ...... 19 RINVOQ TB24 ...... 61 RYLAZE SOLN ...... 19 risedronate sodium tabs 5mg, 30mg, 35mg, RYNODERM CREA ...... 72 150mg ...... 60 RYTARY CPCR ...... 38 RISEDRONATE SODIUM TBEC ...... 60 ryvent tabs ...... 15 RISPERDAL CONSTA SRER 12.5mg, 25mg ...... 42 S RISPERDAL CONSTA SRER 37.5mg, SAIZEN CLICK.EASY SOLR ...... 59 50mg ...... 42 SAIZEN SOLR 5mg, 8.8mg ...... 59 risperidone soln ...... 42 SAIZENPREP SOLR ...... 59 risperidone tabs 0.25mg, 0.5mg, 1mg, 2mg, sajazir soln ...... 23 3mg, 4mg ...... 42 SALEX SHAM ...... 72 risperidone tbdp 0.25mg, 0.5mg, 1mg, 2mg, SALICYLIC ACID CREA ...... 72 3mg, 4mg ...... 42 SALICYLIC ACID ER SOLN ...... 72

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SALICYLIC ACID FOAM ...... 72 sevelamer hcl tabs 400mg, 800mg...... 45 SALICYLIC ACID GEL ...... 72 SEYSARA TABS 60mg, 100mg, 150mg .. 10 SALICYLIC ACID LIQD ...... 72 sharobel tabs ...... 55 SALICYLIC ACID SHAM ...... 72 SHINGRIX SUSR ...... 67 SALICYLIC ACID WART REMOVER LIQD SIGNIFOR LAR SRER 10mg, 20mg, 30mg, ...... 72 40mg, 60mg ...... 59 SALICYLIC ACID-CLEANSER KIT ...... 73 SIGNIFOR SOLN 0.3mg/ml, 0.6mg/ml, SALIMEZ CREA ...... 73 0.9mg/ml ...... 59 SALSALATE TABS ...... 33 SIKLOS TABS ...... 19 SAMSCA TABS 15mg ...... 45 sildenafil citrate soln ...... 30 SANCUSO PTCH ...... 50 sildenafil citrate susr ...... 30 SANDIMMUNE ORAL SOLN 100mg/ml ... 62 sildenafil citrate tabs ...... 30 SANDOSTATIN LAR DEPOT KIT 10mg, SILENOR TABS ...... 42 20mg, 30mg ...... 59 SILIQ SOSY ...... 73 SANTYL OINT ...... 73 silodosin caps 4mg, 8mg ...... 22 SAPHNELO SOLN ...... 62 SILVER SULFADIAZINE CREA ...... 68 SAPHRIS SUBL 2.5mg, 5mg, 10mg ...... 42 SIMBRINZA SUSP ...... 49 sapropterin dihydrochloride pack 100mg, SIMPONI ARIA SOLN ...... 61 500mg ...... 64 SIMPONI SOAJ 50mg/0.5ml, 100mg/ml .. 61 sapropterin dihydrochloride tabs ...... 64 SIMPONI SOSY 50mg/0.5ml, 100mg/ml .. 61 SARCLISA SOLN 500mg/25ml, 100mg/5ml simvastatin tabs 5mg, 10mg, 20mg, 40mg, ...... 19 80mg ...... 26 SAVELLA TABS 12.5mg, 25mg, 50mg, sirolimus soln ...... 62 100mg ...... 39 sirolimus tabs 0.5mg, 1mg, 2mg ...... 62 SAVELLA TITRATION PACK MISC ...... 39 SIRTURO TABS 20mg, 100mg ...... 12 scopolamine pt72 ...... 50 SIVEXTRO SOLR INTRAVENOUS ...... 10 seconal caps ...... 38 SIVEXTRO TABS ...... 10 SECUADO PT24 3.8mg/24hr, 5.7mg/24hr, SKLICE LOTN ...... 68 7.6mg/24hr ...... 42 SKYRIZI (150 MG DOSE) PSKT ...... 73 selegiline hcl caps...... 38 SKYRIZI PEN SOAJ ...... 73 selegiline hcl tabs ...... 38 SKYRIZI SOSY ...... 73 selenium sulfide lotn ...... 68 sod benz-sod phenylacet soln ...... 43 SELENIUM SULFIDE SHAM ...... 68 SODIUM ACETATE SOLN ...... 43 SELZENTRY SOLN ...... 14 SODIUM BICARBONATE SOLN ...... 43 SELZENTRY TABS 25mg, 75mg, 150mg, SODIUM CHLORIDE (PF) SOLN ...... 46 300mg ...... 14 SODIUM CHLORIDE SOLN ...... 46, 64 SEMPREX-D CAPS...... 15 SODIUM CHLORIDE SOLN INJECTION . 46 SENSIPAR TABS 30mg, 60mg, 90mg ..... 58 SODIUM CHLORIDE SOLN SENSORCAINE SOLN ...... 64 INTRAVENOUS 0.45%, 0.9%, 3%, 5% 46 sensorcaine/epinephrine soln ...... 64 SODIUM FLUORIDE CHEW 0.25mg, sensorcaine-mpf soln ...... 64 0.5mg, 1mg ...... 64 sensorcaine-mpf/epinephrine soln ...... 64 SODIUM FLUORIDE SOLN ...... 64 SEREVENT DISKUS AEPB ...... 23 SODIUM FLUORIDE TABS ...... 64 SEROSTIM SOLR 4mg, 5mg, 6mg ...... 59 SODIUM LACTATE SOLN INTRAVENOUS sertraline hcl conc ...... 42 ...... 43 sertraline hcl tabs 25mg, 50mg, 100mg ... 42 sodium phenylbutyrate powd ...... 43 setlakin tabs ...... 54 sodium phenylbutyrate tabs ...... 43 sevelamer carbonate pack 0.8gm, 2.4gm 45 SODIUM PHOSPHATES SOLN ...... 46 sevelamer carbonate tabs ...... 45 sodium polystyrene sulfonate powd ...... 45

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sodium polystyrene sulfonate susp ...... 45 STIOLTO RESPIMAT AERS ...... 21 SODIUM SULFACETAMIDE SHAM ...... 68 STIVARGA TABS ...... 19 SODIUM SULFACETAMIDE WASH LIQD STRENSIQ SOLN 18mg/0.45ml, ...... 68 28mg/0.7ml, 80mg/0.8ml, 40mg/ml ...... 47 sofosbuvir-velpatasvir tabs ...... 14 streptomycin sulfate solr ...... 10 solifenacin succinate tabs 5mg, 10mg ...... 73 STRIANT MISC ...... 53 SOLIQUA SOPN ...... 57 STRIBILD TABS ...... 14 SOLOSEC PACK ...... 12 STRIVERDI RESPIMAT AERS ...... 23 soloxide tbec ...... 10 SUBLOCADE SOSY 100mg/0.5ml, SOLTAMOX SOLN ...... 19 300mg/1.5ml ...... 33 SOLU-CORTEF SOLR ...... 52 SUBSYS LIQD 100mcg, 200mcg, 400mcg, SOLU-MEDROL SOLR ...... 52 600mcg, 800mcg, 1200mcg, 1600mcg 33 SOMATULINE DEPOT SOLN ...... 59 subvenite starter kit-blue kit ...... 36 SOMAVERT SOLR 10mg, 15mg, 20mg, subvenite starter kit-green kit ...... 36 25mg, 30mg ...... 59 subvenite starter kit-orange kit ...... 36 SORILUX FOAM ...... 73 subvenite tabs 25mg, 100mg, 150mg, sorine tabs 80mg, 120mg, 160mg, 240mg 200mg ...... 36 ...... 27 succinylcholine chloride soln ...... 22 sotalol hcl (af) tabs 80mg, 120mg, 160mg 27 SUCRAID SOLN ...... 47 sotalol hcl tabs 80mg, 120mg, 160mg, sucralfate susp ...... 51 240mg ...... 27 sucralfate tabs ...... 51 SOTYLIZE SOLN ...... 27 sulfacetamide sodium (acne) lotn ...... 68 SOVALDI PACK 150mg, 200mg ...... 14 SULFACETAMIDE SODIUM GEL ...... 68 SOVALDI TABS 200mg, 400mg ...... 14 SULFACETAMIDE SODIUM LIQD ...... 68 SPINOSAD SUSP ...... 68 sulfacetamide sodium oint ...... 47 SPIRIVA HANDIHALER CAPS ...... 21 sulfacetamide sodium soln ...... 47 SPIRIVA RESPIMAT AERS ...... 21 SULFACETAMIDE SODIUM-SULFUR SPIRIVA RESPIMAT AERS 2.5mcg/act ... 21 CREA ...... 73 spironolactone tabs 25mg, 50mg, 100mg 29 SULFACETAMIDE SODIUM-SULFUR spironolactone-hctz tabs ...... 29 EMUL ...... 73 SPRAVATO (56 MG DOSE) SOPK ...... 42 SULFACETAMIDE SODIUM-SULFUR SPRAVATO (84 MG DOSE) SOPK ...... 42 LIQD ...... 73 sprintec 28 tabs ...... 55 SULFACETAMIDE SODIUM-SULFUR SPRITAM TB3D 250mg, 500mg, 750mg, LOTN ...... 73 1000mg ...... 36 SULFACETAMIDE SODIUM-SULFUR SPRYCEL TABS 20mg, 50mg, 70mg, PADS ...... 73 80mg, 100mg, 140mg ...... 19 SULFACETAMIDE SODIUM-SULFUR sps susp ...... 45 SUSP ...... 73 sronyx tabs ...... 55 sulfacetamide-prednisolone soln ...... 48 SSD CREA ...... 68 SULFACLEANSE 8/4 SUSP ...... 73 SSS 10-5 CREA ...... 73 sulfadiazine tabs ...... 10 stavudine caps 15mg, 20mg, 30mg, 40mg sulfamethoxazole-trimethoprim soln ...... 10 ...... 14 sulfamethoxazole-trimethoprim susp ...... 10 STELARA SOLN 45mg/0.5ml, 130mg/26ml sulfamethoxazole-trimethoprim tabs...... 10 ...... 73 sulfamez wash emul ...... 73 STELARA SOSY 45mg/0.5ml, 90mg/ml ... 73 SULFAMYLON CREA ...... 68 STERILE WATER FOR IRRIGATION SOLN sulfasalazine tabs ...... 10 ...... 64 sulfasalazine tbec ...... 10 STIMATE SOLN ...... 58 SULFATRIM PEDIATRIC SUSP ...... 10

