Multi-Choice Formulary

KAISER PERMANENTE OF GEORGIA

MULTI-CHOICE FORMULARY

This document includes Kaiser Permanente Georgia’s Multi- Choice formulary as of September 17, 2014. For an updated formulary, please visit our website at members.kp.org or call 1-888-865-5813, Monday through Friday 7:00 a.m. to 7:00 p.m. TTY/TDD users should call 1-800-255-0056. What is the Kaiser Permanente 5813, Monday through Friday 7:00 a.m. to MultiChoice Formulary? 7:00 p.m. TTY/TDD users should call 1-800- A formulary is a list of drugs determined to 255-0056. be safe and effective for our members by our Pharmacy and Therapeutics How do I use the Formulary? There are two easy ways to find your drug committee. Use of the formulary enables within the formulary: Kaiser Permanente to provide optimal care to you and your family at reasonable costs. Medical Condition Kaiser Permanente continually updates the The drug list begins on page 4. The drugs formulary throughout the year based on on this formulary are grouped into new medical evidence, considering the categories depending on the type of recommendations of appropriate physician medical condition that they are used to experts. Our physicians and pharmacists treat. For example, drugs used to treat a work closely together to ensure that our heart condition are listed under the formulary meets your needs. category, “Cardiovascular Drugs.” If you know what your drug is used for, simply This formulary is only for use at PPO look for the category name in the list that Provider (Tier 2) and Non-Participating begins on page 4. Then look under the Provider (Tier 3) pharmacies. To see which category name for your drug. medications are covered at a Select Provider (Tier 1) pharmacy, please Alphabetical Listing reference the Kaiser Permanente HMO If you are not sure what category to look Formulary. under, you can look for the drug in the Index that begins on page 40. The Index Does the formulary ever change? provides an alphabetical list of all of the Yes, Kaiser Permanente periodically drugs included in this document. Both updates the formulary based on new brand-name drugs and generic drugs are medical evidence, considering the listed in the Index. Look in the Index and recommendations of appropriate physician find your drug. Next to the drug, you will experts and notifies our doctors, see the page number where you can find pharmacists, and other clinicians about any coverage information. Turn to the page changes. If a change in the formulary listed in the Index and find the name of affects any of your prescriptions, your your drug on the list. You may also use the doctor or pharmacist will let you know. search function on your computer to The enclosed formulary is current as of search this document for the medication September 17, 2014 and represents the by name. most commonly prescribed medications.

To get updated information about the drugs covered by Kaiser Permanente, please visit our website at members.kp.org or call Member Services at 1-888-865-

• Age Restriction (Age): For certain For more information drugs, Kaiser Permanente limits For more detailed information about your coverage based on a designated age. Kaiser Permanente prescription drug coverage, please review your Evidence of • Criteria Restricted Medication (QRM): Coverage and other plan materials. For certain drugs, Kaiser Permanente requires review and authorization prior If you have questions about Kaiser to dispensing. Your Provider must Permanente, please call Member Services obtain this review and authorization. at 1-888-865-5813, Monday through Friday The list of prescription drugs requiring 7:00 a.m. to 7 p.m. TTY/TDD users should review and authorization is subject to call 1-800-255-0056. periodic review and modification by our Or visit members.kp.org. Pharmacy and Therapeutics Committee.

You can find out if the drug has any additional requirements or limits by looking in the formulary that begins on page 4.

