Non-Formulary Conversion Document 02.08.Xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Accolate tab (Zafirlukast) 20 mg BID ICS inhaler (QVAR or *Flovent or *Flovent 110mcg/puff & 220mcg/puff are non- Asmanex) plus a long acting B2-agonist formulary. If patient is already using steroid and (Serevent) OR an ICS and B2 agonist serevent inhaler and asthma symptoms persist, candidate for singulair Accu-Check Advantage blood glucose test strips One Touch Ultra glucose test strips One Lifescan monitor is formulary and may be Touch Ultra 2 machine -only obtained, by prescription, at KP pharmacy at co- payment. Members will be charged full price for Lifescan monitor at Eckerd Accupril tablet (Quinapril) 10-20 mg QD Prinivil (Lisinopril) tablet 10 mg QD TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I & Thiazide diuretic Four Drug Therapy:Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretics
Accupril tablet (Quinapril)40-80 mg QD Prinivil (Lisinopril) tablet 20-40 mg QD TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy:Add Beta Blocker to ACE-I & Thiazide diuretic Four Drug Therapy:Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretics
Accuretic (Quinapril/HCTZ 10/12.5mg) see strengths Lisinopril/HCTZ 10/12.5MG QD TSPMG Guidelines suggest: below Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy:Add Beta Blocker to ACE-I & Thiazide diuretic Four Drug Therapy:Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretics
Accuretic (Quinapril/HCTZ 20/12.5mg; 20/25mg) Lisinopril/HCTZ 20/12.5MG QD or 20/25mg TSPMG Guidelines suggest: QD Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy:Add Beta Blocker to ACE-I & Thiazide diuretic Four Drug Therapy:Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretics
Accutane caps (Isotretinoin)10-40 mg BID Sotret (Isotretinoin) Or, consider antibiotic, if Physician should place a dated Sotret no previous trial: Tetracycline caps 500 mg qualification sticker on Rx that must be dated w/in QD-BID or Minocycline 50 mg QD-TID 7 days of date Rx is picked up.
Aceon (Perindopril) 4-8mg QD Prinivil (Lisinopril) 20mg-40mg QD TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy:Add Beta Blocker to ACE-I & Thiazide diuretic Four Drug Therapy:Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretics
Page 1 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Aciphex tablet (Rabeprazole) 20-60 mg QD to BID OTC Prilosec 20 to 40mg QD Aciphex is a NF No Initial Fill drug. If Prilosec 40mg QD failure, then consider NF No Initial Fill drug, Protonix titrated up to 80mg QD. (Protonix 40mg=Aciphex 20mg=Prilosec 20mg) Must document failure or intolerance to Prilosec 40mg QD if requesting PPI coverage.
Aclovate (Aclometasone) 0.05% cream, oint DesOwen (Desonide) 0.05% cream, oint, Low potency topical corticosteroids. lotion or Synalar (Fluocinolone) 0.01% soln, oil or Hytone (Hydrocortisone) 2.5% cream, oint, lotion Activella (1mg 17beta estradiol / 0.5mg norethindrone Estrace (17beta estradiol) 1mg QD plus Two individual prescriptions are required. acetate) NorQD 0.35mg (norethindrone) QD Norethindrone 0.35mg functional equivalent dosing to Norethindrone acetate 0.5mg. Actonel (Residronate) 5mg QD or 35mg Qweek Fosamax (Alendronate) 5mg QD or 35mg If preventing osteoporosis, convert 5mg Actonel tablets every week for osteoporosis prevention OR QD to 5mg Fosamax QD OR convert 35mg Fosamax 10mg QD or 70mg w/D Q week Actonel once a week to Fosamax 35mg [37.5ml] for osteoporosis treatment. Fosamax PO once a week. Fosamax Liquid is the 70mg/75ml liquid & Fosamax w/D tablets preferred formulary alternative for this dose : available. Fosamax w/D is the preferred 37.5ml = 35mg dose. If treating osteoporosis, formulary alternative for once-weekly convert 5mg Actonel QD to 10mg Fosamax QD dosing if a 70mg dose is required for the OR convert 35mg Actonel once weekly to treatment of osteoporosis . Fosamax w/D once weekly. Fosamax w/D tablets is the preferred formulary alternative when a 70mg dose is required for once-weekly treatment of osteoporosis .
Actonel (Residronate) 30mg tablet (30mg tablet is Treatment Paget's Disease: Fosamax 40mg . only indicated for Paget's disease treatment) QD Actoplus Met Metformin & pioglitazone as 2 separate agents Acular (ketorolac) 0.5% ophth soln If using for allergic conjunctivitis: OTC Opcon-A (pheniramine and naphazoline) If treating post-op inflammation: Voltaren 0.1% ophth soln Acular PF (preservative free) 0.5% If using for allergic conjunctivitis: OTC Opcon-A (pheniramine and naphazoline) If treating post-op inflammation: Voltaren 0.1% ophth soln Adalat CC (Nifedipine XL) 30, 60, 90 mg tab Nifedipine XL 30, 60 or 90 mg tablet TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I & Thiazide diuretic Four Drug Therapy: Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretics
Adderall (Amphetamine mixtures) XR extended Adderall regular release 5, 10, 20, 30mg Adderall XR is restricted to pediatrics, child release 5mg, 10mg, 15mg, 20mg, 25mg, 30mg tablets, Concerta 18, 27, 36 and 54mg neurology and behavioral health. Titrate to capsules tablets, Methylphenidate 5, 10, 20mg and appropriate dosage using Adderall regular SR 20mg; Methylin (Methylphenidate) ER release tablets before transitioning to once daily 10mg; or generic Dexedrine spansules Adderall XR. Document failed trial on (Dextroamphetamine) 5, 10, 15mg Methylphenidate, Dextroamphetamine and Controlled substances level 2 requiring Adderall IR products before a Non-formulary prescription written by prescriber. Product is considered.
Page 2 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Advair (Fluticasone/Salmeterol 100/50, 250/50, Advair restricted to Peds Pulm, Pulmonology Advair 100/50 i puff BID = 500/50) diskus oral inhaler and Allergy. Document failure on 1 combination QVAR 80mcg i puff BID & Serevent 50mcg diskus i puff BID -OR of alternatives QVAR and Serevent -or- Asmanex Flovent 44mcg ii puffs BID & and Serevent before nonformulary product Serevent 50mcg i puff BID; considered. **Advair 500/50 may warrant approval because of high dose of steroid ingredient. If Advair 250/50 i puff BID = QVAR patient has failed a trial on QVAR 40 inhaler, 80mcg ii puffs BID & Serevent 50mcg i consider Flovent (Fluticasone) 44/puff inhaler puff BID -OR AND Serevent (Salmeterol) 50mcg diskus. Asmanex 220mcg i puff BID [or ii puffs QHS] & Serevent 50mcg diskus i puff BID Advair 500/50 i puff BID -submit .nf form
Advicor (niacin ER/lovastatin) 500/20mg or OTC Slo-niacin or Time-release niacin. Do not recommend flush-free niacin. For 1000/20mg QHS Initiate at 500 mg QD titrated up by 500mg improving HDL, regular niacin is recommended. every 4 weeks up to desired dose plus Rx Titrate immediate release niacin 100 mg QD x Lovastatin 20MG QPM with meal. 1week, then 200 mg QDx 1 week, 300 mg QD x 1 week, 500 mg QD x 1 week, then 500 mg BID thereafter. Slow release or Time release niacin is preferred for LDL lowering. Counsel pt to take niacin with food and try taking an aspirin 30 minutes before niacin to prevent flushing and itching. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 8:30AM and 5:30PM.
Aerobid oral inhaler (Flunisolide) ii-iiii puffs BID QVAR (Beclomethasone HFA) oral inhaler QVAR is the preferred formulary alternative. If 80 mcg i-ii puffs BID or Asmanex patient has failed QVAR, consider Asmanex i-ii (mometasone furoate) oral dry powder puffs QHS. inhaler 200mcg per puff inhale i-ii puffs QHS (or i puff BID) Aeroseb-HC (Hydrocortisone) aerosol 0.5% OTC Hydrocortisone 0.5% cream If require a product for the scalp, consider Synalar (Fluocinolone) soln or oil 0.01% (low potency)
Akineton (Biperiden) 2mg tablet 2mg BID-TID Cogentin (Benztropine) tablet 1-4mg QD- Parkinson's drug therapy BID Alamast (Pemirolast) 0.1% ophthalmic solution i-ii For allergic conjunctivitis: OTC Opcon-A OTC Zaditor 0.25% and Patanol are both dual drops QID (Pheniramine & Naphazoline) or OTC action antihistamine/mast cell stabilizers, are Zaditor 0.25% [NOTE: OTC products are dosed twice daily, and have the same FDA not a covered benefit] approved indications. If treating steroid responsive inflammatory condition consider at least 2 formulary products before prescribing/authorizing NF product: Dexamethasone 0.1% ophth soln or Prednisolone 0.12%-1% ophth soln or Flarex, FML (Fluorometholone) ophth soln 0.1% i-ii drops in affected eye(s) QID Albuterol (Proventil or Ventolin) nebulizer solution Albuterol 20% concentrated nebulizer Premixed nebulized solutions are non formulary. 0.083% 3 ml via nebulizer TID-QID solution 0.5 ml with 2.5 ml saline via Component medications are available separately, nebulizer TID-QID Albuterol 20% soln (formulary) and OTC saline for nebulizer dilution
Aldactone 50 &100 mg tabs Spironolactone (generic Aldactone) 25 mg 50 mg and 100 mg tablets are non-formulary. May substitute 25 mg tablets as appropriate to obtain 50 mg or 100 mg dose. Alesse (0.1 Levonorgestrel/20mcg EE) Levlen (0.15mg Levonorgestrel / 30mcg EE) May consider Microgestin FE 1/20 (1mg or Tri-Levlen (0.05mg Lvngl/30mcg EE x 6 Norethindrone/ 20mcg EE) Document at least 3 days, 0.075mg Lvngl/40mcg EE x 5 days, formulary alternatives before 0.125mg lvngl/ 30mcg EE x 10 days) prescribing/approving a NF product.
Page 3 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Allegra (Fexofenadine) 180mg tabs Nasarel ii sprays per nostril BID or generic Allegra remains formulary for Medicare Part D Flonase (fluticasone) i spray per nostril QD patients. Intranasal steroid (Nasarel or Flonase) and/or Claritin OTC or Zyrtec OTC more effective than nonsedating antihistamines for allergic rhinitis.
Allegra-D (Fexofenadine 60mg and Pseudoephedrine Nasarel ii sprays each nostril BID or generic Allegra (not Allegra-D) remains formulary for 120mg) caps Flonase (fluticasone) i spray each nostril Medicare Part D patients. Allegra-D is QD and/or Claritin D OTC or Zyrtec D OTC excluded from the benefit because pseudoephedrine is available OTC.
Alocril (Nedocromil) 2% ophth soln For allergic conjunctivitis: OTC Opcon-A OTC Zaditor 0.25% and Patanol are both dual (Pheniramine & Naphazoline) or OTC action antihistamine/mast cell stabilizers, are Zaditor 0.25% [NOTE: OTC products are dosed twice daily, and have the same FDA not a covered benefit] approved indications. If treating steroid responsive inflammatory condition consider at least 2 formulary products before prescribing/authorizing a NF product: dexamethasone 0.1% ophth soln or prednisolone 0.12%-1% ophth soln or Flarex, FML (Fluorometholone) ophth soln 0.1% i-ii drops in affected eye(s) QID
Alomide (Lodoxamide) ophth 0.1% ophth soln (mast For allergic conjunctivitis: OTC Opcon-A OTC Zaditor 0.25% and Patanol are both dual cell stabilizing properties) (Pheniramine & Naphazoline) or OTC action antihistamine/mast cell stabilizers, are Zaditor 0.25% [NOTE: OTC products are dosed twice daily, and have the same FDA not a covered benefit] approved indications. If treating steroid responsive inflammatory condition consider at least 2 formulary products before prescribing/authorizing a NF product: dexamethasone 0.1% ophth soln or prednisolone 0.12%-1% ophth soln or Flarex, FML (Fluorometholone) ophth soln 0.1% i-ii drops in affected eye(s) QID
Alora (Estradiol transdermal system) delivers 0.025, Climara 0.025mg, 0.0375mg, 0.05mg, If an estrogen patch is required, Climara. 0.05, 0.075, 0.1 mg Estradiol transdermally per day 0.06mg, 0.075mg, 0.1mg patches apply one when each 9cm2, 18cm2, 27cm2 and 36cm2 patch patch weekly; or Estrace 0.5, 1 or 2mg applied twice weekly (Estradiol) Alphagan P (Brimonidine 0.15%) ophth solution i drop Brimonidine 0.2% ophth solution 1 drop in Other formulary alternatives include: Propine in affected eye TID affected eye TID (Dipivefrin 0.1%) i drop BID or Levobunolol 0.25%- 0.5% or Timolol i drop in affected eye(s) BID if a beta-blocker trial has not been used. Alrex (Loteprednol) 0.2% ophth soln i drop QID Dexamethasone 0.1% ophth soln or Post op inflammation: [Loteprednol 0.5% Prednisolone 0.12%-1% ophth soln or (Lotemax) less effective than Prednisolone Flarex, FML (Fluorometholone) ophth soln Acetate 1% in treatment of acute anterior uveitis] 0.1% i-ii drops in affected eye(s) QID
Altace (Ramipril) 1.25 - 20mg QD Prinivil (Lisinopril) 5mg-40mg QD TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy:Add Beta Blocker to ACE-I & Thiazide diuretic Four Drug Therapy:Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretics
Page 4 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Altocor (Lovastatin extended release) 10mg, 20mg, Lovastatin 10mg, 20mg, or 40mg tablets Altocor 10mg QD equivalent to Lovastatin 10mg 40mg or 60mg QD dose. Simvastatin (generic Zocor) is another formulary option: Altocor 40 mg is equivalent to Lovastatin 40 mg or Simvastatin 20 mg. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM. Amaryl (Glimepiride) tablet 1-4 mg QD Glyburide (generic Micronase) 2.5-10 mg Dose of Glyburide, Glipizide, Metformin and Actos QD or Glipizide (generic Glucotrol) 5-15 must be titrated based on individual needs. mg QD or Metformin (Glucophage) 500 mg BID or Actos 15mg QD Amaryl (Glimepiride) tablet 4mg BID or 8 mg QD Glyburide (generic Micronase) 7.5-10 mg Dose of Glyburide, Glipizide, Metformin and Actos BID or Glipizide (generic Glucotrol) or 10-20 must be titrated based on individual needs. mg BID or Metformin (Glucophage) 850 mg Consider other oral antidiabetics such as BID or Actos 15mg 1 - 3 tablets QD Glipizide in patients >65 due to prolonged half life of Glyburide. Ambien (Zolpidem) tabs 10 mg QHS Generic Ambien (Zolpidem 5 & 10mg) Consider lower doses in geriatric patients.
Ambien CR (Zolpidem controlled-release) 6.25mg and Zolpidem 5 - 10mg 1T PO QHS Consider lower doses in geriatric patients. 12.5mg tablets Amerge (Naratriptan) 2.5mg Maxalt (Rizatriptan) MLT 10mg tablet Maxalt MLT 10 mg is preferred, QTY limit of 9 (Maxalt MLT 5mg tablet is also available) tablets/copay. If failed a trial on Maxalt MLT consider formulary alternative Imitrex 50 mg tablets (qty limit of 9 tablets/copay), nasal, or injectable dosage forms. Quantity limit for Non- formulary Amerge 2.5 mg tablets is 9 tablets/copay). Americaine (Benzocaine) 20% otic drops Auralgan Otic drops . (benzocaine/antipyrine/glycerin) Amevive (Alefacept) IM or IV injection (requires Humira or Enbrel. Amevive requires administration in the administration in medical office, not covered by medical clinic under the medical benefit rather outpatient drug benefit) than under the drug benefit and cannot be dispensed at a copayment from a pharmacy. Amevive coverage criteria for psoriasis: (1) patient is an adult with moderate to severe chronic plaque psoriasis, and (2) has a documented failure, or is not a candidate for topical or systemic therapies (methotrexate, acitretin, PUVA, UVB), and (3) patient has a documented failure, or is not a candidate for a combination of the above treatment options, (4) prescriber must be a Dermatologist
Amiloride 5mg Spironolactone (generic Aldactone) 25 mg .
Amitiza 24 mcg capsules Lactulose, Polyehtylene glycol 3350 [OTC Miralax] Amoxicillin 875mg tablet Amoxicillin 500mg capsules Convert from Amoxicillin 875mg to #2 Amoxicillin 500mg capsules Amiloride/HCTZ 5/50mg QD Triamterene/HCTZ 75/50mg 1/2-1 QD .
Page 5 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Androgel (Testosterone) 1% gel Androderm 2.5 mg/24 hr - 5 mg/24 hr Document indication for medication and failure on transdermal patch; Testosterone injection alternatives. (If patient is using for Sexual 400 mg IM q2-4weeks administered in Dysfunction confirm sexual dysfunction benefits.) medical office. Injectables administered in a medical office are covered under the medical office benefit, NOT the drug benefit and are not available from a pharmacy for a copayment. Methyltestosterone (generic Android or Testred) tabs 10-20 mg QD-BID or Fluoxymesterone (Halotestin) 10 mg QD (tablets require baseline and periodic liver function testing).
Ansaid tabs (Flurbiprofen) 100 mg BID Ibuprofen (generic Motrin) tabs 600-800 mg Additional formulary alternatives: Diclofenac TID or Salsalate (Disalcid)1500mg BID or (Voltaren) 75mg BID or Choline Magnesium Naproxen 500mg BID or Sulindac (Clinoril) Trisalicylate (Trilisate) 750mg BID-TID or 200mg BID Nambumetone (Relafen) 500mg - 750mg #1-2 QD- BID or Etodolac (Lodine) 200mg-500mg Q8-12H up to 1200mg/day or Indomethacin 25-50mg TID or Mobic (Meloxicam) 7.5mg or 15mg.
Antara (Fenofibrate) 43mg, 87mg, & 130mg Fenofibrate 54mg and 160mg QD OR If patient is on Antara (Fenofibrate) 130mg Gemfibrozil 600mg BID capsule QD convert to Fenofibrate 160mg QD; If patient is on Antara 43mg, convert to Fenofibrate 54 mg QD. Fenofibrate preferred if pt also taking statin. If pt has reduced renal function, consider offering gemfibrozil 600mg BID which is safer per kidney guidelines. Cost of fenofibrate and gemfibrozil similar. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM.
Antivert (Meclizine) 12.5mg, 25mg or 50mg all strengths available OTC OTC medications are not covered by the drug benefit Anzemet 100mg tablet Zofran (Ondansetron) tabs 4mg-8mg BID, Zofran oral liquid & IV available via pediatric Zofran (ondansetron) ODT 4mg-8mg floorstock for in office dose to break pediatric n/v cycle & allow hydration in children unable to use phenergan safely (Hyoscyamine, 15mg Butabarbital) Insulin [Novolin R is administered 30 minutes prior to a meal]. Apri (0.15mg Desogestrel/ EE 0.03mg) generic Levlen (0.15mg Levonorgestrel / 30mcg EE) Zovia 1/35 (1mg Ethynodiol Diacetate/ 35mcg EE) Desogen or Tri-Levlen (0.05mg Lvngl/30mcg EE x 6 or Microgestin 1.5/30 (1.5 Norethindrone / 30mcg days, 0.075mg Lvngl/40mcg EE x 5 days, EE) or Sprintec (0.25mg Norgestimate/35mcg EE) 0.125mg Lvngl/ 30mcg EE x 10 days) or Tri-Sprintec, generic Ortho-Tricyclen, (0.18mg Norgestimate x 7 days, 0.215mg Norgestimate x 7 days, 0.25mg Norgestimate x 7 days/ 35 mcg EE) Document at least 3 formulary alternatives before prescribing/approving a NF product.
Aricept ODT (Donepezil orally disintegrating tablet) Aricept (Donepezil) 5mg or 10mg 5mg or 10mg Armour Thyroid Tablet 15mg (1/4 grain); Levothroid (levothyroxine) 1 grain Armour thyroid converts to 50 - 60 mcg of 30mg (1/2 grain); 60mg (1 grain); 90mg (1&1/2 grain); levothroid. Calculate each conversion 120mg (2 grains); 180mg (3 grains); 240mg (4 grains); individually 300mg (5 grains) levothyroxine and liothyronine
Page 6 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Arthrotec (Diclofenac/Misoprostol) 50/200 or 75/200 Monotherapy with Relafen (nabumetone) If patient high risk for GI bleed and NSAID is TID 500mg to 750mg 1-2T QD - BID (first required, consider: nambumetone (Relafen) choice) or Lodine (etodolac) 200-500mg Q8- 500mg to 750mg #1-2 QD-BID or etodolac 12H up to 1200mg/day or Voltaren (Lodine) 200-500mg Q8-12H up to 1200mg/day or (diclofenac) 50 - 75mg TID AND Cytotec Salsalate (Disalcid)1500mg BID or choline (misoprostol) 200mcg TID magnesium trisalicylate (Trilisate) 750mg BID- TID. Consider adding Prilosec OTC 20mg QD to further reduce GI risk. Other formulary NSAIDS include: Ibuprofen (generic Motrin) tabs 600-800 mg TID or naproxen 500mg BID or sulindac (Clinoril) 200mg BID
Astelin (Azelastine) ii puffs each nostril BID Nasarel ii sprays each nostril BID or generic Document diagnosis (Consider OTC Claritin or Flonase (fluticasone) i spray each nostril OTC Zyrtec and Nasarel or Flonase before QD or OTC Claritin or OTC Zyrtec prescribing Astelin unless being used for Vasomotor rhinitis.) Atacand (Candesartan) tab 8-32 mg QD Prinivil (lisinopril) 10-20 mg QD or Cozaar Prinivil is preferred, if no previous ACE inhibitor (losartan) 25 mg - 100mg tab QD trial. If angiotensin 2 receptor blocker is required, convert to Cozaar. Conversion equivalents: Atacand 4mg = Prinivil 5mg = Cozaar 25mg; Atacand 8mg = Prinivil 10mg = Cozaar 25mg; Atacand 16mg = Prinivil 20mg = Cozaar 50mg; Atacand 32mg = Prinivil 40mg = Cozaar 100mg TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy:Add Beta Blocker to ACE-I & Thiazide diuretic Four Drug Therapy:Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretics
Atacand HCT (Candesartan/HCTZ) tab 16/12.5mg, Lisinopril/HCTZ 10/12.5mg, 20/12.5mg QD Prinivil is preferred, if no previous ACE inhibitor 32/12.5mg QD or Cozaar(losartan) 25 mg - 100mg QD trial. If angiotensin 2 receptor blocker is required, AND HCTZ (hydrochlorothiazide) 12.5mg convert to Cozaar. Conversion equivalents: QD Atacand 4mg = Prinivil 5mg = Cozaar 25mg; Atacand 8mg = Prinivil 10mg = Cozaar 25mg; Atacand 16mg = Prinivil 20mg = Cozaar 50mg; Atacand 32mg = Prinivil 40mg = Cozaar 100mg TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy:Add Beta Blocker to ACE-I & Thiazide diuretic Four Drug Therapy:Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretics
Atrovent nasal spray 0.03% or 0.6% ii sprays each Nasarel ii sprays each nostril BID or generic Inhaled steroid sprays are used for allergic nostril BID-QID Flonase (fluticasone) i spray each nostril rhinitis, not for common cold. QD Atrovent HFA (ipratropium bromide) oral inhaler Atrovent (ipratropium bromide) oral inhaler Puff per puff conversion; differ only in the propellant used. Augmentin 125mg/5ml suspension Augmentin 200mg/5ml suspension , Augmentin 250mg/5ml suspension Augmentin 400mg/5ml suspension ,
Page 7 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Augmentin XR (1000mg Alternatively may consider generic Alternatively may consider: Cefuroxime 250mg Q Amoxicillin/62.5mg Clavulanic Acid) #2 Q 12 Hours = Augmentin 875mg (875mg 12 hours OR Biaxin 250mg Q 12 hours OR Avelox 2000mg Amoxicillin / 125mg Clavulanic Acid Q 12 Amoxicillin/125mg Clavulanic Acid) #1 Q 12 400mg QD Hours Hours PLUS Amoxicillin 500mg capsules 2 PO Q 12 hours Avage (Tazarotene) 0.1% Cream Drugs for cosmetic use are NOT covered on drug benefit. Member pays retail price.
Avalide (Irbesartan/HCTZ) tabs 75/12.5 - 300/12.5 mg Lisinopril/HCTZ 10/12.5MG, 20/12.5MG OR Prinivil is preferred, if no previous ACE inhibitor QD 20/25MG QD -OR- Cozaar (losartan) 25 - trial. If angiotensin 2 receptor blocker is required, 100 mg QD AND HCTZ 12.5mg QD convert to Cozaar. Conversion equivalents: Avapro 75mg = Prinivil 5mg = Cozaar 25mg; Avapro 150mg = Prinivil 10-20mg = Cozaar 50mg; Avapro 300 = Prinivil 20-40mg = Cozaar 50- 100mg TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy:Add Beta Blocker to ACE-I & Thiazide diuretic Four Drug Therapy:Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretics
Avandamet: 2/500: Rosiglitazone 2 mg and metformin Metformin & Actos (pioglitazone) are Conversion equivalents: Avandia 2mg=Actos hydrochloride 500 mg; Avandamet: 4/500: formulary agents. 15mg; Avandia 4mg = Actos 30mg; Avandia Rosiglitazone 4 mg and metformin hydrochloride 500 8mg=Actos 45mg. (At KP pharmacies, Actos 15 mg; Avandamet: 2/1000: Rosiglitazone 2 mg and mg tablet is the only strength available). metformin hydrochloride 1000 mg; Avandamet: 4/1000: Rosiglitazone 4 mg and metformin hydrochloride 1000 mg
Avandia (Rosiglitazone) 2 - 8 mg QD or divided BID Actos 15 - 45 mg QD Conversion equivalents: Avandia 2mg=Actos 15mg; Avandia 4mg = Actos 30mg; Avandia 8mg=Actos 45mg. (At KP pharmacies, Actos 15 mg tablet is the only strength available). Avapro (Irbesartan) tabs 75 - 300 mg QD Prinivil (lisinopril) 2.5 - 40 mg QD or Cozaar Prinivil is preferred, if no previous ACE inhibitor (losartan) 25 - 100 mg QD trial. If angiotensin 2 receptor blocker is required, convert to Cozaar. Conversion equivalents: Avapro 75mg = Prinivil 5mg = Cozaar 25mg; Avapro 150mg = Prinivil 10-20mg = Cozaar 50mg; Avapro 300 = Prinivil 20-40mg = Cozaar 50- 100mg TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy:Add Beta Blocker to ACE-I & Thiazide diuretic Four Drug Therapy:Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretics
AVC (Sulfanilamide) vaginal cream No Formulary alternative OTC Monistat vaginal cream or Vagistat Aviane (0.1 Levonorgestrel/20mcg EE) Levlen (0.15mg Levonorgestrel / 30mcg EE) May consider Microgestin FE 1/20 (1mg or Tri-Levlen (0.05mg Lvngl/30mcg EE x 6 Norethindrone/ 20mcg EE) Document at least 3 days, 0.075mg Lvngl/40mcg EE x 5 days, formulary alternatives before 0.125mg lvngl/ 30mcg EE x 10 days) prescribing/approving a NF product.
Page 8 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Avinza (Morphine Sulfate Extended Release Generic of MS Contin covered (morphine Avinza capsules are dosed daily & contain both Capsules) 30mg, 60mg, 90mg, 120mg QD Capsules controlled release) 15mg, 30mg, 60mg, immediate release and extended release contain both immediate release and extended release 100mg, 200mg BID & as necessary, morphine. When converting from Avinza, morphine beads. Morphine immediate release tablet 10mg, calculate total daily Morphine dose QD. Divide 30mg, Roxanol (morphine solution total daily morphine dose by 2 to yield generic MS 10mg/5ml, 20mg/5ml, 100mg/5ml) Contin dose to administer BID. If prescribing immediate release morphine for break thru pain, remember to subtract from the total daily morphine when calculating generic MS Contin dose. Avodart 0.5mg (Dutasteride) Proscar (Finasteride) 5mg Alpha blockers:Doxazosin (generic Cardura) titrated to therapeutic doses (e.g. Doxazosin 2mg 1/2 tab po QHS X 1 week, then 1 tab po QHS x 2 weeks, then 2 tabs po QHS and follow-up w/MD for refill) or Terazosin (generic Hytrin) titrated slowly to therapeutic doses. (eg. 1mg QHS days 1- 3, 2mg QHS days 4-15 then 5mg QHS, if necessary may further increase to 10mg QHS).
Axert (Almotriptan) 12.5mg Maxalt (Rizatriptan) MLT 10mg tablet Maxalt MLT 10 mg is preferred, QTY limit of 9 (Maxalt MLT 5mg tablet is also available) tablets/copay. If failed a trial on Maxalt MLT consider formulary alternative Imitrex 50 mg tablets (qty limit of 9 tablets/copay), nasal, or injectable dosage forms. Quantity limit for Non- formulary Axert is 6 tablets per copay Axid puvules 300mg QD or 150mg BID Cimetidine (Tagamet) 400mg BID or 800mg OTC alternatives: QD -or Ranitidine (Zantac) Pepcid OTC 20mg or Zantac OTC 75mg or 300mg QD -or Famotidine (Pepcid) 40mg 150mg QD Azelex (Azelaic acid) 20% cream BID Acne treatment alternatives: Tretinoin Smallest available tube Tretinoin covered per 0.025% cream (Retin-A or Avita cream copay, larger tubes not covered. Benzamycin and brand names) -or 2% Erythromycin Benzaclin are nonformulary, but 2% Erythromycin solution & 5% Benzoyl Peroxide aqueous solution & 5% Benzoyl Peroxide aqueous gel OR gel -or clindamycin 1% solution or sulfacet 1 % Clindamycin gel & 5% Benzoyl Peroxide R lotion or clindamycin 1% gel & 5% aqueous gel, respectively, may be prescribed Benzoyl Peroxide aqueous gel Rosacea separately and purchased as a pack for one treatment alternative: metronidazole 0.75% copayment at a Kaiser Permanente pharmacy. At cream BID Eckerd, the patient must purchase the OTC product, at KP it will be included at no charge.
Azmacort (triamcinolone) oral inhaler ii-iiii puffs BID- QVAR (beclomethasone HFA) 80mcg/puff QVAR is almost 4 times as potent as Azmacort (2 TID oral inhaler, i-ii puffs BID OR Asmanex puffs Azmacort 100mcg/puff = 1 puff QVAR 80 (mometasone furoate) oral dry powder mcg/puff) If patient has failed trial with QVAR inhaler 200mcg/puff i-ii puffs QHS (or i puff consider conversion to Asmanex. BID) Beclovent (Beclomethasone CFC) 42mcg/puff oral QVAR (Beclomethasone HFA) 40mcg/puff QVAR is twice as potent as Beclovent (2 puffs inhaler ii-iiii puffs BID-TID oral inhaler i-ii puffs BID -or Flovent Beclovent 42mcg/puff = 1 puff QVAR 40 mcg/puff) 44mcg/puff i-ii puffs BID and equipotent to Flovent 44mcg (1 puff QVAR 40mcg = 1 puff Flovent 44mcg/puff). QVAR remains the preferred inhaled corticosteroid at KP GA.
Beconase AQ (beclomethasone) 0.42% nasal spray ii Nasarel ii sprays each nostril BID or generic If the child is less then 4 years old, Nasonex may sprays each nostril BID Flonase (fluticasone) i spray each nostril warrant approval as Nasarel is not indicated for QD patients less than 6 years old & Flonase is not indicated in patients less than 4 years old.
Page 9 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Benicar (Olmesartan) 20-40mg QD Prinivil (Lisinopril) 20-40mg QD or Prinivil is preferred, if no previous ACE inhibitor Cozaar(Losartan) 50mg - 100mg tab QD trial. If angiotensin 2 receptor blocker is required, convert to Cozaar. Conversion equivalents: Benicar 20mg = Prinivil 20mg = Cozaar 50mg; Benicar 40mg = Prinivil 40mg = Cozaar 100mg TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy:Add Beta Blocker to ACE-I & Thiazide diuretic Four Drug Therapy:Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretics
Benicar HCT (Olmesartan/HCTZ) 20/12.5mg or Lisinopril/HCTZ 10/12.5mg, 20/12.5mg OR Prinivil is preferred, if no previous ACE inhibitor 40/12.5mg 20/25mg QD or Cozaar (Losartan) 50mg - trial. If angiotensin 2 receptor blocker is required, 100mg tab QD PLUS HCTZ 25mg 1/2 tablet convert to Cozaar. Conversion equivalents: QAM Benicar 20mg = Prinivil 20mg = Cozaar 50mg; Benicar 40mg = Prinivil 40mg = Cozaar 100mg TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy:Add Beta Blocker to ACE-I & Thiazide diuretic Four Drug Therapy:Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretics
Benicar HCT (Olmesartan/HCTZ) 40/25mg Lisinopril/HCTZ 10/12.5mg, 20/12.5mg or Prinivil is preferred, if no previous ACE inhibitor 20/25mg QD or Cozaar(Losartan) 50 mg - trial. If angiotensin 2 receptor blocker is required, 100mg tab QD PLUS HCTZ 25mg tablet convert to Cozaar. Conversion equivalents: QAM Benicar 20mg = Prinivil 20mg = Cozaar 50mg; Benicar 40mg = Prinivil 40mg = Cozaar 100mg TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy:Add Beta Blocker to ACE-I & Thiazide diuretic Four Drug Therapy:Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretics
Benzac AC wash 2.5% wash affected area QD-BID OTC Benzoyl Peroxide wash QD-BID Benzac AC wash is available OTC; not covered BenzaClin topical gel (Benzoyl Separate Rxs for either 2% Benzamycin and Benzaclin are nonformulary, but Peroxide/Clindamycin) Erythromycin solution PLUS 5% Benzoyl 2% Erythromycin solution & 5% Benzoyl Peroxide Peroxide aqueous gel OR aqueous gel OR 1 % Clindamycin gel & 5% Clindamycin 1% gel PLUS 5% Benzoyl Benzoyl Peroxide aqueous gel, respectively, may Peroxide aqueous gel be prescribed separately and purchased as a pack for one copayment at a Kaiser Permanente pharmacy. At Eckerd, the patient will receive Erythromycin 2% soln OR Clindamycin 1% gel at a copayment & must purchase the OTC Benzoyl Peroxide product, at KP the OTC will be included at no additional charge.