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sulindac tabs ...... 33 TAKHZYRO SOLN ...... 64 sumatriptan soln ...... 37 TALTZ SOAJ ...... 73 sumatriptan succinate refill soct ...... 37 TALTZ SOSY ...... 73 sumatriptan succinate soaj ...... 37 TALZENNA CAPS 0.25mg, 1mg ...... 19 sumatriptan succinate soln ...... 37 tamoxifen citrate tabs ...... 20 sumatriptan succinate sosy ...... 37 tamsulosin hcl caps ...... 22 sumatriptan succinate tabs ...... 37 tapazole tabs 5mg, 10mg ...... 60 sunitinib malate caps 12.5mg, 25mg, taperdex 12-day tbpk ...... 52 37.5mg, 50mg ...... 19 taperdex 6-day tbpk ...... 52 SUNOSI TABS 75mg, 150mg ...... 34 taperdex 7-day tbpk ...... 52 SUPRAX CAPS ...... 11 TARCEVA TABS 25mg, 100mg, 150mg .. 20 suprax chew ...... 11 targadox tabs ...... 11 suprax susr 100mg/5ml, 200mg/5ml ...... 11 TARGRETIN GEL ...... 71 SUPRAX SUSR 500 MG/5ML ...... 11 tarina 24 fe tabs ...... 55 SUPREP BOWEL PREP KIT SOLN ...... 51 tarina fe 1/20 eq tabs ...... 55 SUTENT CAPS 12.5mg, 25mg, 37.5mg, TASIGNA CAPS 50mg, 150mg, 200mg ... 20 50mg ...... 19 tavaborole soln ...... 68 syeda tabs ...... 55 TAVALISSE TABS 100mg, 150mg...... 25 SYLATRON KIT ...... 19 tazarotene crea ...... 73 SYLATRON KIT 600 MCG ...... 19 tazarotene foam ...... 73 SYLVANT SOLR 100mg, 400mg ...... 19 tazicef solr injection 1gm, 2gm, 6gm ...... 11 SYMBICORT AERO ...... 65 TAZORAC CREA ...... 73 SYMDEKO TBPK ...... 65 TAZORAC GEL 0.05%, 0.1% ...... 73 SYMFI LO TABS ...... 14 taztia xt cp24 120mg, 180mg, 240mg, SYMFI TABS ...... 14 300mg, 360mg ...... 28 SYMLINPEN 120 SOPN ...... 57 TAZVERIK TABS ...... 20 SYMLINPEN 60 SOPN ...... 57 TDVAX SUSP ...... 67 SYMPAZAN FILM 10mg, 20mg ...... 36 TECENTRIQ SOLN 840mg/14ml, SYMPAZAN FILM 5mg ...... 36 1200mg/20ml ...... 20 SYMPROIC TABS ...... 51 TECFIDERA CPDR 120mg, 240mg ...... 39 SYMTUZA TABS ...... 14 TECFIDERA MISC ...... 39 SYNAGIS SOLN 50mg/0.5ml, 100mg/ml . 14 TEFLARO SOLR INTRAVENOUS 400mg, SYNAREL SOLN ...... 58 600mg ...... 11 SYNDROS SOLN ...... 50 TEGSEDI SOSY ...... 64 SYNERCID SOLR ...... 11 TEKTURNA HCT TABS ...... 29 SYNJARDY TABS ...... 57 telmisartan tabs 20mg, 40mg, 80mg ...... 29 SYNJARDY XR TB24 ...... 57 telmisartan-amlodipine tabs ...... 28 SYNRIBO SOLR ...... 19 telmisartan-hctz tabs ...... 29 TEMAZEPAM CAPS 15mg, 22.5mg, 30mg, T 7.5mg ...... 38 TABLOID TABS ...... 19 temsirolimus soln ...... 20 TABRECTA TABS 150mg, 200mg ...... 19 tencon tabs ...... 33 TACLONEX SUSP ...... 70 TENIPOSIDE SOLN ...... 20 tacrolimus caps 0.5mg, 1mg, 5mg ...... 62 TENIVAC INJ ...... 67 TACROLIMUS OINT 0.1%, 0.03% ...... 73 tenofovir disoproxil fumarate tabs...... 14 tadalafil (pah) tabs 20mg ...... 30 TEPADINA SOLR ...... 20 tadalafil tabs 2.5mg, 5mg ...... 30 TEPEZZA SOLR ...... 49 TAFINLAR CAPS 50mg, 75mg ...... 19 TEPMETKO TABS ...... 20 TAGRISSO TABS 40mg, 80mg ...... 19 terazosin hcl caps 1mg, 2mg, 5mg, 10mg 25