*Multi-Choice Formulary is for medications covered at Network Pharmacies. Please see HMO Formulary for medications covered at KP Pharmacies* **All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.** Kaiser Permanente of Georgia Multi Choice Formulary 3 Kaiser Permanente of Georgia Multi Choice Formulary ST = Step Therapy, QRM = Physician Review, QL = Quantity Limit, Age = Age Restriction Restrictions Tier Generic Name Brand Name Coverage Status Antihistamine Drugs Antihitamine Drugs 1 carbinoxamine maleate PALGIC Generic 1 cyproheptadine PERIACTIN Generic chlorphenirmine, phenylephrine & 1 POLY HIST FORTE Generic pyrilamine 1 promethazine & phenylephrine PHENERGAN VC Generic QL 1 promethazine PHENERGAN Generic Anti-infective Agents Anthelmintics 2 albendazole ALBENZA Preferred Brand 3 ivermectin STROMECTOL Non-Preferred Anti-infetives, Miscellaneous 3 bismuth subcitrate & metronidazole PYLERA Non-Preferred metronidazole, tetracycline & bismuth 3 HELIDAC Non-Preferred subsalicylate Antibacterials 1 amoxicillin AMOXIL Generic 1 amoxicillin & clavulanate potassium AUGMENTIN Generic amoxicillin & clavulanate potassium 1 AUGMENTIN XR Generic extended-release 1 ampicillin sodium AMPICILLIN Generic 1 azithromycin ZITHROMAX Generic 1 cefaclor CECLOR Generic 1 cefadroxil DURICEF Generic 1 cefdinir OMNICEF Generic 1 cefditoren SPECTRACEF Generic 3 cefixime SUPRAX Non-Preferred 1 cefpodoxime VANTIN Generic 1 cefprozil CEFZIL Generic 3 ceftibuten CEDAX Non-Preferred 1 cefuroxime axetil CEFTIN Generic 1 cephalexin KEFLEX Generic 1 ciprofloxacin CIPRO Generic 1 clarithromycin BIAXIN Generic 1 clarithromycin extended-release BIAXIN XL Generic 1 clindamycin hcl CLEOCIN HCL Generic 1 clindamycin palmitate CLEOCIN PEDIATRIC Generic 1 demeclocycline DECLOMYCIN Generic 1 dicloxacillin DYNAPEN Generic 3 doxycycline ORACEA Non-Preferred 1 doxycycline hyclate PERIOSTAT Generic 3 doxycycline hyclate DORYX Non-Preferred 1 doxycycline monohydrate ADOXA Generic 1 doxycycline monohydrate MONODOX Generic 1 erythromycin & sulfisoxazole E.S.P Generic 1 erythromycin base ERYTHROMYCIN Generic *Multi-Choice Formulary is for medications covered at Network Pharmacies. Please see HMO Formulary for medications covered at KP Pharmacies* **All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.** Kaiser Permanente of Georgia Multi Choice Formulary 4 Kaiser Permanente of Georgia Multi Choice Formulary ST = Step Therapy, QRM = Physician Review, QL = Quantity Limit, Age = Age Restriction Restrictions Tier Generic Name Brand Name Coverage Status 1 erythromycin base delayed-release ERY-TAB Generic 1 erythromycin ethylsuccinate E.E.S. Generic 3 erythromycin ethylsuccinate ERYPED Non-Preferred 3 erythromycin sterate ERYTHROCIN Non-Preferred 3 fidaxomicin DIFICID Non-Preferred 3 gemifloxacin FACTIVE Non-Preferred 1 gentamicin sulfate GARAMYCIN Generic 1 levofloxacin LEVAQUIN Generic 2 linezolid ZYVOX Preferred Brand 1 minocycline DYNACIN Generic 1 minocycline MINOCIN Generic 1 minocycline SOLODYN Generic 1 moxifloxacin AVELOX Generic 1 neomycin sulfate MYCIFRADIN Generic 3 norfloxacin NOROXIN Non-Preferred 1 penicillin v potassium PEN-VEE K Generic 3 rifaximin XIFAXAN Non-Preferred 1 sulfadiazine SULFADIAZINE Generic 1 sulfamethoxazole & trimethoprim BACTRIM DS Generic 1 sulfamethoxazole & trimethoprim SEPTRA Generic 1 sulfasalazine AZULFIDINE Generic 3 telithromycin KETEK Non-Preferred 3 tetracycline TETRACYCLINE Non-Preferred 3 tobramycin inhalation powder TOBI PODHALER Non-Preferred 1 tobramycin inhalation solution TOBI Generic 1 vancomycin hcl VANCOCIN HCL Generic Antifungals QL 1 fluconazole DIFLUCAN Generic 1 flucytosine ANCOBON Generic 1 griseofulvin microsize GRIFULVIN V Generic 1 griseofulvin ultramicrosize GRIS-PEG Generic 1 itraconazole SPORANOX Generic 2 itraconazole (solution) SPORANOX Preferred Brand 1 ketoconazole NIZORAL Generic 1 nystatin MYCOSTATIN Generic 3 posaconazole NOXAFIL Non-Preferred 1 terbinafine LAMISIL Generic 1 voriconazole VFEND Generic Antimycobacterials 1 cycloserine SEROMYCIN Generic 1 dapsone AVLOSULFON Generic 1 ethambutol MYAMBUTOL Generic 1 isoniazid NYDRAZID Generic 1 pyrazinamide PYRAZINAMIDE Generic 1 rifabutin MYCOBUTIN Generic 1 rifampin RIFADIN Generic 1 rifampin & isoniazid RIFAMATE Generic *Multi-Choice Formulary is for medications covered at Network Pharmacies. Please see HMO Formulary for medications covered at KP Pharmacies* **All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.