Page 10 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Benzamycin topical gel (Benzoyl Separate Rxs for Benzamycin is nonformulary, but 2% Erythromycin Peroxide/Erythromycin) 2% Erythromycin solution PLUS 5% solution & 5% Benzoyl Peroxide aqueous gel may Benzoyl Peroxide aqueous gel be prescribed separately and purchased as a pack for one copayment at a Kaiser Permanente pharmacy. At Eckerd, the patient will receive Erythromycin 2% soln for a copayment & must purchase the OTC Benzoyl Peroxide product, at KP the OTC will be included at no additional charge. Beta-val (Betamethasone valerate) 0.1% cream Triamcinolone (generic Aristocort) cream, If failed other alternatives, consider increasing to [MEDIUM potency] oint 0.1% or Valisone (Betamethasone high potency topical corticosteroid fluocinonide valerate) 0.1% lotion (Lidex) 0.05% cream, oint, or gel Beta-val (Betamethasone valerate) 0.1% ointment Lidex (Fluocinonide) 0.05% cream, oint, gel, High potency topical corticosteroids. [high potency] soln or Diprolene AF (Augmented Betamethasone) 0.05% Betaxon (Levobetaxolol) 0.5% ophth soln i drop in Betoptic (Betaxolol) 0.5% ophth soln Timoptic (Timolol) another formulary alternative affected eye BID i drop in affected eye BID Betimol (Timolol) ophth soln 0.25 and 0.5% Timolol ophth soln 0.25% and 0.5% . BG Logic Blood Glucose Strips One Touch Ultra glucose test strips One Lifescan monitor is formulary and may be Touch Ultra 2 machine -only obtained, by prescription, at KP pharmacy at co- payment. Members will be charged full price for Lifescan monitor at Eckerd. If the patient's insulin pump requires the use of a companion BG monitor requiring NF BG strips, please note brand of pump and companion BG monitor on NF Rx for Freestyle or BG Logic BG strips.
Biaxin XL (Clarithromycin XL) 500mg #2 QD Biaxin (Clarithromycin) 500mg BID Convert on a mg per mg basis. Regular release dose divided every 12 hours (ie. Biaxin XL 1000mg QD converts to Biaxin 500mg Q12H)
BiDil (20mg isosorbide dinitrate/37.5mg hydralazine) Isosorbide dinitrate 20mg + hydralazine BiDil's dosing per package insert is 1-2 tabs TID. 25mg 1 & 1/2 tabs (equals one tablet of Therefore, if patient is taking 2 tabs TID of BiDil, BiDil) formulary conversion is isosorbide dinitrate 20mg 2 tabs TID + hydralazine 25mg 3 tabs TID.
Blocadren (Timolol) 5, 10, 20mg tabs 10-20mg BID Atenolol (Tenormin) 25-100mg QD or Propranolol is available as 10, 20, 40, 60, 80, Metoprolol 100 - 400mg QD or Propranolol 90mg tabs. Inderal LA is non-formulary 40 - 320mg BID TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy:Add Beta Blocker to ACE-I & Thiazide diuretic Four Drug Therapy:Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretics
Blood glucose strips, Non Lifescan brands One Touch Ultra glucose test strips One Lifescan monitor is formulary and may be Touch Ultra 2 machine -only obtained, by prescription, at KP pharmacy for a co- payment. Members will be charged full price for Lifescan monitor at Eckerd Boniva 2.5mg QD or 150mg monthly Fosamax (Alendronate) 5mg QD or 35mg For Fosamax 35mg Qweek dose, consider every week for osteoporosis prevention OR Fosamax Liquid [37.5ml] PO once a week. Fosamax 10mg QD or Fosamax w/D Q Fosamax Liquid is the preferred formulary week for osteoporosis treatment. Fosamax alternative for this dose: 37.5ml = 35mg dose. w/D 70mg tablet and Fosamax 70mg/75ml liquid available.
Page 11 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Botox injection Criteria Restricted Medication Criteria Restricted Medication. Provider phones KP QRM to request authorization consideration 404-364-7320. Botox (Myoblock) requires administration in the medical clinic under the medical benefit rather than under the drug benefit and cannot be dispensed at a copayment from a pharmacy.
Brethaire (Terbutaline) 0.2mg aerosol inhaler Albuterol oral inhaler . Bumex (Bumetanide) 0.5,1,2mg tabs Furosemide (generic Lasix) tablets Bumetanide 1mg converts to Furosemide 40mg
Byetta (exanatide) 5mcg/dose and 10mcg/dose Criteria Restricted Medication. Provider prefilled pen phones KP QRM to request authorization consideration 404-364-7320.
Calan (Verapamil) SR tabs 120-240 mg QD Verapamil SR tabs (generic Calan SR) 120, Substitute on a mg for mg basis. 180, 240 mg tabs 120-240mg QD TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretics Calderol (Calcifediol) 20, 50 mcg caps 300- Rocaltrol (Calcitriol) 0.25, 0.5mcg caps 0.25- . 350mcg/wk titrated to effect 1mcg/day titrated to effect or Calciferol (Ergocalciferol) 50,000 units/capsule 15,000- 20,000 units/day titrated to effect
Campral (Acamprosate) 333mg #2 tablets TID Disulfiram 250mg QD or Revia (Naltrexone) Patients failing to respond to, tolerate or not 50mg QD eligible for Disulfiram, due to DM, cardiovascular disease, epilepsy or significant renal/hepatic insufficiency, consider Naltrexone 50mg QD. Naltrexone demonstrated a lower relapse rate, longer time to first relapse & higher number of abstinence days during alcohol dependence treatment trial versus Campral. Campral may be taken concomitantly with opiates. [Campral: Available Part D group]
Capex (Fluocinolone) 0.01% shampoo Fluocinolone 0.01% solution . Captique injectable gel N/A Cosmetic use drug. Not covered on drug benefit. Member pays retail price. Carac (Fluorouracil) 0.5% cream Fluorouracil 1 and 5% cream Used for actinic or solar keratosis of the face or scalp Cardene SR (Nicardipine) 30 - 60mg BID Nifedipine XL 30-90mg QD; or Diltia XT If treating hypertension, consider conversion to a (diltiazem) 120-480mg QD beta blocker (metoprolol, atenolol) or Hydrochlorothiazide or ACEI (lisinopril) or, if not monotherapy, alpha blocker (doxazosin,terazosin) TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics
Page 12 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Cardizem (Diltiazem) CD 120, 180, 240, 300, 360 mg Diltia (Diltiazem) XT 120, 180 and 240mg Convert on a mg for mg basis. If Cardizem CD caps 120-480mg QD caps 120-480mg QD 300mg, consider conversion to either Diltia XT 240mg QD or #2 180mg (360mg dose) QD. Cartia XT request conversion to Diltia XT. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretics Cardizem (Diltiazem) SR 60, 90, 120mg caps 60- Diltia (Diltiazem) XT 120, 180 and 240mg Cardizem SR 60mg BID=Diltia XT 120mg QD, 120mg BID caps 120-240mg QD Cardizem SR 90mg BID=Diltia XT 180mg QD, Cardizem SR 120mg BID=Diltia XT 240 QD TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics
Carmol-HC (Urea/HC) 1 % cream OTC Hydrocortisone 1% cream Alternative product available OTC Carmol 40% (Urea) OTC alternatives: Carmol 20% cream or . Ultra Mide 25% lotion Cartrol (Carteolol) 2.5, 5mg tabs 2.5 - 10mg QD Atenolol (Tenormin) 25 - 100mg QD or Propranolol is available as 10, 20, 40, 60, 80, Metoprolol 100 - 400mg QD or Propranolol 90mg tabs. Inderal LA is non-formulary 40 - 320mg bid TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics
Casodex (Bicalutamide) 50mg QD Eulexin (Flutamide) 250mg TID Both in the same family of antiandrogens. Catapres TTS-1 patch applied weekly Clonidine (generic Catapres) tablet 0.1 mg Clonidine patch is non formulary, tablets are QD formulary Catapres TTS-2 patch applied weekly Clonidine (generic Catapres) tablet 0.2 mg Clonidine patch is non formulary, tablets are QD formulary Catapres TTS-3 patch applied weekly Clonidine (generic Catapres) tablet 0.3 mg Clonidine patch is non formulary, tablets are QD formulary Caverject inj 10 mcg N/A Caverject is not covered for sexual dysfunction unless member's group has purchased sexual dysfunction rider for additional coverage.
Cedax (Ceftibuten) suspension Omnicef 125mg/5ml; Pediazole . (Erythromycin & Sulfamethoxazole); Augmentin 125-250mg/5ml or 200-400mg chew tabs;Amoxicillin 125-250mg/5ml; Biaxin 125-250mg/5ml; Cefaclor suspension
Page 13 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Ceftin (Cefuroxime) 500mg tablets Cefuroxime 250mg tablets In most instances, 250mg BID is sufficient dosing. When 500mg BID dosing is required, mg to mg conversion. (eg. One cefuroxime 500mg tablet BID converts to Two Cefuroxime 250mg tablets)
Ceftin suspension Omnicef 125mg/5ml; Pediazole Cefuroxime 250mg tablets remain on formulary, (Erythromycin & Sulfamethoxazole); Ceftin suspension is non-formulary Augmentin 125-250mg/5ml or 200-400mg chew tabs;Amoxicillin 125-250mg/5ml; Biaxin 125-250mg/5ml; Cefaclor suspension
Cefzil suspension 30 mg/kg/day divided BID TMP-SMX (generic Septra or Bactrim) 6-12 Pharmacologically, Cefaclor is the closest mg/kg/day (TMP) divided BID or antibiotic alternative to Cefzil. Sulfisoxazole/Erythromycin (generic Pediazole) 68 mg/kg/day (Erythromycin) divided TID or Cefaclor (generic Ceclor) 20- 40 mg/kg/day divided BID-TID or Augmentin 45 mg/kg/day (Amoxicillin/Clavulanate) divided BID
Celebrex (celecoxib) 100 - 200mg BID ***Caution Relafen (Nambumetone) 500mg or 750mg 1 Cox 2 inhibitor (Celebrex) is a NF No Initial Fill may increase cardiovascular toxicity*** - 2 QD-BID or Etodolac (gen. Lodine) 200- agent, due to safety concerns with its use. KP 500mg Q8-12H up to 1200mg/day or NSAID GI SCORE tool will assist provider to Ibuprofen (gen. Motrin) tabs 600-800 mg determining if pt is a candidate for Cox-2 inhibitor TID or Naproxen (gen. Naprosyn) 500mg benefit coverage. If pt SCORE >20 and patient BID or Sulindac (gen. Clinoril) 200mg BID has failed a reasonable trial on each of these low or Diclofenac (gen. Voltaren) 75mg BID or GI risk NSAIDs PLUS PPI: Relafen 500mg or Mobic (Meloxicam) 7.5mg or 15mg 750mg 1 - 2 QD-BID PLUS Prilosec 20mg QD; OR, if COX 2 inhibitor is appropriate (GI Etodolac 400-500mg BID PLUS Prilosec 20mg SCORE > 20), see next column. Clinical QD; Salsalate 750mg 1-2 BID PLUS Prilosec trials document: Adding PPI like, Prilosec 20mg QD, meets criteria for Cox 2 inhibitor OTC 20mg QD, to NSAID therapy results in coverage. If pt SCORE < 20 and NSAID is GI ulcer risk equivalent to that with Cox 2 required, consider: Nambumetone (Relafen) inhibitors 500mg #1-2 QD-BID or etodolac (Lodine) 200- 500mg Q8-12H up to 1200mg/day or Salsalate (Disalcid) 1500mg BID or Choline Magnesium Trisalicylate (Trilisate) 750mg BID-TID.
Cenestin (Synthetic Conjugated Estrogen) tabs 0.3- Estrace (Estradiol) 0.5 - 2 mg po QD Prescribed for relief of vasomotor symptoms due 1.25 mg QD to menopause. 0.5mg estradiol = 0.3mg Cenestin; 0.75mg estradiol (1&1/2 0.5mg tablet)=0.45mg Cenestin; 1mg estradiol = 0.625mg Cenestin; 1.5mg estradiol (1&1/2 1mg tablet) = 0.9mg Cenestin; 2mg estradiol = 1.25mg Cenestin) Cerumenex (Triethanolamine Polypeptide Oleate- OTC ear wax removal drops Use OTC ear wax removal product ie Debrox Condensate 10% ear wax removal drops (Carbamide Peroxide) Chantix (Varenicline) oral tablets 1mg BID OTC Nicotrol (Nicotine transdermal system) Smoking cessation products are non formulary 5, 10, 15mg/day Chibroxin (Norfloxacin) ophth soln Ocuflox (Ofloxacin) ophth soln . Chlorhexidine topical soln N/A Available OTC. May be substituted without calling provider. Choledyl (Oxtriphylline) tab Theophylline (generic TheoDur) Convert according to appropriate daily dose of (oxtriphylline=approximately 64% theophylline) theophylline OR consider inhaled Albuterol and/or QVAR (Beclomethazone HFA) Chromagen (Ferrous Fumarate 70mg, OTC alternatives: Niferex 150mg Pt may also opt to pay full price for Rx Cyanocobalamin 10mcg, Ascorbic acid 150mg) (Polysaccharide-iron complex) or Ferrous Chromagen. Vitamins components available OTC Fumarate 200mg: With or Without OTC B12 100mcg plus vitamin C 250mg
Page 14 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Chromagen Forte (Ferrous Fumarate 151mg, Folic OTC alternatives: Niferex 150mg Pt may also opt to pay full price for Rx acid 1mg, Cyanocobalamin 10mcg, Ascorbic acid (Polysaccharide-iron complex) or Ferrous Chromagen. Vitamins components available OTC 60mg) Fumarate 200mg: plus B12 100mcg plus vitamin c 100mg plus Rx Folic Acid 1mg QD
Cialis (Tadalafil) none Cialis is not covered for sexual dysfunction unless member's group has purchased sexual dysfunction rider for additional coverage. Ciloxan (Ciprofloxacin) ophth soln Ocuflox (Ofloxacin) ophth soln . Cipro HC otic soln Cortisporin otic (neomycin/polymyxin/HC) 3 Ciprodex is reserved primarily for use in Acute drops TID, Or gentamicin ophthalmic Otitis Media when patient has tubes. solution 0.3% 3 drops TID -or- Other formulary otic solutions include: Vosol Neomycin/polymyxin/dexamethasone ophth (Acetic Acid) or Vosol HC (Acetic Acid and susp 0.1% 3 drops TID; If Hydrocortisone) fluoroquinolone antibiotic necessary: Ofloxacin 0.3% ophthalmic solution 5-10 drops into ear(s) BID.
Clarinex (Desloratadine) 5mg tabs Claritin OTC or Zyrtec OTC Clarinex not covered by drug benefit. Claritin and Zyrtec available OTC. Intranasal steroids (Nasarel ii sprays per nostril BID or generic Flonase (fluticasone) i spray each nostril QD) more effective than nonsedating antihistamines for allergic rhinitis.
Claritin tabs or redi-tabs 10 mg QD Claritin OTC or Zyrtec OTC Claritin not covered by drug benefit. Claritin and Zyrtec available OTC. Intranasal steroids (Nasarel ii sprays per nostril BID or generic Flonase (fluticasone) i spray each nostril QD) more effective than nonsedating antihistamines for allergic rhinitis.
Claritin-D 24 hour tabs 10 mg (240 mg Claritin-D and Zyrtec-D available OTC. Claritin D not covered by drug benefit. Claritin Pseudoephedrine) QD D and Zyrtec D available OTC. Intranasal steroids (Nasarel ii sprays per nostril BID or generic Flonase (fluticasone) i spray each nostril QD) is more effective than nonsedating antihistamines for allergic rhinitis.
Claritin-D tabs 5 mg (120 mg Pseudoephedrine) BID Claritin-D and Zyrtec-D available OTC. Claritin D not covered by drug benefit. Claritin D and Zyrtec D available OTC. Intranasal steroids (Nasarel ii sprays per nostril BID or generic Flonase (fluticasone) i spray each nostril QD) is more effective than nonsedating antihistamines for allergic rhinitis.
Cleocin 2% vaginal cream 5 gm vaginally QD x 1 Metronidazole (generic Flagyl) tabs 2 gm Metronidazole tablets more effective than week, vaginal suppository (500 mg x 4 tablets) for 1 dose cream/gel
ClimaraPro (Estradiol/Levonorgestrel transdermal Climara (Estradiol) 0.05mg patch PLUS Also available: Climara 0.025mg, 0.0375mg, patches) 0.045mg/0.015mg medroxyprogesterone 2.5-5mg QD .05mg, 0.06mg, 0.075mg, 0.1mg patches apply one patch weekly; or Oral Estradiol 0.5, 1 or 2mg
Clindagel (clindamycin 1%) Generic clindamycin phosphate gel 1% (Cleocin T gel) Clindesse (Clindamycin phosphate) 2% cream single Metronidazole (generic Flagyl) tabs 2 gm Metronidazole tablets more effective than dose formulation (500 mg x 4 tablets) for 1 dose cream/gel. If failed alternatives and vaginal clindamycin required, NF alternative is Clindamycin 2% vaginal cream QD x 1 week.
Page 15 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Cloderm (Clocortolone Pivalate) 0.1% cream Triamcinolone (generic Aristocort or If failed other alternatives, consider increasing to [medium potency] Kenalog) cream, oint 0.1% high potency topical corticosteroid Fluocinonide (Lidex) 0.05% cream, oint, or gel ClosDes Pack (Desonide 1% Cream, 15 gm tube, & Combination package containing Desonide Outside of KP, Desonide 1% available for one OTC Clotrimazole 1%, 15 gm tube) Available as a 1% cream 15 gm tube & Clotrimazole 1% copay. Patient may purchase Clotrimazole 1% as combination package at KP pharmacies only. 15 gm tube available for one copay at KP an OTC product at outside pharmacies. pharmacies only Codiclear DH Syrup (5 mg Hydrocodone/100 mg Robitussin AC generic Syrup (10 mg Other alternatives: Phenergan VC with Codeine Guaifenesin) 5ml Q4H PC & HS Codeine/100 mg Guaifenesin) 10 ml Q4H or or Phenergan with Codeine syrup or Hycodan Robitussin DAC . tablets Colazal (Balsalazide) #3 750 mg caps TID (total daily Asacol (Mesalamine released primarily in Treatment for ulcerative colitis. Colazal is broken dose of 6.75 grams) for 8 weeks ulcerative colitis colon) 400mg #2 TID for 6 wks OR Pentasa down in the body to form Mesalamine. 250mg #4 QID or 500mg #2 QID for 8 wks OR Dipentum 250mg #4 BID OR Azulfidine (Sulfasalazine) 500mg #2 TID-QID
Colestid flavored/unflavored granules bulk powder 1-3 Questran bulk powder 1-3 scoopfuls QD- . teaspoonfuls QD-BID or packet 1-3 packets QD-BID BID or Questran packets 1-3 packets QD- BID or Colestid 1 gm tablet i-iiii tablets QD- BID
CombiPatch (0.05mg Estradiol / 0.14 Norethindrone or Estrace 0.5, 1 or 2mg (Estradiol) AND Combination estrogen and progesterone patch is 0.05mg Estradiol/ 0.25mg Norethindrone patches) Medroxyprogesterone 2.5 or 5mg non formulary. Convert to oral estrogen and apply 1 patch, replacing patch twice wkly progesterone QD.
Combunox (Oxycodone 5mg / ibuprofen 400mg) Generic MS Contin (Morphine controlled Many alternative narcotic pain relievers No fixed combination tabs release) 15,30,60,100,200mg PLUS conversion ratios will fit all patients, especially ibuprofen 400mg tablets; generic Percocet when large opioid doses are involved. The or Percodan (oxycodone 5mg/325mg apap following is a starting point and may need or asa, respectively), Tylox (oxycodone individual adjustment or titration: Oxycontin 5mg/500mg apap), generic Demerol 50mg, package insert states that multiplying the daily 100mg, Fentanyl patches 25mcg, 50mcg, oxycontin dose by 2, yields a suggested daily 75mcg, 100mcg/hr Morphine dose.
Compazine (Prochlorperazine) spansules Compazine tablets or suppositories Spansules are non formulary, tablets and supp are formulary Condylox topical solution Condylox 0.5% gel BID x 3 days then Solution is non formulary, gel is formulary withold x 4 days. May repeat cycle up to 4 times Copegus (Ribavirin) 200mg tab generic Ribavirin 200mg capsule Cordran (Flurandrenolide) 0.025%-0.05% cream, oint, Triamcinolone (generic Aristocort) cream, If failed other alternatives, consider increasing 0.05% lotion or 4mcg/cm2 tape [Medium potency] oint 0.1% steroid potency to fluocinonide (Lidex) 0.05% cream, oint, or gel Cortef Susp (10mg/5mL Hydrocortisone) 20-240 Prelone Syrup generic or Orapred N/A mg/day (15mg/5mL) divide Cortef dose by 4 when converting Corzide (Bendroflumethiazide/Nadolol) 5/40 or 5/80mg Convert to two Rx products Match the Nadolol dose to the original Hydrochlorothiazide 25mg and either combination product Nadolol dose. TSPMG Nadolol 40mg or Nadolol 80mg Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics
Cosopt (Dorzolamide 2%/Timolol 0.5%) i drop in Azopt (Brinzolamide 1%) i drop TID and Combination product, Cosopt, is non formulary. affected eye BID Timoptic (Timolol 0.5%) i drop BID Individual medications, (Azopt and Timoptic not XE) are formulary.
Page 16 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Cotazyme (Pancrelipase enzymes) Pancrease (Pancrelipase enzymes) or Pangestyme is a generic of Pancrease pangestyme Cough and Cold Products OTC equivalents available All cough and cold medications are non-formulary with the exception of Codeine, Hydrocodone, methscopalamine, and Promethazine containing products. Coumadin (Warfarin) tablet Warfarin tablet (Barr generic brand) Brand name non formulary. Covera-HS (Verapamil controlled release) 180, 240mg Verapamil SR tabs (generic Calan SR) 180, Substitute on a mg for mg basis. tabs 180-480mg QHS 240mg tabs 180-480mg QHS TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics
Cozaar (Losartan) 50mg tablets (50mg strength is NF) Cozaar (Losartan) 25mg #2 QD or 100mg Cozaar 50mg strength is non-formulary, please 1/2 tablet QD -or if prescribe 25mg or 100mg tablets. If ACE ACE Inhibitor naïve, Lisinopril 20mg QD Inhibitor naïve, consider conversion to Lisinopril: Cozaar 50mg QD = Lisinopril 20mg QD. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I & Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretic
Creon (Pancrelipase enzymes) Pancrease (Pancrelipase enzymes) Pangestyme is a generic of Pancrease Crestor (Rosuvastatin) 10mg Lovastatin 80 mg QPM w/ meal or Doses of lovastatin > 40mg QD and simvastatin > Simvastatin 40 mg QPM 20mg QD are not recommended in combination with Diltiazem, Verapamil, Amiodarone, or a protease inhibitor. Continue crestor to minimize drug interaction and chance for muscle aches. If crestor is continued, use half tablets. Doses of Lovastatin > 20mg QD and simvastatin > 10mg QD, crestor > 5mg QD not recommended with cyclosporine. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM.
Crestor (Rosuvastatin) 20mg Simvastatin 80 mg QPM Doses of lovastatin > 40mg QD and simvastatin > 20mg QD are not recommended in combination with Diltiazem, Verapamil, Amiodarone, or a protease inhibitor. Continue crestor to minimize drug interaction and chance for muscle aches. If crestor is continued, use half tablets. Doses of Lovastatin > 20mg QD and simvastatin > 10mg QD, crestor > 5mg QD not recommended with cyclosporine. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM. If pt is also on gemfibrozil, please consult PCRS for recommendations.
Page 17 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Crestor (Rosuvastatin) 40mg Consider simvastatin 80mg QD plus Slo- Doses of lovastatin > 40mg QD and simvastatin > Niacin/ time release niacin or BAS first if 20mg QD are not recommended in combination appropriate. Otherwise, Vytorin 10/80 mg with Diltiazem, Verapamil, Amiodarone, or a QHS can be considered. protease inhibitor. Continue crestor to minimize drug interaction and chance for muscle aches. If crestor is continued, use half tablets. Doses of Lovastatin > 20mg QD and simvastatin > 10mg QD, crestor > 5mg QD not recommended with cyclosporine.For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM. If pt is also on gemfibrozil, please consult PCRS for recommendations.
Crestor (Rosuvastatin) 80mg No formulary alternative at this dosage. Cresylate (M-Cresyl acetate) 25% otic Domeboro (Aluminum Acetate and Acetic N/A Acid) otic Crinone (Progesterone) 4% vaginal gel Medroxyprogesterone 2.5 mg QD Crinone 4% vaginal gel is non-formulary, used for post-menopausal hormone replacement. Crinone (Progesterone) 8% vaginal gel N/A Crinone 8% vaginal gel is used for fertility treatment and is covered only for those patient groups who have purchased a fertility treatment rider to expand their drug benefit. Crolom (Cromolyn) 4% ophth soln i-ii drops q6hrs For allergic conjunctivitis: OTC Opcon-A OTC Zaditor 0.25% and Patanol are both dual (mast cell stabilizing properties) (Pheniramine & Naphazoline) or OTC action antihistamine/mast cell stabilizers, are Zaditor 0.25% [NOTE: OTC products are dosed twice daily, and have the same FDA not a covered benefit] approved indications. If treating steroid responsive inflammatory condition: Dexamethasone 0.1% ophth soln or Prednisolone 0.12%-1% ophth soln or Flarex, FML (Fluorometholone) ophth soln 0.1% i-ii drops in affected eye(s) QID
Cryselle (0.3 Norgestrel / 30mcg EE) tablet i QD Levlen (0.15mg Levonorgestrel / 30mcg EE) May consider Tri-Norinyl (.5/1/.5 Norethindrone/ or Tri-Levlen (0.05mg Lvngl/30mcg EE x 6 35 EE) or Microgestin FE (1 mg Norethindrone/ 20 days, 0.075mg Lvngl/40mcg EE x 5 days, EE) or Zovia 1/35 (1mg Ethynodiol Diacetate/ 35 0.125mg Lvngl/ 30mcg EE x 10 days) EE) Document at least 3 formulary alternatives before prescribing/approving a NF product. Cutivate (Fluticasone) 0.05% cream, 0.005% oint Triamcinolone (generic Aristocort, Kenalog) If failed other alternatives, consider increasing [medium potency] cream, oint 0.1% steroid potency to Fluocinonide (Lidex) 0.05% cream, oint, or gel Cyanocobalamin (vitamin b12) injection OTC: Vitamin B12 1mg orally TSPMG clinical practice resource indicates oral b12 may be used in pernicious anemia Cyclessa (tricyclic Desogestrel/EE) 0.1mg/25mcg x Microgestin 1/20 (1mg Other formulary alternatives: Tri-Norinyl (0.5mg 7days; 0.125mg/25mcg x 7days; 0.15mg/25mcg x 7 Norethindrone/20mcg EE) or Microgestin Norethindrone x 7days, 1mg NE x 7 days, 0.5mg days (generic soon available as Velivet by 1.5/30 (1.5NE/30mcgEE) or Levlen (0.15 NE x 7 days/ 35 mcg EE) or Zovia 1/35 Barr) Levonorgestrel/30mcg EE) or Tri-Levlen (Ethynodiol 1mg/35mcg EE), Brevicon (.5mg NE/ (0.05mg Levonorgestrel & 30mcg EE x 6 35mcg EE), Zovia1/35 (Ethynodiol 1mg/35mcg days, 0.075mg Lvn & 40 EE x 5 days, EE), Norinyl 1/35 (1mg NE/ 35mcg EE) Norinyl 0.125mg Lvn & 30mcg EE x 10 days) 1/50 (1mg NE/ 50mcg Mestranol), or NorQD (0.35 NE only) A Desogestrel containing product substitution is not available on formulary. Document at least 3 formulary alternatives before prescribing/approving a NF product.
Cyclocort (Amcinonide) 0.1% cream, oint, lotion [high Lidex (fluocinonide) 0.05% cream, oint, gel, High potency topical corticosteroids. If require a potency] soln or Diprolene AF (augmented lotion, consider stepping down to medium potency betamethasone) 0.05% Valisone (betamethasone valerate) 0.1% lotion
Page 18 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Cymbalta (duloxetine) 20mg If treating depression: Fluoxetine 20mg or If treating neuropathic pain: Nortriptyline (if <65 Citalopram 20mg or Sertraline 25mg or yrs old: 25mg QHS, increase dose 25mg/day at 3- Venlafaxine IR 25mg BID or Effexor XR 7 day intervals prn. If > 65 years old: 10mg QHS, 37.5mg (Effexor XR restricted to increase dose 10mg/day at 3-7 day intervals prn). psychiatry and mental health ). Titrate to Consider adding Gabapentin if needed. Consider response. Sertraline added to formulary as topical capsaicin OTC if area is small. (Duloxetine of 3/8/07. Document response to all is available to MMA group ) formulary SSRI alternatives before prescribing a NF SSRI. Document reason, when patient is medically unable to convert to Formulary alternative.
Cytomel (liothyronine) tablet 25-75 mcg QD Levothroid tabs 0.05-0.1 mg QD, see If interested in converting, please refer to suggested conversions in next column approximate conversions: 15-37.5mg cytomel = 50-60mcg levothroid; 37.5mg cytomel = 75-90mcg levothroid; 50mcg cytomel = 100-120mcg levothroid; 75mcg cytomel = 150-180 levothroid.
Cytovene (gancyclovir) cap 1000mg TID Valcyte 450mg tablet Valcyte (valgancyclovir) - CMV prophylaxis 900mg maintenance therapy for CMV retinitis (following QD; AIDS or s/p organ transplantation 900mg BID induction with IV gancyclovir or insertion of vitrasert) (Treatment doses if Crcl 40-59 = 450mg BID;crcl 25-39 = 450mg QD;crcl 10 - 24 = 450mg Q 2 days; dialysis - valcyte not recommended; also adjust for WBC)
Darvocet-N 50 & -N 100 APAP 1000mg TID-QID, CAUTION: propoxyphene/acetaminophen (Propoxyphene/acetaminophen) Hydrocodone/APAP 5/500mg 1/2 -1T TID, (generic Darvocet) and other propoxyphene Nabumetone 500mg BID, Etodolac 300mg - combinations are on the list to be avoided in 400mg BID -TID the elderly due to increased risks for falls. [Available Part D group]
Darvon & Darvon-N (Propoxyphene) APAP 1000mg TID-QID, CAUTION: propoxyphene/acetaminophen Hydrocodone/APAP 5/500mg 1/2 -1T TID, (generic Darvocet) and other propoxyphene Nabumetone 500mg BID, Etodolac 300mg - combinations are on the list to be avoided in 400mg BID -TID the elderly due to increased risks for falls. [Available Part D group]
Daytrana (Methylphenidate) Concerta 18,27,36,54mg, or Methylin ER Adderall XR is restricted to pediatrics, child 10mg, Methylphenidate 5, 10, 20mg and SR neurology and behavioral health. Titrate to 20mg; or generic Dexedrine spansules appropriate dosage using adderall regular (Dextroamphetamine) 5, 10, 15mg or release tablets before transitioning to once Adderall regular release 5, 10, 20, 30mg daily Adderall XR. Document failed trial on tablets or Adderall XR 5,10,20,25,30mg Methylphenidate, Dextroamphetamine and capsules. Controlled substances level 2 Adderall IR products before a Non-formulary requiring prescription written by prescriber. Product is considered. Methylphenidate is the preferred formulary alternative.
Daypro (Oxaprozin) 600mg tab 1200- 1800mg QD Relafen (Nambumetone) 500mg or 750mg 1 Additional formulary alternatives: Salsalate - 2 QD-BID or Etodolac (Lodine) 200-500mg (Disalcid)1500mg BID or choline magnesium Q8-12H up to 1200mg/day or Ibuprofen trisalicylate (Trilisate) 750mg BID-TID or (Motrin) tabs 600-800mg TID or Naproxen Indomethacin 25-50mg TID. (Naprosyn) 500mg BID or Sulindac (Clinoril) 200mg BID or Diclofenac (Voltaren) 75mg BID or Mobic (Meloxicam) 7.5mg or 15mg
Page 19 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Decadron (Dexamethasone sodium phosphate) 0.1% DesOwen (Desonide) 0.05% cream, oint, Low potency topical corticosteroids. cream [low potency] lotion or Synalar (Fluocinolone) 0.01% soln, oil or Hytone (Hydrocortisone) 2.5% cream, oint, lotion
Decaspray (Dexamethasone) aerosol spray [low DesOwen (Desonide) 0.05% cream, oint, Low potency topical corticosteroids. potency] lotion or Synalar (Fluocinolone) 0.01% soln, oil or Hytone (Hydrocortisone) 2.5% cream, oint, lotion Demadex (Torsemide) tabs 5-100 mg QD Furosemide (generic Lasix) tabs 10-200 mg Multiply daily Demadex dose by 2 to obtain daily per day furosemide dose (example: Demadex 10 mg QD x 2 = furosemide 20 mg QD). Furosemide doses > 60 mg/day should be divided BID.