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terbinafine hcl tabs...... 11 timolol maleate tabs 5mg, 10mg, 20mg.... 27 terbutaline sulfate soln ...... 23 TIMOPTIC OCUDOSE SOLN .25% ...... 49 terbutaline sulfate tabs 2.5mg, 5mg ...... 23 TIMOPTIC-XE SOLG 0.25%, 0.5% ...... 49 terconazole crea ...... 68 tinidazole tabs ...... 12 terconazole supp ...... 68 tiopronin tabs ...... 64 TERIPARATIDE (RECOMBINANT) SOPN TIROSINT CAPS 13mcg, 25mcg, 50mcg, ...... 58 75mcg, 88mcg, 100mcg, 112mcg, testosterone cypionate soln 100mg/ml, 125mcg, 137mcg, 150mcg, 175mcg, 200mg/ml ...... 53 200mcg ...... 60 testosterone enanthate soln ...... 53 TIS-U-SOL SOLN ...... 64 testosterone gel 1%, 1.62%, TIVICAY PD TBSO ...... 14 20.25mg/1.25gm, 25mg/2.5gm, TIVICAY TABS 10mg, 25mg, 50mg ...... 14 40.5mg/2.5gm, 50mg/5gm, 10mg/act ... 53 TIVORBEX CAPS ...... 33 testosterone soln ...... 53 tizanidine hcl caps ...... 22, 23 tetrabenazine tabs 12.5mg, 25mg ...... 39 tizanidine hcl tabs ...... 22 TETRACAINE HCL SOLN ...... 49 TOBI PODHALER CAPS ...... 65 tetracycline hcl caps 250mg, 500mg ...... 11 TOBRADEX OINT ...... 48 texacort soln ...... 71 TOBRADEX ST SUSP ...... 48 THALOMID CAPS 50mg, 100mg, 150mg, tobramycin nebu 300mg/4ml, 300mg/5ml 65 200mg ...... 20 tobramycin soln ...... 47 theo-24 cp24 100mg, 200mg, 300mg, tobramycin sulfate soln injection 80mg/2ml, 400mg ...... 73 10mg/ml ...... 11 theophylline er tb12 100mg, 200mg, tobramycin-dexamethasone susp ...... 48 300mg, 450mg ...... 73 TOBREX OINT ...... 47 theophylline er tb24 400mg, 600mg ...... 73 tofranil tabs 10mg, 25mg, 50mg ...... 43 theophylline soln ...... 73 TOLAK CREA ...... 73 THIOLA EC TBEC 100mg, 300mg ...... 64 tolazamide tabs 250mg, 500mg ...... 57 THIOLA TABS ...... 64 tolbutamide tabs ...... 57 thioridazine hcl tabs 10mg, 25mg, 50mg, tolcapone tabs ...... 38 100mg ...... 42 tolmetin sodium caps ...... 33 thiotepa solr 15mg, 100mg ...... 20 tolmetin sodium tabs ...... 33 thiothixene caps 1mg, 2mg, 5mg, 10mg ... 42 TOLSURA CAPS ...... 11 THYROGEN SOLR...... 64 tolterodine tartrate er cp24 2mg, 4mg ...... 73 THYROLAR-1 TABS...... 60 tolterodine tartrate tabs ...... 73 THYROLAR-1/2 TABS...... 60 TOLVAPTAN TABS 30mg, 15mg ...... 45 THYROLAR-1/4 TABS...... 60 TOPEX TOPICAL ANESTHETIC AERO .. 71 THYROLAR-2 TABS...... 60 topicort crea 0.05%, 0.25% ...... 70 THYROLAR-3 TABS...... 60 topicort gel ...... 71 tiadylt er cp24 120mg, 180mg, 240mg, topicort oint ...... 71 300mg, 360mg, 420mg ...... 28 topiramate cpsp 15mg, 25mg ...... 36 tiagabine hcl tabs 2mg, 4mg, 12mg, 16mg topiramate er cs24 25mg, 50mg, 100mg, ...... 36 150mg, 200mg ...... 36 TIBSOVO TABS ...... 20 topiramate tabs 25mg, 50mg, 100mg, TIGECYCLINE SOLR INTRAVENOUS .... 11 200mg ...... 36 TIGLUTIK SUSP ...... 39 toposar soln ...... 20 tilia fe tabs ...... 55 TOPOTECAN HCL SOLN ...... 20 timolol maleate pf soln ...... 49 topotecan hcl solr ...... 20 timolol maleate solg 0.25%, 0.5% ...... 49 toremifene citrate tabs ...... 20 timolol maleate soln 0.25%, 0.5% ...... 49

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torsemide tabs 5mg, 10mg, 20mg, 100mg triamcinolone acetonide oint 0.025%, ...... 45 0.05%, 0.1%, 0.5% ...... 71 TOSYMRA SOLN ...... 37 triamcinolone acetonide pste ...... 71 tovet foam ...... 71 triamcinolone acetonide susp ...... 53 TPN ELECTROLYTES CONC triamterene caps 50mg, 100mg ...... 45 INTRAVENOUS ...... 46 triamterene-hctz caps ...... 45 TRACLEER TABS 62.5mg, 125mg ...... 66 triamterene-hctz tabs ...... 45 TRACLEER TBSO ...... 66 trianex oint ...... 71 TRADJENTA TABS ...... 57 triazolam tabs 0.125mg, 0.25mg ...... 38 tramadol hcl er (biphasic) tb24 100mg, TRICITRATES SOLN ...... 43 200mg, 300mg ...... 33 triderm crea 0.1%, 0.5% ...... 71 tramadol hcl er cp24 100mg, 150mg, trientine hcl caps ...... 52 200mg, 300mg ...... 33 tri-estarylla tabs ...... 55 tramadol hcl er tb24 100mg, 200mg, 300mg trifluoperazine hcl tabs 1mg, 2mg, 5mg, ...... 33 10mg ...... 43 tramadol hcl tabs 50mg, 100mg ...... 33 trifluridine soln ...... 47 tramadol-acetaminophen tabs ...... 33 trihexyphenidyl hcl soln ...... 38 trandolapril tabs 1mg, 2mg, 4mg ...... 29 trihexyphenidyl hcl tabs 2mg, 5mg ...... 38 trandolapril-verapamil hcl er tbcr ...... 28 TRIKAFTA TBPK ...... 65 tranexamic acid soln ...... 24 tri-legest fe tabs ...... 55 tranexamic acid tabs ...... 24 tri-lo-estarylla tabs ...... 55 TRANSDERM SCOP (1.5 MG) PT72 ...... 50 tri-lo-sprintec tabs ...... 55 tranylcypromine sulfate tabs ...... 43 trilyte solr ...... 51 TRAVASOL SOLN INTRAVENOUS ...... 44 trimethobenzamide hcl caps ...... 50 TRAVATAN Z SOLN ...... 49 trimethoprim tabs ...... 15 travoprost (bak free) soln ...... 49 tri-mili tabs ...... 55 TRAZIMERA SOLR 150mg, 420mg ...... 20 trimipramine maleate caps 25mg, 50mg, trazodone hcl tabs ...... 43 100mg ...... 43 trazodone hcl tabs 50mg, 100mg, 150mg 43 TRINESSA (28) TABS ...... 55 TRECATOR TABS ...... 12 TRINTELLIX TABS 5mg, 10mg, 20mg ..... 43 TRELEGY ELLIPTA AEPB ...... 52 tri-nymyo tabs ...... 55 TRELSTAR MIXJECT SUSR ...... 20 tri-previfem tabs ...... 55 TREMFYA SOPN ...... 73 TRIPTODUR SRER ...... 58 TREMFYA SOSY ...... 73 TRISENOX SOLN ...... 20 treprostinil soln 20mg/20ml, 50mg/20ml, TRISENOX SOLN 10mg/10ml ...... 20 100mg/20ml, 200mg/20ml ...... 66 tri-sprintec tabs ...... 55 tretinoin caps ...... 20 tritocin oint ...... 71 tretinoin crea 0.025%, 0.05%, 0.1% ...... 71 TRIUMEQ TABS ...... 14 tretinoin gel 0.01%, 0.025%, 0.05% ...... 71 TRI-VITAMIN/FLUORIDE SOLN ...... 74 tretinoin microsphere gel 0.04%, 0.1% .... 71 TRI-VITE/FLUORIDE SOLN ...... 74 tretinoin microsphere pump gel 0.04%, trivora (28) tabs ...... 55 0.1% ...... 71 tri-vylibra lo tabs ...... 55 trexall tabs 5mg, 7.5mg, 10mg, 15mg ...... 20 tri-vylibra tabs ...... 55 trezix caps ...... 33 TRIZIVIR TABS ...... 14 triamcinolone acetonide aers ...... 71 TRODELVY SOLR ...... 20 triamcinolone acetonide crea 0.025%, TROKENDI XR CP24 25mg, 50mg, 100mg, 0.1%, 0.5% ...... 71 200mg ...... 36 triamcinolone acetonide lotn 0.025%, 0.1% TROPHAMINE SOLN INTRAVENOUS .... 44 ...... 71 trospium chloride er cp24 ...... 74