** Kaiser Permanente of Georgia Multi Choice Formulary 5 Kaiser Permanente of Georgia Multi Choice Formulary ST = Step Therapy, QRM = Physician Review, QL = Quantity Limit, Age = Age Restriction Restrictions Tier Generic Name Brand Name Coverage Status 3 rifapentine PRIFTIN Non-Preferred Antiprotozoals 1 atovaquone MEPRON Generic 1 atovaquone & proguanil MALARONE Generic 1 chloroquine phosphate ARALEN Generic 1 hydroxychloroquine sulfate PLAQUENIL Generic 1 mefloquine LARIAM Generic 1 metronidazole FLAGYL Generic 3 metronidazoleextended-release FLAGYL ER Non-Preferred 3 nitazoxanide ALINIA Non-Preferred 1 paromomycin sulfate HUMATIN Generic 2 primaquine phosphate PRIMAQUINE Preferred Brand 2 pyrimethamine DARAPRIM Preferred Brand 1 quinine sulfate QUALAQUIN Generic Antiviral QL 2 abacavir sulfate & lamivudine EPZICOM Preferred Brand QL 2 abacavir sulfate solution ZIAGEN Preferred Brand QL 1 abacavir sulfate tablet ZIAGEN Generic QL 1 abacavir, lamivudine & zidovudine TRIZIVIR Generic 1 acyclovir ZOVIRAX Generic QL 1 adefovir dipivoxil HEPSERA Generic QL 2 atazanavir sulfate REYATAZ Preferred Brand QL 3 boceprevir VICTRELIS Non-Preferred QL 2 darunavir ethanolate PREZISTA Preferred Brand QL 2 delavirdine mesylate RESCRIPTOR Preferred Brand QL 1 didanosine VIDEX EC Generic QL 2 didanosine solution VIDEX Preferred Brand 3 dolutegravir TIVICAY Non-Preferred QL 2 efavirenz SUSTIVA Preferred Brand QL 2 efavirenz, emtricitab & tenofovir ATRIPLA Preferred Brand elvitegravir, cobicistat, emtricitabine, 2 STRIBILD Preferred Brand QL & tenofovir QL 2 emtricitabine EMTRIVA Preferred Brand QL 2 emtricitabine & tenofovir TRUVADA Preferred Brand QL 2 emtricitabine, rilpivirine, & tenofovir COMPLERA Preferred Brand QL 2 enfuvirtide FUZEON Preferred Brand QL 3 entecavir BARACLUDE Non-Preferred QL 2 etravirine INTELENCE Preferred Brand 1 famciclovir FAMVIR Generic QL 2 fosamprenavir calcium LEXIVA Preferred Brand 1 ganciclovir CYTOVENE Generic QL 2 indinavir sulfate CRIXIVAN Preferred Brand 3 interferon alfacon-1 INFERGEN Non-Preferred QL 3 lamivudine EPIVIR HBV Non-Preferred QL 1 lamivudine EPIVIR Generic QL 1 lamivudine & zidovudine COMBIVIR Generic QL 2 lopinavir & ritonavir KALETRA Preferred Brand *Multi-Choice Formulary is for medications covered at Network Pharmacies. Please see HMO Formulary for medications covered at KP Pharmacies* **All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.** Kaiser Permanente of Georgia Multi Choice Formulary 6 Kaiser Permanente of Georgia Multi Choice Formulary ST = Step Therapy, QRM = Physician Review, QL = Quantity Limit, Age = Age Restriction Restrictions Tier Generic Name Brand Name Coverage Status QL 2 maraviroc SELZENTRY Preferred Brand QL 2 nelfinavir mesylate VIRACEPT Preferred Brand QL 1 nevirapine solution VIRAMUNE Generic QL 1 nevirapine tablet VIRAMUNE Generic QL 2 oseltamivir phosphate TAMIFLU Preferred Brand 3 palivizumab SYNAGIS Non-Preferred QL 2 peginterferon alfa-2a PEGASYS Preferred Brand 2 peginterferon-alfa 2b PEG-INTRON Preferred Brand QL 2 raltegravir ISENTRESS Preferred Brand 1 ribavirin REBETOL Generic QL 3 rilpivirine EDURANT Non-Preferred QL 1 rimantadine FLUMADINE Generic QL 2 ritonavir NORVIR Preferred Brand QL 2 saquinavir mesylate INVIRASE Preferred Brand QL 3 simeprevir OLYSIO Non-Preferred QL 3 sofusbuvir SOVALDI Non-Preferred QL 1 stavudine ZERIT Generic QL 3 telaprevir INCIVEK Non-Preferred QL 3 tenofovir VIREAD Non-Preferred QL 2 tipranavir APTIVUS Preferred Brand 1 valacyclovir VALTREX Generic 3 valganciclovir VALCYTE Non-Preferred QL 2 zanamivir RELENZA Preferred Brand QL 1 zidovudine RETROVIR Generic Urinary Antiinfectives 1 methenamine hippurate HIPREX Generic methenamine, sodium biphosphate, 3 phenyl salicylate, methylene blue, URELLE Non-Preferred and hyoscyamine 2 nitrofurantoin FURADANTIN Preferred Brand 1 nitrofurantoin macrocrystal MACRODANTIN Generic 1 nitrofurantoin monohydrate MACROBID Generic 1 trimethoprim PROLOPRIM Generic Antineoplastic Agents Antineoplastic Agents 2 abiraterone ZYTIGA Preferred Brand 1 anastrozole ARIMIDEX Generic 3 axitinib INLYTA Non-Preferred 2 bexarotene TARGRETIN Preferred Brand 1 bicalutamide CASODEX Generic 3 bosutinib BOSULIF Non-Preferred 2 busulfan MYLERAN Preferred Brand 1 capecitabine XELODA Generic 3 ceritinib ZYKADIA Non-Preferred 2 chlorambucil LEUKERAN Preferred Brand 2 crizotinib XALKORI Preferred Brand 1 cyclophosphamide CYTOXAN Generic *Multi-Choice Formulary is for medications covered at Network Pharmacies. Please see HMO Formulary for medications covered at KP Pharmacies* **All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.