Demulen 1/35 compak i QD Zovia 1/35 (generic Demulen) i QD May be substituted without calling provider. Demulen 1/50 compak i QD Zovia 1/50 (generic Demulen) i QD May be substituted without calling provider. Denavir Cream (Penciclovir) apply Q2H while awake X Herpes Labialis: OTC Abreva. OTC OTC Abreva (Docosanol cream) has been shown 4 days Carmex or Orabase to prevent drying and to reduce herpes labialis course by 18 hours. fissuring. Domoboro soaks may relieve Abreva blocks viral entry into cells; therefore, not itching and dry blisters; Acyclovir (generic likely to lead to viral resistance. [ Available Part Zovirax) tab 400 mg TID x 5 days D group]
Depakote ER (Divalproex sodium extended release) Depakote (Divalproex sodium) tablets Depakote ER does not offer clinical benefit over regular release are covered Depakote regular release. Unlike Depakote, Depakote ER may not be dosed higher than 1000mg/day Depo-Testosterone 200 mg/ml inj Methyltestosterone (generic Android or Testosterone injection 400 mg IM q2-4weeks Testred) tabs 10-20 mg QD-BID or administered in medical office. Injectables Fluoxymesterone (Halotestin) 10 mg QD administered in a medical office are covered Check baseline and periodic liver function under the medical office benefit, NOT the drug tests if using oral supplementation. benefit and are not available from a pharmacy for a copayment. Dermatop (Prednicarbate 0.1%) Lidex (Fluocinonide) 0.05% cream, oint, gel High potency topical corticosteroids. If require a or Diprolene AF (Augmented lotion, consider stepping down to medium potency Betamethasone) 0.05% Valisone (Betamethasone valerate) 0.1% lotion
Desogen (Desogestrel 0.15mg/EE 30mcg) 28 tabs i Levlen (0.15mg Levonorgestrel / 30mcg EE) Zovia 1/35 (1mg Ethynodiol Diacetate/ 35mcg EE) QD or Tri-Levlen (0.05mg Lvngl/30mcg EE x 6 or Microgestin 1.5/30 (1.5 Norethindrone / 30mcg days, 0.075mg Lvngl/40mcg EE x 5 days, EE) or Sprintec (0.25mg Norgestimate/35mcg EE) 0.125mg Lvngl/ 30mcg EE x 10 days) or Tri-Sprintec, generic Ortho-Tricyclen, (0.18mg Norgestimate x 7 days, 0.215mg Norgestimate x 7 days, 0.25mg Norgestimate x 7 days/ 35 mcg EE) Document at least 3 formulary alternatives before prescribing/approving a NF product.
Detrol Regular Release (Tolterodine) tab 1-2mg BID Oxybutynin (generic Ditropan) 5-10 mg tab i . (regular release is non formulary) QD-BID (immediate release tablet) or Oxybutynin XL (generic Ditropan XL) 5- 15mg QD or Oxytrol patch Detrol LA (Tolterodine long-acting) 2-4mg QD Oxybutynin (generic Ditropan) 5-10 mg tab i (removed from formulary as of 7/1/07) QD-BID (immediate release tablet) or Oxybutynin XL (generic Ditropan XL) 5- 15mg QD or Oxytrol patch Dextrostix blood glucose test strips One Touch Ultra glucose test strips One Lifescan monitor is formulary and may be Touch Ultra 2 machine -only obtained, by prescription, at KP pharmacy at a co- payment. Members will be charged full price for Lifescan monitor at Eckerd
Page 20 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
DHT (Dihydrotachyesterol) aka Hytakerol 0.125, 0.2, Rocaltrol (Calcitriol) 0.25, 0.5mcg caps 0.25- 0.4mg tabs 0.1-0.25mg QD and titrate to effect 1mcg/day titrated to effect or Calciferol (Ergocalciferol) 50,000 units/capsule 15,000- 20,000 units/day titrated to effect
Diatx (1.5mg B1;1.5mg B2; 20mg B3; 10mg B5; 50mg OTC Nephro-vite (Vitamin C 100mg, folate Nephro-vite OTC NDC # 54391-0002-01. B6; 1mcg B12; 60mg C; 5mg folic acid; 300mg d 0.8mg, niacin B3 20mg, thiamin B1 1.5mg, Biotin) riboflavin B2 1.7mg, Pantothenic Acid B5 5mg, Pyridoxine B6 10mg, Cyanocobalamin B12 6mcg, d biotin 300mcg) PLUS folic acid OTC (if need greater than .8mg in Nephro Vite) Didrex (Benzphetamine) N/A Weight loss agents not covered. Differin (Adapalene) 0.1% gel and cream Retin A Micro 0.04% and 0.1% gel, 20gm or Retin A Micro is restricted to Dermatology. Retin-A 0.01% 15gm gel or Retin A 0.1% Only the smallest unit size is covered for Retin A 20gm cream products. Covered only for the treatment of acne, member pays copay. Not covered for cosmetic treatment (wrinkles), member pays full price.
Diflucan (Fluconazole) tab 50mg, 100mg, 200mg tab 50mg, 100mg and 200mg strengths are not QD covered for vaginal yeast infections. Diflucan (Fluconazole) tab 150 mg i x 1 dose Fluconazole 150mg strength is Formulary with a quantity limit of 1 tablet per copay. Fluconazole 150mg covered for vaginal yeast infections when OTC vaginal preps cannot be used. Diflunisal (generic Dolobid) tabs 500 mg BID Ibuprofen (Motrin) tabs 600-800 mg TID or Additional formulary alternatives: Diclofenac Salsalate (Disalcid)1500mg BID or (Voltaren) 75mg BID or Choline Magnesium Naproxen 500mg BID or Sulindac (Clinoril) Trisalicylate (Trilisate) 750mg BID-TID or 200mg BID Nambumetone (Relafen) 500mg or 750mg 1 - 2 QD-BID or Etodolac (Lodine) 200-500mg Q8-12H up to 1200mg/day or Indomethacin 25-50mg TID or Mobic (Meloxicam) 7.5mg or 15mg . Diltiazem Gel (compounded formulation for anal Nitroglycerin 0.2% Ointment (commercially . fissure, not commercially available) available), apply very small amount (to avoid/minimize absorption related side effects) via Q-tip to anal fissure
Diovan (Valsartan) 80-320 mg QD Prinivil (Lisinopril) 5-40mg QD or Cozaar 25- Prinivil (Lisinopril) is preferred, if no previous 100mg QD ACE inhibitor trial. If angiotensin 2 receptor blocker is required, convert to Cozaar. Conversion: Diovan 80mg=Prinivil 5-10mg=Cozaar 25mg; Diovan 160mg=Prinivil 10-20mg=Cozaar 50mg; Diovan 320mg=Prinivil 20-40mg=Cozaar 100mg TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics
Page 21 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Diovan HCT (160mg Valsartan/ 12.5mg Prinzide (lisinopril & HCTZ) 10/12.5mg, Prinzide (lisinopril & HCTZ) is preferred, if no Hydrochlorothiazide) QD 20/12.5mg or 20/25mg OR Cozaar 50mg previous ACE inhibitor trial. Must have (25mg tabs x 2=50mg) QD plus HCTZ separate prescription for HCTZ if Cozaar (Hydrochlorothiazide) 25 mg 1/2 tab QD prescribed. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics
Diovan HCT 80mg Valsartan /12.5mg Prinivil 5-10 mg QD or Cozaar 25mg tab QD Prinivil (lisinopril)+ HCTZ or Prinzide is Hydrochlorothiazide QD plus HCTZ (hydrochlorothiazide) 25 mg 1/2 preferred, if no previous ACE inhibitor trial. tab QD or Prinzide (lisinopril & HCTZ) TSPMG Guidelines suggest: 10/12.5mg Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics
Diprosone (Betamethasone Dipropionate) 0.05% Lidex (Fluocinonide) 0.05% cream, oint, gel, High potency topical corticosteroids. cream, oint [high potency] soln or Diprolene AF (Augmented Betamethasone) 0.05% Diprosone (Betamethasone Dipropionate) 0.05% Valisone (Betamethasone Valerate) 0.1% If failed other alternatives, consider increasing lotion [medium potency] lotion or Triamcinolone (generic Aristocort steroid potency to Fluocinonide (Lidex) 0.05% or Kenalog) cream, oint 0.1% cream, oint, or gel Ditropan (Oxybutynin) XL 5-10 mg tab i QD Oxybutynin (generic Ditropan) 5-10 mg tab i QD-BID (immediate release tablet) or Oxybutynin XL (generic Ditropan XL) 5- 15mg QD or Oxytrol patch Diuril (Chlorothiazide) tablet Hydrochlorothiazide tablet N/A Divigel (Estradiol) .1% Climara (.025mg, .0375mg, .05mg, .06mg, Divigel (Estradiol) .1% is available in 3 doses of 0.25mg estradiol/day, 0.5mg estradiol/day, and 1.0mg .075mg, .075mg, .1mg patches) apply 1 0.25mg, 0.5mg, and 1.0mg corresponding to estradiol/day patch a week; Estrace (Estradiol) .5mg- Estradiol 0.25mg, 0.5mg, and 1.0mg 2mg po daily, OR Premarin Vaginal Cream
Dolobid (Diflunisal) tabs 500 mg BID Ibuprofen (generic Motrin) tabs 600-800 mg Additional formulary alternatives: Diclofenac TID or Salsalate (Disalcid)1500mg BID or (Voltaren) 75mg BID or Choline Magnesium Naproxen 500mg BID or Sulindac (Clinoril) Trisalicylate (Trilisate) 750mg BID-TID or 200mg BID Nambumetone (Relafen) 500mg or 750mg #1-2 QD-BID or Etodolac (Lodine) 200mg-500mg Q8- 12H up to 1200mg/day or Indomethacin 25-50mg TID or Mobic (Meloxicam) 7.5mg or 15mg.
Donnatal elixir Antispasmodic elixir (generic Donnatal) Generic may be substituted. Brand is non- formulary and not covered. Doryx 100mg (Doxycycline) Doxycycline 50mg or 100mg .
Page 22 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Duac gel (Clindamycin gel/Benzoyl peroxide gel) Separate Rxs for either 2% Benzamycin and Duac are nonformulary, but 2% Erythromycin solution PLUS 5% Benzoyl Erythromycin solution & 5% Benzoyl Peroxide Peroxide aqueous gel OR aqueous gel OR 1 % Clindamycin gel & 5% Clindamycin 1% gel PLUS 5% Benzoyl Benzoyl Peroxide aqueous gel, respectively, may Peroxide aqueous gel be prescribed separately and purchased as a pack for one copayment at a Kaiser Permanente pharmacy. At Eckerd, the patient will receive Erythromycin 2% soln OR Clindamycin 1% gel at a copayment & must purchase the OTC Benzoyl Peroxide product, at KP the OTC will be included at no additional charge.
DuoNeb (Albuterol 3mg/Ipratropium 0.5mg) inhalation Combivent (Albuterol/Ipratropium) oral Albuterol inhalation solution 0.5% 20ml AND solution for use with nebulizer inhaler Ipratropium 0.02% 2.5ml for use with nebulizer
Duricef (Cefadroxil) cap 500 mg BID Cephalexin (generic Keflex) cap 500 mg First generation cephalosporins BID Dyazide (Triamterene 37.5 mg/HCTZ 25 mg) tabs Triamterene 75 mg/HCTZ 50 mg (generic Cut Generic Maxzide tablet in half to obtain Maxzide) 1/2 tab dose equivalent dose. Dynabac (Dirithromycin) tab: 500 mg QD for 7-14 Erythromycin (base or estolate) 250-500 mg Dynabac offers no clinical advantage over days (adults) Q6-8H (adult) erythromycin when dosed appropriately Dynacin (Minocycline HCL) 50, 75, or 100mg Minocycline 50mg or 100mg capsules . Capsules Dynacirc (Isradipine) caps 10 mg BID Nifedipine XL (generic Procardia XL) tab 60 Nifedipine XL, generic of Procardia XL, is mg QD covered. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics Dynacirc (Isradipine) caps 2.5 mg BID Nifedipine XL tab 30 mg QD Nifedipine XL, generic of Procardia XL, is covered. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics
Dynacirc (Isradipine) caps 5 mg BID Nifedipine XL tab 30 mg QD Nifedipine XL, generic of Procardia XL, is covered. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics Edecrin (Ethacrynic acid) 25 and 50mg loop diuretic Lasix (Furosemide) Or, if allergic to Dose of converted diuretic to be adjusted for each sulfonamide drugs, Spironolactone individual
Page 23 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Effexor (Venlafaxine) XR caps 37.5-225 mg QD Venlafaxine IR 25mg - 100mg BID or Effexor XR is restricted to Psychiatry and Prozac (Fluoxetine) caps 20 mg QD or Mental Health. Venlafaxine IR is formulary Celexa (Citalopram) 20mg QD or Sertraline without restrictions. Prozac is the preferred 25-100 mg QD. Please titrate to response formulary SSRI. (Prozac may also be prescribed to manage hot flashes in women with a history of breast cancer) [Effexor XR: Available Part D]
Efudex (Fluorouracil) 2% cream, soln Efudex 5% cream, Fluoroplex 1% Efudex 2% is non formulary Elestat (Epinastine) 0.05% ophth soln For allergic conjunctivitis: OTC Opcon-A OTC Zaditor 0.25% and Patanol are both dual (Pheniramine & Naphazoline) first line action antihistamine/mast cell stabilizers, are option; or OTC Zaditor 0.25% [NOTE: OTC dosed twice daily, and have the same FDA products are not a covered benefit] approved indications. If treating steroid Formulary alternatives: prednisolone. responsive inflammatory condition consider at least 2 formulary products before prescribing/authorizing a NF product: Dexamethasone 0.1% ophth soln or Prednisolone 0.12%-1% ophth soln or Flarex, FML (Fluorometholone) ophth soln 0.1% i-ii drops in affected eye(s) QID. Consider at least 2 formulary products before prescribing/authorizing a NF product. Eldoquin (Hydroquinone) cream or lotion No formulary alternative Cosmetic drug is not covered on drug benefit. Member pays retail price. If prescribed along with Differin, Retin A, or Avita creams, they are also being used as cosmetic therapy and are not covered. Eligard (Leuprolide acetate) 7.5mg injection Lupron or Eligard to be supplied by the TSPMG physicians provide injectables prescribing physician and administered in administered in medical office through floor stock. MD office under the patient's medical If network physicians cannot obtain Lupron or benefit. Eligard, please complete KP NF Rx form for Lupron requesting benefit coverage at the time of dispensing. Elocon (Mometasone) 0.1% cream, oint, lotion Triamcinolone (generic Aristocort/ gen. If failed other alternatives, consider increasing [medium potency] Kenalog) cream, oint 0.1%; If elocon lotion steroid potency to Fluocinonide (Lidex) 0.05% use gen. Valisone (Betamethasone cream, oint, or gel Valerate) 0.1% lotion Emadine (Emedastine) .05% ophth soln 1 drop QID For allergic conjunctivitis: OTC Opcon-A OTC Zaditor 0.25% and Patanol are both dual (Pheniramine & Naphazoline) or OTC action antihistamine/mast cell stabilizers, are Zaditor 0.25% [NOTE: OTC products are dosed twice daily, and have the same FDA not a covered benefit] approved indications. If treating steroid responsive inflammatory condition consider at least 2 formulary products before prescribing/authorizing a NF product: Dexamethasone 0.1% ophth soln or Prednisolone 0.12%-1% ophth soln or Flarex, FML (Fluorometholone) ophth soln 0.1% i-ii drops in affected eye(s) QID
Emend (Aprepitant) 125mg prior to chemotherapy Zofran (Ondansetron) 24 mg and Emend is NF, consider adding only after failed then 80mg on days 2 and 3. (neurokinin 1 receptor Dexamethasone 12mg PO prior to Zofran & Dexamethasone combination therapy. antagonist) chemotherapy followed by 8mg PO QD on Emend is administered as part of a three drug days 2 thru 4 regimen including Zofran, Dexamethasone and Emend. Embeline E (Clobetasol propionate) 0.05% emollient Temovate (Clobetasol) 0.05% cream, oint, Very high potency topical corticosteroids. cream gel, scalp soln or Diprolene (Augmented Betamethasone Dipropionate) 0.05% oint
E-mycin tablet EC 333 mg TID or 500 mg BID Ery-tab 333 mg TID or 500 mg BID Different Erythromycin formulations
Page 24 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Enablex (Darifenacin) extended release 7.5mg and Oxybutinin (generic Ditropan) 5-10 mg tab i . 15mg tablets QD-BID (immediate release tablet) or Oxybutynin XL (generic Ditropan XL) 5- 15mg QD or Oxytrol patch Enjuvia (Synthetic Conjugated Estrogens) 0.3mg- Estrace (Estradiol) 0.5, 1 or 2mg QD Estradiol (generic estrace) preferred. 0.5mg 1.25mg Estradiol = 0.3mg Premarin; 0.75mg Estradiol (1&1/2 0.5mg tablet) = 0.45mg Premarin; 1mg Estradiol = 0.625mg Premarin; 1.5mg Estradiol (1&1/2 1mg tablet) = 0.9mg Premarin; 2mg Estradiol = 1.25mg Premarin Enpresse (0.05mg Levonorgestrel/ 30mcg EE x 6 Tri-Levlen (0.05 Lvngl/30mcg EE x 6 days, Document at least 3 formulary alternatives days, 0.075mg Lvngl/ 40 mcg EE x 5 days, 0.125mg 0.075mg Lvngl/40mcg EE x 5 days, before prescribing/approving a NF product. Lvngl/30mcg EE x 10 days) 0.125mg Lvngl/30mcg EE x 10days)
Entex LA OTC Robitussin CF or Congestac All cough and cold medications with OTC equivalents are non-formulary with exception of Codeine, Hydrocodone, and Promethazine containing products. Entocort (budesonide) Asacol (Mesalamine released primarily in colon) 400mg #2 TID for 6 wks OR Pentasa 250mg #4 QID or 500mg #2 QID for 8 wks OR Dipentum 250mg #4 BID OR Azulfidine (Sulfasalazine) 500mg #2 TID-QID
E-pilo (Epinephrine 1% and Pilocarpine 1,2,4 or 6%) i- Epinephrine 1% i-ii drops QD - QID AND Combination eye drop is not covered, but ii drops QD - QID Pilocarpine 1, 2, 4, or 6% i-ii drops QD - component eye drops are individually covered. QID Epivir HBV (lamivudine) tablet Epivir 150 mg tablet QD Esclim (Estradiol transdermal patches) apply twice Climara 0.025mg, 0.0375mg, 0.05mg, If an estrogen patch is required, Climara. weekly Patch strengths 5mg, 7.5mg, 10mg 0.06mg, 0.075mg, 0.1mg patches apply one 15mg, 20mg deliver 0.025mg, 0.0375mg, 0.05mg, patch weekly; or Estrace 0.5, 1 or 2mg 0.075mg, 0.1mg Estradiol QD (Estradiol) Esgic tabs Butalbital Compound 1-2 tabs Q4H (max: 6 . tabs/day) Estraderm transdermal patch 0.05 mg/day Climara .025mg, 0.0375mg, .05mg, 0.06mg, If an estrogen patch is required, Climara. 0.075mg, 0.1mg patches apply one patch weekly; or Estrace 0.5, 1 or 2mg (Estradiol)
Estraderm transdermal patch 0.1 mg/day Climara 0.025mg, 0.0375mg, .05mg, If an estrogen patch is required, Climara. 0.06mg, 0.075mg, 0.1mg patches apply one patch weekly; or Estrace 0.5, 1 or 2mg (Estradiol) Estrasorb (estradiol topical emulsion) 1.74 gram foil Climara 0.025mg, 0.0375mg, .05mg, The dose of estradiol topical emulsion for the pouch 0.06mg, 0.075mg, 0.1mg patches apply one treatment of moderate to severe vasomotor patch weekly; or Estrace (Estradiol) 0.5mg symptoms is 3.48 grams daily (two foil pouches of (note larger estrogen dose when 1.74 grams, one half dose rubbed into the thigh administered orally) or Premarin Vaginal and calf area of each leg) which delivers 0.05 Cream milligrams of estradiol per day Estratab tablet 0.3-1.25 mg QD Climara 0.025mg, 0.0375mg, .05mg, If an estrogen patch is required, Climara. 0.06mg, 0.075mg, 0.1mg patches apply one patch weekly; or Estrace 0.5, 1 or 2mg (Estradiol) Estratest and Estratest HS tab Syntest DS and Syntest HS respectively EstroGel (Estradiol gel) 1.25gm Climara 0.025mg, 0.0375mg, .05mg, The dose of estradiol gel for the treatment of 0.06mg, 0.075mg, 0.1mg patches apply one moderate to severe vasomotor symptoms is 1.25 patch weekly; or Estrace (Estradiol) 0.5mg grams daily (two foil pouches of 1.74 grams, one (note larger estrogen dose when half dose rubbed into the thigh and calf area of administered orally) or Premarin Vaginal each leg) which delivers 0.75 milligrams of Cream estradiol
Page 25 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
EstroStep (1mg Norethindrone/20mcg EE x 5day, Tri-Norinyl (0.5mg NE/35mcg EE x7 day, Or may consider Microgestin FE (1mg NE/20mcg 1mg NE/30mcg EE x 7 day, 1mg NE/35mcg EE x 9 1mg NE/35mcg EE x 7 day, 0.5mg NE/35 EE x 21 day plus 75mg Ferrous Fumarate) day) mcg EE x 7 day) or Norinyl 1/35 (1mg NE/35mcg EE) plus OTC Iron Supplement (Ferrous Fumerate 75 mg) EstroStep FE (1mg Norethindrone/20mcg EE x 5day, Tri-Norinyl (0.5mg NE/35mcg EE x7 day, Or may consider Microgestin FE (1mg NE/20mcg 1mg NE/30mcg EE x 7 day, 1mg NE/35mcg EE x 9 1mg NE/35mcg EE x 7 day, 0.5mg NE/35 EE x 21 day plus 75mg Ferrous Fumarate) day, 75mg Ferrous Fumarate x 7 days) mcg EE x 7 day) or Norinyl 1/35 (1mg Document at least 3 formulary alternatives NE/35mcg EE) plus OTC Iron Supplement before prescribing/approving a NF product. (Ferrous Fumerate 75 mg)
Ethyl Chloride spray (topical anesthetic, vapocoolant) OTC topical anesthetic alternatives: Pt may also choose to purchase NF Ethyl Aerofreeze spray (topical anesthetic, Chloride spray at full prescription price. vapocoolant) OR OTC L-M-X4 (4% topical lidocaine cream) or OTC Lidosense 4 (4% topical lidocaine cream) or Rx Lidocaine 4% topical soln apply to affected area Q3-4H
Ethyol inj N/A Ethyol is indicated for prevention of xerostomia in patients receiving radiation therapy (head and neck cancer). Northside Radiation Therapy group may prescribe up to 20 vials for a member to pick up at KP facility pharmacy only (zero copay, pharmacist override), to be administered prior to radiation therapy.
Evoxac (Cevimeline) 30mg capsules TID Pilocarpine 3% ophthalmic solns 5 - 10 N/A drops TID taken orally Exelderm (Sulconazole) 1% cream OTC Lamisil AT or clotrimazole containing Clotrimazole or Terbinafine (Lamisil) for tinea OTC products: Lotrimin AF or OTC Mycelex pedis, tinea corporis, tinea circinata (ringworm of or OTC Micatin cream body), tinea cruris, tinea inguinalis (jock itch), tinea versicolor; Clotrimazole for intertrigo (rash in body folds or beneath breasts) or candidiasis (including rash on penis or corners of mouth) [OTC alternatives are not recommended for tinea capitis (ringworm of scalp), tinea faceii or barbae (ringworm of the beard…barber's itch]
Exforge (Amlodipine/Valsartan) Amlodipine(Norvasc) generic 5mg or 10mg+ Prinivil (Lisinopril) is preferred, if no previous ACE 5/160, 10/160, 5/325, 10/325mg Prinivil (Lisinopril) 5-40mg QD or Cozaar inhibitor trial. If angiotensin 2 receptor blocker is (Losartan) 25-100mg QD required, convert to Cozaar.
Conversion: Diovan 160mg=Prinivil 10-20mg=Cozaar 50mg;
Diovan 320mg=Prinivil 20-40mg=Cozaar 100mg
TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I & Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I & Thiazide Diuretic
Page 26 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Famvir (Famcyclovir) 125, 250, 500mg tabs Herpes Herpes zoster Acyclovir 800mg Q4H, 5 Acyclovir only oral antiviral covered for herpes. zoster 500mg Q8H x 7 days; genital herpes times daily x 7 days (10 days if For recommendations please see TSPMG clinical recurrence 125mg BID x 5 days immunocompromised); genital herpes practice resource acyclovir 400mg TID x 7-10 days (5 days when treating recurrences, may use 800mg BID x 5 days for recurrence); chronic suppressive therapy 400mg BID, titrate to lowest effective suppressive dose
Felbatol (Felbamate) Tegretol (carbamazepine), Neurontin Adjunctive therapy for partial seizures (gabapentin), Topamax (topiramate), [conversion to a formulary alternative not Tranxene (clorazepate), Lamotrigine 5- recommended when patient is stable on non 25mg chews and Lamictal 100mg-200mg formulary antiseizure medication for seizure oral tablets management]
Feldene (Piroxicam) Relafen (Nambumetone) 500mg or 750mg 1 Additional formulary alternatives: Salsalate - 2 QD-BID or Etodolac (Lodine) 200-500mg (Disalcid)1500mg BID or choline magnesium Q8-12H up to 1200mg/day or Ibuprofen trisalicylate (Trilisate) 750mg BID-TID or (Motrin) tabs 600-800mg TID or Naproxen Indomethacin 25-50mg TID. CAUTION: Feldene (Naprosyn) 500mg BID or Sulindac (Piroxicam) is on the list to be avoided in the (Clinoril) 200mg BID or Diclofenac elderly due to increased risks of GI complications. (Voltaren) 75mg BID or Mobic (Meloxicam) [Available Part D group] 7.5mg or 15mg Femhrt (5mcg Ethinyl Estradiol / 1 mg Norethindrone Estradiol 0.5mg or 1mg QD plus Two individual prescriptions are required. acetate) Medroxyprogesterone 2.5-5mg QD 0.5mg Estradiol = 0.3mg Premarin; 0.75mg Estradiol (1&1/2 0.5mg tablet) = 0.45mg Premarin; 1mg Estradiol = 0.625mg Premarin; 1.5mg Estradiol (1&1/2 1mg tablet) = 0.9mg Premarin; 2mg Estradiol = 1.25mg Premarin
Femstat (2% Butoconazole) vaginal cream OTC OTC Mycelex3 (2% butoconazole) Other Products that are available Over the Counter are OTC alternatives include: Monistat vaginal not covered by the drug benefit. cream or Vagistat Fenesin (Guaifenesin) ER tabs 600 mg BID OTC Mucinex (600mg Guaifenesin long Cold products are non formulary. Member may acting) or OTC Guaifenesin 400mg regular select OTC product or pay cash for prescription release or OTC Guaifenesin syrup ii cold product teaspoonfuls Q4H or OTC Guaifenesin gel cap ii capsules Q6H (generic Robitussin)
Fenesin tablet SA OTC Mucinex (600mg Guaifenesin long Cold products are non formulary. Member may acting) or OTC Guaifenesin 400mg regular select OTC product or pay cash for prescription release or OTC Guaifenesin syrup ii cold product teaspoonfuls Q4H or OTC Guaifenesin gel cap ii capsules Q6H (generic Robitussin)
Ferrlicit injectable InFeD injectable
Finevin or Finacea (Azelaic Acid) Cream Acne treatment alternatives: Tretinoin Smallest available tube Tretinoin covered per 0.025% cream (Retin-A or Avita cream copay, larger tubes not covered. Benzamycin and brand names) or 2% Erythromycin solution Benzaclin are nonformulary, but 2% Erythromycin & 5% Benzoyl Peroxide aqueous gel or solution & 5% Benzoyl Peroxide aqueous gel OR clindamycin 1% solution or sulfacet R lotion 1 % Clindamycin gel & 5% Benzoyl Peroxide or clindamycin 1% gel & 5% Benzoyl aqueous gel, respectively, may be prescribed Peroxide aqueous gel Rosacea treatment separately and purchased as a pack for one alternative: metronidazole 0.75% cream copayment at a Kaiser Permanente pharmacy. At BID Eckerd, the patient must purchase the OTC product, at KP it will be included at no charge.
Fioricet/Codeine caps Fioricet tabs (Butalbital/apap/caff), tylenol . #3 (generic), Fiorinal with Codeine (Butalbital Compound with Codeine)
Page 27 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Flomax (Tamsulosin) 0.4-0.8 mg QD Doxazosin (generic Cardura) titrated to Restricted to Urology and KP Hospitalists. therapeutic doses (eg. Doxazosin 2mg 1/2 tab PO QHS X 1 week, then 1 tab QHS x 2 weeks, then 2 tabs QHS and follow-up w/MD for refill) -or- Terazosin (Hytrin) titrated slowly to therapeutic doses (eg. Terazosin 1mg po QHS x 3 nights then 2 caps QHS x 7 nights, then 5 caps QHS and follow-up with MD for refill)
Flovent (Fluticasone) 110mcg/puff and 220mcg/puff i- QVAR 80mcg/puff i-ii puffs PO BID or QVAR is the preferred corticosteroid formulary ii puffs BID Asmanex (mometasone furoate) oral dry alternative. The dry powder inhaler Asmanex powder inhaler 200mcg per puff inhale i-ii (mometasone) may offer another formulary ICS puffs QHS (or i puff BID) alternative for patients ≥ 12 yrs old more likely to adhere to once daily maintenance therapy. Asmanex is considered equipotent to fluticasone and approx twice as potent as beclomethasone.
Florone (Diflorasone) 0.05% cream, oint Lidex (Fluocinonide) 0.05% cream, oint, gel, High potency topical corticosteroids. soln or Diprolene AF (Augmented Betamethasone) 0.05% Floxin tab 200 mg BID Cipro tab 250 mg BID Cipro and Avelox are formulary quinolones Floxin tab 300 mg BID Cipro tab 500 mg BID Cipro and Avelox are formulary quinolones Floxin tab 400 mg BID Cipro tab 500 mg BID Cipro and Avelox are formulary quinolones Floxin (Ofloxacin) 0.3% Otic Solution 5ml bottle Ofloxacin 0.3% Ophthalmic solution 5ml Ophthalmic solution may be administered in the bottle ear Fluocinonide 0.05% soln Fluocinolone 0.01% soln or Fluocinonide Fluocinonide is a high potency steroid. 0.05% cream, gel or ointment Fluocinolone is a low potency steroid.
Fluonid (Fluocinolone) 0.01% soln Synalar (Fluocinolone) 0.01% soln Generic available Fluor-op (Fluorometholone) 0.1% ophth susp FML (Fluorometholone 0.1%) ophth susp The smallest available unit size only Fluorouracil 2% cream Fluorouracil 1% or 5% cream 2% is non formulary Flurosyn (Fluocinolone) 0.01% cream DesOwen (Desonide) 0.05% cream, oint, Low potency topical corticosteroids. lotion or Synalar (Fluocinolone) 0.01% soln, oil or Hytone (Hydrocortisone) 2.5% cream, oint, lotion FML Forte (Fluorometholone) 0.25% ophth susp FML (Fluorometholone 0.1%) ophth susp; Eye drops are covered for the smallest available Dexamethasone 0.1% ophth soln or unit size only Prednisolone 0.12%-1% ophth soln FML-S (Fluorometholone 0.1%/Sulfacetamide10%) FML (Fluorometholone 0.1%) AND Bleph-10 FML-S is non formulary, but component eye drops (Sulfacetamide 10%) Or Blephamide are formulary individually. Eye drops are covered (Prednisolone 0.2% / Sulfacetamide 10%) for the smallest available unit size only.
Focalin (Dexmethylphenidate) 2.5 to 10mg BID Methylphenidate 5 to 20mg BID No clinical advantage of Focalin over Ritalin. Plasma-level data suggest the d-enantiomer is bioequivalent to racemic methylphenidate in a 1:2 dose ratio (eg, 5 mg dexmethylphenidate bioequivalent to 10 mg methylphenidate) Document failed trial on Methylphenidate, Dextroamphetamine and Adderall IR products before a Non-formulary Product is considered
Folic Acid 1mg OTC (National Vitamin Company brand) FolpaceRx (folic acid 2.05mg; hydroxycobalamin B12a OTC vitamin supplement components 425mcg; pyridoxine B6 25mg; d-alpha tocopheryl succinate Vit E 100IU; magnesium oxide 100mg)
Foradil (Formoterol) dry powder oral inhaler Serevent (Salmeterol) diskus 50mcg i 12mcg/puff i puff BID puff BID Fortamet (Metformin extended release) 500mg, Metformin regular release 500mg, 850mg or Metformin ER is also a formulary alternative. 1000mg tablets 1000mg tablets
Page 28 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Forteo (Teriparatide) 20mcg injection recombinant Fosamax 10mg QD or Fosamax w/ D 70mg human parathyroid hormone subcutaneous injection Q week for osteoporosis treatment.
Fortovase (Saquinavir) cap Invirase (saquinavir) 200mg capsule New patients may self refer to ID by phoning 770-431-4360.
Fosamax (Alendronate) 70mg plain tablet Fosamax w/D 70 mg Q week is formulary. Fosrenol (Lanthanum carbonate) 250mg or 500mg Phoslo 667mg (Calcium Acetate) tablet ii-iiii Lanthanum and Sevelamer are Calcium- Tablets tablets with each meal /Aluminum-free Phosphate binders for hypophosphatemia in patients with end stage renal disease. If a NF calcium/aluminum free phosphate binder is required, Sevelamer is KP NF alternative of choice. Fragmin (Dalteparin) injection Lovenox (Enoxaparin) injections Limit of 10 syringes Lovenox, 5 day supply, for initial fill Freestyle Blood Glucose test strips One Touch Ultra glucose test strips One Lifescan monitor is formulary and may be Touch Ultra 2 machine -only obtained, by prescription, at KP pharmacy at co- payment. Members will be charged full price for Lifescan monitor at Eckerd. If the patient's insulin pump requires the use of a companion BG monitor requiring NF BG strips, please note brand of pump and companion BG monitor on NF Rx for Freestyle or BG Logic BG strips.