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trospium chloride tabs ...... 74 UREA LOTN 40% ...... 73 TRULANCE TABS ...... 51 UREA-C40 LOTN ...... 73 TRUMENBA SUSY ...... 67 urecholine tabs 5mg, 10mg, 25mg, 50mg 22 TRUSELTIQ (100MG DAILY DOSE) CPPK uredeb crea ...... 73 ...... 20 URETRON D/S TABS ...... 15 TRUSELTIQ (125MG DAILY DOSE) CPPK URIN DS TABS ...... 15 ...... 20 URSODIOL CAPS 200mg, 400mg ...... 51 TRUSELTIQ (50MG DAILY DOSE) CPPK ursodiol caps 300mg ...... 51 ...... 20 ursodiol tabs 250mg, 500mg ...... 51 TRUSELTIQ (75MG DAILY DOSE) CPPK URYL TABS ...... 15 ...... 20 USTELL CAPS ...... 15 TRUXIMA SOLN 100mg/10ml, 500mg/50ml UTICAP CAPS ...... 15 ...... 20 UTIRA-C TABS ...... 15 TUKYSA TABS 50mg, 150mg ...... 20 UTRONA-C TABS ...... 15 TURALIO CAPS ...... 20 TWINRIX SUSY ...... 67 V TYBOST TABS ...... 14 VABOMERE SOLR INTRAVENOUS ...... 11 tydemy tabs ...... 55 valacyclovir hcl tabs 1gm, 500mg ...... 14 TYKERB TABS ...... 20 VALCHLOR GEL ...... 73 tylenol with codeine #3 tabs ...... 33 valganciclovir hcl solr ...... 14 tylenol with codeine #4 tabs ...... 33 valganciclovir hcl tabs ...... 14 TYMLOS SOPN ...... 58 valproate sodium soln ...... 36 TYPHIM VI SOLN ...... 67 valproic acid caps ...... 36 TYSABRI CONC INTRAVENOUS ...... 39 valproic acid soln ...... 36 TYVASO REFILL SOLN ...... 66 valrubicin soln ...... 20 TYVASO SOLN ...... 66 valsartan tabs 40mg, 80mg, 160mg, 320mg TYVASO STARTER SOLN ...... 66 ...... 30 valsartan-hydrochlorothiazide tabs ...... 30

U VALTOCO 10 MG DOSE LIQD ...... 36 UBRELVY TABS 50mg, 100mg ...... 37 VALTOCO 15 MG DOSE LQPK ...... 36 UCERIS FOAM ...... 71 VALTOCO 20 MG DOSE LQPK ...... 36 UDENYCA SOSY ...... 25 VALTOCO 5 MG DOSE LIQD ...... 36 UKONIQ TABS ...... 20 vanadom tabs ...... 22 ULORIC TABS 40mg, 80mg ...... 60 vanatol lq soln ...... 33 ULTOMIRIS SOLN ...... 64 vancomycin hcl caps ...... 11 ULTRAVATE LOTN ...... 71 vancomycin hcl solr ...... 11 UMECTA MOUSSE FOAM ...... 73 VANCOMYCIN HCL SOLR 250 MG ...... 11 UNITHROID TABS 25mcg, 50mcg, 75mcg, vancomycin hcl solr intravenous 1gm, 88mcg, 100mcg, 112mcg, 125mcg, 10gm, 500mg ...... 11 137mcg, 150mcg, 175mcg, 200mcg, VANDAZOLE GEL ...... 68 300mcg ...... 60 VANOXIDE-HC LOTN ...... 71 UNITUXIN SOLN ...... 20 VANTAS KIT ...... 20 UPLIZNA SOLN ...... 62 VAQTA SUSP ...... 67 UPTRAVI SOLR ...... 66 VARIVAX INJ ...... 67 UPTRAVI TABS 200mcg, 400mcg, 600mcg, VARIZIG SOLN ...... 66 800mcg, 1000mcg, 1200mcg, 1400mcg, VARUBI (180 MG DOSE) TBPK ...... 50 1600mcg ...... 66 VASCEPA CAPS 0.5gm, 1gm ...... 26 UPTRAVI TBPK ...... 66 VAXCHORA SUSR ...... 67 UREA CREA 39% ...... 73 vecamyl tabs ...... 29

Kaiser Permanente 2021 Comprehensive Formulary • 115

VECTICAL OINT ...... 73 VILTEPSO SOLN ...... 64 VELCADE SOLR ...... 20 VIMIZIM SOLN ...... 47 velivet tabs ...... 55 VIMPAT SOLN ...... 36 VELPHORO CHEW ...... 45 VIMPAT TABS ...... 36 VELTASSA PACK 8.4gm, 16.8gm, 25.2gm vinblastine sulfate soln ...... 20 ...... 45 vincasar pfs soln ...... 20 VEMLIDY TABS ...... 14 vincristine sulfate soln ...... 20 VENCLEXTA STARTING PACK TBPK .... 20 vinorelbine tartrate soln ...... 20 VENCLEXTA TABS 10mg ...... 20 VIOKACE TABS ...... 47 VENCLEXTA TABS 50mg, 100mg ...... 20 VIRACEPT TABS 250mg, 625mg ...... 14 venlafaxine hcl er cp24 37.5mg, 75mg, VIREAD POWD ...... 14 150mg ...... 43 VIREAD TABS 150mg ...... 14 venlafaxine hcl er tb24 37.5mg, 75mg, VIREAD TABS 200mg, 250mg ...... 14 150mg, 225mg ...... 43 VISTOGARD PACK ...... 60 venlafaxine hcl tabs 25mg, 37.5mg, 50mg, VITAMINS ACD-FLUORIDE SOLN ...... 74 75mg, 100mg ...... 43 VITRAKVI CAPS 25mg, 100mg ...... 20 VENTAVIS SOLN 10mcg/ml, 20mcg/ml ... 66 VITRAKVI SOLN ...... 20 VENTOLIN HFA AERS ...... 23 VIVITROL SUSR ...... 40 VERAPAMIL HCL ER CP24 100mg, VIZIMPRO TABS 15mg, 30mg, 45mg ...... 20 120mg, 180mg, 200mg, 240mg, 300mg, VOCABRIA TABS ...... 14 360mg ...... 28 VORAXAZE SOLR ...... 60 verapamil hcl er tbcr 120mg, 180mg, 240mg voriconazole solr intravenous ...... 11 ...... 28 voriconazole susr ...... 11 verapamil hcl soln ...... 28 voriconazole tabs ...... 12 verapamil hcl tabs ...... 28 VOSEVI TABS ...... 14 verapamil hcl tabs 80mg, 120mg ...... 28 VOTRIENT TABS ...... 20 VEREGEN OINT ...... 73 VP-PNV-DHA CAPS ...... 74 VERELAN CP24 ...... 28 VPRIV SOLR ...... 47 veripred 20 soln ...... 53 VRAYLAR CAPS 1.5mg, 3mg, 4.5mg, 6mg VERSACLOZ SUSP ...... 43 ...... 43 VERZENIO TABS 50mg, 100mg, 150mg, VRAYLAR CPPK ...... 43 200mg ...... 20 VUMERITY (STARTER) CPDR ...... 64 vestura tabs ...... 55 VUMERITY CPDR ...... 64 VIBERZI TABS 75mg, 100mg ...... 51 vyfemla tabs ...... 55 VIBRAMYCIN SYRP...... 11 vylibra tabs...... 55 vicodin es tabs ...... 33 VYNDAMAX CAPS ...... 28 vicodin hp tabs ...... 33 VYNDAQEL CAPS ...... 28 vicodin tabs ...... 33 VYONDYS 53 SOLN ...... 64 VICTOZA SOPN ...... 57 VYVANSE CAPS 10mg, 20mg, 30mg, VIDEX EC CPDR 125mg, 200mg, 400mg 14 40mg, 50mg, 60mg, 70mg ...... 34 VIDEX SOLR 2gm, 4gm ...... 14 VYVANSE CHEW 10mg, 20mg, 30mg, VIEKIRA PAK TBPK ...... 14 40mg, 50mg, 60mg ...... 34 VIEKIRA XR TB24 ...... 14 VYXEOS SUSR ...... 20 vienva tabs ...... 55 VYZULTA SOLN ...... 49 vigabatrin pack ...... 36 vigabatrin tabs ...... 36 W vigadrone pack ...... 36 WAKIX TABS 4.45mg, 17.8mg ...... 35 VIIBRYD STARTER PACK KIT ...... 43 warfarin sodium tabs 1mg, 2mg, 2.5mg, VIIBRYD TABS 10mg, 20mg, 40mg ...... 43 3mg, 4mg, 5mg, 6mg, 10mg ...... 24