** Kaiser Permanente of Georgia Multi Choice Formulary 7 Kaiser Permanente of Georgia Multi Choice Formulary ST = Step Therapy, QRM = Physician Review, QL = Quantity Limit, Age = Age Restriction Restrictions Tier Generic Name Brand Name Coverage Status 2 dasatinib SPRYCEL Preferred Brand 3 enzalutamide XTANDI Non-Preferred 2 erlotinib TARCEVA Preferred Brand 2 estramustine EMCYT Preferred Brand 2 everolimus AFINITOR Preferred Brand 1 exemestane AROMASIN Generic 1 flutamide EULEXIN Generic 2 hydroxyurea DROXIA Preferred Brand 1 hydroxyurea HYDREA Generic QRM 3 ibrutinib IMBRUVICA Non-Preferred 2 imatinib mesylate GLEEVEC Preferred Brand 2 lapatinib TYKERB Preferred Brand 2 lenalidomide REVLIMID Preferred Brand 1 letrozole FEMARA Generic 1 leuprolide acetate LUPRON Generic 3 lomustine CEENU Non-Preferred 2 melphalan ALKERAN Preferred Brand 1 mercaptopurine PURINETHOL Generic 1 methotrexate sodium RHEUMATREX Generic 3 methotrexate sodium TREXALL Non-Preferred 2 mitotane LYSODREN Preferred Brand 2 nilotinib TASIGNA Preferred Brand 2 pazopanib VOTRIENT Preferred Brand QRM 3 pomalidomide POMALYST Non-Preferred 3 ponatinib ICLUSIG Non-Preferred 2 procarbazine MATULANE Preferred Brand 3 ruxolitinib JAKAFI Non-Preferred 2 sorafenib tosylate NEXAVAR Preferred Brand 2 sunitinib malate SUTENT Preferred Brand 1 tamoxifen citrate NOLVADEX Generic 1 temozolomide TEMODAR Generic 2 thioguanine TABLOID Preferred Brand 2 topotecan HYCAMTIN Preferred Brand 1 tretinoin VESANOID Generic 2 vandetanib CAPRELSA Preferred Brand 2 vemurafenib ZELBORAF Preferred Brand 2 vorinostat ZOLINZA Preferred Brand Autonomic Drugs Anticholinergic Agents 1 atropine sulfate ATROPINE SULFATE Generic 1 dicyclomine BENTYL Generic 1 glycopyrrolate ROBINUL Generic 1 glycopyrrolate ROBINULFORTE Generic 1 hyoscyamine sulfate LEVBID Generic 1 hyoscyamine sulfate LEVSIN Generic 1 hyoscyamine sulfate SYMAX Generic 3 hyoscyamine sulfate SYMAX DUOTAB Non-Preferred *Multi-Choice Formulary is for medications covered at Network Pharmacies. Please see HMO Formulary for medications covered at KP Pharmacies* **All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.** Kaiser Permanente of Georgia Multi Choice Formulary 8 Kaiser Permanente of Georgia Multi Choice Formulary ST = Step Therapy, QRM = Physician Review, QL = Quantity Limit, Age = Age Restriction Restrictions Tier Generic Name Brand Name Coverage Status 1 ipratropium bromide ATROVENT Generic 2 ipratropium bromide ATROVENTHFA Preferred Brand 1 methscopolamine PAMINE Generic 1 propantheline bromide PRO-BANTHINE Generic 2 tiotropium SPIRIVA Preferred Brand Autonomic Drugs, Miscellaneous 3 varenicline CHANTIX Non-Preferred Parasympathomimetic (Cholinergic) Agents 1 bethanechol chloride URECHOLINE Generic 1 cevimeline hcl EVOXAC Generic 1 donepezil ARICEPT Generic 1 donepezil ARICEPT ODT Generic 1 galantamine hydrobromide RAZADYNE Generic 1 galantamine hydrobromide RAZADYNEER Generic 1 neostigmine bromide PROSTIGMIN Generic 1 pilocarpine SALAGEN Generic 2 pyridostigmine MESTION TIMESPAN Preferred Brand 1 pyridostigmine MESTION Generic 1 rivastigmine tartrate EXELON Generic 2 rivastigmine tartrate (solution) EXELON Preferred brand Skeletal Muscle Relaxants 1 baclofen LIORESAL Generic 1 carisoprodol SOMA Generic 1 carisoprodol/aspirin SOMA COMPOUND Generic 1 chlorzoxazone PARAFON FORTE DSC Generic 1 cyclobenzaprine FLEXERIL Generic 3 cyclobenzaprine extended-release AMRIX Non-Preferred 1 dantrolene sodium DANTRIUM Generic 1 metaxalone SKELAXIN Generic 1 methocarbamol ROBAXIN Generic 1 orphenadrine citrate NORFLEX Generic 1 orphenadrine, aspirin, & caffeine NORGESIC Generic 1 tizanidine ZANAFLEX Generic Sympatholytic (Adrenergic Blocking) Agents 1 alfuzosin hcl UROXATRAL Generic 1 dihydroergotamine mesylate D.H.E.45 Generic 2 dihydroergotamine mesylate MIGRANAL Preferred Brand 1 ergoloid mesylates HYDERGINE Generic 1 ergotamine & caffeine CAFERGOT Generic 3 phenoxybenzamine DIBENZYLINE Non-Preferred 3 silodosin RAPAFLO Non-Preferred 1 tamsulosin hcl FLOMAX Generic Sympathomimetic (Adrenergic) Agents 1 albuterol nebulizer solution ACCUNEB Generic 2 albuterol sulfate PROAIR HFA Preferred Brand 3 albuterol sulfate PROVENTIL HFA Non-Preferred 3 albuterol sulfate VENTOLIN HFA Non-Preferred *Multi-Choice Formulary is for medications covered at Network Pharmacies. Please see HMO Formulary for medications covered at KP Pharmacies* **All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.