Frova (Frovatriptan) 2.5mg Maxalt (Rizatriptan) MLT 10mg tablet Maxalt MLT 10 mg is preferred, QTY limit of 9 (Maxalt MLT 5mg tablet is also available) tablets/copay. If failed a trial on Maxalt MLT consider formulary alternative Imitrex 50 mg tablets (qty limit of 9 tablets/copay), nasal, or injectable dosage forms. Quantity limit for Non- formulary Frova is 9 tablets per copay Fulvicin U/F (Griseofulvin microsized) Grifulvin V 500mg tablets and Grifulvin Fulvicin U/F is no longer available from the suspension (125mg/ml) Dosing:Adults 500- manufacturer 1000mg as single or divided doses; Children: 10-20 mg/kg/day in single or divided doses Fulvicin P/G (Griseofulvin ultra-microsized) Grifulvin V 500mg tablets and Grifulvin Griseofulvin ultra-microsized products are no suspension (125mg/ml) Dosing:Adults 500- longer being manufactured. Griseofulvin 1000mg as single or divided doses; microsized remains available. Griseofulvin Children: 10-20 mg/kg/day in single or conversion factor: 0.66mg ultramicrosize = 1mg divided doses microsize (eg. Ultramicrosize 330mg=microsize 500mg) Gabitril (Tiagabine) Tegretol (carbamazepine), Neurontin Adjunctive therapy for partial seizures (gabapentin), Topamax (topiramate), [conversion to a formulary alternative not Tranxene (clorazepate), Lamotrigine 5- recommended when patient is stable on non 25mg chews and Lamictal 100mg-200mg formulary antiseizure medication for seizure oral tablets management] Generet-500 w/folic tab SA i QD OTC prenatal vitamin i QD Prescription prenatal vitamins are not covered Geodon (Ziprasidone) 20-80mg bid Seroquel (Quetiapine) 25, 100, 200, 300mg Consider 1/2 tablet dosing whenever possible. or Zyprexa (Olanzapine) 2.5, 5, 7.5, 10, (eg. Seroquel 200mg 1/2 tablet for Seroquel 15mg tabs 10-15mg qd or Risperdal 100mg dose. Risperdal 1mg 1/2 tablet for (Risperidone) 4-6mg qd Risperdal 0.5mg dose.) [Ziprasidone: Available Part D group] Glucose meter One Touch Ultra glucose test strips One Lifescan monitor is formulary and may be Touch Ultra 2 machine -only obtained, by prescription, at KP pharmacy at a co- payment. Members will be charged full price for Lifescan monitor at Eckerd Glucotrol (Glipizide) XL tab 10 mg QD Glipizide (generic Glucotrol) tab 10 mg QD XL Glucotrol (glipizide XL) is non-formulary, regular release is formulary and is equally effective Glucotrol (Glipizide) XL tab 20 mg QD Glipizide (generic Glucotrol) tab 10 mg BID XL Glucotrol (glipizide XL) is non-formulary, regular release is formulary and is equally effective
Page 29 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Glucotrol (Glipizide) XL tab 5 mg QD Glipizide (generic Glucotrol) tab 5 mg QD XL Glucotrol (glipizide XL) is non-formulary, regular release is formulary and is equally effective Glucovance (Glyburide/Metformin) 1.25/250mg, Glyburide 1.25-5mg tab BID AND Metformin Combination product is non-formulary, but 2.5/500, 5/500 tabs BID 500mg BID component medications are formulary individually. In order to increase metformin efficacy, consider converting Glucovance 1.25/250mg BID to glyburide 1.25mg BID PLUS metformin 500mg BID. Glynase (Micronized Glyburide) tab 1.5 mg QD Glyburide (generic Micronase) tab 2.5 mg Glynase (Micronized Glyburide) is non formulary, QD regular Glyburide is formulary. Consider other oral antidiabetics such as Glipizide in patients >65 due to prolonged half life of Glyburide.
Glynase (Micronized Glyburide) tab 3 mg QD Glyburide (generic Micronase) tab 5 mg QD Glynase (Micronized Glyburide) is non formulary, regular Glyburide is formulary. Consider other oral antidiabetics such as Glipizide in patients >65 due to prolonged half life of Glyburide.
Glynase (Micronized Glyburide) tab 6 mg BID Glyburide (generic Micronase) tab 10 mg Glynase (Micronized Glyburide) is non formulary, BID regular Glyburide is formulary. Consider other oral antidiabetics such as Glipizide in patients >65 due to prolonged half life of Glyburide.
Glynase (Micronized Glyburide) tab 6 mg QD Glyburide (generic Micronase) tab 10 mg Glynase (Micronized Glyburide) is non formulary, QD regular Glyburide is formulary Glyset (Miglitol) 25 - 100mg TID Glyburide (generic Micronase) 2.5-5 mg QD Alpha-glucosidase inhibitors are non formulary.
GoLYTELY (Polyethylene Glycol electrolyte soln) Colyte (Polyethylene Glycol 3350) powder . (only stable 48 hours after mixing) for bowel cleaning Gris-PEG (Griseofulvin Ultramicrosized) Grifulvin V 500mg tablets and Grifulvin Griseofulvin Ultra-microsized products are no suspension (125mg/ml) Dosing:Adults 500- longer being manufactured. Griseofulvin 1000mg as single or divided doses; microsized remains available. Griseofulvin Children: 10-20 mg/kg/day in single or conversion factor: 0.66mg ultramicrosize = 1mg divided doses microsize (eg. Ultramicrosize 330mg=microsize 500mg) Grisactin (Griseofulvin Microsized) Grifulvin V 500mg tablets and Grifulvin Grisactin is no longer available from suspension (125mg/ml) Dosing:Adults 500- manufacturer. 1000mg as single or divided doses; Children: 10-20 mg/kg/day in single or divided doses Grisactin Ultra (Griseofulvin Ultramicrosized) Grifulvin V 500mg tablets and Grifulvin Griseofulvin Ultra-microsized products are no suspension (125mg/ml) Dosing:Adults 500- longer being manufactured. Griseofulvin 1000mg as single or divided doses; microsized remains available. Griseofulvin Children: 10-20 mg/kg/day in single or conversion factor: 0.66mg ultramicrosize = 1mg divided doses microsize (eg. Ultramicrosize 330mg=microsize 500mg) Guaifenesin LA tab i BID OTC Mucinex (600mg Guaifenesin long All cough and cold medications with OTC acting) or OTC 400mg Guaifenesin regular equivalents are non-formulary with exception of release or OTC Guaifenesin syrup ii codeine, hydrocodone, and promethazine teaspoonfuls Q4H or OTC Guaifenesin gel containing products. cap ii capsules Q6H (generic Robitussin)
Gynezole 1 (2% butoconazole) vaginal cream OTC Mycelex3 (2% butoconazole) Other Products that are available over the counter are OTC alternatives include: Monistat vaginal not covered by the drug benefit. cream or Vagistat
Page 30 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
H Pylori treatment pack (only available at KP Metronidazole 500mg QID, Tetracycline Alternative, if failed first treatment course: Biaxin pharmacies for one copayment. At Eckerd, dispense 500mg QID (or Amoxicillin if Ten allergic), (Clarithromycin) 500mg bid, Flagyl as Rx for Metronidazole 500mg QID #56 & and Pepto-bismol 2 tabs QID x 14 days and (Metronidazole) 500mg bid and Prilosec OTC Tetracycline 500mg QID #56 and OTC Pepto-bismol 2 Prilosec OTC 20mg BID -- packet of all 4 20mg bid x 14 days Either treatment pack is tablets QID & Prilosec OTC 20mg BID available for one copayment at KP recommended for 14 days; however, if patient pharmacies able to tolerate at least 7 days may not be necessary to initiate alternate H Pylori treatment course. Habitrol (Nicotine transdermal system) 7, 14, OTC Nicotrol (Nicotine transdermal system) Nicotine replacement products are non formulary 21mg/day 5, 10, 15mg/day Halcion (Triazolam) tabs 0.125-0.25 mg at HS Temazepam (generic Restoril) 15-30 mg Consider lower doses in geriatric patients. capsule at HS or Oxazepam (gen Serax) 10- Consider OTC melatonin to reduce 30mg or Lorazepam 0.5mg QHS or benzodiazepine usage Caution: do not abruptly Hydroxyzine (generic Atarax) 10-25 mg at discontinue benzodiazepines after long-term use. HS [Haloperidol: Available Part D group]
Halog (Halcinonide) 0.1% cream, oint [high potency] Lidex (Fluocinonide) 0.05% cream, oint, gel, High potency topical corticosteroids. soln or Diprolene AF (Augmented Betamethasone) 0.05% Helidac (250mg Metronidazole QID, 500mg HP Pack: Tetracycline 500 mg QID x 14 HP Pack (Helicobacter pylori treatment pack) Tetracycline QID, 2x262mg Bismuth subsalicylate QID days, Metronidazole 500 mg QID x 14 days, Individual components dispensed as 2 individual x 14 days) Bismuth subsalicylate 2 tabs QID x 14 days prescriptions (500mg Metronidazole QID and and Prilosec OTC 20mg BID x 14 days (HP 500mg Tetracycline QID) PLUS OTC Pepto Pack available at KP pharmacies for one Bismol (bismuth subsalicylate) & Prilosec OTC at copayment) Eckerds. [If member allergic to or failed TEN, substitute Amoxicillin 500mg QID] Second line alternative: Prilosec OTC 20mg BID, Biaxin 500mg BID, and Flagyl 500mg BID or Amoxicillin 1000mg BID x 14 days
Hemocyte Plus OTC equivalent (Fe 106 mg, B1, B2, B3, Vitamins components available OTC in one or B5, B6, B12, C 200 mg, folic acid 1 mg) more OTC preparations for equivalency. Hibiclens (Chlorhexidine) top soln N/A Available OTC, may be substituted. HMS (Medrysone) 1% ophth susp For allergic conjunctivitis: OTC Opcon-A OTC Zaditor 0.25% and Patanol are both dual (Pheniramine & Naphazoline) or OTC action antihistamine/mast cell stabilizers, are Zaditor 0.25% [NOTE: OTC products are dosed twice daily, and have the same FDA not a covered benefit] approved indications. If treating steroid responsive inflammatory condition consider at least 2 formulary products before prescribing/authorizing a NF product :Dexamethasone 0.1% ophth soln or Prednisolone 0.12%-1% ophth soln or Flarex, FML (Fluorometholone) ophth soln 0.1% i-ii drops in affected eye(s) QID
Humabid LA OTC Mucinex (600mg Guaifenesin long All cough and cold medications with OTC acting) or OTC Guaifenesin 400mg regular equivalents are non-formulary with exception of release or OTC Guaifenesin syrup ii codeine, hydrocodone, and promethazine teaspoonfuls Q4H or OTC Guaifenesin gel containing products. cap ii capsules Q6H (generic Robitussin)
Humalog (insulin Lispro) inj 100 u/ml NovoLog (insulin Aspart) U-100 vial, OR, if Humalog converts to Novolog on a unit for unit no previous trial on regular insulin, consider basis. [Humalog and NovoLog are administered conversion to Novolin Regular Insulin 15 minutes prior to meals, whereas Novolin R is administered 30-60 minutes before meals.] Novolog vial is compatible with currently marketed insulin pumps. NF Novolog cartridge is preferred if older pump requiring cartridge.
Page 31 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Humalog Mix 50/50 (50% insulin lispro protamine/ Consider conversion to both Novolin NPH [Humalog and NovoLog are administered 15 50% insulin lispro) vial 100 u/ml and either NovoLog or Novolin R, minutes prior to meals, whereas Novolin R is individually. Converting physician specifies administered 30-60 minutes before meals.] eg. the number of units of each. Draw the 20 units of Humalog mix 50/50 converts to 10 NovoLog or Novolin R (which ever ordered) units of NovoLog mixed with 10 units of Novolin into the syringe before drawing the NPH into NPH to equal a total of 20 units mixed insulin the syringe.
Humalog Mix 75/25 (75% insulin lispro protamine / Consider conversion to Novolin 70/30 (70% Consider Novolin 70/30 [Humalog and NovoLog 25% insulin lispro) vial 100u/ml isophane insulin susp / 30% regular insulin are administered 15 minutes prior to meals, OR both Novolin NPH and NovoLog, whereas Novolin R is administered 30-60 minutes individually. Converting physician specifies before meals.] eg. 20 units of humalog mix 75/25 the number of units of each. Draw the converts to 20 units of novolin 70/30 OR 20 NovoLog into the syringe before drawing the units of humalog mix 75/25 converts to 15 units NPH into the syringe NPH and 5 units NovoLog.
Humalog pen NovoLog (insulin Aspart) U-100 vial, OR, if Humalog converts to Novolog on a unit for unit no previous trial on regular insulin, consider basis. Humalog is administered 15 minutes prior conversion to Novolin Regular Insulin to meals, Novolin R is administered 30-60 minutes before meals. Insulin pens are non- formulary. However, Insulin pens may be available thru the NF Rx process when the physician documents the member is unable to accurately draw up insulin due to young age, visual impairment, Parkinson's Disease, rheumatoid arthritis or upper extremity amputation; or, when administering doses less than 5 units; or, when pediatric patient's school or day care requires use of insulin cartridge device for insulin administration while outside of their primary caretaker's care. Humatrope (Human Growth Hormone) vial Criteria Restricted Medication. Once Criteria Restricted Medication. Pediatric approved, the approval and date range Endocrinologist phone KP QRM to request for approval is noted in the Kaiser authorization consideration 404-364-7320. May pharmacy computer system. Norditropin only be dispensed at a Kaiser Pharmacy. (somatropin) is preferred growth Normally vials are approved. If Humatrope hormone and must be tried prior to cartridges are medically necessary, Novofine 30 approval for other growth hormone needle tips will be dispensed. The prescribing products Endocrinologist will provide the Humatropen.
Humegon injection Repronex injection May be substituted on a unit for unit basis without calling practitioner. Menotropins are only covered for members with fertility benefit. Humibid DM tablet SA i tablet BID OTC Mucinex (600mg Guaifenesin long All cough and cold medications with OTC acting) or OTC Guaifenesin 400mg regular equivalents are non-formulary with exception of release or OTC Guaifenesin syrup ii Codeine, Hydrocodone, and Promethazine teaspoonfuls Q4H or OTC Guaifenesin gel containing products. cap ii capsules Q6H (generic Robitussin)
Humibid LA tabs i tablet BID OTC Mucinex (600mg Guaifenesin long All cough and cold medications with OTC acting) or OTC Guaifenesin 400mg regular equivalents are non-formulary with exception of release or OTC Guaifenesin syrup ii codeine, hydrocodone, and promethazine teaspoonfuls Q4H or OTC Guaifenesin gel containing products. cap ii capsules Q6H (generic Robitussin)
Humorsol (Demecarium) 0.125 - 0.25% ophth soln Phospholine iodide (echothiophate 0.03- Cholinesterase inhibitors to reduce IOP in reversible cholinesterase inhibitor 0.25%) ophth soln irreversible glaucoma. Smallest package size is formulary. cholinesterase inhibitor Ophthalmologist to determine appropriateness of conversion and dose.
Page 32 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Humulin N, R, L or U-100 vials Novolin N or R U-100 vials May be substituted without calling provider. Penfills are not covered. Humulin Ultralente and Lente will soon be discontinued by manufacturer.
Humulin R 500 units/ml vials Novolin R 100 units/ml vials If injection volume of 100units/ml concentration can be safely administered SQ, do not convert to more concentrated 500units/ml. Hylaform Plus (hylan-b) gel N/A Cosmetic use drug. Not covered on drug benefit. Member pays retail price. Hycodan (Hydrocodone/Homatropine) syrup i Hydrocodone/Homatropine (Hycodan) tab i Hycodan syrup is non-formulary, tablets are teaspoonful Q4-6H prn tablet Q4-6H prn formulary. Robitussin AC generic Syrup (10 mg Codeine/100 mg Guaifenesin) 10 ml Q4H or Robitussin DAC; phenergan VC with codeine or phenergan with codeine syrup Hydroquinone cream or lotion No formulary alternative Cosmetic use drug. Not covered on drug benefit. Member pays retail price. If prescribed along with Differin, Retin A, or Avita creams, they are also being used as cosmetic therapy and are not covered. Hydroxyzine pamoate caps (generic Vistaril) 25-50 mg Hydroxyzine HCl tabs (generic Atarax) 25- Substitute on a mg for mg basis. TID-QID 50 mg TID-QID Hygroton (chlorthalidone) tabs Hydrochlorothiazide tabs . Hytakerol (Dihydrotachyesterol) aka DHT 0.125, 0.2, Rocaltrol (Calcitriol) 0.25, 0.5mcg caps 0.25- . 0.4mg tabs 0.1-0.25mg qd and titrate to effect 1mcg/day titrated to effect or Calciferol (Ergocalciferol) 50,000 units/capsule 15,000- 20,000 units/day titrated to effect
Hyzaar tabs 100mg (Cozaar100/HCTZ25) QD or Cozaar 100 mg QD plus Two separate prescriptions for Cozaar and HCTZ 50mg (Cozaar 50mg/HCTZ 12.5mg) BID Hydrochlorothiazide 25 mg tablet QD. are required. TSPMG guidelines recommend trial on ACEI (Prinivil) before prescribing ARB (Cozaar) Hyzaar tabs 50mg (Cozaar 50mg/12.5mg HCTZ) i Cozaar 50 mg QD plus Hydrochlorothiazide Two separate prescriptions for Cozaar and HCTZ tablet QD 25 mg 1/2 tablet QD. are required. TSPMG guidelines recommend trial on ACEI (Prinivil) before prescribing ARB (Cozaar) Iletin NPH, R &L 100U/ml vial Novolin NPH, R & L 100U/ML vials May be substituted on a unit for unit basis Ilozyme (Pancrelipase enzymes) Pancrease (pancrelipase enzymes) or Pangestyme is a generic of Pancrease pangestyme Imitrex (Sumatriptan) 25 tabs OR 100mg tabs Maxalt (Rizatriptan) MLT 10mg tablet Maxalt MLT 10 mg is preferred, QTY limit of 9 (Maxalt MLT 5mg tablet is also available) tablets/copay. If failed a trial on Maxalt MLT consider formulary alternative Imitrex 50 mg tablets (qty limit of 9 tablets/copay), nasal, or injectable dosage forms. Imitrex 5 mg nasal spray Imitrex 20 mg nasal spray Imitrex 20 mg nasal spray is significantly more effective than Imitrex 5 mg nasal spray. The same precautions and contraindications apply for both strengths of nasal spray. Maximum prescription quantity for Imitrex 20 mg spray is 6 bottles/prescription. Indapamide tab (generic Lozol)1.25 mg QD Hydrochlorothiazide (HCTZ) tab 12.5 mg N/A QD Indapamide tab 2.5 mg QD Hydrochlorothiazide (HCTZ) tab 25 mg QD N/A
Indapamide tab 5 mg QD Hydrochlorothiazide (HCTZ) tab 50 mg QD N/A
Page 33 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Inderal LA (Propranolol) capsule Atenolol 25, 50mg, 100mg tablets QD or Migraine or Tremor Prophylaxis: Propranolol tabs metoprolol 50mg,100mg tablets QD-BID - 80-320mg divided BID - TID -OR- Metoprolol or- Propranolol (10, 20, 40, 60, 80, 90mg (less than 80mg, Propranolol converts to 50mg tabs) 40-320mg divided BID-TID or Metoprolol; 80-120mg of Propranolol converts to Nadolol 20, 40, 80, 120, 160mg tablets QD 100mg Metoprolol; 120-160mg Propranolol HTN: may effectively use Atenolol, converts to 150mg Metoprolol; >160mg Metoprolol, Nadolol or Propranolol regular Propranolol converts to 200mg Metoprolol divide release. For Migraine Prophylaxis: dose BID) -OR- Nadolol 80mg-240mg QD (2mg Propranolol regular release BID - TID, Propranolol roughly equivalent to 1mg Nadolol); Nadolol, Metoprolol or Atenolol. For Tremor Atenolol is an option for migraine, not tremor (less Prophylaxis: Propranolol regular release than 160mg Propranolol converts to Atenolol BID-TID, Metoprolol or Nadolol. 50mg QD, more than 160mg Propranolol converts to Atenolol 100mg QD (beta blocker dosages are titrated to patient's lowest effective dose)
Infergen (interferon alpha con) Peg-Intron (Pegylated Interferon alpha 2 b Per Hepatitis C clinic, Infergen generally reserved injection) vials OR Redipen OR for patients who have failed to maintain clearance Pegasys (Pegylated Interferon alpha 2 a of viral load with Peg-Intron or Pegasys. If no injection) vials or prefilled syringe response to Infergen in 12 weeks, consider d/c Infergen. Innohep (Tinzaparin) injection Lovenox (Enoxaparin) injections Limit of 10 syringes Lovenox, 5 day supply, for initial fill Inspirease spacer device EZ spacer or aerochamber spacer devices N/A
Inspra (Eplerenone) 25-100mg QD If using for CHF and desire aldosterone Use 25mg Spironolactone tablets to obtain 50mg antagonism formulary alternative is: or 100mg dose. If prescribing to treat HTN: Spironolactone 25mg tablets consider HCTZ 25mg QD or another first line antihypertensive medication ie. Metoprolol, Atenolol, Lisinopril. Intrinsa (Testosterone) Transdermal Estratest or Estratest HS oral Medications used expressly for the treatment of sexual dysfunction are excluded from the drug benefit. Patients without a sexual dysfunction benefit may choose to purchase Intrinsa at the full retail price. Intrinsa is marketed to modestly improve sexual desire in women with hypoactive sexual desire following surgically-induced menopause on concurrent estrogen therapy.
Iressa (Gefitinib) Platinum containing combination Iressa Survival Evaluation in Lung Cancer (ISEL) chemotherapy with paclitaxel or Docetaxel trial compared Iressa with best supportive care in chemotherapy the treatment of Non small cell lung cancer patients who had received one to two prior chemotherapy regimens. Iressa treatment was not associated with a significant survival improvement. Isoptin (Verapamil) SR tabs 120, 180, 240mg QD Verapamil SR tabs (generic Calan SR) 120, Substitute on a mg for mg basis. 180, 240 mg tabs 120-240mg QD TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine Calcium channel Blocker to Beta Blocker, ACE-Inhibitor and Thiazide Diuretics
Januvia (sitagliptin) 25mg, 50mg and 100mg oral Metformin regular release 500mg, 850mg or TSPMG guidelines suggest: tablets 1000mg tablets twice daily dosing -or- Second line - metformin plus sulfonylurea extended release 500mg-750mg tabs up to Third line - Actos 15-45mg QD 4 tablets, once daily dosing Januvia provided no significant advantages over metformin or SFUs to obtain glucose goals.
Page 34 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Jenest-28 (0.5mg Norethindrone/ 35mcg Ethinyl Tri-Levlen (EE 30/40/30 / Levonorgestrel Other alternatives: Norinyl 1/35 Estradiol x 10 days, 1mg NE/ 35mcg EE x 11 days) 0.05/.075/.125) (EE35/Norethindrone 1mg) OR Microgestin FE (EE 20mcgl/ Norethindrone 1mg) Document at least 3 formulary alternatives before prescribing/approving a NF product.
Junel 1/20 (1mg Norethindrone / 20 mcg) Microgestin FE (1mg Norethindrone/ 20 Document at least 3 formulary alternatives mcg EE x 21 days then 75mg Ferrous before prescribing/approving a NF product. Fumarate x 7 days Kariva (20 mcg Ethinyl Estradiol / 0.15mg Levlen (0.15mg Levonorgestrel / 30mcg EE) A Desogestrel containing product substitution is Desogestrel) or Tri-Levlen (0.05mg Lvngl/30mcg EE x 6 not available on formulary. or may consider days, 0.075mg Lvngl/40mcg EE x 5 days, Brevicon (0.5mg Norethindrone/ 35 EE) or Zovia 0.125mg Lvngl/ 30mcg EE x 10 days) or 1/35 (Ethynodiol Diacetate 1mg/ 35mcg EE) or Microgestin FE 1/20 (1mg Norethindrone / Norinyl 1/35 (Norethindrone 1mg/ 35mcg EE) 20mcg EE) Document at least 3 formulary alternatives before prescribing/approving a NF product.
K-Dur (Potassium Chloride) tab K-Tab (10meq/tab) K-Tab tablets cannot be split, prescribe in appropriate dosage. Potassium is slowly released from a wax matrix as it passes thru the GI tract. The expended inert, porous, wax/polymer matrix is not absorbed and may be excreted intact in the stool. Kerlone (Betaxolol) 10, 20mg tabs 10-20mg qd Atenolol (gen Tenormin) 25-100mg QD or Propranolol is available as 10, 20, 40, 60, 80, Metoprolol 100 - 400mg QD or Propranolol 90mg tabs. Inderal LA is non-formulary. Atenolol 40 - 320mg BID max dose is 200mg QD; Metoprolol maximum dose is 450mg daily in divided doses; Propranolol maximum dose is 480mg per day in divided doses
Ketek (Telithromycin) 800mg QD Biaxin 500mg BID or Avelox (Moxifloxacin) . 400 mg QD or Augmentin 875 mg BID or Cefuroxime (gen Ceftin) 250mg BID
Ketoprofen (generic Orudis) 100-300mg daily (divided Ibuprofen (generic Motrin) tabs 600-800 mg Additional formulary alternatives: Diclofenac TID-QID) TID or Salsalate (Disalcid)1500mg BID or (Voltaren) 75mg BID or Choline Magnesium Naproxen 500mg BID or Sulindac (Clinoril) Trisalicylate (Trilisate) 750mg BID-TID or 200mg BID Nambumetone (Relafen) 500mg or 750mg #1-2 QD-BID or Etodolac (Lodine) 200mg-500mg Q8- 12H up to 1200mg/day or Indomethacin 25-50mg TID or Mobic (Meloxicam) 7.5mg or 15mg.
Ketorolac (generic Toradol) tab 10 mg Q4-6H PRN Ibuprofen 800 mg TID PRN or Naproxen Due to the risk of renal failure and GI bleeding, 250-500 mg Q6-8H or sulindac (Clinoril) ketorolac tablets should not be administered more 200mg BID or diclofenac (Voltaren) 75mg than 5 days. Ketorolac tablets are FDA approved BID or Relafen 500mg or 750mg 1 -2 QD - for use after Ketorolac injection only. BID or etodolac (Lodine) 200-500mg Q8- 12H up to 1200mg/day or Mobic (Meloxicam) 7.5mg or 15mg Kineret (Anakinra) IL-1 blocker Enbrel 25 mg SQ twice weekly (TNF blocker) Klaron Lotion (Sulfacetamide only) Sulfacetamide/sulfur lotion N/A K-Lor or K-Lyte (Potassium Chloride) 25 meq packets Potassium Chloride 20meq packet Prescribe according to meq per packet
Kytril (granisitron) 1mg BID Zofran (ondansetron) 100mg QD Lac-Hydrin cream 12% Ammonium Lactate lotion OTC May be substituted without calling provider. Lacriserts (Hydroxypropyl Methylcellulose) Hydroxypropyl Methylcellulose is available OTC products are available in various OTC products (Clear Eyes, Alcon ophthalmic solution)
Page 35 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Lamisil (Terbinafine) 250mg tab Fungal nail infection is considered cosmetic treatment and is not covered Unless : fungal culture positive and i) If a finger nail, limited to one 6 week treatment course, ii) If a toe nail, only covered if the patient has diabetes or vascular disease, then restricted to one 12 wk course.
Lantus (Insulin Glargine) vials dosed QHS Novolin NPH (Humulin Restricted to Pediatric Endocrinology and Ultralente will soon be discontinued by Endocrinology. Must call practitioner for manufacturer) conversion. Lantus must not be mixed or diluted with any other insulin or solution. Insulin pens are non-formulary. Lantus Insulin pens are not generally covered for pediatrics, as once daily administration may be administered under the primary caregiver's care. Insulin pens may be available thru the NF Rx process when the physician documents the member is unable to accurately draw up insulin due to young age, visual impairment, Parkinson's Disease, rheumatoid arthritis or upper extremity amputation; or, when administering doses less than 5 units; or, when pediatric patient's school or day care requires use of insulin cartridge device for insulin administration while outside of their primary caretaker's care.
Lescol (Fluvastatin) 20 mg QHS Lovastatin 10mg QHS or Simvastatin 20 mg Simvastatin 20mg dose would be expected to QHS provide significantly more LDL lowering than lescol 20mg dose. Consider maximizing dose of Lovastatin to 80mg QPM or Simvastatin to 80 mg QHS before determining that the formulary alternatives are ineffective. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM.
Lescol (Fluvastatin) 40 mg QHS Lovastatin 20 mg QHS or Simvastatin 20 Simvastatin 20mg dose would be expected to mg QHS provide significantly more LDL lowering than lescol 40mg dose. Consider maximizing dose of Lovastatin to 80mg QPM or Simvastatin to 80 mg QHS before determining that the formulary alternatives are ineffective. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM.
Lescol (Fluvastatin) 80 mg QHS Lovastatin 40 mg QHS or Simvastatin 20 Consider maximizing dose of Lovastatin to 80mg mg QHS QPM or Simvastatin to 80mg QHS before determining that the formulary alternatives are ineffective. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM
Lescol XL (Fluvastatin) 80mg QHS Lovastatin 40 mg QHS or Simvastatin Consider Maximizing dose of Lovastatin to 80mg 20mg QPM and Simvastatin to 80mg QHS before determining that the formulary alternatives are ineffective. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM
Page 36 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Lessina ((0.1mg Levonorgestrel/20mcg Ethinyl Levlen (0.15mg Levonorgestrel / 30mcg EE) or may consider Microgestin FE 1/20 (1mg Estradiol) or Tri-Levlen (0.05mg Lvngl/30mcg EE x 6 Norethindrone/ 20mcg ee) or Brevicon (0.5mg days, 0.075mg Lvngl/40mcg EE x 5 days, Norethindrone/ 35 EE) or Zovia 1/35 (Ethynodiol 0.125mg Lvngl/ 30mcg EE x 10 days) Diacetate 1mg/ 35mcg EE) or Norinyl 1/35 (Norethindrone 1mg/ 35mcg EE) Document at least 3 formulary alternatives before prescribing/approving a NF product.
Letaris (ambrisentan) Remodulin (Trepostinil), Flolan Flolan requires administration in the medical 5mg, 10mg tablets (epoprostenol) and Tracleer (Bosentan) clinic under the drug benefit.
Leukine (Sargramostim) injection N/A No refills, pt must present a new rx for each fill Levaquin 500 mg QD for sinusitis Avelox (Moxifloxacin) 400 mg QD See TSPMG Practice Resource for recommendations Levaquin tab 250 mg QD for UTI Cipro 250 - 500 mg BID Do not use Avelox for UTI Levaquin (levofloxacin) tab 500 mg QD for bronchitis Avelox (moxifloxacin) 400 mg QD or generic . or community acquired pneumonia Augmentin 875 mg BID or Biaxin 500 mg BID Levatol (Pensutolol) 20mg tabs 20 - 40mg QD Atenolol (gen Tenormin) 25 - 100mg QD or Propranolol is available as 10, 20, 40, 60, 80, Metoprolol 100 - 400mg QD or Propranolol 90mg tabs. Inderal LA is Non-formulary. 40 - 320mg bid TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics
Levbid tab 0.375 mg BID Hyoscyamine (Levsin) 0.125 mg tab TID- N/A QID Levemir (detemir) long-acting insulin; administered Novolin NPH Must call practitioner for conversion. Changing the once or twice daily basal insulin to Levemir can be done on a unit-to- unit basis, then adjusted to meet glycemic targets. Levemir must not be mixed or diluted with any other insulin or solution. Levemir is not to be used in infusion pumps. Insulin pens are non-formulary.
Levitra (Vardenafil) 2.5mg, 5mg, 10mg, 20mg none Levitra is not covered for sexual dysfunction unless member's group has purchased sexual dysfunction rider for additional coverage. Consider Levitra 20mg 1/2 tablet when prescribing Levitra 10mg dose to reduce patient expense.
Levlite (0.1mg Levonorgestrel/20mcg Ethinyl Levlen (0.15mg Levonorgestrel / 30mcg EE) or may consider Microgestin FE 1/20 (1mg Estradiol) [generic now manufactured: Lessina; or Tri-Levlen (0.05mg Lvngl/30mcg EE x 6 Norethindrone/ 20mcg ee) or Brevicon (0.5mg Alesse; Aviane] days, 0.075mg Lvngl/40mcg EE x 5 days, Norethindrone/ 35 EE) or Zovia 1/35 (Ethynodiol 0.125mg Lvngl/ 30mcg EE x 10 days) Diacetate 1mg/ 35mcg EE) or Norinyl 1/35 (Norethindrone 1mg/ 35mcg EE) Document at least 3 formulary alternatives before prescribing/approving a NF product.
Levora ((0.15 Levonorgestrel/30mcg EE) Levlen (0.15 Levonorgestrel/30mcg EE) Document at least 3 formulary alternatives before prescribing/approving a NF product.
Page 37 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Lexapro (Escitalopram) 5mg, 10mg, 20mg Prozac (Fluoxetine) caps 10-40 mg QD or Lexapro (Escitalopram) is the S-isomer of Celexa Celexa (Citalopram) 20 - 40mg or Sertraline (Citalopram). Consider a trial on Citalopram 20- 25-100mg QD, conversion dosing to be 40mg prior to Lexapro 10-20mg. Citalopram 20mg determined by physician dosing equivalent is Lexapro 10mg.Consider Citalopram 40mg 1/2 tablet for Citalopram 20mg dose. Document response to all formulary SSRI alternatives before prescribing a NF SSRI. Document reason, when patient is medically unable to convert to Formulary alternative. Lexxel (Enalapril/Felodipine) 5/2.5mg, 5/5mg Prinivil (Lisinopril) 5mg QD AND Felodipine Combination product is non formulary. Felodipine extended release tabs ER 2.5mg or 5mg 2.5mg is equivalent to generic Nifedipine XL 30mg or Diltia XT 120mg; felodipine ER 5mg = generic Nifedipine XL 30 to 60mg or Diltia XT 240mg.