116 • Kaiser Permanente 2021 Comprehensive Formulary

WATER FOR IRRIGATION, STERILE XPOVIO (60 MG ONCE WEEKLY) TBPK SOLN ...... 64 20mg, 60mg ...... 21 wixela inhub aepb ...... 65 XPOVIO (60 MG TWICE WEEKLY) TBPK wymzya fe chew ...... 55 ...... 21 WYNZORA CREA ...... 73 XPOVIO (80 MG ONCE WEEKLY) TBPK 20mg, 40mg ...... 21 X XPOVIO (80 MG TWICE WEEKLY) TBPK XALKORI CAPS 200mg, 250mg ...... 20 ...... 21 XARELTO STARTER PACK TBPK ...... 24 XTAMPZA ER C12A 9mg, 13.5mg, 18mg, XARELTO TABS 2.5mg, 10mg, 15mg, 27mg, 36mg ...... 34 20mg ...... 24 XTANDI CAPS ...... 21 XATMEP SOLN ...... 20 XTANDI TABS 40mg, 80mg ...... 21 XCOPRI (250 MG DAILY DOSE) TBPK ... 36 xulane ptwk ...... 55 XCOPRI (350 MG DAILY DOSE) TBPK ... 36 XUREA CREA ...... 73 XCOPRI TABS 200 MG ...... 37 XURIDEN PACK ...... 64 XCOPRI TABS 50mg, 100mg, 150mg ..... 36 xylocaine dental soln ...... 64 XCOPRI TBPK ...... 37 XYOSTED SOAJ 50mg/0.5ml, 75mg/0.5ml, XCOPRI TBPK 14 x 12.5 MG & 14 X 25 MG 100mg/0.5ml ...... 53 ...... 37 XYREM SOLN ...... 39 XELJANZ SOLN ...... 61 XYWAV SOLN ...... 39 XELJANZ TABS 5mg, 10mg ...... 61

XELJANZ XR TB24 11mg, 22mg ...... 61 Y XELPROS EMUL ...... 49 YERVOY SOLN ...... 21 XEMBIFY SOLN SUBCUTANEOUS YF-VAX INJ ...... 67 2gm/10ml, 4gm/20ml, 10gm/50ml, YONDELIS SOLR ...... 21 1gm/5ml ...... 66 YONSA TABS ...... 21 XENLETA SOLN ...... 11 YUPELRI SOLN ...... 21 XENLETA TABS ...... 11 YUTIQ IMPL ...... 48 XEOMIN SOLR ...... 64 yuvafem tabs ...... 58 XEOMIN SOLR 50unit, 100unit ...... 64 XEPI CREA ...... 68 Z XERESE CREA ...... 68 zafemy ptwk ...... 55 XERMELO TABS ...... 50 zafirlukast tabs 10mg, 20mg ...... 64 XGEVA SOLN ...... 60 zaleplon caps 5mg, 10mg ...... 38 XHANCE EXHU ...... 48 ZALTRAP SOLN 100mg/4ml, 200mg/8ml 21 XIFAXAN TABS 200mg, 550mg ...... 11 zarah tabs ...... 55 XIIDRA SOLN ...... 48 zarontin soln ...... 37 XIMINO CP24 45mg, 90mg, 135mg ...... 11 ZARXIO SOSY 300mcg/0.5ml, XOFLUZA (40 MG DOSE) TBPK ...... 14 480mcg/0.8ml ...... 25 XOFLUZA (80 MG DOSE) TBPK ...... 14 zebutal caps ...... 34 XOLAIR SOLR ...... 65 ZEJULA CAPS ...... 21 XOLAIR SOSY 75mg/0.5ml, 150mg/ml .... 65 ZELAPAR TBDP ...... 38 XOSPATA TABS ...... 20 ZELBORAF TABS ...... 21 XPOVIO (100 MG ONCE WEEKLY) TBPK ZEMAIRA SOLR INTRAVENOUS ...... 65 20mg, 50mg ...... 20 ZEMBRACE SYMTOUCH SOAJ ...... 37 XPOVIO (40 MG ONCE WEEKLY) TBPK ZEMDRI SOLN INTRAVENOUS ...... 11 20mg, 40mg ...... 20 zenatane caps 10mg, 20mg, 30mg, 40mg XPOVIO (40 MG TWICE WEEKLY) TBPK ...... 73 20mg, 40mg ...... 20

Kaiser Permanente 2021 Comprehensive Formulary • 117

ZENPEP CPEP ...... 47 zoledronic acid soln ...... 60 zenzedi tabs 2.5mg, 5mg, 7.5mg, 10mg, ZOLINZA CAPS ...... 21 15mg, 20mg, 30mg ...... 35 zolmitriptan soln ...... 37 ZEPATIER TABS ...... 14 zolmitriptan tabs ...... 37 ZEPOSIA 7-DAY STARTER PACK CPPK zolmitriptan tbdp ...... 37 ...... 39 zolpidem tartrate er tbcr 6.25mg, 12.5mg 38 ZEPOSIA CAPS ...... 39 zolpidem tartrate subl 1.75mg, 3.5mg ...... 38 ZEPOSIA STARTER KIT CPPK ...... 39 zolpidem tartrate tabs 5mg, 10mg ...... 38 ZEPZELCA SOLR ...... 21 ZOMACTON SOLR ...... 59 ZERBAXA SOLR INTRAVENOUS ...... 11 ZOMACTON SOLR 5mg ...... 59 ZERIT CAPS 15mg, 20mg, 30mg, 40mg . 14 ZOMIG SOLN ...... 37 ZERUVIA PTCH ...... 71 zonisamide caps 25mg, 50mg, 100mg ..... 37 ZETONNA AERS ...... 48 ZONTIVITY TABS ...... 24 zidovudine caps ...... 14 ZORBTIVE SOLR ...... 59 zidovudine syrp ...... 14 ZORTRESS TABS 0.25mg ...... 62 zidovudine tabs ...... 14 ZORTRESS TABS 0.5mg, 0.75mg, 1mg . 62 ZIEXTENZO SOSY ...... 25 ZORVOLEX CAPS ...... 34 zileuton er tb12 ...... 64 ZOSTAVAX SUSR ...... 67 ZINBRYTA SOSY ...... 39 ZOSYN SOLN INTRAVENOUS ...... 11 ZIONODIL 100 LOTN ...... 71 zovia 1/35e (28) tabs ...... 55 ZIONODIL LOTN ...... 71 ZUBSOLV SUBL ...... 40 ZIOPTAN SOLN ...... 49 ZUPLENZ FILM 4mg, 8mg ...... 50 ziprasidone hcl caps 20mg, 40mg, 60mg, ZYCLARA PUMP CREA ...... 73 80mg ...... 43 ZYDELIG TABS 100mg, 150mg ...... 21 ziprasidone mesylate solr ...... 43 ZYKADIA CAPS ...... 21 ZIPSOR CAPS ...... 34 ZYKADIA TABS ...... 21 ZIRABEV SOLN 400mg/16ml, 100mg/4ml ZYLET SUSP ...... 48 ...... 21 ZYNLONTA SOLR ...... 21 ZIRGAN GEL ...... 47 ZYPITAMAG TABS 1mg, 2mg, 4mg ...... 26 ZITHROMAX PACK ...... 11 ZYPREXA RELPREVV SUSR ...... 43 ZOKINVY CAPS 50mg, 75mg ...... 64 ZYTIGA TABS ...... 21 zoledronic acid conc ...... 60 ZYVOX SOLN INTRAVENOUS ...... 11

118 • Kaiser Permanente 2021 Comprehensive Formulary Notice of nondiscrimination Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Permanente does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We also: • Provide no cost aids and services to people with disabilities to communicate effectively with us, such as: ♦ Qualified sign language interpreters. ♦ Written information in other formats, such as large print, audio, and accessible electronic formats. • Provide no cost language services to people whose primary language is not English, such as: ♦ Qualified interpreters. ♦ Information written in other languages.

If you need these services, call Member Services at 1-800-443-0815 (TTY 711), 8 a.m. to 8 p.m., seven days a week.

If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Civil Rights Coordinator by writing to One Kaiser Plaza, 12th Floor, Suite 1223, Oakland, CA 94612 or calling Member Services at the number listed above. You can file a grievance by mail or phone. If you need help filing a grievance, our Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

60899008 Multi-language Interpreter Services

English ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-800-443-0815 (TTY: 711).

Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-443-0815 (TTY: 711).

Chinese 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-443-0815 （TTY：711）。

Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-443-0815 (TTY: 711).

Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-443-0815 (TTY: 711).