** Kaiser Permanente of Georgia Multi Choice Formulary 9 Kaiser Permanente of Georgia Multi Choice Formulary ST = Step Therapy, QRM = Physician Review, QL = Quantity Limit, Age = Age Restriction Restrictions Tier Generic Name Brand Name Coverage Status 1 albuterol sulfate tablet VOSPIRE ER Generic 2 albuterol sulfate & ipratropium COMBIVENT RESPIMAT Preferred Brand 1 albuterol sulfate & ipratropium DUONEB Generic 3 arformoterol BROVANA Non-Preferred 1 epinephrine ADRENACLICK Generic 3 epinephrine AUVI-Q Non-Preferred 3 epinephrine EPIPEN Non-Preferred 3 epinephrine EPIPEN JR Non-Preferred 3 epinephrine TWINJECT Non-Preferred 3 formoterol fumarate FORADIL Non-Preferred 1 levalbuterol nebulizer solution XOPENEX NEBULIZER Generic 3 levalbuterol tartrate XOPENEX HFA Non-Preferred 1 midodrine hcl PROAMATINE Generic 3 pirbuterol acetate MAXAIR AUTOHALER Non-Preferred 2 salmeterol SEREVENT DISKUS Preferred Brand 1 terbutaline sulfate BRETHINE Generic Blood Formation, Coagulation, and Thrombosis Coagulants and Anticoagulants 1 aminocaproic acid AMICAR Generic 1 anagrelide AGRYLIN Generic 3 apixaban ELIQUIS Non-Preferred 2 aspirin & dipyridamole AGGRENOX Preferred Brand 1 cilostazol PLETAL Generic 2 clopidogrel PLAVIX Generic QL 3 dabigatran PRADAXA Non-Preferred 3 dalteparin FRAGMIN Non-Preferred 1 dipyridamole PERSANTINE Generic 1 enoxaparin LOVENOX Generic 1 fondaparinux ARIXTRA Generic 1 heparin HEPARIN SODIUM Generic 1 pentoxifylline TRENTAL Generic QL 3 rivaroxaban XARELTO Non-Preferred 3 ticagrelor BRILINTA Non-Preferred 1 ticlopidine TICLID Generic 1 warfarin COUMADIN Generic Hematopoietic Agents 2 darbepoetin alfa ARANESP Preferred Brand QRM 3 eltrombopag PROMACTA Non-Preferred 2 epoetin alfa PROCRIT Preferred Brand 3 epoetin alfa EPOGEN Non-Preferred 2 filgrastim NEUPOGEN Preferred Brand 2 oprelvekin NEUMEGA Preferred Brand 3 pegfilgrastim NEULASTA Non-Preferred 2 sargramostim LEUKINE Preferred Brand Cardiovascular Drugs α-Adrenergic Blocking Agents 1 doxazosin CARDURA Generic *Multi-Choice Formulary is for medications covered at Network Pharmacies. Please see HMO Formulary for medications covered at KP Pharmacies* **All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.** Kaiser Permanente of Georgia Multi Choice Formulary 10 Kaiser Permanente of Georgia Multi Choice Formulary ST = Step Therapy, QRM = Physician Review, QL = Quantity Limit, Age = Age Restriction Restrictions Tier Generic Name Brand Name Coverage Status 1 prazosin MINIPRESS Generic 1 terazosin HYTRIN Generic Antilipemic Agents 1 atorvastatin LIPITOR Generic 1 cholestyramine light QUESTRAN LIGHT Generic 1 cholestyramine QUESTRAN Generic 3 colesevelam WELCHOL Non-Preferred 1 colestipol COLESTID Generic 3 ezetimibe ZETIA Non-Preferred 3 ezetimibe & simvastatin VYTORIN Non-Preferred 1 fenofibrate LOFIBRA TAB Generic 1 fenofibrate TRICOR Generic 1 fenofibrate, micronized LOFIBRA CAP Generic 1 fenofibric acid TRILIPIX Generic 3 fluvastatin extended-release LESCOL XL Non-Preferred 1 fluvastatin LESCOL Generic 1 gemfibrozil LOPID Generic QRM 3 lomitapide JUXTAPID Non-Preferred 1 lovastatin MEVACOR Generic 3 lovastatine extended-release ALTOPREV Non-Preferred QRM 3 mipomersen sodium KYNAMRO Non-Preferred 3 niacin NIASPAN Non-Preferred 3 niacin & lovastatin ADVICOR Non-Preferred 3 omega-3 acid ethyl esters LOVAZA Non-Preferred 3 omega-3-carboxylic acid EPANOVA Non-Preferred 3 pitavastatin LIVALO Non-Preferred 1 pravastatin PRAVACHOL Generic 3 rosuvastatin CRESTOR Non-Preferred 1 simvastatin ZOCOR Generic Calcium Channel Blocking Agents 1 amlodipine NORVASC Generic 1 amlodipine & benazepril LOTREL Generic 1 amlodipine & atorvastatin CADUET Generic 3 amlodipine & olmesartan AZOR Non-Preferred 3 amlodipine & valsartan EXFORGE Non-Preferred amlodipine, valsartan & 3 EXFORGE HCT Non-Preferred hydrochlorothiazide amlodipine, olmesartan & 3 TRIBENZOR Non-Preferred hydrochlorothiazide 1 diltiazem extended-release CARDIZEM CD Generic 1 diltiazem extended-release TIAZAC Generic 1 diltiazem extended-release CARTIA XT Generic 1 diltiazem extended-release CARDIZEM LA Generic 1 diltiazem CARDIZEM Generic 1 felodipine PLENDIL Generic 1 isradipine DYNACIRC Generic 3 isradipine DYNACIRC CR Non-Preferred *Multi-Choice Formulary is for medications covered at Network Pharmacies. Please see HMO Formulary for medications covered at KP Pharmacies* **All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.