Liadla (Meslamine) 1.2 g delayed-release tablets Asacol (Mesalamine released primarily in colon) 400mg #2 TID for 6 wks OR Pentasa 250mg #4 QID or 500mg #2 QID for 8 wks OR Dipentum 250mg #4 BID OR Azulfidine (Sulfasalazine) 500mg #2 TID-QID
Lidoderm 5% (Lidocaine) Patch Lidocaine topical gel (per chronic pain Capsaicin cream is another OTC alternative for guideline) or OTC L-M-X4 (4% topical post herpetic neuralgia. lidocaine cream) or OTC Lidosense 4 (4% topical lidocaine cream) or OTC Axsain cream (4% lidocaine combined with 0.25% capsaicin cream) Limbrel (flavocoxid) capsules **this is a prescription If physician would like to consider an Limbrel is a food supplement marketed for an anti- food supplement, not an FDA approved drug. The alternative anti-inflammatory agent, inflammatory effect. Though a prescription is product consists of Flavonoids and flavans from consider these formulary required, this food supplement is not covered by phytochemical food source materials which may alternatives:Relafen (Nambumetone) the KP drug benefit. The patient may choose to posses anti-inflammatory and analgesic properties. 500mg or 750mg 1 - 2 QD-BID or Etodolac purchase this food supplement at the full (gen. Lodine) 200-500mg Q8-12H up to prescription price . 1200mg/day or Ibuprofen (gen. Motrin) tabs 600-800 mg TID or Naproxen (gen. Naprosyn) 500mg BID or Sulindac (gen. Clinoril) 200mg BID or Diclofenac (gen. Voltaren) 75mg BID or Mobic (Meloxicam) 7.5mg or 15mg Lipitor tab 10 mg QD Lovastatin 40mg QPM w/ meal OR If pt needs Lipitor, use half tabs. Consider Simvastatin 20mg po QPM maximizing dose of Lovastatin to 80mg and Simvastatin to 80mg before determining that the formulary alternatives are ineffective. See box below for drug interactions. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM.
Lipitor tab 20 mg QD Lovastatin 80 mg QPM w/ meal or Doses of lovastatin > 40mg QD and simvastatin > Simvastatin 40 mg QPM 20mg QD are not recommended in combination with Diltiazem, Verapamil, Amiodarone, or a protease inhibitor. Doses of Lovastatin > 20mg QD and simvastatin > 10mg QD not recommended with cyclosporine. Continue Lipitor to minimize drug interaction and chance for muscle aches. If Lipitor is continued, use half tablets. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM.
Page 38 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Lipitor tab 40 mg QD Simvastatin 80 mg QPM Doses of lovastatin > 40mg QD and simvastatin > 20mg QD are not recommended in combination with Diltiazem, Verapamil, Amiodarone, or a protease inhibitor. Doses of Lovastatin > 20mg QD and simvastatin > 10mg QD not recommended with cyclosporine. Continue Lipitor to minimize drug interaction and chance for muscle aches. If Lipitor is continued, use half tablets. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM.
Lipitor tab 80 mg QD Consider simvastatin 80mg QD plus Slo- Doses of lovastatin > 40mg QD and simvastatin > Niacin/ time release niacin or BAS first if 20mg QD are not recommended in combination appropriate. Otherwise, Vytorin 10/80 mg with Diltiazem, Verapamil, Amiodarone, or a QHS can be considered. protease inhibitor. Doses of Lovastatin > 20mg QD and simvastatin > 10mg QD not recommended with cyclosporine. Continue Lipitor to minimize drug interaction and chance for muscle aches. If Lipitor is continued, use half tablets. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM.
Livostin (Levocabastine) .05% i drop QID up to 2 For allergic conjunctivitis: OTC Opcon-A OTC Zaditor 0.25% and Patanol are both dual weeks (antihistamine eye drop) (Pheniramine & Naphazoline) or OTC action antihistamine/mast cell stabilizers, are Zaditor 0.25% [NOTE: OTC products are dosed twice daily, and have the same FDA not a covered benefit] approved indications. If treating steroid responsive inflammatory condition consider at least 2 formulary products before prescribing/authorizing a NF product : Dexamethasone 0.1% ophth soln or Prednisolone 0.12%-1% ophth soln or Flarex, FML (Fluorometholone) ophth soln 0.1% i-ii drops in affected eye(s) QID
Locoid (Hydrocortisone Butyrate) 0.1% topical oint, Triamcinolone (generic Aristocort or If failed other alternatives, consider increasing soln [medium potency] Kenalog) cream, oint 0.1% OR Valisone steroid potency to Fluocinonide (Lidex) 0.05% (Betamethasone Valerate) 0.1% lotion (if cream, oint, or gel lotion needed) Locoid Lipocream (hydrocortisone) 0.1% Kenalog (Triamcinolone) 0.1% cream, oint - Locoid lipocream is restricted to Dermatology. or- Lidex (Fluocinonide) 0.025-0.05% cream, oint Lodine XR tabs 400-600 mg QD Etodolac ( gen. Lodine) 200-500mg Q8-12H Salsalate (Disalcid)1500mg BID or choline up to 1200mg/day or Relafen magnesium trisalicylate (Trilisate) 750mg BID-TID (Nambumetone) 500mg or 750mg tablet #2 or nambumetone (Relafen) 500mg or 750mg #1- QD-BID or Ibuprofen (gen. Motrin) tabs 600- 2 QD-BID 800 mg TID or Naproxen (gen. Naprosyn) 500mg BID or Sulindac (gen. Clinoril) 200mg BID Diclofenac (gen. Voltaren) 75mg BID or Mobic (Meloxicam) 7.5mg or 15mg
Loestrin 21 (1mg Norethindrone/ 20 mcg EE) Microgestin FE (1mg Norethindrone/ 20 Final 7 days of Loestrin FE pack are iron rather mcg EE x 21 days then 75mg Ferrous than placebo tablets. (NF Giselle are equivalent Fumarate x 7 days to microgestin 1/20, with 7 placebo rather than iron tabs) Document at least 3 formulary alternatives before prescribing/approving a NF product. Loestrin 24 Fe Levlen, microgestin fe 1/20 and 1.5/30, All-flex diaphragms or paragard T380 and Mirena zovia 1/35, norinyl 1+35, brevicon, Norinyl (levonorgestrel) IUDs also formulary contraceptive 1+50, trilevlen, trinorinyl, depo-provera options Document at least 3 formulary injection alternatives before prescribing/approving a NF product.
Page 39 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Loniten (Minoxidil) tablet 10-40 mg QD Minoxidil 10-40mg QD is on the formulary Minoxidil is not covered for the treatment of male pattern baldness. Lo/Ovral-28 (0.3 Norgestrel / 30mcg EE) tablet i QD Levlen (0.15mg Levonorgestrel / 30mcg EE) May consider Tri-Norinyl (.5/1/.5 Norethindrone/ [generic Lo/Ovral is also manufactured, Low-Ogestrel, or Tri-Levlen (0.05mg Lvngl/30mcg EE x 6 35 EE) or Microgestin FE (1 mg Norethindrone/ 20 Cryselle] days, 0.075mg Lvngl/40mcg EE x 5 days, EE) or Zovia 1/35 (1mg Ethynodiol Diacetate/ 35 0.125mg Lvngl/ 30mcg EE x 10 days) EE) Document at least 3 formulary alternatives before prescribing/approving a NF product. Loprox (Ciclopirox) lotion Lamisil AT Cream OTC Loprox non formulary. Lorabid (Loracarbef) suspension Omnicef 125mg/5ml; pediazole . (Erythromycin & Sulfamethoxazole); Augmentin 125-250mg/5ml or 200-400mg chew tabs;Amoxicillin 125-250mg/5ml; Biaxin 125-250mg/5ml; cefaclor suspension
Lortab elixir Generic Tylenol #3 elixir (Codeine N/A 12mg/acetaminophen120mg per 5ml) or (Hydrocodone/acetaminophen (generic Lortab) tabs, caps Lotemax (Loteprednol) 0.5% ophth soln i-ii drops QID Dexamethasone 0.1% ophth soln or [Loteprednol 0.5% (Lotemax) less effective than Prednisolone 0.12%-1% ophth soln or Prednisolone Acetate 1% in treatment of acute Flarex, FML (Fluorometholone) ophth soln anterior uveitis] 0.1% i-ii drops in affected eye(s) QID
Lotensin (Benazepril) 5-80 mg QD (generic also Prinivil (Lisinopril) tab 5-80 mg QD Substitute on a mg for mg basis. marketed) TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE- Inhibitor and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics
Lotrel (Amlodipine/Benazepril) 2.5/10, 5/10, 5/20mg, Nifedipine XL 30mg or 60mg OR Diltia XT Amlodipine 2.5, 5 & 10mg are equivalent to 10/20mg tabs 120mg - 480mg QD OR Felodipine ER Nifedipine XL 30, 30 &60mg, respectively OR 2.5mg-10mg OR Amlodipine 2.5mg-10mg Diltia XT 120, 240 & 360mg respectively OR AND Prinivil (Lisinopril) 10 or 20mg QD Felodipine ER 2.5, 5 & 10mg respectively; Benazepril 10 -20mg is equivalent to Lisinopril 10 - 20 mg. Convert to either Amlodipine & Lisinopril, Nifedipine XL & Lisinopril or Diltia XT & Lisinopril or Felodipine ER & Lisinopril. Lotrisone (Clotrimazole/Betamethasone) cream apply OTC Lotrimin (Clotrimazole) cream plus Rx Lotrisone/Desonide combination pack only to affected area BID Desonide 0.05% cream apply both creams available at KP facility pharmacies for a single to affected area BID copay. At Eckerd pharmacy, patient will pay one copay for Desonide and will purchase OTC Lotrimin (Clotrimazole) cream at full OTC price.
Lotronex (Alosetron) Generic Levsin 0.125mg Last line agent for women with severe diarrhea prominent Irritable bowel syndrome. Lotronex not available at all pharmacies due to restricted prescribing process. [Alosetron: Available Part D group]
Lovenox Lovenox is formulary Lovenox initial dispensing limit of 10 syringes, 5 day supply. Larger quantities will need approval from Pharmacy call 404-365-4234
Page 40 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Low-Ogestrel (0.3 Norgestrel / 30mcg EE) tablet i QD Levlen (0.15mg Levonorgestrel / 30mcg EE) May consider Tri-Norinyl (.5/1/.5 Norethindrone/ or Tri-Levlen (0.05mg Lvngl/30mcg EE x 6 35 EE) or Microgestin FE (1 mg Norethindrone/ 20 days, 0.075mg Lvngl/40mcg EE x 5 days, EE) or Zovia 1/35 (1mg Ethynodiol Diacetate/ 35 0.125mg Lvngl/ 30mcg EE x 10 days) EE) Document at least 3 formulary alternatives before prescribing/approving a NF product.
Lozol (Indapamide) tab 1.25 mg QD Hydrochlorothiazide (HCTZ) tab 12.5 mg N/A QD Lozol (Indapamide) tab 2.5 mg QD Hydrochlorothiazide (HCTZ) tab 25 mg QD N/A
Lozol (Indapamide) tab 5 mg QD Hydrochlorothiazide (HCTZ) tab 50 mg QD N/A
Lunesta (Eszopiclone) 1mg, 2mg or 3mg tablets Temazepam (generic Restoril) 15-30 mg Consider lower doses in geriatric patients. capsule at HS or Oxazepam (gen Serax) 10- Consider OTC Melatonin to reduce 30mg or Lorazepam 0.5mg QHS or benzodiazepine usage Caution: do not abruptly Hydroxyzine (generic Atarax) 10-25 mg at discontinue benzodiazepines after long-term use. HS, Trazodone 50-100mg QHS, or Caution: do not abruptly discontinue Zolpidem (gen Ambien) 5-10mg benzodiazepines after long-term use. Document failed trial on at least 1 Benzodiazepine, Trazodone, and Zolpidem before prescribing NF product. Lupron 1 mg/0.2 mg 2-wk kit Lupron or Eligard to be supplied by the TSPMG physicians provide injectables prescribing physician and administered in administered in medical office through floor stock. MD office under the patient's medical If network physicians cannot obtain Lupron, benefit. please complete KP NF Rx form requesting benefit coverage at the time of Lupron dispensing.
Lupron depot 3.75 mg kit Lupron or Eligard to be supplied by the TSPMG physicians provide injectables prescribing physician and administered in administered in medical office through floor stock. MD office under the patient's medical If network physicians cannot obtain Lupron, benefit. please complete KP NF Rx form requesting benefit coverage at the time of Lupron dispensing.
Lustra (Hydroquinone) cream 4% No formulary alternative Drugs for cosmetic use are NOT covered on drug benefit. Member pays retail price. If prescribed along with Differin, Retin A, or Avita creams, they also are not covered as they are being used as cosmetic therapy.
Luvox tab 25-100 mg QD or 100-150 mg BID Consult Psychiatrist to determine When conversion appropriate, Prozac is the appropriateness of conversion to Prozac. preferred agent. Initiation of low-dose Prozac 20 mg QD with dosage titration to desired response is suggested. Luxiq (Betamethasone Valerate) foam for scalp Synalar (Fluocinolone) 0.01% soln, oil or Luxiq is medium potency, Synalar 0.01% is a low Temovate (Clobetasol) .0.05% scalp soln potency topical corticosteroid product, (Restricted to Derm) Lyrica (pregabalin) capsules ** Gabapentin 100mg, 300mg and 400mg If treating neuropathic pain: Nortriptyline is capsules considered first-line agent (if <65 yrs old: 25mg QHS, increase dose 25mg/day at 3-7 day intervals prn. If > 65 years old: 10mg QHS, increase dose 10mg/day at 3-7 day intervals prn).**For discontinuation, Lyrica should be tapered gradually over a minimum 1 week period rather than abruptly discontinued per manufacturer
Page 41 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Mavik (Trandolapril) 1, 2, 4mg tabs 1-4mg QD Prinivil (Lisinopril) 5 - 40mg QD Prinivil is preferred ACE inhibitor. Conversion equivalents: Mavik 1mg=Prinivil 5-10mg; Mavik 2mg=Prinivil 10-20mg; Mavik 4mg=Prinivil 20- 40mg TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics
Maxair (Pirbuterol) 0.2 mg oral inhaler ii puffs Q4H prn Ventolin oral inhaler ii puffs Q4H prn Substitute on a puff for puff basis.
Maxalt (Rizatriptan) Maxalt (Rizatriptan) MLT 10mg tablet Dose on a mg for mg basis. QTY limit of #9 tabs (Maxalt MLT 5mg tablet is also available) per co-pay. Patients on Propranolol require dose reduction of Maxalt or Maxalt MLT to 5 mg.
Maxiflor (Diflorasone) 0.05% cream, oint Lidex (Fluocinonide) 0.05% cream, oint, gel, High potency topical corticosteroids. soln or Diprolene AF (Augmented Betamethasone) 0.05% Maxivate (Betamethasone Dipropionate) 0.05% Lidex (Fluocinonide) 0.05% cream, oint, gel, High potency topical corticosteroids. cream, oint soln or Diprolene AF (Augmented Betamethasone) 0.05% Maxivate (Betamethasone Dipropionate) 0.05% lotion Valisone (Betamethasone Valerate) 0.1% If failed other alternatives, consider increasing [medium potency] lotion or Triamcinolone (generic Aristocort, steroid potency to Fluocinonide (Lidex) 0.05% Kenalog) cream, oint 0.1% cream, oint, or gel Maxzide (Triamterene/HCTZ) 75/50 tablet Triamterene/hydrochlorothiazide 75/50 mg May be substituted mg for mg without calling (generic Maxzide) tabs practitioner. Brand name is non-formulary Mazanor (mazindol) n/a Weight loss agents not covered.
Medrol 2, 8, 16, 24 & 32 mg tabs Methylprednisolone 4 mg (generic Medrol) Methylprednisolone 4 mg tablet may be tab substituted to obtain appropriate dose without calling provider. Melanex (Hydroquinone) soln 3% N/A Drugs for cosmetic use are NOT covered on drug benefit. Member pays retail price. If prescribed along with Differin, Retin A, or Avita creams, they also are not covered as they are being used as cosmetic therapy.
Mentax (Butenafine) 1% cream OTC Lotrimin Ultra (Butenafine) 1% cream Mentax not covered since also available as Lotrimin Ultra available over-the-counter Meridia caps 10-15 mg QD N/A Agents for obesity or weight loss not covered. Patient pays full retail price. Metadate CD 20mg (Methylphenidate) Concerta 18,27,36,54mg, or Methylin ER Adderall XR is restricted to pediatrics, child 10mg, Methylphenidate 5, 10, 20mg and SR neurology and behavioral health. Titrate to 20mg; or generic Dexedrine spansules appropriate dosage using adderall regular (Dextroamphetamine) 5, 10, 15mg or release tablets before transitioning to once Adderall regular release 5, 10, 20, 30mg daily Adderall XR. Document failed trial on tablets or Adderall XR 5,10,20,25,30mg Methylphenidate, Dextroamphetamine and capsules. Controlled substances level 2 Adderall IR products before a Non-formulary requiring prescription written by prescriber. Product is considered. Methylphenidate is the preferred formulary alternative.
Page 42 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Metadate ER 10mg or 20mg (Methylphenidate) Methylin ER 10mg (methylphenidate), Adderall XR is restricted to pediatrics, child Concerta, Methylphenidate 5, 10, 20mg and neurology and behavioral health. Titrate to SR 20mg; or generic Dexedrine spansules appropriate dosage using adderall regular (Dextroamphetamine) 5, 10, 15mg or release tablets before transitioning to once Adderall regular release 5, 10, 20, 30mg daily Adderall XR. Document failed trial on tablets or Adderall XR 5,10,20,25,30mg Methylphenidate, Dextroamphetamine and capsules. Controlled substances level 2 Adderall IR products before a Non-formulary requiring prescription written by prescriber. Product is considered. Methylphenidate is the Methylphenidate is the preferred formulary preferred formulary alternative. alternative.
Metimyd (10% Sulfacetamide/ 0.5% Prednisolone) Blephamide (10% Sulfacetamide/ 0.2 % . ophth oint or soln Prednisolone) ophth oint or soln Metrogel vaginal gel 0.75% i applicatorful vaginally Metronidazole (generic Flagyl) tabs 2 gm Vaginal gel not covered, oral tablets offer greater BID x 5 days (500 mg x 4 tablets) for 1 dose efficacy. Metrogel vaginal gel is only manufactured as 45 gram package.
Metrogel 1% Metrogel 0.75% Availabe at internal KP pharmacies only Micardis (Telmisartan) 40-80 mg tab QD Prinivil (Lisinopril) 10-20 mg QD or Cozaar Prinivil is preferred, if no previous ACE inhibitor (Losartan) 25-50 mg tab QD trial. If angiotensin 2 receptor blocker is required, convert to Cozaar. Conversion: Micardis 40mg=Prinivil 10-20mg=Cozaar 25mg; Micardis 80mg=Prinivil 20-40mg=Cozaar 50mg TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics
Micardis HCT (Telmisartan/HCTZ) 40/12.5mg- Prinivil (lisinopril) 10-20 mg QD or Cozaar Prinivil is preferred, if no previous ACE inhibitor 80/12.5mg tab QD (losartan) 25-50 mg tab QD AND HCTZ trial. If angiotensin 2 receptor blocker is required, 12.5mg QD convert to Cozaar. Conversion: Micardis 40mg=Prinivil 10-20mg=Cozaar 25mg AND a prescription for HCTZ 12.5mg QD; Micardis 80mg=Prinivil 20-40mg=Cozaar 50mg AND a prescription for HCTZ 12.5mg QD TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE- Inhibitor and Thiazide Diuretics
Microgestin (1mg Norethindrone/ 20 mcg) Microgestin FE (1mg Norethindrone/ 20 Document at least 3 formulary alternatives mcg EE x 21 days then 75mg Ferrous before prescribing/approving a NF product. Fumarate x 7 days Micronor (Norethindrone) 0.35mg {other generic NorQD (norethindrone) 0.35mg May substitute without contacting practitioner names: Camila, Nora-Be, Errin, Jolivette} Miralax (polyethylene glycol 3350) . Miralax is now available OTC. OTC products are not a covered benefit.
Page 43 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Mircette (20 mcg Ethinyl Estradiol / 0.15mg Levlen (0.15mg Levonorgestrel / 30mcg EE) A Desogestrel containing product substitution is Desogestrel) [generic Mircette is now manufactured: or Tri-Levlen (0.05mg Lvngl/30mcg EE x 6 not available on formulary. or may consider Kariva] days, 0.075mg Lvngl/40mcg EE x 5 days, Brevicon (0.5mg Norethindrone/ 35 EE) or Zovia 0.125mg Lvngl/ 30mcg EE x 10 days) or 1/35 (Ethynodiol Diacetate 1mg/ 35mcg EE) or Microgestin FE 1/20 (1mg Norethindrone / Norinyl 1/35 (Norethindrone 1mg/ 35mcg EE) 20mcg EE) Document at least 3 formulary alternatives before prescribing/approving a NF product.
Modicon (0.5mg Norethindrone / 35 mcg EE) generic Brevicon (0.5mg Norethindrone / 35 May substitute without contacting practitioner mcg EE) Mononessa (0.25mg Norgestimate/ 35mcg EE) Sprintec (0.25mg Norgestimate/ 35 mcg Document at least 3 formulary alternatives EE) before prescribing/approving a NF product.
Monopril (Fosinopril) tab 10-80 mg QD Prinivil (Lisinopril) tab 10-80 mg QD Substitute on a mg for mg basis. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics
MS Contin (Morphine CR) Generic of MS Contin covered (Morphine Generic Percocet or Percodan (Oxycodone controlled release) 15mg, 30mg, 60mg, 5mg/325mg APAP or ASA, respectively), Tylox 100mg, 200mg Morphine immediate release (Oxycodone 5mg/500mg APAP), generic Demerol tablet 10mg, 30mg, roxanol (Morphine 50mg, 100mg, Fentanyl patches 25mcg, 50mcg, solution 10mg/5ml, 20mg/5ml, 100mg/5ml) 75mcg, 100mcg/hr
Mupirocin 2% Cream Mupirocin 2% Ointment . MUSE supps N/A Muse is not covered for sexual dysfunction unless member's group has purchased sexual dysfunction rider for additional coverage. Mysoline tablets Primidone tabs (generic Mysoline) May be substituted on a mg for mg basis without calling practitioner. Brands are non-formulary
Naftin (Naftifine) 1% cream or gel OTC Lamisil AT or Clotrimazole containing Clotrimazole or Terbinafine (Lamisil) for tinea OTC products: Lotrimin AF or OTC Mycelex pedis, tinea corporis, tinea circinata (ringworm of or OTC Micatin cream body), tinea cruris, tinea inguinalis (jock itch), tinea versicolor; Clotrimazole for intertrigo (rash in body folds or beneath breasts) or candidiasis (including rash on penis or corners of mouth) [OTC alternatives are not recommended for tinea capitis (ringworm of scalp), tinea faceii or barbae (ringworm of the beard…barber's itch or fungal nails]
Nalfon (Fenoprofen) 300-600 mg TID - QID Ibuprofen (generic Motrin) tabs 600-800 mg Additional formulary alternatives: Diclofenac TID or Salsalate (Disalcid)1500mg BID or (Voltaren) 75mg BID or Choline Magnesium Naproxen 500mg BID or Sulindac (Clinoril) Trisalicylate (Trilisate) 750mg BID-TID or 200mg BID Nambumetone (Relafen) 500mg or 750mg 1-2 QD- BID or Etodolac (Lodine) 200mg-500mg Q8-12H up to 1200mg/day or Indomethacin 25-50mg TID or Mobic (Meloxicam) 7.5mg or 15mg.
Nasacort or Nasacort AQ or Nasacort HFA Nasarel ii sprays each nostril BID or generic Please document failure of both Nasarel & generic (Triamcinolone) 25mcg/spray nasal inhaler ii sprays Flonase (fluticasone) i spray each nostril Flonase (fluticasone) before prescribing/approving each nostril BID QD a NF product.
Page 44 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Nasalide (Flunisolide) 25mcg/spray nasal spray ii Nasarel ii sprays each nostril BID or generic Please document failure of both Nasarel & generic sprays in each nostril BID-TID Flonase (fluticasone) i spray each nostril Flonase (fluticasone) before prescribing/approving QD a NF product. Nascobal (Cyanocobalamin) nasal spray OTC B12 (cyanocobalamin) 1mg tablet See TSPMG Adult Practice Resource for Anemia. orally QD Nasonex (mometasone) nasal spray ii sprays each Nasarel ii sprays each nostril BID or generic If the child is less then 4 years old, Nasonex may nostril QD Flonase (fluticasone) i spray each nostril warrant approval as Nasarel is not indicated for QD patients less than 6 years old & Flonase is not indicated in patients less than 4 years old.
Necon 0.5/35 (0.5mg Norethindrone/ 35 mcg EE) Brevicon (0.5mg Norethindrone/ 35mcgEE) Another alternative: generic Demulen (1mg Ethynodiol Diacetate / 35mcg EE) Document at least 3 formulary alternatives before prescribing/approving a NF product.
Necon 1/35 (1mg Norethindrone/ 35 mcg EE) Norinyl 1/35 (1mg Norethindrone/ 35mcg N/A EE) Necon 1/50 (1mg Norethindrone/ 50 mcg EE) Norinyl 1+50 (1mg NE/mestranol 0.5mg) or Document at least 3 formulary alternatives Zovia (generic Demulen) 1/50 (1mg before prescribing/approving a NF product. Ethynodiol Diacetate / 50mcg EE) i QD
Necon 10/11 (0.5mg Norethindrone/ 35mcg Ethinyl Brevicon (0.5mg NE/35mcg EE) or Norinyl Document at least 3 formulary alternatives Estradiol x 10 days, 1mg NE / 35mcg EE x 11 days) 1/35 (1mg NE/35mcg EE) or Tri-Norinyl before prescribing/approving a NF product. (0.5mg NE x 7days, 1mg NE x 7 days, 0.5mg NE x 7 days /35mcg EE) Nelova 0.5/35 (0.5mg Norethindrone / 35 mcg EE) Brevicon (0.5mg Norethindrone/ 35mcgEE) N/A or generic Demulen (1mg Ethynodiol Diacetate / 35mcg EE) Nelova 1/35 (1mg Norethindrone / 35 mcg EE) Norinyl 1/35 (1mg Norethindrone/ 35mcg N/A EE) Nelova 1/50M (1mg Norethindrone/ 50 mcg EE) Norinyl 1+50 (1mg NE/Mestranol 0.5mg) or Document at least 3 formulary alternatives Zovia (generic Demulen) 1/50 (1mg before prescribing/approving a NF product. Ethynodiol Diacetate / 50mcg EE) i QD
Nelova 10/11 (0.5mg Norethindrone/ 35mcg Ethinyl Brevicon (0.5mg NE/35mcg EE) or Norinyl Document at least 3 formulary alternatives Estradiol x 10 days, 1mg NE/ 35mcg EE x 11 days) 1/35 (1mg NE/35mcg EE) or Tri-Norinyl before prescribing/approving a NF product. (0.5mg NE x 7days, 1mg NE x 7 days, 0.5mg NE x 7 days /35mcg EE) Neo-Synalar (Neomycin/Fluocinolone) 0.025% cream Triamcinolone (generic Aristocort, Kenalog) If failed other alternatives, consider increasing cream, oint 0.1% steroid potency to fluocinonide (Lidex) 0.05% cream, oint, or gel. Pt may also use OTC neomycin, in addition to Rx topical steroid, if needed. Nephrocaps (Vitamin C 100mg, folate 1mg, niacin B3 OTC Nephro-vite (Vitamin C 100mg, folate Nephro-vite OTC NDC # 54391-0002-01 20mg, thiamin B1 1.5mg, riboflavin B2 1.7mg, 0.8mg, niacin B3 20mg, thiamin B1 1.5mg, Pantothenic Acid B5 5mg, Pyridoxine B6 10mg, riboflavin B2 1.7mg, Pantothenic Acid B5 Cyanocobalamin B12 6mcg, biotin 150mcg) 5mg, Pyridoxine B6 10mg, Cyanocobalamin B12 6mcg, biotin 300mcg)
Nephro-Vite RX (Vitamin C 60mg, folate 1mg, niacin OTC Nephro-vite (Vitamin C 60mg, folate Nephro-vite OTC NDC # 54391-0002-01 B3 20mg, thiamin B1 1.5mg, riboflavin B2 1.7mg, 0.8mg, niacin B3 20mg, thiamin B1 1.5mg, Pantothenic Acid B5 10mg, Pyridoxine B6 10mg, riboflavin B2 1.7mg, Pantothenic Acid B5 Cyanocobalamin B12 6mcg, biotin 300mcg) 10mg, Pyridoxine B6 10mg, Cyanocobalamin B12 6mcg, biotin 300mcg)
Page 45 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Neulasta (Pegfilgrastim) injection Neupogen (Filgrastim) injection Pegylated Filgrastim prolongs the Filgrastim half life, resulting in one Neulasta injection roughly comparable to 11 daily Neupogen injections. MD to address dosage conversion individually.
Neupogen (Filgrastim) injection N/A No refills. Requires a new Rx for each fill Neupro Patch (Rotigotine) 2mg, 4mg and 6mg patch Carbidopa/Levodopa Tolcapone (Tasmar) is on the formulary but all Entecapone (Comtan) other therapies should be tried first due to risk Benztropine (Cogentin) of death or hepatic failure. The patient and the Tolcapone (Tasmar) prescriber must complete informed consent forms provided by the manufacturer
Neutrogena Melanex N/A Drugs for cosmetic use are NOT covered on drug benefit. Member pays retail price. If prescribed along with Differin, Retin A, or Avita creams, they also are not covered as they are being used as cosmetic therapy.
Nexium (Esomeprazole) DR 20mg cap 20-40mg QD OTC Prilosec 20mg - 40mg QD Nexium is a NF No Initial Fill drug. If Prilosec 40mg QD failure, consider NF No Initial Fill drug, Protonix titrated up to 80mg QD. (Protonix 40mg=Nexium 20mg=Prilosec 20mg) Must document failure or intolerance to Prilosec 40mg QD if requesting PPI coverage.
Niaspan (Niacin extended release) 500mg, 750mg, Contact Prescriber to request conversion to Niaspan may be appropriate if OTC niacin 1000mg tablets OTC niacin. (Do NOT recommend flush- ineffective or if pt intolerant. If patient not taking a free niacin) statin, consider converting to Lovastatin or Simvastatin. For LDL lowering consider Slo- niacin or Time-release niacin: 500 mg QD titrated up by 500mg every 4 weeks up to desired dose. Maximum 2000mg daily dose. For HDL increase or to lower Lipoprotein a 'Lp(a)', consider niacin immediate release: initiate Niacin IR daily after dinner: titrate dose from 100mg QD x 1 week; 200mg QD x 1 week; then 300mg QD x 1 week; then 500mg QD, titrate up to lowest effective & tolerated dose. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM.
Nicoderm (Nicotine) Transdermal system OTC Nicotrol (Nicotine transdermal system) Nicotine replacement products are non formulary. 7,14,21mg/day 5, 10, 15mg/day Nicorette (Nicotine) gum OTC Nicotrol (Nicotine transdermal system) Nicotine replacement products are non formulary. 5, 10, 15mg/day Niferex-150 forte (150mg polysaccharide iron OTC Niferex-150 plus OTC B12 100mcg OTC products available: Niferex 150mg, B12 complex, 1mg folic acid, 25mcg B12) capsule i QD and Folic acid 0.4mg or plus folic acid 1mg 100mcg, Folic acid 0.4mg Rx Nitro-Dur (Nitroglycerin) transdermal 0.1,0.2,0.4, Minitran (Nitroglycerin) transdermal 0.1, 0.2, Nitro-Dur 0.3 and 0.8mg/hr patches are covered, 0.6mg/hr patches 0.4, 0.6mg/hr patches since Minitran is not available in these 2 strengths.
Page 46 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Nizoral (Ketoconazole) cream Lamisil AT cream available OTC. Nizoral tablets are covered. Clotrimazole or Terbinafine (Lamisil AT) for tinea pedis, tinea corporis, tinea circinata (ringworm of body), tinea cruris, tinea inguinalis (jock itch), tinea versicolor; Clotrimazole for intertrigo (rash in body folds or beneath breasts) or candidiasis (including rash on penis or corners of mouth) [OTC alternatives are not recommended for tinea capitis (ringworm of scalp), tinea faceii or barbae (ringworm of the beard…barber's itch or fungal nails]
Nizoral (Ketoconazole) shampoo 2% Nizoral A-D shampoo available OTC or Nizoral A-D shampoo available OTC Selenium sulfide 2.5% shampoo is formulary alternative Nordette (0.15 Levonorgestrel/30mcg EE) Levlen (0.15 Levonorgestrel/30mcg EE) Document at least 3 formulary alternatives before prescribing/approving a NF product.