Korean 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-443-0815 (TTY: 711)번으로 전화해 주십시오.

Armenian ՈՒՇԱԴՐՈՒԹՅՈՒՆ՝ Եթե խոսում եք հայերեն, ապա ձեզ անվճար կարող են տրամադրվել լեզվական աջակցության ծառայություններ: Զանգահարեք 1-800-443-0815 (TTY (հեռատիպ)՝ 711):

Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-443-0815 (телетайп: 711).

Japanese 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-443-0815 （TTY:711）まで、お電話にてご連絡ください。

60897108 CA

Hmong LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-800-443-0815 (TTY: 711).

Thai เรียน: ถ้าคุณพูดภาษาไทยคุณสามารถใช้บริการช่วยเหลือทางภาษาได้ฟรี โทร 1-800-443-0815 (TTY: 711).

Farsi ﺗﻮﺟﮫ: اﮔﺮ ﺑﮫ زﺑﺎن ﻓﺎرﺳﯽ ﮔﻔﺘﮕﻮ ﻣﯽ ﮐﻨﯿﺪ، ﺗﺴﮭﯿﻼت زﺑﺎﻧﯽ ﺑﺼﻮرت را ﮕﺎنﯾ ﺑﺮای ﺷﻤﺎ ﻓﺮاھﻢ ﻣﯽ ﺑﺎﺷﺪ. ﺑﺎ (TTY: 711) 0815-443-800-1 ﺗﻤﺎس ﺑﮕ ﺪﯾﺮﯿ . .

Arabic ﻣﻠﺤﻮظﺔ: إذا ﻛﻨﺖ ﺗﺘﺤﺪث اذﻛﺮ اﻟﻠﻐﺔ، ﻓﺈن ﺧﺪﻣﺎت اﻟﻤﺴﺎﻋﺪة اﻟﻠﻐﻮﯾﺔ ﺗﺘﻮاﻓﺮ ﻟﻚ ﺑﺎﻟﻤﺠﺎن. اﺗﺼﻞ ﺑﺮﻗﻢ - 0815-443-800-1 (رﻗﻢ ھﺎﺗﻒ اﻟﺼﻢ واﻟﺒﻜﻢ: 711-).

Notice of nondiscrimination

Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Permanente does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We also:

● Provide no cost aids and services to people with disabilities to communicate effectively with us, such as: ♦ Qualified sign language interpreters. ♦ Written information in other formats, such as large print, audio, and accessible electronic formats. ● Provide no cost language services to people whose primary language is not English, such as: ♦ Qualified interpreters. ♦ Information written in other languages.

If you need these services, call Member Services at 1-800-476-2167 (TTY 711),8 a.m. to 8 p.m., seven days a week.

If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Civil Rights Coordinator by writing to 2500 South Havana, Aurora, CO 80014 or calling Member Services at the number listed above. You can file a grievance by mail or phone. If you need help filing a grievance, our Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

61102709_CO Multi-language Interpreter Services

English ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-800-476-2167 (TTY: 711).

Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-476-2167 (TTY: 711).

Chinese 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-476-2167 （TTY：711）。

Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-476-2167 (TTY: 711).

Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-476-2167 (TTY: 711).

Korean 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-476-2167 (TTY: 711)번으로 전화해 주십시오.

Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-476-2167 (телетайп: 711).

Japanese 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-476-2167 （TTY:711）まで、お電話にてご連絡ください。

Amharic ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-800-476-2167 (መስማት ለተሳናቸው: 711).

German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-476-2167 (TTY: 711). French ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-476-2167 (ATS : 711).

Farsi ﺗﻮﺟﮫ: اﮔﺮ ﺑﮫ زﺑﺎن ﻓﺎرﺳﯽ ﮔﻔﺘﮕﻮ ﻣﯽ ﮐﻨﯿﺪ، ﺗﺴﮭﯿﻼت زﺑﺎﻧﯽ ﺑﺼﻮرت را ﮕﺎنﯾ ﺑﺮای ﺷﻤﺎ ﻓﺮاھﻢ ﻣﯽ ﺑﺎﺷﺪ. ﺑﺎ (TTY: 711) 2167-476-800-1 ﺗﻤﺎس ﺑﮕ ﺪﯾﺮﯿ . .

Arabic ﻣﻠﺤﻮظﺔ: إذا ﻛﻨﺖ ﺗﺘﺤﺪث اذﻛﺮ اﻟﻠﻐﺔ، ﻓﺈن ﺧﺪﻣﺎت اﻟﻤﺴﺎﻋﺪة اﻟﻠﻐﻮﯾﺔ ﺗﺘﻮاﻓﺮ ﻟﻚ ﺑﺎﻟﻤﺠﺎن. اﺗﺼﻞ ﺑﺮﻗﻢ 1-008-674-7612 (رﻗﻢ ھﺎﺗﻒ اﻟﺼﻢ واﻟﺒﻜﻢ: 117-).

Yoruba AKIYESI: Ti o ba nso ede Yoruba ofe ni iranlowo lori ede wa fun yin o. E pe ero ibanisoro yi 1-800-476-2167 (TTY: 711).

Cushite-Oromo XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-800-476-2167 (TTY: 711).

Nepali 鵍यान िदनहोसु :् तपाइ�ले नेपाली बो쥍नहु �ꅍछ भने तपाइ�को िनि륍त भाषा सहायता सेवाह� िनःश쥍कु �पमा उपल녍ध छ । फोन गन셍होसु ् 1-800-476-2167 (िटिटवाइ: 711) ।

Notice of nondiscrimination Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We also: • Provide no cost aids and services to people with disabilities to communicate effectively with us, such as: ♦ Qualified sign language interpreters. ♦ Written information in other formats, such as large print, audio, and accessible electronic formats. • Provide no cost language services to people whose primary language is not English, such as: ♦ Qualified interpreters. ♦ Information written in other languages.

If you need these services, call Member Services at 1-800-232-4404 (TTY 711), 8 a.m. to 8 p.m., seven days a week.

If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Civil Rights Coordinator by writing to Attention: Member Services, Nine Piedmont Center, 3495 Piedmont Road NE, Atlanta, GA 30305 or calling Member Services at the number listed above. You can file a grievance by mail or phone. If you need help filing a grievance, our Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

61104516 Multi-language Interpreter Services

English ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-800-232-4404 (TTY: 711).

Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-232-4404 (TTY: 711).

Chinese 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-232-4404 （TTY：711）。

Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-232-4404 (TTY: 711).

Korean 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-232-4404 (TTY: 711)번으로 전화해 주십시오.

Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-232-4404 (телетайп: 711).

Japanese 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。 1-800-232-4404（TTY:711）まで、お電話にてご連絡ください。

Amharic ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-800-232-4404 (መስማት ለተሳናቸው: 711).

60505608 Farsi ﺗﻮﺟﮫ: اﮔﺮ ﺑﮫ زﺑﺎن ﻓﺎرﺳﯽ ﮔﻔﺘﮕﻮ ﻣﯽ ﮐﻨﯿﺪ، ﺗﺴﮭﯿﻼت زﺑﺎﻧﯽ ﺑﺼﻮرت را ﮕﺎنﯾ ﺑﺮای ﺷﻤﺎ ﻓﺮاھﻢ ﻣﯽ ﺑﺎﺷﺪ. ﺑﺎ (TTY: 711) 4404-232-800-1 ﺗﻤﺎس ﺑﮕ یﺮﯿ

Arabic ﻣﻠﺤﻮظﺔ: إذا ﻛﻨﺖ ﺗﺘﺤﺪث اذﻛﺮ اﻟﻠﻐﺔ، ﻓﺈن ﺧﺪﻣﺎت اﻟﻤﺴﺎﻋﺪة اﻟﻠﻐﻮﯾﺔ ﺗﺘﻮاﻓﺮ ﻟﻚ ﺑﺎﻟﻤﺠﺎن. اﺗﺼﻞ ﺑﺮﻗﻢ 1-008-232-4044 (رﻗﻢ ھﺎﺗﻒ اﻟﺼﻢ واﻟﺒﻜﻢ: 117-).

German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-232-4404 (TTY: 711).

French ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-232-4404 (ATS : 711).

Portuguese ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-232-4404 (TTY: 711).