** Kaiser Permanente of Georgia Multi Choice Formulary 11 Kaiser Permanente of Georgia Multi Choice Formulary ST = Step Therapy, QRM = Physician Review, QL = Quantity Limit, Age = Age Restriction Restrictions Tier Generic Name Brand Name Coverage Status 1 nicardipine CARDENE Generic 1 nifedipine PROCARDIA Generic 1 nifedipine extended-release ADALAT CC Generic 1 nifedipine extended-release PROCARDIA XL Generic 1 nimodipine NIMOTOP Generic 3 nisoldipine SULAR Non-Preferred 1 Trandolapril & verapamil TARKA Generic 1 verapamil sustained-release cap VERELAN Generic 3 verapamil COVERA-HS Non-Preferred 1 verapamil extended-release cap VERELAN PM Generic 1 verapamil sustained-release cap CALAN SR Generic 1 verapamil sustained-release tab ISOPTIN SR Generic Cardiac Drugs 1 amiodarone PACERONE Generic 1 digoxin LANOXIN Generic 1 disopyramide NORPACE Generic 2 disopyramide controlled-release NORPACE CR Preferred Brand 2 dofetilide TIKOSYN Preferred Brand 3 dronedarone MULTAQ Non-Preferred 1 flecainide TAMBOCOR Generic 1 mexiletine MEXITIL Generic 1 propafenone RYTHMOL Generic 3 propafenone RYTHMOL SR Non-Preferred 1 quinidine gluconate QUINAGLUTE Generic 1 quinidine QUINIDINE SULFATE Generic QL 3 ranolazine RANEXA Non-Preferred Hypotensive Agents 1 clonidine extended-release KAPVAY Generic 1 clonidine CATAPRES Generic 1 clonidine transdermal CATAPRES-TTS Generic 1 guanfacine TENEX Generic 1 hydralazine APRESOLINE Generic 1 methyldopa ALDOMET Generic 1 methyldopa & hydrochlorothiazide ALDORIL-25 Generic 1 minoxidil LONITEN Generic 3 reserpine SERPASIL Non-Preferred Renin-Angiotensin-Aldosterone System Inhibitors 3 aliskiren TEKTURNA Non-Preferred aliskiren, amlodipine & 3 AMTURNIDE Non-Preferred hydrochlorothiazide 3 aliskiren & amlodipine TEKAMLO Non-Preferred 3 aliskiren & hydrochlorothiazide TEKTURNA HCT Non-Preferred 3 aliskiren & valsartan VALTURNA Non-Preferred 3 azilsartan EDARBI Non-Preferred 1 benazepril LOTENSIN Generic 1 benazepril & hydrochlorothiazide LOTENSIN HCT Generic 1 candesartan ATACAND Generic *Multi-Choice Formulary is for medications covered at Network Pharmacies. Please see HMO Formulary for medications covered at KP Pharmacies* **All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.** Kaiser Permanente of Georgia Multi Choice Formulary 12 Kaiser Permanente of Georgia Multi Choice Formulary ST = Step Therapy, QRM = Physician Review, QL = Quantity Limit, Age = Age Restriction Restrictions Tier Generic Name Brand Name Coverage Status 1 candesartan & hydrochlorothiazide ATACAND HCT Generic 1 captopril CAPOTEN Generic 1 captopril & hydrochlorothiazide CAPOZIDE Generic 1 enalapril VASOTEC Generic 1 enalapril & hydrochlorothiazide VASERETIC Generic 1 eplerenone INSPRA Generic 3 eprosartan TEVETEN Non-Preferred 3 eprosartan & hydrochlorothiazide TEVETEN Non-Preferred 1 fosinopril MONOPRIL Generic 1 fosinopril & hydrochlorothiazide MONOPRIL HCT Generic 1 irbesartan AVAPRO Generic 1 irbesartan & hydrochlorothiazide AVALIDE Generic 1 lisinopril ZESTRIL Generic 1 lisinopril & hydrochlorothiazide ZESTORETIC Generic 1 losartan COZAAR Generic 1 losartan & hydrochlorothiazide HYZAAR Generic 1 moexipril UNIVASC Generic 1 moexipril & hydrochlorothiazide UNIRETIC Generic 3 olmesartan BENICAR Non-Preferred 3 olmesartn & hydrochlorothiazide BENICAR HCT Non-Preferred 1 perindopril ACEON Generic 1 quinapril hcl ACCUPRIL Generic 1 quinapril & hydrochlorothiazide ACCURETIC Generic 1 ramipril ALTACE Generic 1 spironolactone & hydrochlorothiazide ALDACTAZIDE Generic 1 spironolactone ALDACTONE Generic 1 telmisartan MICARDIS Generic 1 telmisartan & hydrochlorothiazide MICARDIS HCT Generic 1 trandolapril MAVIK Generic 1 valsartan DIOVAN Generic 1 valsartan & hydrochlorothiazide DIOVAN HCT Generic Vasodilating Agents 2 ambrisentan LETAIRIS Preferred Brand 2 bosentan TRACLEER Preferred Brand 3 isosorbide dinitrate & hydralazine BIDIL Non-Preferred 1 isosorbide dinitrate ISORDIL Generic 1 isosorbide mononitrate IMDUR Generic 2 macitentan OPSUMIT Preferred Brand 3 nitroglycerin aerosol NITROMIST Non-Preferred 1 nitroglycerin solution NITROLINGUAL Generic 2 nitroglycerin subligual NITROSTAT Preferred Brand 2 nitroglycerin topical ointment NITRO-BID Preferred Brand Excludes 0.8mg 1 nitroglycerin transdermal patch NITRO-DUR Generic strength

*Multi-Choice Formulary is for medications covered at Network Pharmacies. Please see HMO Formulary for medications covered at KP Pharmacies* **All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.