Norflex (Orphenadrine Citrate) 100mg Flexeril (Cyclobenzaprine) 10mg tab or Use Cyclobenzaprine 10mg 1/2 tablet for Robaxin (Methocarbamol) 750mg tab or Cyclobenzaprine 5mg. Soma (Carisoprodol) 350mg or Parafon Forte DSC (Chlorzoxazone) 500mg Norgesic (25mg Orphenadrine Citrate/385mg Flexeril (Cyclobenzaprine) 10mg tab or Pt may also take OTC aspirin or ibuprofen, for Aspirin/30mg Caffeine) Robaxin (Methocarbamol) 750mg tab or analgesia. Use Cyclobenzaprine 10mg 1/2 tablet Soma (Carisoprodol) 350mg or Parafon for Cyclobenzaprine 5mg. Forte DSC (Chlorzoxazone) 500mg Noritate (Metronidazole) 1% cream Metrocream 0.75% cream or Metrogel 0.75% gel Noroxin tablet 400 mg BID Cipro tab 500 mg BID . Norplant system (discontinued by manufacturer) . . Novolin L U - 100 vial (Novolin Lente no longer Novolin N U-100 vial Both Novolin L and NPH are intermediate acting manufactured) insulins. Novolin N Penfill Novolin N U-100 vial Insulin pens are non-formulary. However, Insulin pens may be available thru the NF Rx process when the physician documents the member is unable to accurately draw up insulin due to young age, visual impairment, Parkinson's Disease, rheumatoid arthritis or upper extremity amputation; or, when administering doses less than 5 units; or, when pediatric patient's school or day care requires use of insulin cartridge device for insulin administration while outside of their primary caretaker's care.
Novolin R Penfill Novolin R U-100 vial Insulin pens are non-formulary. However, Insulin pens may be available thru the NF Rx process when the physician documents the member is unable to accurately draw up insulin due to young age, visual impairment, Parkinson's Disease, rheumatoid arthritis or upper extremity amputation; or, when administering doses less than 5 units; or, when pediatric patient's school or day care requires use of insulin cartridge device for insulin administration while outside of their primary caretaker's care.
Page 47 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
NovoLog 70/30 (70% Insulin aspart protamine / 30% Novolin 70/30 administering the same units Novolog 70/30 penfills non-formulary. Insulin Insulin aspart) penfill per dose as previous NovoLog 70/30 pens are non-formulary. However, Insulin pens regimen (administer Novolin 70/30 30 may be available thru the NF Rx process when minutes prior to a meal, administer the physician documents the member is unable to NovoLog 15 minutes prior to a meal) OR accurately draw up insulin due to young age, Novolin NPH (intermediate acting) visual impairment, Parkinson's Disease, administering 70% of previous NovoLog rheumatoid arthritis or upper extremity 70/30 as NPH PLUS Novolin R (short acting amputation; or, when administering doses less insulin) vials administering 30% of previous than 5 units; or, when pediatric patient's school or NovoLog 70/30 dose (administering Regular day care requires use of insulin cartridge device 30 minutes prior to a meal) OR, if an for insulin administration while outside of their Endocrinologist, 70% of dose from Novolin primary caretaker's care. NPH (intermediate acting) plus 30% of dose Novolog is administered 15 minutes prior to from Novolog (short acting insulin) meals, whereas Novolin R is administered 30-60 Physician to specify the number of units of minutes before meal each insulin. Draw the NovoLog or Novolin R (whichever ordered) into the syringe before drawing the NPH into the syringe.
NuvaRing (Etonogestrel 0.12mg/EE 0.015mg released Levlen, microgestin fe 1/20 and 1.5/30, All-flex diaphragms or paragard T380 and Mirena per day) zovia 1/35, norinyl 1+35, brevicon, Norinyl (levonorgestrel) IUDs also formulary contraceptive 1+50, trilevlen, trinorinyl, depo-provera options. NuvaRing may not be suitable for injection Document at least 3 formulary women with conditions that make the vagina more alternatives before susceptible to vaginal irritation/vaginitis. Consider prescribing/approving a NF product. oral progestin only contraception with NorQD to minimize oral contraceptive associated BP elevation. Nuquin HP cream 4% (Solaquin forte) topical depigmenting agent--cosmetic use, Drugs for cosmetic use are NOT covered on no formulary agent available. drug benefit. Member pays retail price. If prescribed along with Differin, Retin A, or Avita creams, they are also being used as cosmetic therapy and are not covered. Ocufen (Flurbiprofen 0.03%) ophth soln If using for allergic conjunctivitis: OTC . Opcon-A (Pheniramine & Naphazoline) If treating steroid responsive inflammatory condition consider at least 2 formulary products before prescribing/authorizing a NF product consider at least 2 formulary products before prescribing/authorizing a NF product: Dexamethasone 0.1% ophth soln or Prednisolone 0.12%-1% ophth soln or Flarex, FML (Fluorometholone) ophth soln 0.1% i-ii drops in affected eye(s) QID
Ocupress (Carteolol) 1% ophth soln i drop in affected Timoptic (Timolol) ophth soln 0.25-0.5% i N/A eye BID drop in affected eye(s) BID or Betoptic (Betaxolol) 0.5% or Betagan (Levabunolol) 0.25-0.5%
Ogestrel (0.5mg Norgestrel/ 50mcg EE) tablets i QD Norinyl 1+50 (1mg Norethindrone/ 50mcg Document at least 3 formulary alternatives Mestranol) i QD or Zovia (generic Demulen) before prescribing/approving a NF product. 1/50 (1mg Ethynodiol Diacetate/50mcg EE) i QD Olux (Clobetasol) 0.05% foam Temovate (Clobetasol) 0.05% scalp soln Omacor (Omega-3 acid ethyl ester) . This is a prescription omega-3 fatty acid product. It is a dietary supplement. Dietary supplements are not eligible for drug benefit coverage. Omnicef (Cefdinir) capsule 300mg Cefuroxime 250mg or Augmentin or Bactrim Omnicef suspension 125mg or 250mg/5ml are DS or Biaxin formulary; Omnicef capsules are non-formulary
Page 48 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Optivar (Azelastine) 0.05% ophth soln For allergic conjunctivitis: OTC Opcon-A OTC Zaditor 0.25% and Patanol are both dual (Pheniramine & Naphazoline) or OTC action antihistamine/mast cell stabilizers, are Zaditor 0.25% [NOTE: OTC products are dosed twice daily, and have the same FDA not a covered benefit] approved indications. If treating steroid responsive inflammatory condition: Dexamethasone 0.1% ophth soln or Prednisolone 0.12%-1% ophth soln or Flarex, FML (Fluorometholone) ophth soln 0.1% i-ii drops in affected eye(s) QID
Ortho-Cept 28 (0.15mg Desogestrel/ 30mcg EE) tab i Levlen (0.15mg Levonorgestrel / 30mcg EE) Zovia 1/35 (1mg Ethynodiol Diacetate/ 35mcg EE) QD or Tri-Levlen (0.05mg Lvngl/30mcg EE x 6 or Microgestin 1.5/30 (1.5 Norethindrone / 30mcg days, 0.075mg Lvngl/40mcg EE x 5 days, EE) or Sprintec (0.25mg Norgestimate/35mcg EE) 0.125mg Lvngl/ 30mcg EE x 10 days) or Tri-Sprintec, generic Ortho-Tricyclen, (0.18mg Norgestimate x 7 days, 0.215mg Norgestimate x 7 days, 0.25mg Norgestimate x 7 days/ 35 mcg EE) Document at least 3 formulary alternatives before prescribing/approving a NF product.
Ortho-Cyclen (0.25mg Norgestimate/ 35mcg EE) Sprintec (0.25mg Norgestimate/ 35 mcg Document at least 3 formulary alternatives (generics:sprintec, mononessa) EE) before prescribing/approving a NF product.
Ortho Evra (150 Norelgestromin/ 20 EE) contraceptive Microgestin 1/20 (1mg Norethindrone / Zovia 1/35 (1mg Ethynodiol Diacetate/ 35mcg EE) patch {Norelgestromin is a metabolite of 20mcg EE) or Levlen (0.15 Levonorgestrel / or Microgestin 1.5/30 (1.5 Norethindrone / 30mcg Norgestimate} 30mcg EE) or Sprintec (0.25mg EE) or Norinyl 1/50 (1mg NE/ 50mcg Mestranol), Norgestimate/35 mcg EE) or Brevicon or Tri-Norinyl (0.5mg Norethindrone x 7days, 1mg (.5mg NE/ 35mcg EE), or Norinyl 1/35 (1mg NE x 7 days, 0.5mg NE x 7 days/ 35 mcg EE) OR NE/ 35mcg EE) Tri-Levlen (0.05mg Levonorgestrel & 30mcg EE x 6 days, 0.075mg Lvngl & 40mcg EE x 5 days, 0.125mg Lvngl & 30mcg EE x 10 days)or Nor-qd (0.35 NE only) Document at least 3 formulary alternatives before prescribing/approving a NF product.
Ortho-Novum 1/35 (1mg NE/35mcg EE) Norinyl 1/35 (1mg . Norethindrone/35mcgEE) Ortho-Novum 1/50 (1mg Norethindrone/ Mestranol Norinyl 1/50 (1mg Norethindrone/ 50mcg 50mcg) Mestranol) Ortho-Novum 10/11 (0.5mg Norethindrone/ 35mcg Brevicon (0.5mg NE/35mcg EE) or Norinyl Aranelle is a generic name for Tri-Norinyl (0.5mg Ethinyl Estradiol x 10 days, 1mg NE/ 35mcg EE x 1/35 (1mg NE/35mcg EE) or Tri-norinyl Norethindrone x 7days, 1mg NE x 7 days, 0.5mg 11days) {generic: Necon 10/11} (0.5mg NE x 7days, 1mg NE x 7 days, NE x 7 days/ 35 mcg EE) Document at least 3 0.5mg NE x 7 days /35mcg EE) formulary alternatives before prescribing/approving a NF product.
Ortho-prefest (1mg 17beta Estradiol / 90 mcg Estrace (Estradiol) 0.5 - 2mg plus Two individual prescriptions are required. 0.5mg Norgestimate cyclic) Medroxyprogesterone 2.5-5mg QD or plus Estradiol = 0.3mg Premarin; 0.75mg Estradiol NorQD 0.35mg (norethindrone) QD (1&1/2 0.5mg tablet) = 0.45mg Premarin; 1mg Estradiol = 0.625mg Premarin; 1.5mg Estradiol (1&1/2 1mg tablet) = 0.9mg Premarin; 2mg Estradiol = 1.25mg Premarin
Page 49 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Ortho-Novum 7/7/7 (0.5mg NE x 7 days, 0.75mg NE x Nortrel 7/7/7 (0.5mg NE x 7 days, 0.75mg Tri-Norinyl (0.5mg Norethindrone x 7days, 1mg 7 days, 1 mg NE x 7 days/ 35 mcg EE) NE x 7 days, 1 mg NE x 7 days/ 35 mcg NE x 7 days, 0.5mg NE x 7 days/ 35 mcg EE) OR EE) Tri-Levlen (0.05mg Levonorgestrel & 30mcg EE x 6 days, 0.075mg Lvngl & 40mcg EE x 5 days, 0.125mg Lvngl & 30mcg EE x 10 days Document at least 3 formulary alternatives before prescribing/approving a NF product.
Ortho-tricyclen (0.18mg Norgestimate x 7 days, Tri-Sprintec (0.18mg Norgestimate x 7 days, Tri-Levlen (0.05mg Levonorgestrel & 30mcg EE x 0.215mg Norgestimate x 7 days, 0.25mg 0.215mg Norgestimate x 7 days, 0.25mg 6 days, 0.075mg Lvngl & 40mcg EE x 5 days, Norgestimate x 7 days/ 35 mcg EE) Norgestimate x 7 days/ 35 mcg EE); or, 0.125mg Lvgn & 30mcg EE x 10 days) or Sprintec (0.25mg Norgestimate/ 35 mcg Brevicon (.5mg NE/ 35mcg EE), Levlen (0.15 EE), or Zovia1/35 (Ethynodiol 1mg/35mcg Lvngl/30mcg EE), Microgestin 1/20 (1 NE/20mcg EE) or Tri-Norinyl (0.5mg Norethindrone x EE), Microgestin 1.5/30 (1.5 NE/30 EE), Norinyl 7days, 1mg NE x 7 days, 0.5mg NE x 7 1/35 (1mg NE/ 35mcg EE) Norinyl 1/50 (1mg NE/ days/ 35 mcg EE) 50mcg Mestranol), or NorQD (0.35 NE only) Document at least 3 formulary alternatives before prescribing/approving a NF product.
Ortho Tri-Cyclen Lo (0.18mg Norgestimate x 7 days, Tri-Sprintec (0.18mg Norgestimate x 7 days, Microgestin FE 1/20 (1 NE/20mcg EE), Tri-Levlen 0.215mg Norgestimate x 7 days, 0.25mg 0.215mg Norgestimate x 7 days, 0.25mg (0.05mg Levonorgestrel & 30mcg EE x 6 days, Norgestimate x 7 days/ 25 mcg EE) Norgestimate x 7 days/ 35 mcg EE); or, 0.075mg Lvngl & 40mcg EE x 5 days, 0.125mg Sprintec (0.25mg Norgestimate/ 35 mcg Lvgn & 30mcg EE x 10 days) or Brevicon (.5mg EE), or Zovia1/35 (Ethynodiol 1mg/35mcg NE/ 35mcg EE), Levlen (0.15 Lvngl/30mcg EE), EE) or Tri-Norinyl (0.5mg Norethindrone x Microgestin FE 1.5/30 (1.5 NE/30 EE), Norinyl 7days, 1mg NE x 7 days, 0.5mg NE x 7 1/35 (1mg NE/ 35mcg EE) Norinyl 1/50 (1mg NE/ days/ 35 mcg EE) 50mcg Mestranol), or NorQD (0.35 NE only) Document at least 3 formulary alternatives before prescribing/approving a NF product.
Orudis (Ketoprofen) 50mg - 75mg TID - QID Ibuprofen (generic Motrin) tabs 600-800 mg Additional formulary alternatives: Diclofenac TID or Salsalate (Disalcid)1500mg BID or (Voltaren) 75mg BID or Choline Magnesium Naproxen 500mg BID or Sulindac (Clinoril) Trisalicylate (Trilisate) 750mg BID-TID or 200mg BID Nambumetone (Relafen) 500mg or 750mg 1-2 QD- BID or Etodolac (Lodine) 200mg-500mg Q8-12H up to 1200mg/day or Indomethacin 25-50mg TID or Mobic (Meloxicam) 7.5mg or 15mg..
Oruvail (Ketoprofen ER) 100 - 200mg QD Ibuprofen (generic Motrin) tabs 600-800 mg Additional formulary alternatives: Diclofenac TID or Salsalate (Disalcid)1500mg BID or (Voltaren) 75mg BID or Choline Magnesium Naproxen 500mg BID or Sulindac (Clinoril) Trisalicylate (Trilisate) 750mg BID-TID or 200mg BID Nambumetone (Relafen) 500mg or 750mg 1-2 QD- BID or Etodolac (Lodine) 200mg-500mg Q8-12H up to 1200mg/day or Indomethacin 25-50mg TID or Mobic (Meloxicam) 7.5mg or 15mg.
Ovcon 35 (0.4mg norethindrone/ 35mcg EE) Brevicon (0.5mg ne/35mcg EE) or Norinyl Document at least 3 formulary alternatives 1/35 (1mg ne/35mcg EE) or Tri-Norinyl before prescribing/approving a NF product. (0.5mg ne x 7days, 1mg ne x 7 days, 0.5mg ne x 7 days /35mcg EE) Ovcon 50 Zovia (generic Demulen) 1/50 (1mg Document at least 3 formulary alternatives Ethynodiol Diacetate/50mcg EE) i QD or before prescribing/approving a NF product. Norinyl 1+50 (1mg Norethindrone/ 50mcg Mestranol) i QD Ovral (0.5mg Norgestrel/ 50mcg EE) tablets i QD Norinyl 1+50 (1mg Norethindrone/ 50mcg Document at least 3 formulary alternatives (generic Ovral (Ogestrel) is now manufactured) Mestranol) i QD or Zovia (generic Demulen) before prescribing/approving a NF product. 1/50 (1mg Ethynodiol Diacetate/50mcg EE) i QD
Page 50 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Ovrette (Norgestrel 0.075mg) qd Nor-QD (Norethindrone 0.35mg) QD Document at least 3 formulary alternatives before prescribing/approving a NF product.
Oxistat (Oxiconazole cream) OTC Lamisil AT or clotrimazole containing Clotrimazole or Terbinafine (Lamisil) for tinea OTC products: Lotrimin AF or OTC Mycelex pedis, tinea corporis, tinea circinata (ringworm of or OTC Micatin cream body), tinea cruris, tinea inguinalis (jock itch), tinea versicolor; Clotrimazole for intertrigo (rash in body folds or beneath breasts) or candidiasis (including rash on penis or corners of mouth) [OTC alternatives are not recommended for tinea capitis (ringworm of scalp), tinea faceii or barbae (ringworm of the beard…barber's itch or fungal nails]
Oxycodone IR Oxycodone 5mg/325mg APAP Morphine sulfate immediate release 15 or 30mg tabs [Morphine 30-40mg converts to Oxycodone 15-30mg] Oxycontin 160 mg ER Generic oxycodone extended release (available in 10mg, 20mg, 40mg & 80mg strengths) Palladone (hydromorphone hcl) extended release Hydromorphone regular release 2mg or Do not consume any form of alcohol while taking 12mg, 16mg, 24mg, 32mg capsules 4mg tablets Palladone as it will result in destruction of extended release mechanism, acute drug release and overdose potential. Panretin (Alitretinoin) 0.1% topical gel Criteria: (1)Patient has AIDS-related KS, and (2) has signs and symptoms indicative of localized disease (e.g. few lesions,low rate of growth,no visceral KS identified, no fevers, drenching night sweats or weight loss, no prior opportunistic infection), and (3) has failed cryotherapy (this is treatment of choice), OR (4) patient not considered candidate for other treatment options, or patient has failed other treatment options.
Paremyd (Hydroxyamphetamine hydrobromide Cyclogyl (Cyclopentolate) ophth soln Pupil dilation in ophth. Diagnostic procedures and 1%/Tropicide 0.25%) ophth soln eye exams
Patanol (Olopatadine) 0.1% For allergic conjunctivitis: OTC Opcon-A OTC Zaditor 0.25% and Patanol are both dual (Pheniramine & Naphazoline) or OTC action antihistamine/mast cell stabilizers, are Zaditor 0.25% [NOTE: OTC products are dosed twice daily, and have the same FDA not a covered benefit] approved indications. If treating steroid responsive inflammatory condition: Dexamethasone 0.1% ophth soln or Prednisolone 0.12%-1% ophth soln or Flarex, FML (Fluorometholone) ophth soln 0.1% i-ii drops in affected eye(s) QID
Paxil (Paroxetine regular release) 10 - 40mg tabs Prozac caps 10-40 mg QD or Celexa The controlled-release product is non formulary. and Paxil CR (Paroxetine Controlled Release) (Citalopram) 20-40mg QD or Sertraline 25 - Paxil 10mg bioequivalent to Paxil CR 12.5mg. 12.5mg, 25mg tabs (Paxil regular 100mg QD (added to formulary Mar 8th Paxil (Paroxetine) is non-formulary as of 1/1/2008. release is non-formulary as of 1/1/2008) 2007) Document response to all formulary SSRI alternatives before prescribing a NF SSRI. Document reason, when patient is medically unable to convert to Formulary alternative.
Peak Flow Meter Not covered by drug benefit Obtain peak flow meter at MD office
PediaPred (5mg/5ml Prednisolone) Prelone 5mg or15mg/5ml, Orapred Watch change in solution strength, Prelone 15mg/5ml available 5mg/5ml and 15mg /5ml
Page 51 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Penlac (Ciclopirox) 8% topical solution N/A Penlac demonstrates a very low cure rate. Fungal nail infection is considered cosmetic treatment and is not covered Unless : fungal culture positive and i) If a finger nail, limited to one 6 week treatment course, ii) If a toe nail, only covered if the patient has diabetes or vascular disease, then restricted to one 12 wk course.
Percocet tablet 2.5mg, 7.5mg or 10mg Oxycodone Oxycodone 5mg/325mg acetaminophen Brand names non-formulary. Controlled preparations (generic Percocet) or Oxycodone substance level 2 requires hand written Rx by 5mg/500mg acetaminophen (generic Tylox) physician
Pergonal injection Repronex injection May be substituted on a unit for unit basis without calling practitioner. Menotropins are only covered for members with fertility benefit rider.
Periostat (Doxycycline) caps 20 mg BID up to 9 Doxycycline 50mg capsule QD OR 100 mg Periostat is not covered. Member will pay full months tablets 1/4 tab (25 mg) BID price if dispensed Periostat. Phendimetrazine N/A Weight loss agents not covered. Phentermine HCL caps N/A Weight loss agents not covered. Pilagan (Pilocarpine nitrate) 1 - 4% ophth soln i-ii Pilocarpine HCL (generic Isopto Carpine) Direct acting miotics to lower IOP in glaucoma drops in affected eye TID-QID 0.25-10% ophth soln i-ii drops in affected eye TID-QID OR Isopto Carbachol (Carbachol) 0.75-2.25% ophth soln ii drops in affected eye TID Plexion (Sodium Sulfacetamide 10% and Sulfur 5%) Sulfacetamide/sulfur lotion lotion Poly-pred (Neomycin/Polymyxin/Prednisolone) ophth Maxitrol (Dexamethasone/Neomycins/Poly- . susp or ophth oint myxin) ophth susp or ophth oint
Ponstel (Mefenamic acid) 250mg QID (not Ibuprofen (generic Motrin) tabs 600-800 mg Additional formulary alternatives: Diclofenac recommended for longer than 1 week) TID or Salsalate (Disalcid)1500mg BID or (Voltaren) 75mg BID or Choline Magnesium Naproxen 500mg BID or Sulindac (Clinoril) Trisalicylate (Trilisate) 750mg BID-TID or 200mg BID Nambumetone (Relafen) 500mg or 750mg 1-2 QD- BID or Etodolac (Lodine) 200mg-500mg Q8-12H up to 1200mg/day or Indomethacin 25-50mg TID or Mobic (Meloxicam) 7.5mg or 15mg.
Portia (0.15 Levonorgestrel/30mcg EE) Levlen (0.15 Levonorgestrel/30mcg EE) . Pramasone (Pramoxine 1%/Hydrocortisone 2.5%) Pramasone (Pramoxine 1%/Hydrocortisone OTC Amlactin AP (ammonium lactate lotion 2.5%) Rectal foam 12%/Pramoxine 1%) or HC cream 2.5% & OTC Benadryl cream Prandin (Repaglinide) 1-4 mg TID Glyburide (generic Micronase) 5-10 mg QD- Both Prandin and Glyburide stimulate beta cell BID or Metformin 500mg BID or Glipizide receptors to increase insulin production
Premarin Estradiol 0.5mg-2mg QD 0.5mg Estradiol = 0.3mg Premarin; 0.75mg Estradiol (1&1/2 0.5mg tablet) = 0.45mg Premarin; 1mg Estradiol = 0.625mg Premarin; 1.5mg Estradiol (1&1/2 1mg tablet) = 0.9mg Premarin; 2mg Estradiol = 1.25mg Premarin Premphase packets: premarin 0.625mg QD days 1- Estrace (Estradiol) 1mg QD plus Two individual prescriptions are required. 0.5mg 14, then (premarin / medroxyprogesterone) Medroxyprogesterone 5mg QD days 15 thru Estradiol = 0.3mg Premarin; 0.75mg Estradiol 0.625mg/5mg tab i QD days 15-28 28 (1&1/2 0.5mg tablet) = 0.45mg Premarin; 1mg Estradiol = 0.625mg Premarin; 1.5mg Estradiol (1&1/2 1mg tablet) = 0.9mg Premarin; 2mg Estradiol = 1.25mg Premarin Prempro (Premarin / Estrace (Estradiol) 0.75mg (1&1/2 0.5mg Two individual prescriptions are required. 0.5mg Medroxyprogesterone)0.45/1.5mg QD Estradiol tablet) QD PLUS Estradiol = 0.3mg Premarin; 0.75mg Estradiol Medroxyprogesterone 1/2 to one 2.5mg (1&1/2 0.5mg tablet) = 0.45mg Premarin; 1mg tablet QD Estradiol = 0.625mg Premarin; 1.5mg Estradiol (1&1/2 1mg tablet) = 0.9mg Premarin; 2mg Estradiol = 1.25mg Premarin
Page 52 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Prempro (Premarin / Medroxyprogesterone) Estrace (Estradiol) 1mg QD plus Two individual prescriptions are required. 0.5mg 0.625/2.5mg -0.625mg/5mg tab i QD Medroxyprogesterone 2.5-5mg QD Estradiol = 0.3mg Premarin; 0.75mg Estradiol (1&1/2 0.5mg tablet) = 0.45mg Premarin; 1mg Estradiol = 0.625mg Premarin; 1.5mg Estradiol (1&1/2 1mg tablet) = 0.9mg Premarin; 2mg Estradiol = 1.25mg Premarin Prenatal vitamins no formulary alternative Prenatal vitamins are available OTC Prevacid-DR (Lansoprazole) cap 15-30 mg QD OTC Prilosec 20mg - 40mg QD Prevacid is a NF No Initial Fill Drug. If Prilosec 40mg QD failure, consider NF No Initial Fill drug, Protonix titrated up to 80mg QD. (Protonix 40mg=Prevacid 30mg=Prilosec 20mg) Must document failure or intolerance to Prilosec 40mg QD if requesting PPI coverage.
Preven Emergency Contraception kit (0.25mg Levlen (0.15mg Levonorgestrel / 0.03mg Must be taken within 72 hours of unprotected Levonorgestrel/0.05 Ethinyl Estradiol) 2 tablets now Ethinyl Estradiol) #4 Levlen tablets now and intercourse. then 2 tablets in 2 hours then repeat in 12 hours OR Plan B (0.75mg Levonorgestrel) 1 tablet now then 1 tablet in 2 hours Prevpack (Prevacid DR (Lansoprazole) 30mg BID, HP Pack: Tetracycline 500 mg QID x 14 HP Pack (Helicobacter pylori treatment pack) Biaxin (Clarithromycin) 500mg BID and Amoxicillin days, Metronidazole 500 mg QID x 14 days, Individual components dispensed as 2 individual 500mg QID x 10-14 days) Bismuth subsalicylate 2 tabs QID x 14 days prescriptions PLUS OTC Pepto Bismol & Prilosec & Prilosec OTC 20mg BID x 14 days (HP OTC at Eckerd. Second line alternative: Prilosec Pack available at KP pharmacies for one OTC 20mg BID, Biaxin 500mg BID, and Flagyl copayment) 500mg BID or Amoxicillin 1000mg BID x 14 days
Prilosec (Omeprazole) 20mg cap 20-60mg QD OTC Prilosec 20mg tablet. (If cannot If patient has failed Prilosec 40mg QD, consider swallow tablet, OTC prilosec will disperse in NF No Initial Fill drug, Protonix titrated up to 80mg 5cc of water in less than 60 seconds with daily (Protonix 40mg=Prilosec 20mg). Must gentle agitation) document failure or intolerance to Prilosec 40mg QD if requesting PPI coverage; Initial dosing for kids >/= 20kg or 3 years of age is Prilosec 20mg QD
Proamatine (midodrine) 2.5-10 mg TID Fludrocortisone (generic Florinef) dosing to Consider Fludrocortisone if patient has not yet be determined by prescriber. been stabilized on Midodrine. If orthostatic hypotension stabilized on Midodrine, consider continuing Midodrine. Procardia XL tablet 30-90 mg QD Nifedipine XL 30, 60 or 90 mg tablet We cover generic Procardia XL (nifedipine XL) instead of generic Adalat CC (nifedipine XL). Substitute on a mg per mg basis. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics
Proctocort 1% (1% Hydrocortisone) cream Proctofoam HC (1% Select appropriate option Hydrocortisone/pramoxine 1%) OR Hydrocortisone cream 2.5% with rectal tip OR Hydrocortisone 25mg suppository Proctocream HC (2.5% Hydrocortisone cream) or (1% Proctofoam HC (1% Select appropriate option Hydrocortisone and 1% Pramoxine) Hydrocortisone/Pramoxine 1%) OR Hydrocortisone cream 2.5% with rectal tip OR Hydrocortisone 25mg suppository
Page 53 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Proctosol HC Cream 2.5% Proctofoam HC (1% Select appropriate option Hydrocortisone/pramoxine 1%) OR Hydrocortisone cream 2.5% with rectal tip OR Hydrocortisone 25mg suppository Profen II tab 37.5-600 i tablet BID OTC congestac (60mg Pseudoephedrine All cough and cold medications are non-formulary and 400mg Guaifenesin/tablet) Q6H or OTC with the exception of Codeine, Hydrocodone, and Mucinex (600mg Guaifenesin long acting) or Promethazine containing products. OTC Guaifenesin 400mg regular release plus OTC Pseudoephedrine
Prometrium capsule 100 mg QD-BID Medroxyprogesterone 2.5-5 mg QD or If Prometrium is being used in early pregnancy, Aygestin (norethindrone) 5mg coverage is addressed by the fertility benefit. Propecia N/A Cosmetic drug use is not covered under drug benefit. Propecia for male pattern baldness or removal of female facial hair is considered cosmetic. Member pays full retail price.
ProStep (Nicotine) Transdermal system 11,22mg/day OTC Nicotrol (Nicotine transdermal system) Nicotine replacement products are non formulary. 5, 10, 15mg/day Protonix (Pantoprazole) 40mg QD to BID Prilosec OTC 20 - 40mg QD Protonix is a NF No Initial Fill drug. If patient has failed Prilosec (Omeprazole) titrated up to 40mg daily, consider NF No Initial Fill drug, Protonix. Must document failure or intolerance to Prilosec 40mg QD if requesting PPI coverage.
Protopic (Tacrolimus) 0.03% and 0.1% oint Corticosteroid potency to be determined by Locoid lipocream restricted to derm. Covered ind patient need. very high potency: corticosteroid topicals listed by potency under Diprolene (augmented Betamethasone formulary alternative column. ***Protopic is Dipropionate) 0.05% oint or Temovate preferred over Elidel for diagnosis of Vitiligo and (Clobetasol) 0.05% cream, oint, gel, scalp should be approved for that condition*** soln. High potency: Lidex (Fluocinonide) 0.05% cream, oint, gel, soln or Diprolene AF (Augmented Betamethasone) 0.05% Medium potency: Triamcinolone (generic Aristocort, Kenalog) cream, oint 0.1% or Valisone (Betamethasone Valerate) 0.1% lotion or Locoid Lipocream (Hydrocortisone Butyrated) 0.1% Low potency: DesOwen (Desonide) 0.05% cream, oint, lotion or Synalar (Fluocinolone) 0.01% soln, oil or Hytone (Hydrocortisone) 2.5% cream, oint, lotion
Proventil (Albuterol) oral inhaler ii puffs Q4H prn Albuterol oral inhaler ii puffs Q4H prn May be substituted on a puff for puff basis without calling practitioner. Proventil HFA (Albuterol) oral inhaler ii puffs Q4H prn Albuterol oral inhaler ii puffs Q4H prn May be substituted on a puff for puff basis.
Proventil (Albuterol) tabs, SR tabs, oral soln, neb soln Albuterol (generic Ventolin) immediate Extended release Albuterol tablets are no longer release tablets or oral inhaler manufactured. Consider Albuterol inhaler or immediate release tablets. If long acting beta 2 agonist necessary, consider serevent inhaler. If steroid inhaler necessary, QVAR (Beclomethasone) inhaler is preferred formulary agent Provera tablets 2.5-10 mg QD Medroxyprogesterone tabs 2.5 -10 mg QD May be substituted on a mg for mg basis without calling practitioner.
Page 54 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Prozac (Fluoxetine) Weekly 90mg enteric coated Prozac (Fluoxetine) 20mg QD Prozac Weekly is non formulary, Prozac capsule administered daily is formulary. Document response to all formulary SSRI alternatives before prescribing a NF SSRI. Document reason, when patient is medically unable to convert to Formulary alternative.
Psorcon (Diflorasone) 0.05% cream, oint (emolient Lidex (Fluocinonide) 0.05% cream, oint, gel, High potency topical corticosteroids. base oint) soln or Diprolene AF (Augmented Betamethasone) 0.05% Psorcon (Diflorasone) 0.05% oint (not the emolient Diprolene (Augmented Betamethasone Very high potency topical corticosteroids. base oint) Dipropionate) 0.05% oint or Temovate (Clobetasol) 0.05% cream, oint, gel, scalp soln Pulmicort (Budesonide) 200 mcg turbuhaler i-ii puff QVAR (Beclomethasone HFA) 80mcg i-ii QVAR 80mcg (preferred agent) is equipotent to BID puffs BID or Asmanex (Mometasone Pulmicort 200mcg. If patient has failed QVAR, furoate) oral dry powder inhaler 200mcg per consider Asmanex (≥12 yrs old). Asmanex is puff i - ii puffs QHS (or i puff BID) equipotent to fluticasone and approx twice as potent as budesonide and beclomethasone. QVAR remains the preferred inhaled corticosteroid at KP GA. TSPMG guidelines support Pulmicort when an oral inhaled steroid is needed during pregnancy.
Pulmicort (Budesonide) respules for nebulization If child can use inhaler, consider (5-11 yoa) Pulmicort respules are formulary when QVAR 40mcg i puff BID nebulization is required. Pulmicort is the only inhaled steroid available for nebulization.
Pyridium (Phenazopyridine) 100mg or 200mg tablets OTC Pyridium 95mg or 100mg tablets .