French Creole ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-232-4404 (TTY: 711). Notice of nondiscrimination Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Permanente does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We also: • Provide no cost aids and services to people with disabilities to communicate effectively with us, such as: ♦ Qualified sign language interpreters. ♦ Written information in other formats, such as large print, audio, and accessible electronic formats. • Provide no cost language services to people whose primary language is not English, such as: ♦ Qualified interpreters. ♦ Information written in other languages.

If you need these services, call Member Services at 1-800-805-2739 (TTY 711), 8 a.m. to 8 p.m., seven days a week.

If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Civil Rights Coordinator by writing to 711 Kapiolani Blvd, Honolulu, HI 96813 or calling Member Services at the number listed above. You can file a grievance by mail or phone. If you need help filing a grievance, our Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Kaiser Permanente is an HMO plan with a Medicare contract. Enrollment in Kaiser Permanente depends on contract renewal.

KAH2711 Multi-language Interpreter Services

English ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-800-805-2739 (TTY: 711).

Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-805-2739 (TTY: 711).

Chinese 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-805-2739 （TTY：711）。

Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-805-2739 (TTY: 711).

Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-805-2739 (TTY: 711).

Korean 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-805-2739 (TTY: 711)번으로 전화해 주십시오.

Japanese 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-805-2739 （TTY:711）まで、お電話にてご連絡ください。

Lao ໂປດຊາບ: ຖ້ າວ່ າ ທ່ ານເວົ້ າພາສາ ລາວ, ການໍບິລການຊ່ ວຍເຫືຼ ອດ້ ານພາສາ, ໂດຍບໍ່ ເສັ ຽ ຄ່ າ, ແ ມ ່ ນ ມີ ພ້ ອມໃຫ້ ທ່ ານ. ໂທຣ 1-800-805-2739 (TTY: 711).

Ilocano PAKDAAR: Nu saritaem ti Ilocano, ti serbisyo para ti baddang ti lengguahe nga awanan bayadna, ket sidadaan para kenyam. Awagan ti 1-800-805-2739 (TTY: 711).

Samoan MO LOU SILAFIA: Afai e te tautala Gagana fa'a Sāmoa, o loo iai auaunaga fesoasoan, e fai fua e leai se totogi, mo oe, Telefoni mai: 1-800-805-2739 (TTY: 711).

H1230_2017MLI accepted

Marshallese LALE: Ñe kwōj kōnono Kajin Ṃajōḷ, kwomaroñ bōk jerbal in jipañ ilo kajin ṇe aṃ ejjeḷọk wōṇāān. Kaalọk 1-800-805-2739 (TTY: 711)

Trukese MEI AUCHEA: Ika iei foosun fonuomw: Foosun Chuuk, iwe en mei tongeni omw kopwe angei aninisin chiakku, ese kamo. Kori 1-800-805-2739 (TTY: 711).

Hawaiian E NĀNĀ MAI: Inā hoʻopuka ʻoe i ka ʻōlelo hoʻokomo ʻōlelo, loaʻa ke kōkua manuahi iā ʻoe. E kelepona iā 1-800-805-2739 (TTY: 711).

Pohnpeian Ni songen mwohmw ohte, komw pahn sohte anahne kawehwe mesen nting me koatoantoal kan ahpw wasa me ntingie Lokaiahn Pohnpei komw kalangan oh ntingidieng ni lokaiahn Pohnpei. Call 1-800-805-2739 (TTY: 711).

Bisayan ATENSYON: Kung nagsulti ka og Cebuano, aduna kay magamit nga mga serbisyo sa tabang sa lengguwahe, nga walay bayad. Tawag sa 1-800-805-2739 (TTY: 711).

Tongan FAKATOKANGA’I: Kapau ‘oku ke Lea-Fakatonga, ko e kau tokoni fakatonu lea ‘oku nau fai atu ha tokoni ta’etotongi, pea teke lava ‘o ma’u ia. Telefoni mai 1-800-805-2739 (TTY: 711).

Notice of nondiscrimination Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Permanente does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We also: • Provide no cost aids and services to people with disabilities to communicate effectively with us, such as: ♦ Qualified sign language interpreters. ♦ Written information in other formats, such as large print, audio, and accessible electronic formats. • Provide no cost language services to people whose primary language is not English, such as: ♦ Qualified interpreters. ♦ Information written in other languages.

If you need these services, call Member Services at 1-888-777-5536 (TTY 711), 8 a.m. to 8 p.m., seven days a week.

If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Civil Rights Coordinator by writing to 2101 East Jefferson Street, Rockville, MD 20852 or calling Member Services at the number listed above. You can file a grievance by mail or phone. If you need help filing a grievance, our Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 1-800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

61102310 Multi-language Interpreter Services

English ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-888-777-5536 (TTY: 711).

Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-777-5536 (TTY: 711).

Chinese 㲐シ烉⤪㝄ぐἧ䓐䷩橼ᷕ㔯炻ぐ⎗ẍ⃵屣䌚⼿婆妨㎜≑㚵⊁ˤ婳农暣 1-888-777-5536 炷TTY烉711炸ˤ

Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-888-777-5536 (TTY: 711).

Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-888-777-5536 (TTY: 711).

Korean .ՎԻ ࢇࡈଜݨ ܹ ࢑ݡТЬה ݛձٸࡈଜݤЕ ˁࡉ, ߯߭ एࡕ ۰ی ࣯ࢂ: ଞ˲߭ձ .ࡳԻ ࢷ୘ଥ ࣯ݫݤࠝء(TTY: 711) 1-888-777-5536

Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-888-777-5536 (телетайп: 711).

Japanese ὀព஦㡯㸸᪥ᮏㄒࢆヰࡉࢀࡿሙྜࠊ↓ᩱࡢゝㄒᨭ᥼ࢆࡈ฼⏝࠸ࡓࡔࡅࡲࡍࠋ 1-888-777-5536㸦TTY:711㸧ࡲ࡛ࠊ࠾㟁ヰ࡟࡚ࡈ㐃⤡ࡃࡔࡉ࠸ࠋ

Thai Á¦¸¥œ ™µ‡o »–¡—£µ¬µÅš¥‡¼ »–­µ¤µ¦™Ä ¦o ·„µ¦nª¥Á®¨º°šµŠ£µ¬µÅ—¢¦o ¸ Ú¦1-888-777-5536 (TTY: 711).

Hindi ڙȡ“ ‘Ʌ: ™Ǒ‘ ]” Ǒ¡‘ȣȲ –Ȫ› ȯ ¡ɇ Ȫ ]”€ȯ ͧ›f ˜ÝǕ ˜Ʌ —ȡŸȡ ¡ȡ™ȡ ȯȡf Ȳ `”›Þ’ ¡ɇ@ 1-888-777-5536 (TTY: 711) ”š €Ȩ› €šɅ@

Amharic 8n·>: ÕŠô,p LŒL š0’ Ÿ ‡ Õp0õ œ0ßn á0ñqxŃ [‡Ģ Øùʽp kÅ÷ìkºŁ ·Ü Ÿk ¼ DČ0 Úܼ 1-888-777-5536 (8p k6Šs¼: 711). Farsi ϪΟϮΗ : اﮔﺮ ﺑﮫ زﺑﺎن ﻓﺎرﺳﯽ ﮔﻔﺘﮕﻮ ﻣﯽ ﮐﻨﯿﺪ، ﺗﺴﮭﯿﻼت زﺑﺎﻧﯽ ﺑﺼﻮرت راﯾﮕ ﺎن ﺑﺮای ﺷﻤﺎ ﻓﺮاھﻢ ﻣﯽ ﺑﺎﺷﺪ. ﺑﺎ (TTY: 711) 5536-777-888-1 ﺗﻤﺎس ﺑﮕﯿﺮی

Arabic ﻣﻠﺤﻮ ظﺔ: إذا ﻛﻨﺖ ﺗﺘﺤﺪث اذﻛﺮ اﻟﻠﻐﺔ، ﻓﺈن ﺧﺪﻣ ﺎت اﻟﻤﺴﺎﻋﺪة اﻟﻠﻐﻮﯾﺔ ﺗﺘﻮاﻓﺮ ﻟﻚ ﺑﺎﻟﻤ ﺠﺎ ن. اﺗﺼﻞ ﺑﺮﻗﻢ 5536-777-888-1 (رﻗﻢ ھﺎﺗﻒ اﻟﺼﻢ واﻟﺒﻜﻢ: 711-). German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-888-777-5536 (TTY: 711).