** Kaiser Permanente of Georgia Multi Choice Formulary 14 Kaiser Permanente of Georgia Multi Choice Formulary ST = Step Therapy, QRM = Physician Review, QL = Quantity Limit, Age = Age Restriction Restrictions Tier Generic Name Brand Name Coverage Status butalbital, acetaminophen, caffeine, 1 FIORICET W/ CODEINE Generic & codeine 1 butalbital, aspirin, & caffeine FIORINAL Generic 1 butalbital, aspirin, caffeine, & codeine FIORINAL W/ CODEINE Generic 1 butorphanol tartrate STADOL Generic SOMA COMPOUND W/ 1 carisoprodol, aspirin, & codeine Generic CODEINE 3 celecoxib CELEBREX Non-Preferred 1 codeine CODEINE SULF Generic 1 diclofenac potassium CATAFLAM Generic 1 diclofenac sodium VOLTAREN Generic 1 diclofenac sodium PENNSAID Generic 2 diclofenac sodium & misoprostol ARTHROTEC Generic 1 diclofenac sodium extended release VOLTAREN XR Generic 1 diflunisal DIFLUNISAL Generic 1 etodolac LODINE Generic 3 fenoprofen calcium NALFON Non-Preferred 3 fentanyl film ONSOLIS Non-Preferred 3 fentanyl intranasal LAZANDA Non-Preferred 1 fentanyl lozenge ACTIQ Generic 3 fentanyl sublingual ABSTRAL Non-Preferred 3 fentanyl tablet FENTORA Non-Preferred QL 1 fentanyl transdermal DURAGESIC Generic 1 flurbiprofen ANSAID Generic 3 hydrocodone ZOHYDRO ER Non-Preferred 1 hydrocodone & acetaminophen NORCO Generic 1 hydrocodone & ibuprofen VICOPROFEN Generic 3 hydromorphone oral suspension DILAUDID Non-Preferred 1 hydromorphone tablet DILAUDID Generic 3 hydromorphone tablet EXALGO Non-Preferred 1 ibuprofen MOTRIN Generic 1 indomethacin INDOCIN Generic 1 ketoprofen KETOPROFEN Generic QL 1 ketorolac tablet TORADOL Generic 1 levorphanol LEVO-DROMORAN Generic 1 meclofenamate MECLOMEN Generic QL 1 mefenamic acid PONSTEL Generic 1 meloxicam MOBIC Generic 1 meperidine tablet DEMEROL Generic 1 methadone DOLOPHINE Generic 2 morphine MORPHINE SULFATE Preferred Brand 1 morphine MSIR Generic 3 morphine beads AVINZA Non-Preferred 3 morphine extended-relase capsule KADIAN Non-Preferred 1 morphine extended-release tablet MS CONTIN Generic 1 nabumetone RELAFEN Generic 1 nalbuphine NUBAIN Generic *Multi-Choice Formulary is for medications covered at Network Pharmacies. Please see HMO Formulary for medications covered at KP Pharmacies* **All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.** Kaiser Permanente of Georgia Multi Choice Formulary 15 Kaiser Permanente of Georgia Multi Choice Formulary ST = Step Therapy, QRM = Physician Review, QL = Quantity Limit, Age = Age Restriction Restrictions Tier Generic Name Brand Name Coverage Status 1 naproxen NAPROSYN Generic 1 naproxen sodium ANAPROX Generic 3 naproxen sodium NAPRELAN Non-Preferred 1 opium & belladonna alkaloids B & O SUPPRETTES Generic 3 opium tincture OPIUM Non-Preferred 1 oxaprozin DAYPRO Generic 1 oxycodone ROXICODONE Generic 1 oxycodone & acetaminophen PERCOCET Generic 2 oxycodone & acetaminophen ROXICET Preferred Brand 1 oxycodone & aspirin PERCODAN Generic QL 3 oxycodone & ibuprofen COMBUNOX Non-Preferred QL 3 oxycodone controlled-release OXYCONTIN Non-Preferred 3 oxymorphone OPANA Non-Preferred 3 oxymorphone extended-release OPANA ER Non-Preferred 1 pentazocine & naloxone TALWIN NX Generic 1 piroxicam FELDENE Generic 1 salsalate DISALCID Generic 1 sulindac CLINORIL Generic QL 3 tapentadol NUCYNTA Non-Preferred 1 tolmetin sodium TOLECTIN 600 Generic 1 tramadol ULTRAM Generic 1 tramadol & acetaminophen ULTRACET Generic 1 tramadol extended-release ULTRAM ER Generic Anorexigenic Agents and Respiratory and Cerebral Stimulants 1 amphetamine & dextroamphetamine ADDERALL Generic amphetamine & dextroamphetamine 1 ADDERALL XR Generic extended-release QL 3 armodafinil NUVIGIL Non-Preferred QL 1 dexmethylphenidate FOCALIN Generic dexmethylphenidate extended- 3 FOCALIN XR Non-Preferred release QL 1 dextroamphetamine sulfate DEXTROSTAT Generic dextroamphetamine sulfate 1 DEXEDRINE Generic QL extended-release 3 lisdexamfetamine VYVANSE Non-Preferred 1 methamphetamine DESOXYN Generic 1 methylphenidate METHYLIN Generic 1 methylphenidate RITALIN Generic QL 1 methylphenidate extended-release METADATE ER Generic QL 1 methylphenidate extended-release CONCERTA Generic 1 methylphenidate extended-release METADATE CD Generic QL 3 methylphenidate extended-release RITALIN LA Non-Preferred QL 1 methylphenidate sustained release RITALIN SR Generic QL 3 methylphenidate transdermal patch DAYTRANA Non-Preferred QL 1 modafinil PROVIGIL Generic Anticonvulsants 1 carbamazepine TEGRETOL Generic *Multi-Choice Formulary is for medications covered at Network Pharmacies. Please see HMO Formulary for medications covered at KP Pharmacies* **All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.