Pyridium plus (Phenazopyridine 150mg, 0.3mg OTC generic Pyridium (95mg or 100mg Pyridium 95mg or 100mg OTC Hyoscyamine, 15mg Butabarbital) Phenazopyridine) with or without Rx generic Levsin (Hyoscyamine 0.125mg)
Quinamm (Quinine sulfate) tabs N/A Available on exception basis for malaria. Not covered for leg cramps since potential risk outweighs potential benefit. Quixin (Levofloxacin) 0.5% ophth soln Ofloxacin 0.3% or Gentamicin 0.3% or Lasik ophthalmic surgery is not a covered benefit. Tobramycin 0.3% or Sodium Sulfacetamide Medications related to non covered procedures, ophth soln or Zymar 0.3% eg. Lasik surgery, are not covered by the drug benefit. Raptiva (Efalizumab) Humira preferred in psoriasis. Raptiva coverage criteria for psoriasis: (1) patient is an adult with moderate to severe chronic plaque psoriasis, and (2) has a documented failure, or is not a candidate for topical or systemic therapies (methotrexate, acitretin, PUVA, UVB), and (3) patient has a documented failure, or is not a candidate for a combination of the above treatment options, (4) prescriber must be a Dermatologist
Razadyne (Galantamine) 8-16mg BID Aricept (Donazepril) 5 - 10mg tab QD;Exelon Consider Aricept 10mg 1/2 tablet when prescribing Aricept 5mg. Relenza 5 mg dose inhalation (diskhaler device) Oseltamivir (Tamiflu) See special criteria for oseltamivir during flu season only. Relpax (Eletriptan) 20mg, 40mg Maxalt (Rizatriptan) MLT 10mg tablet Maxalt MLT 10 mg is preferred, QTY limit of 9 (Maxalt MLT 5mg tablet is also available) tablets/copay. If failed a trial on Maxalt MLT consider formulary alternative Imitrex 50 mg tablets (qty limit of 9 tablets/copay), nasal, or injectable dosage forms. Quantity limit for Non- formulary Relpax is 6 tablets per copay
Page 55 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Remeron (Mirtazapine) Sol-Tab15mg or 30mg Mirtazapine regular release tablets 15mg, Consider Celexa 40mg 1/2 tablet when 30mg or 45mg Or, Prozac (Fluoxetine) prescribing Celexa 20mg. Consider Paroxetine caps 10-40 mg QD or Celexa (Citalopram) 40mg 1/2 tablet when prescribing Paroxetine 20 - 40mg QD or Paxil (Paroxetine) tabs 20- 20mg dose. [Mirtazapine - Available Part D 40 mg QD group] Remicade (Infliximab) administered IV TNF blocker Enbrel 25 mg SQ twice weekly. Humira Remicade is provided and administered at a KP preferred in psoriasis. Infusion center. Physician to provide referral to KP infusion center for Remicade administration (contact Jill Broner at Cumberland 770-431-4367 or at SWD Kim 770-603-3572). IV infusion to be ordered by Rheumatology or GI. Refer practitioner questions regarding medical benefit coverage to provider relations.
Reminyl (Galantamine) 8-16mg BID Aricept (Donazepril) 5 - 10mg tab QD Consider Aricept 10mg 1/2 tablet when prescribing Aricept 5mg. Renagel (Sevelamer) 800-1600mg with each meal Phoslo 667mg (Calcium acetate) tablet ii-iiii Sevelamer is a calcium-/aluminum-free phosphate tablets with each meal binder for hypophosphatemia in patients with end stage renal disease Renova (Tretinoin) 0.02% cream N/A Drugs for cosmetic use are NOT covered on drug benefit. Member pays retail price.
Rescula (Unoprostone isopropyl) 0.15% ophth soln Lumigan (Bimatoprost) 0.03% ophth Prostamide analog to reduce IOP in glaucoma. solution 1 drop in affected eye QHS Lumigan is not as effective when administered more often than QD. Separate Lumigan from administration of other eye drops by at least 5 minutes. Restoril (Temazepam) 7.5mg QHS Temazepam (generic Restoril) 15 mg Temazepam 15mg and 30mg strengths are capsule at HS or Oxazepam (gen Serax) 10- available on the formulary. 30mg or Lorazepam 0.5mg QHS or Hydroxyzine (generic Atarax) 10-25 mg at HS or Trazodone 50-100mg QHS
Retin-A (Tretinoin) 0.025% cream or gel Avita (Tretinoin) 0.025% cream or gel Formulary for acne only. Smallest unit size is covered. Drugs for cosmetic use (eg. Wrinkles) are not covered on drug benefit, member will retail price.
Retin-A micro gel 0.04% or 0.1% apply QHS Retin-A cream 0.1% (20 gm tube) apply Retin A Micro gel is restricted to Dermatology. QHS or Retin-A gel 0.025% (15 gm tube) Formulary for acne only. Smallest unit size is apply QHS covered. Drugs for cosmetic use (eg. Wrinkles) are not covered on drug benefit, member will retail price. Revatio (Sildenafil) 20mg TID Tracleer (Bosetan) Rhinocort (Budesonide) nasal spray ii-iiii sprays each Nasarel ii sprays each nostril BID or generic Please document failure of both Nasarel & generic nostril BID Flonase (fluticasone) i spray each nostril Flonase (fluticasone) before prescribing/approving QD a NF product. Riomet (Metformin) oral solution Metformin oral tablets .
Ritalin LA (Methylphenidate HCL extended release) Concerta 18, 27, 36, 54mg, or Methylin ER Adderall XR is restricted to pediatrics, child 20, 30 & 40mg beaded capsules 10mg (methylphenidate), Methylphenidate neurology and behavioral health. 5, 10, 20mg and SR 20mg; or generic Titrate to appropriate dosage using adderall Dexedrine spansules (Dextroamphetamine) regular release tablets before transitioning to 5, 10, 15mg or Adderall regular release 5, once daily Adderall XR. 10, 20, 30mg tablets or Adderall XR 5, 10, 20, 25, 30mg capsules. Controlled substances level 2 requiring prescription written by prescriber. Methylphenidate is the preferred formulary alternative.
Page 56 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Rowasa suppositories Cortenema 100mg/60ml, Rowasa enema or Rowasa suppositories are unavailable from mftr Canasa (Mesalamine) 1000mg suppository indefinitely (10/01) so Rowasa removed from formulary and replaced by Canasa suppositories
Rozerem (Ramelteon) 8mg QHS Generic Ambien (Zolpidem 5 & 10mg) has Consider lower doses in geriatric patients. been added to the formulary as of 6/1/07. Consider OTC Melatonin to reduce Please consider less costly alternatives benzodiazepine usage Caution: do not abruptly before prescribing Zolpidem. Oxazepam discontinue benzodiazepines after long-term use. (gen Serax) 10-30mg or Lorazepam 0.5mg Document failed trial on at least 1 QHS or Hydroxyzine (generic Atarax) 10-25 Benzodiazepine, Trazodone, and Zolpidem before mg at HS or Trazodone 50-100mg QHS or prescribing NF product. Temazepam (generic Restoril) 15-30 mg capsule at HS are all much less costly than Zolpidem.
Rynatan suspension (Chlorpheniramine, Nasarel ii sprays each nostril BID or generic OTC alternatives: Triaminic cold and cough; cold Phenylephrine) new formulation removed Pyrilamine Flonase (fluticasone) i spray each nostril and allergy (see Triaminic dosing sheet) or QD or OTC Claritin syrup and OTC Robitussin product sheet. Claritin syrup OTC Phenylephrine HCl Saizen (Somatotropin) injection Criteria Restricted Medication. Once Criteria Restricted Medication. Pediatric approved, the approval and date range Endocrinologist phone KP QRM to request for approval is noted in the Kaiser authorization consideration 404-364-7320. pharmacy computer system. Norditropin (somatropin) is preferred growth hormone and must be tried prior to approval for other growth hormone products
Salagen (Pilocarpine) 5mg tablets Pilocarpine 4% (4mg/0.1ml) ophthalmic soln Symptomatic treatment. Please consider titrating 3 drops TID taken orally (equivalent to 5mg the number of drops and frequency of Pilocarpine TID) administration to patient's response and tolerance. {Pilocarpine 6% (6mg/0.1ml) ophthalmic soln 2 drops TID (equiv to 6mg Pilocarpine TID}
Sanorex (Mazindol) N/A Weight loss agents not covered.
Santyl 30gm (Collagenase) Accuzyme (papain-urea) ointment 30gm Santyl on MMA formulary only. Accuzyme first line formulary option Sarafem (Fluoxetine) 20mg caps Prozac (Fluoxetine) 20mg QD Document response to all formulary SSRI alternatives before prescribing a NF SSRI. Document reason, when patient is medically unable to convert to Formulary alternative.
Sculptra (poly-l-lactic acid) N/A Cosmetic use drug. Not covered on drug benefit. Member pays retail price.
Seasonale (Levonorgestrel 0.15mg / Ethinyl Estradiol Levlen (Levonorgestrel 0.15mg /30mcg Instruct pt to take one active Levlen tablet per day 30mcg) 84 active tablets followed by 7 placebo tabs = Ethinyl Estradiol) 28 day packet for 84 days (do not take the 7 placebo tablets 90 day supply included with the first 3 Levlen packets) on day 85 patient will take one placebo tablet daily for 7 days
Semprex D OTC products, Dimetapp Semprex D is an Antihistamine/Decongestant combo Serzone (Nefazodone) 100-300mg BID Consider Prozac caps 10-40 mg QD or Brand name Serzone is no longer manufactured. Celexa (Citalopram) 20-40mg QD or Paxil Generic Nefazodone is manufactured but remains tabs 20-40 mg QD NF. Singulair 4mg chew tab or granules OR 5mg chew tab ICS inhaler (QVAR or *Flovent or *Flovent 110mcg/puff & 220mcg/puff are non- QD Asmanex) plus a long acting B2-agonist formulary. If patient is already using steroid and (Serevent) OR an ICS and B2 agonist serevent inhaler and asthma symptoms persist, candidate for singulair
Page 57 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Singulair 5-10 mg QD ICS inhaler (QVAR or *Flovent or *Flovent 110mcg/puff & 220mcg/puff are non- Asmanex) plus a long acting B2-agonist formulary. If patient is already using steroid and (Serevent) OR an ICS and B2 agonist serevent inhaler and asthma symptoms persist, candidate for singulair
Skelaxin (Metaxalone) 400mg-800mg TID-QID Flexeril (Cyclobenzaprine) 10mg tab or Use Cyclobenzaprine 10mg 1/2 tablet for Robaxin (Methocarbamol) 750mg tab or Cyclobenzaprine 5mg. Soma (Carisoprodol) 350mg or Parafon Forte DSC (Chlorzoxazone) 500mg Solage (Mequinol 2%, Tretinoin 0.01%) N/A Drugs for cosmetic use are NOT covered on drug benefit. Member pays retail price. If prescribed along with Differin, Retin A, or Avita creams, they also are not covered as they are being used as cosmetic therapy.
Solaquin-Forte cream or gel N/A Drugs for cosmetic use are NOT covered on drug benefit. Member pays retail price. If prescribed along with Differin, Retin A, or Avita creams, they also are not covered as they are being used as cosmetic therapy.
Soma Compound (200mg carisoprodol/325mg aspirin) Soma (carisoprodol) 350mg plus OTC Other Formulary alternatives include: Flexeril aspirin (Cyclobenzaprine) 10mg tab or Robaxin (Methocarbamol) 750mg tab or Parafon Forte DSC (Chlorzoxazone) 500mg plus OTC aspirin
Sonata (Zaleplon) capsule 10 mg at HS Temazepam (generic Restoril) 15-30 mg Consider lower doses in geriatric patients. capsule at HS or Oxazepam (gen Serax) 10- Consider OTC melatonin to reduce 30mg or Lorazepam 0.5mg QHS or benzodiazepine usage Caution: do not abruptly Hydroxyzine (generic Atarax) 10-25 mg at discontinue benzodiazepines after long-term use. HS, Trazodone 50-100mg QHS, or Caution: do not abruptly discontinue Zolpidem (gen Ambien) 5-10mg benzodiazepines after long-term use. Document failed trial on at least 1 Benzodiazepine, Trazodone, and Zolpidem before prescribing NF product. Soriatane (Acitretin) cap N/A Soriatane is restricted to Dermatology.
Spectazole (Econazole) cream OTC Lamisil AT or Clotrimazole containing Clotrimazole or Terbinafine (Lamisil) for tinea OTC products: Lotrimin AF or OTC Mycelex pedis, tinea corporis, tinea circinata (ringworm of or OTC Micatin cream body), tinea cruris, tinea inguinalis (jock itch), tinea versicolor; Clotrimazole for intertrigo (rash in body folds or beneath breasts) or candidiasis (including rash on penis or corners of mouth) [OTC alternatives are not recommended for tinea capitis (ringworm of scalp), tinea faceii or barbae (ringworm of the beard…barber's itch or fungal nails]
Stadol NS 10 mg/ml i spray in one nostril Q3-4H Ibuprofen 600-800 mg TID or The Federal Drug Enforcement Agency (DEA) Acetaminophen with Codeine i-ii tablets ranks Stadol nasal spray among the top abused Q6H or morphine or Oxycodone / drugs. acetaminophen or NSAID Stalevo 50 (12.5mg Carbidopa / 50mg Levodopa/ 25mg Carbidopa / 100mg Levodopa regular . 200mg Entacapone) release 1/2 tablet PLUS Comtan (Entacapone) 200mg tablet Stalevo 100 (25mg Carbidopa/ 100mg 25mg Carbidopa /100mg Levodopa regular . Levodopa/200mgEntacapone) release tablet PLUS Comtan (Entacapone) 200mg tablet Stalevo 150 (37.5mg Carbidopa/ 150mg 25mg Carbidopa /100mg Levodopa regular . Levodopa/200mgEntacapone) release 1 &1/2 tablets PLUS Comtan (Entacapone) 200mg tablet
Page 58 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Starlix (Nateglinide) 120mg TID Glyburide (generic Micronase) 5-10 mg QD- Both Starlix and Glyburide stimulate beta cell BID or Glucophage (Metformin) 500mg BID receptors to increase insulin production. Caution or glipizide patient to monitor for big shifts when changing diabetic Rx. Consider other oral antidiabetics such as Glipizide in patients >65 due to prolonged half life of Glyburide.
Strattera (Atomoxetine) 10mg, 18mg, 25mg, 40mg Concerta 18,27,36,54mg, or Methylin ER Adderall XR is restricted to pediatrics, child and 60mg 10mg (Methlyphenidate) Methylphenidate neurology and behavioral health. Titrate to 5, 10, 20mg and SR 20mg; or generic appropriate dosage using adderall regular Dexedrine spansules (Dextroamphetamine) release tablets before transitioning to once 5, 10, 15mg or Adderall regular release 5, daily Adderall XR. Document failed trial on 10, 20, 30mg tablets or Adderall XR Methylphenidate, Dextroamphetamine and 5,10,20,25,30mg capsules. Adderall IR products before a Non-formulary Controlled substances level 2 requiring Product is considered. Methylphenidate is the prescription written by prescriber. preferred formulary alternative. Methylphenidate is the preferred formulary alternative.
Sular (Nisoldipine) 10-40mg QD Nifedipine XL (generic Procardia XL) 30- Nisoldipine 10-20, 30 & 40mg are equivalent to 90mg QD or Felodipine ER (generic Nifedipine XL 30, 60 &90mg, respectively OR Plendil) 2.5mg-10mg, or Amlodipine Felodipine ER 2.5mg, 5mg & 10mg respectively, (generic Norvasc) 2.5mg-10mg or Diltia XT OR Amlodipine 2.5mg, 5mg, & 10mg respectively (Diltiazem) 120-480mg QD OR Diltia XT 120, 240 & 360-480mg respectively TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics
Supartz (Hyaluronic sodium) Criteria Restricted Medication. Provider phones KP QRM to request authorization consideration 404-364-7320. Suprax 200-400 mg tablets or suspension Ceftin 250 mg tab BID or Augmentin 500 Ceftin tablets are formulary. Ceftin suspension is mg tab BID or Biaxin (no XL) 500mg BID non-formulary. Suspensions: Omnicef 125mg/5ml; pediazole (erythromycin & sulfamethoxazole); augmentin 125- 250mg/5ml or 200-400mg chew tabs;amoxicillin 125-250mg/5ml; Biaxin 125- 250mg/5ml Symbicort (Budesonide/Formeterol 80/4.5, 160/4.5, For the 80/4.5 dose try: Turbuhaler) QVAR 80 mcg i puff BID & Serevent 50 mcg i puff BID OR Asmanex i puff qhs & Serevent 50 mcg i puff BID
For the 160/4.5 dose try: QVAR 80 mcg ii puffs BID & Serevent 50 mcg i puff BID OR Asmanex ii puffs qhs or i puff BID & Serevent 50 mcg i puff BID
Symbyax (Olanzapine/Fluoxetine) 6mg/25mg; Zyprexa (Olanzapine) 2.5mg, 5mg, Each component of this combination product is 6mg/50mg; 12mg/25mg; and 12mg/50mg 7.5mg,10mg or 15mg tabs PLUS Fluoxetine Formulary when dispensed individually as Zyprexa 20mg capsules 5mg or 10mg QD and Fluoxetine 20mg #1 or #2 QD.
Page 59 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Symlin (pramlintide) 0.6mg/ml injection Criteria Restricted Medication. Provider phone KP QRM 404-364-7320 to request authorization consideration.
Synagis (Palivizumab) injection is a humanized N/A Injectables administered in medical office and are monoclonal antibody targeted to the F protein of covered under medical office benefit, not drug respiratory syncytial virus (RSV) benefit. Synagis is only covered when administered in a Kaiser Permanente office. Call KP Synagis clinic (770) 931-6059 for more information. Synalar (Fluocinolone) 0.01% cream [low potency] DesOwen (Desonide) 0.05% cream, oint, Low potency topical corticosteroids. Synalar lotion or Synalar (Fluocinolone) 0.01% soln, 0.01% soln and oil are covered. Synalar 0.025% oil or Hytone (Hydrocortisone) 2.5% cream, cream, oint and synalar 0.2% are not covered. oint, lotion Synalar (fluocinolone) 0.025% cream, oint [medium Triamcinolone (generic Aristocort) cream, Locoid lipocream is restricted to Dermatology. potency] oint 0.1% or Valisone (betamethasone If failed other alternatives, consider increasing valerate) 0.1% lotion or Locoid lipocream steroid potency to fluocinonide (Lidex) 0.05% (hydrocortisone butyrate) 0.1% apply to cream, oint, or gel affected area BID
Synalar (Fluocinolone) 0.2% cream [high potency] Lidex (Fluocinonide) 0.05% cream, oint, gel, High potency topical corticosteroids. soln or Diprolene AF (Augmented Betamethasone) 0.05%
Synthroid tablet 0.025-0.3 mg QD Levothroid tabs 0.025-0.3 mg QD Substitute on a mg for mg basis. (ie. if Synthroid 0.1mg convert to levothroid 0.1mg)
Taclonex (Calcipotriene and betamethasone) Dovonex (calcipotriene) and Betamethasone diprionate ointment 0.05%
Talwin NX i tablet Q3-4H Acetaminophen with codeine (generic . Tylenol #3) i-ii tablets Q6H Tamiflu (Oseltamivir) capsule 75 mg Tamiflu must be Amantadine caps 100 mg BID Amantadine dose should be reduced to 100 mg initiated w/in 48 hrs of symptom onset QD in adults > 65 years of age. Pediatric dose is 4.4 mg/kg/day, max 150 mg/day. Rimantadine (Flumadine) 100mg tablets are also available. (Tamiflu covers flu strains A and B, Amantadine covers strain A only)
Tarceva (Erlotinib) 25mg, 100mg, 150mg tablets Platinum containing combination Tarceva indicated for local advanced or chemotherapy with paclitaxel or Docetaxel metastatic non-small cell lung cancer after failure chemotherapy of at least one prior chemotherapy regimen (platinum containing first line)
Targretin (Bexarotene) 1% topical gel interferon alpha, topical carmustine Criteria: (1) patient has cutaneous T-cell lymphoma (CTCL) and (2) patient has cutaneous lesions, and (3) patient has failed interferon alfa, topical carmustine, PUVA, electron beam radiotherapy OR (5) patient is not considered candidate or has failed other treatment options
Page 60 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Tarka (Trandolapril/Verapamil) 1mg/240mg, 2/180mg, Prinivil (Lisinopril) 5-40mg QD AND Combination product is not covered. Conversion 4/240mg tablets Verapamil SR 180mg or 240mg Trandolapril 1mg=Prinivil 5-10mg; Trandolapril 2mg=Prinivil 10-20mg; Trandolapril 4mg=Prinivil 20-40mg. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics
Tasmar (Tolcapone) tab 100-200 mg TID Comtan (Entacapone) 200 mg tabs with Tasmar is on the formulary; however, all other each dose of Levodopa/Carbidopa, MAX Parkinson's therapies should be tried before 1600mg/day Tasmar due to risk of severe hepatic damage and death, liver function tests must be completed every two weeks while on therapy. Patient and practitioner must complete informed consent (provided by manufacturer) prior to initiation of therapy. Tazorac (Tazarotene) 0.05%, 0.1% cream (severe For Psoriasis: Dovonex (Calcipotriene) If failed several very high potency steroids, psoriasis) 0.005% oint or Diprolene (Augmented consider Tazorac severe psoriasis. Betamethasone) oint or Temovate (Betamethasone Dipropionate 0.05% cream (Clobetasol) oint, cream or Lidex demonstrates good efficacy when nec to use a (Fluocinonide) 0.05% oint, cream For Acne: steroid crm w/ Tazorac) Acne: Retin A Microgel Retin-A cream 0.1% (20 gm tube) apply is restricted to Dermatology. Smallest unit size QHS or Retin-A gel 0.025% (15 gm tube) is covered, larger tubes are not covered. Retin-A, apply QHS or Retin A Micro gel Differin not covered for cosmetic use (wrinkles)
Taztia XT (Diltiazem extended release) 120, 180, 240, Diltia (Diltiazem) XT 120, 180 and 240mg Substitute on a mg for mg basis. Convert Taztia 300, 360mg 120 - 480mg QD caps 120-480mg QD XT 300mg to Diltia XT 240mg or 360mg (#2 x 180mg), Taztia XT 480mg convert to Diltia XT 480mg (#2 x 240mg cap) TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics
Teczem (5mg Enalapril/180mg Diltiazem) extended Prinivil (Lisinopril) 5mg QD AND Diltia XT Combination product is non formulary. Individual release tab (Diltiazem) 180mg QD medications are formulary. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics
Tegison (Etretinate) capsules Soritaine (Acitretin) capsules Soriatane is restricted to Dermatology.
Page 61 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Tegretol-XR (Carbamazepine) 100, 200, 400mg tab Carbatrol (Carbamazepine) 200, 300mg Substitute on a mg for mg basis to produce same BID extended release caps BID total daily dose. Note Carbatrol strengths differ from Tegretol XR strengths. Tekturna (Aliskerin) 150 mg and 300 mg tablets Lisinopril 10 -20 mg daily or Cozaar 25- 100 mg daily Tenex tablet 1 mg QD Clonidine (generic Catapres) tab 0.1 mg Titrate dose to blood pressure response. BID or Methyldopa (generic Aldomet) 250 TSPMG Guidelines suggest: mg TID Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics
Tenoretic (Atenolol / Chlorthalidone) 50/25, 100/25mg Atenolol (generic Tenormin) 50mg-100mg TSPMG Guidelines suggest: AND 25mg Hydrochlorothiazide Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics
Tenuate (Diethylpropion) N/A Weight loss agents not covered. Tequin (Gatifloxacin) tab 400 mg QD x 7-10 days for If treating URTI: Avelox bronchitis ; 400 mg QD x 7-14 days for community- (moxifloxacin) 400mg QD or generic acquired pneumonia ; 400 mg QD x 10 days for Augmentin 875 mg BID or Biaxin 500 mg sinusitis BID If treating UTI: Fluoroquinolone of choice is Cipro or consider Bactrim DS.
Terazol vaginal cream or suppositories Diflucan (Fluconazole) 150mg tablet OTC products are available. In keeping with treatment recommendations, Fluconazole 150mg quantity is limited to 1 tablet per copay.
Tessalon perles (Benzonatate) Phenergan syrup, Phen. VC with Codeine, Phenergan VC (promethazine, phenylephrine, Phen with codeine; Robitussin AC or codeine); Robitussin AC (guaifenesin, codeine); Robitussin DAC; Hycodan tablets (not Robitussin DAC (Guaifenesin, codeine, syrup) or OTC products pseudoephedrine); Hycodan tabs (hydrocodone/homatropine) OR OTC products
Testoderm TTS 5 mg transdermal patch QD are no Androderm 2.5mg-5mg/24 hour transdermal Document indication for medication and failure on longer manufactured. patches; Testosterone injection 400 mg IM alternatives. (If patient is using for Sexual q2-4weeks administered in medical office. Dysfunction confirm sexual dysfunction benefits.) Injectables administered in a medical office are covered under the medical office benefit, NOT the drug benefit and are not available from a pharmacy for a copayment. Methyltestosterone (generic Android or Testred) tabs 10-20 mg QD-BID or Fluoxymesterone (Halotestin) 10 mg QD (tablets require baseline and periodic liver function testing)
Page 62 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Testoderm Scrotal patch 4mg or 6mg/24 hours are no Androderm 2.5mg-5mg/24 hour transdermal Document indication for medication and failure on longer manufactured, will remain available until supply patches; Testosterone injection 400 mg IM alternatives. (If patient is using for Sexual exhausted q2-4weeks administered in medical office. Dysfunction confirm sexual dysfunction benefits.) Injectables administered in a medical office are covered under the medical office benefit, NOT the drug benefit and are not available from a pharmacy for a copayment. Methyltestosterone (generic Android or Testred) tabs 10-20 mg QD-BID or Fluoxymesterone (Halotestin) 10 mg QD (tablets require baseline and periodic liver function testing)
Testosterone 2 to 3% manually compounded in cream N/A commercially available NF product Testosterone base 2% in moisturizing cream ndc# 65628-021-01
Testosterone 2 to 3% manually compounded in an N/A commercially available NF product Testosterone ointment base 2% in ointment ndc# 65628-020-01
Testosterone cyp 200 mg/ml injected Q 2-4 weeks Testosterone injection 400 mg IM q2- 4weeks administered in medical office. Injectables administered in a medical office are covered under the medical office benefit, NOT the drug benefit and are not available from a pharmacy for a copayment. Methyltestosterone (generic Android or Testred) tabs 10-20 mg QD-BID or Fluoxymesterone (Halotestin) 10 mg QD (tablets require baseline and periodic liver function testing); Androderm 2.5mg-5mg/24 hour transdermal patches
Tevetan (Eprosartan) 400, 600mg tabs 400-800mg Prinivil (Lisinopril) 10 - 40mg QD or Cozaar Prinivil is preferred, if no previous ACE inhibitor QD (also available as Tevetan HCT (Tevetan and (Losartan) 25 - 100mg QD trial. If angiotensin 2 receptor blocker is required, HCTZ) convert to Cozaar. Conversion: Tevetan 400mg=Prinivil10mg=Cozaar 25mg; Tevetan 600mg=Prinivil 20mg=Cozaar 50mg; Tevetan 800mg=Prinivil 40mg=Cozaar 100mg TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics
Thalidomide 50mg capsules N/A Prescriber must contact mnfctr, Selgine, @ 1-888- 423-5436 to obtain authorization # which is then written on the prescription. Prescriptions are then filled at STEPS participating Eckerd pharmacies.
Page 63 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Tiamate (Diltiazem extended release) 120, 180, Diltia (Diltiazem) XT 120, 180, 240mg caps Substitute on a mg for mg basis. 240mg 120 - 480 mg QD 120-480mg QD TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics
Tiazac (Diltiazem extended release) 120, 180, 240, Diltia (Diltiazem) XT 120, 180, 240mg caps Substitute on a mg for mg basis. Convert Tiazac 300, 360mg 120 - 540mg QD 120-480mg QD 300mg to Diltia XT 240mg or 360mg (#2 x 180mg) Tiazac 480mg convert to Diltia XT 480mg (#2 x 240mg cap) TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics
Ticlid (Ticlopidine) 250mg BID Aggrenox (dipyridamole/asa) 25/200mg BID Aspirin therapy remains first line option. (if CVA) Or, Plavix 75mg QD (if Formulary alternatives are available for patients cardiac stent, PTCA, MI or if CVA and ASA who have failed aspirin trial or who are not intolerant) candidates for aspirin trial. Tikosyn (Dofetilide) 125-500mcg capsules BID N/A Tikosyn is available at specific Eckerd pharmacies. Call 1-877-TIKOSYN to locate the nearest Eckerd pharmacy. The Eckerd pharmacist will verify that the prescriber is documented in the database as participating in the TIKOSYN educational distribution program.
Tilade (Nedocromil) 2 puffs QID QVAR (Beclomethasone HFA) 40mcg/puff Inhaled corticosteroid QVAR preferred oral inhaler, i-ii puffs BID -OR- Flovent (Fluticasone) 44mcg/puff oral inhaler, i - ii puffs BID -OR- Intal (Cromolyn) 2 puffs QID
Timoptic-XE (Timolol gel forming soln) 0.25-0.5% i Timoptic ophth sol'n 0.25-0.5% i drop in Timoptic XE (gel forming solution allows QD drop in affected eye(s) QD affected eye(s) BID administration with equivalent efficacy) is non formulary, timolol ophthalmic solution (BID administration initially, in some patients physician may reduce to QD when IOP stable) is formulary. If physician requests alternative beta blocker: Betoptic (Betaxolol) 0.25-0.5% i drop BID or Betagan (Levobunolol) 0.25-0.5% i drop BID are also formulary
Tindamax (Tinidazole) 250mg, 500mg tablets Metronidazole tablets Equal efficacy with metronidazole in treatment of non-metronidazole resistant trichomoniasis or giardiasis Tolectin (Tolmetin) 200, 300, 600mg caps 200 - Ibuprofen (generic Motrin) tabs 600-800 mg Additional formulary alternatives: Diclofenac 600mg TID TID or Salsalate (Disalcid)1500mg BID or (Voltaren) 75mg BID or Choline Magnesium Naproxen 500mg BID or Sulindac (Clinoril) Trisalicylate (Trilisate) 750mg BID-TID or 200mg BID Nambumetone (Relafen) 500mg or 750mg 1-2 QD- BID or Etodolac (Lodine) 200mg-500mg Q8-12H up to 1200mg/day or Indomethacin 25-50mg TID or Mobic (Meloxicam) 7.5mg or 15mg.
Page 64 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Topamax tablet Seizure formulary alternatives - Tegretol, Topamax is restricted to Neurology. Please Neurontin, Lamictal, Depakote, Depakene, consider half tablets when prescribing. Keppra [R], Trileptal [R] Topicort (Desoximetasone) 0.05% cream Triamcinolone (generic Aristocort, Kenalog) Locoid lipocream is restricted to Dermatology. cream, oint 0.1% or Valisone If failed other alternatives, consider increasing (Betamethasone Valerate) 0.1% lotion or steroid potency to Fluocinonide (Lidex) 0.05% Locoid Lipocream (Hydrocortisone Butyrate) cream, oint, or gel. 0.1% apply to affected area BID
Topicort (Desoximetasone) 0.25% cream, oint or Lidex (Fluocinonide) 0.05% cream, oint, gel, High potency topical corticosteroids. 0.05% gel soln or Diprolene AF (Augmented Betamethasone) 0.05% Toradol (Ketorolac) tab 10 mg Q6H Ibuprofen (generic Motrin) 600-800 mg TID Due to the risk of renal failure and GI bleeding, or Acetaminophen w/codeine (generic ketorolac tablets should not be administered more Tylenol #3) i-ii Q6H than 5 days. Ketorolac tablets are FDA approved for use after ketorolac injection only.
Toradol (Ketorolac) tab 10mg Q4-6H prn Ibuprofen 800 mg TID PRN or Naproxen Due to the risk of renal failure and GI bleeding, 250-500 mg Q6-8H or sulindac (Clinoril) ketorolac tablets should not be administered more 200mg BID or diclofenac (Voltaren) 75mg than 5 days. Ketorolac tablets are FDA approved BID or Relafen 500mg tab #2 QD - BID or for use after ketorolac injection only. etodolac (Lodine) 200-500mg Q8-12H up to 1200mg/day or Mobic (Meloxicam) 7.5mg or 15mg. Transderm-Nitro (Nitroglycerin) transdermal patch 0.1, Minitran (Nitroglycerin) transdermal 0.1, 0.2, Nitro-Dur 0.3 and 0.8mg/hr patches are covered, 0.2,0.3, 0.4, 0.6, 0.8mg/hr patches 0.4, 0.6mg/hr patches since Minitran is not available in these 2 strengths. Tranxene-SD (Clorazepate) 11.25mg, 22.5mg QD Clorazepate (generic Tranxene) 3.25, 7.5, Tranxene-SD 11.25mg QD = Clorazepate 3.25mg 15mg TID TID; Tranxene-SD 22.5mg QD = Clorazepate 7.5mg TID Travatan (Travaprost) 1 drop in affected eye QHS Lumigan (Bimatoprost) 0.03% ophth Prostamide analog to reduce IOP in glaucoma. solution 1 drop in affected eye QHS Not recommended to dose Travatan or Lumigan more frequently than qd. Separate administration from other eye drops by at least 5 minutes.
Triamcinolone acetonide (generic Kenalog or Lidex (Fluocinonide) 0.05% cream, oint, gel High potency topical corticosteroids. Aristocort) 0.5% cream, oint or Diprolene AF (Augmented Betamethasone) 0.05%
Tricor (all formulations and doses 48mg to 200mg Fenofibrate 160 mg QD or 54 mg QD. If pt Fenofibrate preferred if pt also taking statin. If QD) on Tricor dose < 100mg daily, convert to pt has reduced renal function, consider offering 54mg dose, if on dose > 100mg daily gemfibrozil 600mg BID which is safer per kidney convert to 160mg QD. guidelines. Cost of fenofibrate and gemfibrozil similar. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM.
Trileptal (Oxcarbazepine) tabs or liquid Tegretol (carbamazepine), Neurontin Trileptal is restricted to Neurology and (gabapentin), Topamax (topiramate), Behavioral Health for the initial prescription Tranxene (clorazepate), Lamotrigine 5- fill. Reserved for patients with a good therapeutic 25mg chews and Lamictal 100mg-200mg response to Carbamazepine, but poor tolerability oral tablets or drug interactions with Carbamazepine. Lamictal 25mg oral tablets are non-formulary as of 3/22/07; if a 25mg dose is required, Lamotrigine chewables are preferred.
Page 65 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Tri-Luma (Fluocinolone Acetonide 0.01%, N/A Drugs for cosmetic use are NOT covered on Hydroquinone 4%, Tretinoin 0.05%) cream drug benefit. Member pays retail price. If prescribed along with Differin, Retin A, or Avita creams, they also are not covered as they are being used as cosmetic therapy.