French ATTENTION : Si vous parlez français, des services d 'aide linguistique vous sont proposés gratuitement. Appelez le 1-888-777-5536 (ATS : 711).

Yoruba AKIYESI: Ti o ba nso ede Yoruba ofe ni iranlowo lori ede wa fun yin o. E pe ero ibanisoro yi 1-888-777-5536 (TTY: 711).

Portuguese ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-888-777-5536 (TTY: 711).

Italian ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-888-777-5536 (TTY: 711).

Bengali ΐϠҝ ͵჈Έι ΎΛΆ ͨΉΛΈ ΋ΚθΐΚ, ͵΅Κ ΋ΐά΄ ΉΚάΏΈ, ΄ΚΔάΐ ΛΈιͶΏͺΚΗ ΌΚΒΚ ΓΔΚΗ΄Κ ΉΛΏάΒ΋Κ ͫΉΐѐ ͨάͻ͡ έΊΚΈ ͵჈Έ 1-888-777-5536 (TTY: 711)͡

Urdu ﺧﺒﺮدار: اﮔﺮ آپ اردو ﺑﻮﻟﺘﮯ ﮨﯿﮟ، ﺗﻮ آپ ﮐﻮ زﺑﺎن ﮐﯽ ﻣﺪد ﮐﯽ ﺧﺪﻣﺎت ﻣﻔﺖ ﻣﯿﮟ دﺳﺘﯿﺎب ﮨﯿﮟ ۔ ﮐﺎل ﮐﺮﯾﮟ 1-888-777-5536 (TTY: 711). French Creole ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-888-777-5536 (TTY: 711).

Gujarati ɅIWhk : Ks S\p ȤK^hSjk Zs_Sh es, Ss iW:ɃƣDk [hch deh] dpahB S\h^h \hN° ;X_ƞV Jp. YsW D^s 1-888-777-5536 (TTY: 711). Notice of nondiscrimination Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Permanente does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We also: • Provide no cost aids and services to people with disabilities to communicate effectively with us, such as: ♦ Qualified sign language interpreters. ♦ Written information in other formats, such as large print, audio, and accessible electronic formats. • Provide no cost language services to people whose primary language is not English, such as: ♦ Qualified interpreters. ♦ Information written in other languages.

If you need these services, call Member Services at 1-877-221-8221 (TTY 711), 8 a.m. to 8 p.m., seven days a week.

If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Civil Rights Coordinator by writing to 500 NE Multnomah St., Suite 100, Portland OR 97232 or calling Member Services at the number listed above. You can file a grievance by mail or phone. If you need help filing a grievance, our Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

259165643_SA_08-18 Multi-language Interpreter Services

English ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-877-221-8221 (TTY: 711).

Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-877-221-8221 (TTY: 711).

Chinese 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-877-221-8221 （TTY：711）。

Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-877-221-8221 (TTY: 711).

Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-877-221-8221 (TTY: 711).

Korean 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-877-221-8221 (TTY: 711)번으로 전화해 주십시오.

Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-877-221-8221 (телетайп: 711).

Japanese 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。 1-877-221-8221（TTY:711）まで、お電話にてご連絡ください。

Punjabi ਿਧਆਨ ਿਦਓ: ਜੇ ਤੁਸ� ਪੰਜਾਬੀ ਬੋਲਦੇ ਹੋ, ਤ� ਭਾਸ਼ਾ ਿ ਵੱ ਚ ਸਹਾਇਤਾ ਸੇਵਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਧ ਹੈ। （ ） 1-877-221-8221 TTY:711 'ਤੇ ਕਾਲ ਕਰੋ।

Mon-Khmer Cambodian 䮚បយ័ត� ៖ េបើសិន�អ�កនិ�យ ��ែខ� រ, េស�ជំនួយែផ�ក�� េ�យមិនគិតឈ� �ល គឺ�ច�នសំ�ប់បំេរ �អ�ក។ ចូ រ ទូរស័ព� 1-877-221-8221 (TTY: 711)។

295108782_11-18 Thai เรียน: ถ้าคุณพูดภาษาไทยคุณสามารถใช้บริการช่วยเหลือทางภาษาได้ฟรี โทร 1-877-221-8221（TTY:711).

Farsi ﺗﻮﺟﮫ: اﮔﺮ ﺑﮫ زﺑﺎن ﻓﺎرﺳﯽ ﮔﻔﺘﮕﻮ ﻣﯽ ﮐﻨﯿﺪ، ﺗﺴﮭﯿﻼت زﺑﺎﻧﯽ ﺑﺼﻮرت را ﮕﺎنﯾ ﺑﺮای ﺷﻤﺎ ﻓﺮاھﻢ ﻣﯽ ﺑﺎﺷﺪ. ﺑﺎ (TTY: 711) 8221-221-877-1 ﺗﻤﺎس ﺑﮕ ﺪﯾﺮﯿ . .

Arabic ﻣﻠﺤﻮظﺔ: إذا ﻛﻨﺖ ﺗﺘﺤﺪث اذﻛﺮ اﻟﻠﻐﺔ، ﻓﺈن ﺧﺪﻣﺎت اﻟﻤﺴﺎﻋﺪة اﻟﻠﻐﻮﯾﺔ ﺗﺘﻮاﻓﺮ ﻟﻚ ﺑﺎﻟﻤﺠﺎن. اﺗﺼﻞ ﺑﺮﻗﻢ 8221-221-877 1- (رﻗﻢ ھﺎﺗﻒ اﻟﺼﻢ واﻟﺒﻜﻢ: 711-).

Amharic ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-877-221-8221 (መስማት ለተሳናቸው: 711).

German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-877-221-8221 (TTY: 711).

French ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-877-221-8221 (ATS : 711).

Cushite-Oromo XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-877-221-8221 (TTY: 711).

Lao ໂປດຊາບ: ຖ້ າວ່ າ ທ່ ານເວົ້ າພາສາ ລາວ, ການໍບິລການຊ່ ວຍເຫືຼ ອດ້ ານພາສາ, ໂດຍບໍ່ ເສັ ຽ ຄ່ າ, ແ ມ ່ ນ ມີ ພ້ ອມໃຫ້ ທ່ ານ. ໂທຣ 1-877-221-8221 (TTY: 711).

Ukrainian УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 1-877-221-8221 (телетайп: 711).

Romanian ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la 1-877-221-8221 (TTY: 711).

This formulary was updated on 10/01/2021. For more recent information or other questions, please contact the number for your Kaiser Permanente Region listed below, seven days a week, 8 a.m. to 8 p.m., or visit kp.org/seniorrx.

Kaiser Permanente Regional

CALIFORNIA REGIONS HAWAII REGION Kaiser Foundation Health Plan, Inc. Kaiser Foundation Health Plan, Inc. 393 E. Walnut St. 711 Kapiolani Blvd. Pasadena, CA 91188-8514 Honolulu, HI 96813 Kaiser Permanente Senior Advantage Kaiser Permanente Senior Advantage (HMO) (HMO) and Senior Advantage Medicare Member Services Medi-Cal Plan South (HMO SNP) 1-800-805-2739 TTY 711 Member Service Contact Center 1-800-443-0815 TTY 711 MID-ATLANTIC STATES REGION (District of Columbia, Maryland, COLORADO REGION and Virginia) Kaiser Foundation Health Plan of Colorado Kaiser Foundation Health Plan 10350 E. Dakota Ave. of the Mid-Atlantic States, Inc. Denver, CO 80247 2101 East Jefferson St. Kaiser Permanente Senior Advantage (HMO) Rockville, MD 20852 Kaiser Permanente Medicare Advantage (HMO) Member Services 1-800-476-2167 TTY 711 Member Services 1-888-777-5536 TTY 711

GEORGIA REGION NORTHWEST REGION Kaiser Foundation Health Plan Kaiser Foundation Health Plan of Georgia, Inc. of the Northwest Nine Piedmont Center 500 NE Multnomah St., Suite 100 3495 Piedmont Road NE Portland, OR 97232 Atlanta, GA 30305 Kaiser Permanente Senior Advantage (HMO) Kaiser Permanente Senior Advantage (HMO) and Senior Advantage Medicare Member Services Medicaid Plan (HMO D-SNP) 1-877-221-8221 TTY 711

Member Services 1-800-232-4404 TTY 711

kp.org/seniorrx

Please recycle.

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