Trinalin (1mg Azatadine / 120mg Pseudoephedrine) OTC Chlor-Trimeton 12-hour Relief i tablet All cough and cold medications are non-formulary repetab i Q12H BID or OTC Drixoral Cold & Allergy i tablet with the exception of Codeine, Hydrocodone, and BID Promethazine containing products.
Tri-Nasal (Triamcinolone) nasal spray Nasarel ii sprays each nostril BID or generic Please document failure of both Nasarel & generic Flonase (fluticasone) i spray each nostril Flonase (fluticasone) before prescribing/approving QD a NF product.
Triphasil (0.05mg Levonorgestrel/ 30mcg EE x 6 days, Tri-Levlen (0.05 Lvngl/30mcg EE x 6 days, Document at least 3 formulary alternatives 0.075mg Lvngl/ 40 mcg EE x 5 days, 0.125mg 0.075mg Lvngl/40mcg EE x 5 days, before prescribing/approving a NF product. Lvngl/30mcg EE x 10 days) 0.125mg Lvngl/30mcg EE x 10days)
Trivora-28 (0.05mg Levonorgestrel/ 30mcg EE x 6 Tri-Levlen (0.05 Lvngl/30mcg EE x 6 days, Document at least 3 formulary alternatives days, 0.075mg Lvngl/ 40 mcg EE x 5 days, 0.125mg 0.075mg Lvngl/40mcg EE x 5 days, before prescribing/approving a NF product. Lvngl/30mcg EE x 10 days) 0.125mg Lvngl/30mcg EE x 10days)
Trusopt (Dorzolamide) 2% ophth soln i drop in Azopt (Brinzolamide) 1% ophth susp i drop . affected eye TID in affected eye TID Tussionex (Chlorpheniramine 8mg and Hydrocodone Phenergan syrup, Phen. VC with Codeine, Phenergan VC (promethazine, phenylephrine, 10mg) suspension Phen with codeine; Robitussin AC or codeine); Robitussin AC (guaifenesin, codeine); Robitussin DAC; Hycodan tablets (not Robitussin DAC (Guaifenesin, codeine, syrup) or OTC products pseudoephedrine); Hycodan tabs (hydrocodone/homatropine) OR OTC products
Tympagesic (5% Benzocaine, 5% Antipyrine, 0.25% Auralgan Otic (1.4% Benzocaine, 5.4% N/A Phenylephrine, propylene glycol) Otic drops Antipyrine, Glycerin) Tysabri (natalizumab) once every 4 weeks in a dose Must go through through manufacturer's of 300 mg diluted in 100 ml Normal Saline given TOUCH program and then meet QRM Criteria Restricted Medication Natalizumab intravenously over about one hour criteria. should usually be reserved for use in patients who have had an inadequate response to other MS therapies or patients who are not able to tolerate other MS therapies. Patients who are stable and well-controlled on other MS therapies should not be changed to natalizumab. Ultracet (Tramadol 37.5mg/APAP 325mg) Q4-6H Tramadol 50mg Q 4 - 6 hours PLUS OTC Acetaminophen w/codeine (generic Tylenol #3) i-ii Acetaminophen 325mg Q 4 - 6 hours Q6H or NSAID. Ultrase (Pancrelipase enzymes) Pancrease (Pancrelipase enzymes) or Pangestyme is a generic of Pancrease Pangestyme Ultravate (Halobetasol) 0.05% cream, oint Diprolene (Augmented Betamethasone Very high potency topical corticosteroids. Dipropionate) 0.05% oint or Temovate (Clobetasol) 0.05% cream, oint, gel, scalp soln Uniphyl T.R. tab 400 mg QD generic Theo-Dur tab 200 mg BID N/A Uniphyl T.R. tab 600 mg QD generic Theo-Dur tab 300 mg BID N/A Uniretic (Moexipril/HCTZ) 7.5/12.5 and 15/25mg Prinivil (Lisinopril) 5mg - 40mg QD and TSPMG Guidelines suggest: HCTZ 12.5mg - 25mg QD Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics
Page 66 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Univasc (Moexipril) 7.5, 15mg tabs 7.5 - 30mg QD Prinivil (Lisinopril) 5mg - 40mg QD TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics
Urised tablet Usept or Urinary Antiseptic #2 which are May be substituted tablet for tablet without calling Methenamine compound (generic Urised) practitioner.
Urispas (Flavoxate) tabs Ditropan (Oxybutynin) tablets or Oxytrol . patch Uroxatral (Alfuzosin) 2.5mg IR QID; 5mg ER BID or Doxazosin (generic Cardura) titrated to Both agents are alpha-1 adrenoceptor antagonists 10mg ER QD therapeutic doses (e.g. Doxazosin 2mg 1/2 and are capable of producing first-dose orthostatic tab po QHS X 1 week, then 1 tab po QHS x hypotension. When initiating therapy, dose 2 weeks, then 2 tabs po QHS and follow-up titration will help minimize orthostatic hypotension w/MD for refill) or Terazosin (generic Hytrin) risk. titrated slowly to therapeutic doses. (eg. 1mg QHS days 1-3, 2mg QHS days 4-15 then 5mg QHS, if necessary may further increase to 10mg QHS
Uticort (Betamethasone Benzoate) 0.025% cream Triamcinolone (generic Aristocort, Kenalog) If failed other alternatives, consider increasing cream, oint 0.1% steroid potency to fluocinonide (Lidex) 0.05% cream, oint, or gel Vagifem (25.8mcg Estradiol vaginal tablets) Premarin vaginal cream 1/2 to 2 grams . inserted vaginally daily to several times weekly Valisone (Betamethasone Valerate) 0.1% cream Triamcinolone (generic Aristocort) cream, If failed other alternatives, consider increasing to oint 0.1% or Valisone (betamethasone high potency topical corticosteroid fluocinonide valerate) 0.1% lotion (Lidex) 0.05% cream, oint, or gel Valisone (Betamethasone Valerate) 0.1% ointment Lidex (Fluocinonide) 0.05% cream, oint, gel, High potency topical corticosteroids. soln or Diprolene AF (Augmented Betamethasone) 0.05% Valisone reduced strength (Betamethasone Valerate) Hydrocortisone 2.5% cream, oint or lotion Hydrocortisone 0.5-1% is available OTC 0.01% cream Valtrex (Valacyclovir) 500mg tab Herpes Zoster 1000 Herpes zoster Acyclovir 800mg Q4H, 5 Valacyclovir is broken down into Acyclovir by the mg TID x 7 days; recurrent genital herpes 500 mg BID times daily x 7 days (10 days if body. x 5 days immunocompromised); genital herpes Herpes Labialis: consider OTC Abreva, Carmex or acyclovir 400mg TID x 7-10 days (5 days Orabase or oral Acyclovir if unresponsive to OTC when tx recurrence, may use 800mg BID x therapy. 5 days for recurrence); chronic suppressive therapy 400mg BID, titrate to lowest effective suppressive dose Vancenase (beclomethasone) nasal inhaler (pts ≥6 Nasarel ii sprays each nostril BID or generic If the child is less then 4 years old, Nasonex may yrs old) Flonase (fluticasone) i spray each nostril warrant approval as Nasarel is not indicated for QD patients less than 6 years old & Flonase is not indicated in patients less than 4 years old.
Vanceril oral inhaler ii-iiii puffs BID-TID QVAR (Beclomethasone HFA) 40mcg/puff QVAR is twice as potent as Vanceril (2 puffs oral inhaler, i-ii puffs BID. 42mcg/puff = 1 puff QVAR 40 mcg/puff) and equipotent to Flovent 44mcg (1 puff QVAR 40mcg = 1 puff Flovent 44mcg/puff). QVAR remains the preferred inhaled corticosteroid at KP GA.
Page 67 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Vaniqa (Eflornithine) 13.9% cream N/A Drugs for cosmetic use are NOT covered on drug benefit. (Vaniqa removes unwanted facial hair.) Member pays retail price.
Vanlev (Omapatrilat) 10 - 80mg QD [dual Lisinopril 20 - 80mg QD (one trial compares No dual vasopeptidase alternative on formulary. vasopeptidase (metalloprotease) inhibitor--ACEI and lisinopril 20mg to Vanlev 20-40mg) may Prinivil (ACEI) is closest mechanistic alternative neutral endopeptidase inhibitor] CHF dose: 10 - consider adding HCTZ 12.5mg QD to with or without HCTZ. Conversion dose should be 40mg QD HTN dose: 20 - 80mg QD maintain dual mechanism of action provided individualized and adjusted to patient response. by Vanlev; lisinopril/HCTZ 10/12.5, 20/12.5 or 20/25mg or Cozaar 25 - 100mg QD
Vanos (fluocionide) Lidex (anhydrous fluocinonide cream); Lidex- E (aqueous fluocinonide cream) Vantin (Cefpodoxime) suspension Omnicef 125mg/5ml; Pediazole . (Erythromycin & Sulfamethoxazole); Augmentin 125-250mg/5ml or 200-400mg chew tabs;Amoxicillin 125-250mg/5ml; Biaxin 125-250mg/5ml; Cefaclor suspension
Vaseretic tablet 10-25 mg ii tablets QD Lisinopril/HCTZ 20/25mg QD Two individual prescriptions are required. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting Dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics
Vaseretic tablet 10-25 mg QD Lisinopril/HCTZ 10/12.5mg, 20/12.5mg, Two individual prescriptions are required. 20/25mg QD TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics
Vaseretic tablet 5-12.5 mg QD Lisinopril/ HCTZ 10/12.5mg 1/2-1tab QD Two individual prescriptions are required. TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics
Vasosulf (15% Sulfacetamide/ 0.125% Phenylephrine) 15% Sulfacetamide ophth soln AND OTC Combination product is non formulary. Phenylephrine 0.12% ophth soln Sulfacetamide ophth soln is formulary and phenylephrine ophth soln is over the counter.
Ventolin Albuterol
Page 68 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Veramyst (Fluticasone) 27.5 mcg/inhalation Generic Nasarel (flunisolide) ii sprays each nostril BID or generic Flonase (fluticasone) i spray each nostril QD or QVAR i-ii puffs BID
Verelan (Verapamil) 120, 180, 240, 360mg QD Verapamil SR tabs (generic Calan SR) 120, Convert on a mg for mg basis. 180, 240mg tabs 120-240 mg QD TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics
Verelan PM (Verapamil) 100, 200, 300mg caps 100- Verapamil SR tabs (generic Calan SR) 120, Conversion equivalents: 400mg QHS 180, 240mg tabs QD Verelan PM 100mg = Verapamil SR 120mg; Verelan PM 200mg = Verapamil SR 180-240mg; Verelan PM 300mg = Verapamil SR 240-360mg; Verelan PM 400mg = Verapamil SR 360mg TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics
Vesicare (Solifenacin succinate) 5mg and 10mg Oxybutinin (generic Ditropan) 5-10 mg tab i If failed oxybutynin (regular and XL) consider tablets QD-BID (immediate release tablet) or Detrol LA (Detrol 1mg BID is equivalent to Detrol Oxybutynin XL (generic Ditropan XL) 5- LA 2mg QD) If initiating Detrol therapy, the initial 15mg QD or Oxytrol patch recommended dose Detrol LA is 4 mg QD; may decrease to 2 mg QD depending on tolerability and response.
Vexol (Rimexolone) ophth susp 1% i-ii drops in Consider at least 2 formulary products N/A affected eye(s) QID before prescribing/authorizing a NF product: Dexamethasone 0.1% ophth soln or Prednisolone 0.12%-1% ophth soln or Flarex, FML (Fluorometholone) ophth soln 0.1% i-ii drops in affected eye(s) QID
Vfend (voriconazole) . Consult with an ID specialist Viagra 25, 50, 100mg tabs N/A Member's group must have purchased sexual dysfunction rider for coverage. Consider Viagra 100mg 1/2 tablet when prescribing Viagra 50mg dose to reduce patient expense.
Vicon forte or Magna C-7 forte i QD Vitamins components available OTC as: N/A OTC Stresstabs + Zinc i QD or OTC Centrum Silver i QD or other OTC vitamins
Vicoprofen (7.5mg Hydrocodone/ 200mg Ibuprofen) Hydrocodone/Acetaminophen in the Generics of the following used: Lortab 7.5/500; following strengths: 5mg/500mg; Lorcet plus 7.5mg/650mg; Lorcet 10mg/650mg; 7.5mg/500mg; 7.5mg/650mg, 10mg/650mg, Vicodin 5mg/500mg; Vicodin 5mg/500mg; Vicodin 7.5mg/750mg AND OTC ibuprofen 200mg ES 7.5mg/750mg.
Page 69 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Vigamox (Moxifloxacin) 0.5% Ofloxacin 0.3% or Gentamicin 0.3% or Lasik ophthalmic surgery is not a covered benefit. Tobramycin 0.3% or Sodium Sulfacetamide Medications related to non covered procedures ophth soln or Zymar 0.3% are not covered by the drug benefit.
Viokase (Pancrelipase enzymes) Pancrease (Pancrelipase enzymes) or Pangestyme is a generic of Pancrease Pangestyme Viquin forte no formulary alternative Cosmetic use drug. Not covered on drug benefit. Member pays full retail price. Visken (Pindolol) 5, 10mg tabs 5-30mg BID Atenolol (generic tenormin) 25 - 100mg QD Propranolol is available as 10, 20, 40, 60, 80, or metoprolol 100 - 400mg QD or 90mg tabs. Inderal LA is non-formulary. propranolol 40 - 320mg BID TSPMG Guidelines suggest: Initial therapy: Thiazide diuretics Two Drug Therapy: Add ACE-I to Thiazide diuretic Three Drug Therapy: Add Beta Blocker to ACE-I and Thiazide diuretic Four Drug Therapy: Add Long Acting dihydropyridine CCB to Beta Blocker, ACE-I and Thiazide Diuretics
Vistaril (Hydroxyzine Pamoate) cap 25-50 mg TID-QID Hydroxyzine HCl tabs (generic Atarax) 25- 50 mg TID-QID Vivelle (Estradiol) transdermal patch apply twice Climara 0.025mg, 0.0375mg, 0.05mg, If an estrogen patch is required, Climara. weekly 2.17mg, 3.28mg, 4.33mg, 6.57mg, 8.66mg 0.06mg, 0.075mg, 0.1mg patches apply one patches deliver 0.025mg/day, 0.0375mg/day, patch weekly; or Estrace 0.5, 1 or 2mg 0.05mg/day, 0.075mg/day, 0.1mg/day respectively. (Estradiol)
Vivelle-DOT (Estradiol) transdermal patch apply twice Climara .025mg, 0.0375mg, .05mg, 0.06mg If an estrogen patch is required, Climara. weekly 0.78mg, 1.17mg, 1.56mg, patches deliver .075mg, .1mg patches apply one patch NF Vivelle DOT delivers the same estradiol dose 0.05mg/day, 0.075mg/day, 0.1mg/day respectively. weekly; or Estrace 0.5, 1 or 2mg (Estradiol) as NF Vivelle, though actual patch size is smaller. 66% smaller patch size than Vivelle Vivelle and Vivelle DOT are AB rated equivalents. NF Vivelle, not NF Vivelle DOT, may be dispensed at KP pharmacies. Volmax (Albuterol extended release) tablets Consider Albuterol inhaler, QVAR Extended release Albuterol tablets are no longer (Beclomethasone) inhaler if asthma and not manufactured. using steroid inhaler, Serevent inhaler if long acting beta 2 agonist necessary, or immediate release albuterol tablets. Vytorin (Ezetimibe/Simvastatin) 10/10, 10/20, 10/40 Consider trying Simvastatin (generic Zocor) Vytorin 10/80mg is formulary. Vytorin may be (effective 9/05,Vytorin 10/80mg is formulary) PLUS either: Cholestyramine powder OR appropriate if simvastatin 80mg QD plus niacin or Cholestyramine light powder 4-8 gm BID BAS was ineffective OR if pt on concurrent OR Slo-niacin OR Time-release niacin 500 medication(s) whose absorption would be mg BID OR Colestid 1gm tablets 2-4gm inhibited by BAS such as tranplant medications. BID. Cholestyramine preferred over Vytorin is preferred over use of zetia plus statin as Colestid. The effects of Ezetimibe on separate prescriptions. All other Vytorin doses cardiovascular morbidity and mortality have other than 10/80 mg are non-formulary. For not been established. For vytorin 10-40mg questions, consider calling Pharmacy Cardiac dose, consider vytorin 10-80mg tablet, 1/2 Risk Service at 770-496-3560 between 830AM tablet po QD. and 530PM.
Wellbutrin SR 200mg (Bupropion) Wellbutrin SR 150mg or Wellbutrin 75mg or Smoking cessation products are non formulary 100mg tablets. Wellbutrin XL 150mg & 300mg QD Wellbutrin SR (bupropion SR) 150mg or [Wellbutrin XL: Available Part D group] Wellbutrin (bupropion 75mg or 100mg) tablets
Page 70 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Welchol (Colesevelam) 3 tabs BID Consider Cholestyramine powder 4 - 8gm Welchol is a bile acid sequestrant, reducing LDL QD -OR- Colestid (colestipol) 1gm tablets: 2 cholesterol by 18%. Cholestyramine/Colestipol gm BID or 4gm QD -OR- if a statin is not reduce LDL cholesterol by 30%. Statins reduce already being used, consider Lovastatin 20- LDL cholesterol by 30-60%. May prefer to avoid 40mg QPM -OR- Simvastatin 20mg QHS - all BAS including welchol for pts on cyclosporine Or- Vytorin 10/80 -OR- Zetia or HIV meds. Welchol may have less binding effects than other BAS. BAS therapy may be preferred over statin for patients with very elevated liver tests. Consider adding OTC Slo- Niacin 500mg QD titrated to BID to statin before adding BAS, if appropriate for pt. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM.
Westcort (Hydrocortisone valerate) cream, oint 0.2% Triamcinolone (generic Aristocort, Kenalog) If failed other alternatives, consider increasing to apply to affected are BID [medium potency] cream, oint 0.1% high potency topical corticosteroid fluocinonide (Lidex) 0.05% cream, oint, or gel Xalatan ophth sol'n 1 drop in affected eye QD - BID Lumigan (Bimatoprost) 0.03% ophth Prostamide analog to reduce IOP in glaucoma. solution 1 drop in affected eye QHS Lumigan is not as effective when administered more often than QD. Convert Xalatan 1 drop BID to lumigan 1 drop QD. separate Lumigan from administration of other eye drops by at least 5 minutes. Xanax XR 0.5mg, 1mg, 2mg or 3mg tablets QD alprazolam 0.25mg, 0.5mg, 1mg, 2mg When converting, Xanax XR once daily is equivalent to the same total daily dose of alprazolam (generic Xanax) immediate-release administered in divided doses TID (e.g. Xanax XR 2mg would convert to alprazolam 0.5mg TID - QID) Xatral (Alfuzosin) 7.5 - 10mg divided into 3 daily doses Doxazosin (generic Cardura) titrated to Unless converting from an equivalent dose of an (alpha 1 adrenergic blocker) therapeutic doses (e.g. Doxazosin 2mg 1/2 alpha adrenergic blocker, titrate Terazosin slowly tab po QHS X 1 week, then 1 tab po QHS x to therapeutic doses. 2 weeks, then 2 tabs po QHS and follow-up w/MD for refill) or Terazosin (generic Hytrin) titrated slowly to therapeutic doses. (eg. 1mg QHS days 1-3, 2mg QHS days 4-15 then 5mg QHS, if necessary may further increase to 10mg QHS
Xenical cap 120 mg TID N/A Agents for weight loss or obesity are not covered. Patient pays full retail price. Xifaxan (Rifaximin) 200mg #2 BID x 3 days for For Travelers' Diarrhea: Ciprofloxacin . travelers' diarrhea 500mg BID x 3 days
Xolair (Omalizumab) injectable (not self Criteria Restricted Medication Criteria Restricted Medication. Provider phone administered, to be provided by physician in office) KP QRM 404-364-7320 to request authorization consideration.
Xopenex inhalation solution 0.625 mg TID-QID via Albuterol inhalation solution 2.5 mg TID-QID N/A nebulizer via nebulizer Xylocaine 2% jelly Lidocaine topical gel (per chronic pain N/A guideline) or OTC L-M-X4 (4% topical lidocaine cream) or OTC Lidosense 4 (4% topical lidocaine cream) or OTC Axsain cream (4% lidocaine combined with 0.25% capsaicin cream)
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Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Xyzal (Levocetirizine) tablets Claritin OTC or Zyrtec OTC Intranasal steroids (Nasarel ii sprays per nostril BID or generic Flonase (fluticasone) i spray each nostril QD) more effective than nonsedating antihistamines for allergic rhinitis.
Yasmin 28 (3 mg Drospirenone/ 30 mcg EE) Sprintec, generic Ortho-Cyclen, (0.25mg Levlen (0.15 Levonorgestrel/ 30 mcg EE) or Norgestimate/ 35 mcg EE) or Zovia 1/35 Microgestin 1.5/30 (1.5 Norethindrone/30mcg EE) (Ethynodiol 1mg/35mcg EE) or Tri-Levlen (0.05mg Levonorgestrel & 30mcg EE x 6 days, 0.075mg Lvngl & 40mcg EE x 5 days, 0.125mg Lvngl & 30mcg EE x 10 days) or Brevicon (.5mg ne/ 35EE), Microgestin 1/20 (1 NE/20mcg EE), Zovia1/35 (Ethynodiol 1mg/35 EE), Norinyl 1/35 (1mg NE/ 35mcg EE) Norinyl 1/50 (1mg NE/ 50mcg Mestranol), or NORQD (0.35 NE only) Document diagnosis (If PCOS is the reason for the request then benefit coverage may be extended).
Zaditor (ketotifen) .025% ophth soln For allergic conjunctivitis: OTC Opcon-A OTC Zaditor 0.25% and Patanol are both dual (Pheniramine & Naphazoline) or OTC action antihistamine/mast cell stabilizers, are Zaditor 0.25% [NOTE: OTC products are dosed twice daily, and have the same FDA not a covered benefit] approved indications. If treating steroid responsive inflammatory condition consider at least 2 formulary products before prescribing/authorizing a NF product : Dexamethasone 0.1% ophth soln or Prednisolone 0.12%-1% ophth soln or Flarex, FML (Fluorometholone) ophth soln 0.1% i-ii drops in affected eye(s) QID
Zegerid (Omeprazole) powder for oral suspension OTC Prilosec 20mg tablet. (If cannot Prilosec OTC 20mg swallow tablet, OTC prilosec will disperse in 5cc of water in less than 60 seconds with gentle agitation. Dose should be taken immediately after dispersal in liquid.)
Zelnorm (Tegaserod) 2mg BID 5HT4 agonist [also Lactulose 3 tablespoonsful QD to TID OR Miralax is now available OTC. OTC products are branded zelmac] OTC Miralax (Polyethylene glycol powder not a covered benefit. Prescribers are encouraged for oral solution) 17gm in 8 ounces of water to to consider OTC options if appropriate. Zelnorm QD OR other OTC bulk forming laxatives used for shortterm treatment of women with for constipation irritable bowel syndrome and primary symptom constipation. (Zelnorm available MMA group)
Zestril (Lisinopril) Lisinopril (generic prinivil)
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Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Zetia (Ezetimibe) 10mg QD tablet OTC Slo-Niacin/ Time Release niacin Zetia monotherapy may be appropriate only if 500mg OR cholestyramine powder 4 - 8gm pt has intolerance to MULTIPLE statins. Note BID OR Colestid (colestipol) 1gm tablets 2- that zetia is not recommended to use in 4gm BID OR if a statin is not already being combination with gemfibrozil. The effects of used, consider Lovastatin 20-40mg QPM Ezetimibe on cardiovascular morbidity and OR Simvastatin 20mg QHS mortality have not been established. Zetia is expected to lower LDL 15 -20% compared to statins that can lower LDL 30-60%. Zetia is no more effective than BAS therapy in lowering cholesterol. Adding Zetia to statin therapy may be appropriate if max dose statin plus niacin or BAS was ineffective OR if pt is not appropriate candidate for niacin or BAS OR if pt has intolerance to simvastatin or Vytorin. Vytorin is preferred over use of zetia plus statin as separate prescriptions. All other Vytorin doses other than 10/80 mg are non-formulary. For questions, consider calling Pharmacy Cardiac Risk Service at 770-496-3560 between 830AM and 530PM.
Zoloft (Sertraline) tab 25-100 mg QD Prozac caps 10-40 mg QD or Celexa Prozac is the preferred agent. Initiation of low- (Citalopram) 20-40mg QD or Sertraline 25 - dose Prozac with dosage titration to desired 100mg QD (added to formulary Mar 8th response is suggested. Document response to 2007) all formulary SSRI alternatives before prescribing a NF SSRI. Document reason, when patient is medically unable to convert to Formulary alternative.
Zofran (Ondansetron) tabs 4mg-8mg BID & Zofran Limited to 14 day supply per prescription, Zofran oral liquid & IV available via pediatric (ondansetron) ODT 4mg-8mg per 30 days floorstock for in office dose to break pediatric n/v cycle & allow hydration in children unable to use phenergan safely (headache (Maxalt MLT 5mg tablet is also available) limit of 9 tablets/copay. If failed a trial on Maxalt MLT consider formulary alternative Imitrex 50 mg tablets (qty limit of 9 tablets/copay), nasal, or injectable dosage forms. Quantity limit for Non- formulary Zomig 5mg is 3 tablets per copay; for Zomig 2.5mg it's 6 tablets per copay.
Zomig (Zolmitriptan) 5mg Nasal Spray Maxalt (Rizatriptan) MLT 10mg orally Imitrex 20 mg nasal spray is significantly more disintegrating tablet (Maxalt MLT 5mg effective than Imitrex 5 mg nasal spray. The tablet is also available) QTY limit of 9 same precautions and contraindications apply for tablets/copay OR, if both strengths of nasal spray. Maximum nasal spray required, Imitrex 20mg Nasal prescription quantity for Imitrex 20 mg spray is 6 Spray bottles/prescription. Zonegran (Zonisamide) tab Neurontin (gabapentin), Topamax Adjunctive therapy for partial seizures in adults > (topiramate), Tranxene (clorazepate), 16 yrs of age. Lamictal 25mg oral tablets are non- Tegretol (carbamazepine), Lamotrigine 5- formulary as of 3/22/07; if a 25mg dose is 25mg chews and Lamictal 100mg-200mg required, Lamotrigine chewables are preferred. oral tablets
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Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review)
Zovirax 5% ointment 6 times per day x 7 days TSPMG clinical practice resource Principles and Practice of Infectious Disease encourages treatment with oral Acyclovir "discourages use of topical acyclovir" stating that (generic Zovirax) tab. 1st episode Herpes it "offers no significant clinical benefit in HSV simplex: 400mg TID x 7-10 days, infections" Acyclovir ointment is ineffective in recurrence 800mg BID x 5 days, treatment or prevention of herpes labialis. suppression 400mg BID titrate to lowest Consider OTC Abreva ( shortened the course by effective dose. Herpes Zoster: acyclovir 18 hours) or Carmex or Orabase for herpes 800mg 5 times per day x 7-10 days. labialis to prevent drying and fissuring. Domoboro soaks may relieve itching and dry blisters. Consider OTC Capsaicin cream for pain associated with shingles. Zyban (Bupropion SR) 150mg OTC Nicotrol (Nicotine transdermal system) Smoking cessation products are non formulary 5, 10, 15mg/day Zyflo tab 600 mg QID ICS inhaler (QVAR or *Flovent or *Flovent 110mcg/puff & 220mcg/puff are non- Asmanex) plus a long acting B2-agonist formulary . (Serevent) OR an ICS and B2 agonist Zylet (loteprednol etabonate 0.5% / tobramycin 0.3%) Tobramycin 0.3% ophth drops PLUS either: Post op inflammation (when steroids not desired): ophthalmic suspension Dexamethasone 0.1% ophth soln or Voltaren 0.1% ophth soln [Loteprednol 0.5% Prednisolone 0.12%-1% ophth soln or (Lotemax) less effective than Prednisolone Flarex, FML (Fluorometholone) ophth soln Acetate 1% in treatment of acute anterior uveitis] 0.1% i-ii drops in affected eye(s) QID
Zyprexa zydis (Olanzapine) orally disintegrating tabs Seroquel (quetiapine) or Zyprexa Consider using 1/2 tablet dosing whenever 5, 10, 15, 20mg (olanzapine) 2.5, 5, 7.5, 10, 15mg tabs or appropriate (eg. Seroquel 200mg 1/2 tablet for Risperdal (risperidone) Seroquel 100mg dose or Risperdal 1mg 1/2 tablet for Risperdal 0.5mg dose.) Zyrtec tab 5 -10 mg QD Claritin and Zyrtec available OTC. Nasarel ii Intranasal steroids (Nasarel or Flonase) more spray per nostril BID or generic Flonase effective than nonsedating antihistamines for (fluticasone) 1SP EN QD allergic rhinitis.
Zyrtec-D 5/120MG Claritin D and Zyrtec D available OTC. Intranasal steroids (Nasarel or Flonase) more Nasarel ii spray per nostril BID or generic effective than nonsedating antihistamines for Flonase (fluticasone) 1SP EN QD allergic rhinitis. Zyrtec-D is excluded from the benefit because pseudoephedrine is available OTC.
Zyrtec syrup Claritin and Zyrtec syrups available OTC. Intranasal steroids (Nasarel or Flonase) more effective than nonsedating antihistamines for allergic rhinitis.
zzPrepared: February 8, 1998 Beth Barham, Pharm.D. zzUpdated: April 10, 2000 Theresa Betteker, Pharm.D zzUpdated: August 18, 1999 Beth Barham, Pharm.D. zzUpdated: August 18, 1999 Beth Barham, Pharm.D. zzUpdated: December 7, 1999 Beth Barham, Pharm.D. zzUpdated: July 25, 2001 Debbi Baker, Pharm. D. zzUpdated: August 14, 2001 Debbi Baker, Pharm. D. zzUpdated: September 13, 2001 Debbi Baker, Pharm. D. zzUpdated: October 31, 2001 Debbi Baker, Pharm. D. zzUpdated: November 21, 2001 Debbi Baker, Pharm. D. zzUpdated: January 8, 2002 Beth Barham, Pharm.D. zzUpdated: April 10, 2002 Debbi Baker, Pharm. D. zzUpdated: April 22, 2002 Debbi Baker, Pharm. D. zzUpdated: June 19, 2002 Debbi Baker, Pharm. D. zzUpdated: July 22, 2002 Debbi Baker, Pharm. D. zzUpdated: September 13, 2001 Debbi Baker, Pharm. D. zzupdated: December 11, 2002 Debbi Baker, Pharm. D. zzUpdated: January 8, 2003 Debbi Baker, Pharm. D. zzUpdated: March 26, 2003 Debbi Baker, Pharm. D.
Page 74 Non-formulary conversion document 02.08.xls Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s) Comments No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) zzUpdated: July 11, 2003 Debbi Baker, Pharm. D. zzUpdated: July 18, 2003 Debbi Baker, Pharm. D. zzUpdated: September 26, 2003 Debbi Baker, Pharm. D. zzUpdated: October 22, 2003 Debbi Baker, Pharm. D. zzUpdated: November 12, 2003 Debbi Baker, Pharm. D. zzUpdated: December 2, 2003 Debbi Baker, Pharm. D. zzUpdated: February 10, 2004 Debbi Baker, Pharm. D. zzUpdated: February 27, 2004 Debbi Baker, Pharm. D. zzUpdated: March 15, 2004 Debbi Baker, Pharm. D. zzUpdated: April 19, 2004 Debbi Baker, Pharm. D. zzUpdated: May 14,2004 Debbi Baker, Pharm. D. zzUpdated: July 13, 2004 Debbi Baker, Pharm. D. zzUpdated: September 15, 2004 Debbi Baker, Pharm. D. zzUpdated: October 19, 2004 Debbi Baker, Pharm. D. zzUpdated: November 12, 2004 Debbi Baker, Pharm. D. zzUpdated: December 20, 2004 Debbi Baker, Pharm. D. zzUpdated: January 25, 2005 Debbi Baker, Pharm. D. zzUpdated: February 15, 2005 Debbi Baker, Pharm. D. zzUpdated: March 31, 2005 Debbi Baker, Pharm. D. zzUpdated: May 20,2005 Debbi Baker, Pharm. D. zzUpdated: June 7, 2005 Debbi Baker, Pharm. D. zzUpdated: July 7, 2005 Debbi Baker, Pharm. D. zzUpdated: July 11, 2005 Elizabeth Flores, Pharm.D. zzUpdated: July 21, 2005 Elizabeth Flores, Pharm.D. zzUpdated: August 15,2005 Phyllis Lockridge, Pharm.D. zzUpdated: August 25, 2005 Jacinda Byrd-Smith, Pharm. D. zzUpdated: September 14,2005 Debbi Baker, Pharm. D. zzUpdated: September 21,2005 Phyllis Lockridge, Pharm.D. zzUpdated: September 27,2005 Phyllis Lockridge, Pharm.D. zzUpdaated: January 25, 2006 Phyllis Lockridge, Pharm.D. zzUpdated: March 1, 2006 Phyllis Lockridge, Pharm.D. zzUpdated: June ***, 2006 Pat daCosta, Pharm.D. zzUpdated: August 21, 2006 Pat daCosta, Pharm.D. zzUpdated: December 7, 2006 Pat daCosta, Pharm.D. zzUpdated: February 21, 2007 Pat daCosta, Pharm.D. zzUpdated: March 16, 2007 Pat daCosta, Pharm.D. zzUpdated: May 29, 2007 Pat daCosta, Pharm.D. zzUpdated: August 22, 2007 Charnelda Gray, Pharm.D., BCPS zzUpdated: December 5, 2007 Charnelda Gray, Pharm.D., BCPS zzUpdated: February 25, 2008 Dionne Maddox, Pharm.D.
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