** Kaiser Permanente of Georgia Multi Choice Formulary 16 Kaiser Permanente of Georgia Multi Choice Formulary ST = Step Therapy, QRM = Physician Review, QL = Quantity Limit, Age = Age Restriction Restrictions Tier Generic Name Brand Name Coverage Status 1 carbamazepine extended-release cap CARBATROL Generic 3 carbamazepine extended-release cap EQUETRO Non-Preferred 3 carbamazepine extended-release tab TEGRETOL XR Non-Preferred 3 clobazam ONFI Non-Preferred 1 clonazepam KLONOPIN Generic 1 diazepam DIASTAT Generic 2 diazepam DIASTAT ACUDIAL Preferred Brand 1 divalproex sodium DEPAKOTE Generic 1 divalproex sodium capsule DEPAKOTE SPRINKLE Generic 1 divalproex sodium extended release DEPAKOTE ER Generic 3 eslicarbazepine APTIOM Non-Preferred 3 ethontoin PEGANONE Non-Preferred 1 ethosuximide ZARONTIN Generic 3 ezogaine POTIGA Non-Preferred 1 felbamate FELBATOL Generic 1 gabapentin NEURONTIN Generic QL 3 lacosamide VIMPAT Non-Preferred 1 lamotrigine LAMICTAL Generic 1 lamotrigine extended-release LAMICTAL XR Generic 1 levetiracetam KEPPRA Generic 1 levetiracetam extended-release KEPPRA XR Generic 2 methsuximide CELONTIN Preferred Brand 1 oxcarbazepine TRILEPTAL Generic 3 perampanel FYCOMPA Non-Preferred 1 phenytoin sodium extended-release DILANTIN Generic 1 phenytoin sodium extended-release PHENYTEK Generic 1 phenytoin suspension DILANTIN Generic 3 pregabalin LYRICA Non-Preferred 1 primidone MYSOLINE Generic 3 rufinamide BANZEL Non-Preferred 1 tiagabine GABITRIL Generic 1 topiramate capsule TOPAMAX SPRINKLE Generic 1 topiramate tablet TOPAMAX Generic 1 valproate sodium DEPAKENE Generic 1 valproic acid DEPAKENE Generic QRM 3 vigabatrin SABRIL Non-Preferred 1 zonisamide ZONEGRAN Generic Antimigraine Agents QL 3 almotriptan AXERT Non-Preferred 1 ergotamine & caffeine MIGERGOT Generic QL 3 eletriptan RELPAX Non-Preferred QL 3 frovatriptan FROVA Non-Preferred QL 1 naratriptan AMERGE Generic QL 1 rizatriptan MAXALT Generic QL 1 rizatriptan orally disentigrating MAXALT MLT Generic QL 1 sumatriptan IMITREX Generic QL 1 zolmitriptan ZOMIG Generic *Multi-Choice Formulary is for medications covered at Network Pharmacies. Please see HMO Formulary for medications covered at KP Pharmacies* **All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.** Kaiser Permanente of Georgia Multi Choice Formulary 17 Kaiser Permanente of Georgia Multi Choice Formulary ST = Step Therapy, QRM = Physician Review, QL = Quantity Limit, Age = Age Restriction Restrictions Tier Generic Name Brand Name Coverage Status QL 1 zolmitriptan orally disentigrating ZOMIG ZMT Generic Antiparkinsonian Agents 1 amantadine SYMMETREL Generic 1 benztropine COGENTIN Generic 1 bromocriptine PARLODEL Generic 3 bromocriptine CYCLOSET Non-Preferred 1 cabergoline DOSTINEX Generic 3 carbidopa LODOSYN Non-Preferred 1 carbidopa & levodopa SINEMET Generic 3 carbidopa & levodopa PARCOPA Non-Preferred carbidopa & levodopa extended 1 SINEMET CR Generic release 2 carbidopa, levodopa, & entacapone STALEVO Preferred Brand 1 entacapone COMTAN Generic 1 pramipexole MIRAPEX Generic 3 pramipexole extended-release MIRAPEX ER Non-Preferred 3 rasagiline AZILECT Non-Preferred 1 ropinirole REQUIP Generic 1 ropinirole extended-release REQUIP XL Generic 3 rotigotine NEUPRO Non-Preferred 1 selegiline ELDEPRYL Generic 3 selegiline ZELAPAR Non-Preferred 3 selegiline transdermal EMSAM Non-Preferred 2 tolcapone TASMAR Preferred Brand 1 trihexyphenidyl ARTANE Generic Anxiolytics, Sedatives, and Hypnotics 1 alprazolam XANAX Generic 1 alprazolam extended-release XANAX XR Generic 3 alprazolam orally disintegrating NIRAVAM Non-Preferred 1 buspirone BUSPAR Generic 1 chlordiazepoxide LIBRIUM Generic 1 clorazepate TRANXENE Generic 1 diazepam VALIUM Generic 1 estazolam PROSOM Generic 1 eszopiclone LUNESTA Generic 1 flurazepam DALMANE Generic 1 hydroxyzine hcl ATARAX Generic 1 hydroxyzine pamoate VISTARIL Generic 1 lorazepam ATIVAN Generic 1 meprobamate MILTOWN Generic 1 oxazepam SERAX Generic 1 phenobarbital PHENOBARBITAL Generic 3 ramelteon ROZEREM Non-Preferred 1 temazepam RESTORIL Generic 1 triazolam HALCION Generic 1 zaleplon SONATA Generic 3 zolipdem sublingual EDLUAR Non-Preferred *Multi-Choice Formulary is for medications covered at Network Pharmacies. Please see HMO Formulary for medications covered at KP Pharmacies* **All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.** Kaiser Permanente of Georgia Multi Choice Formulary 18 Kaiser Permanente of Georgia Multi Choice Formulary ST = Step Therapy, QRM = Physician Review, QL = Quantity Limit, Age = Age Restriction Restrictions Tier Generic Name Brand Name Coverage Status 1 zolpidem AMBIEN Generic 1 zolpidem extended-release AMBIEN CR Generic 3 zolpidem oral spray ZOLPIMIST Non-Preferred Central Nervous System Agents Miscellaneous 1 acamprosate CAMPRAL Generic 3 atomoxetine STRATTERA Non-Preferred 3 dextromethorphan & quinidine NUEDEXTA Non-Preferred 3 guanfacine extended-release INTUNIV Non-Preferred 2 memantine NAMENDA Preferred Brand QL 3 milnacipran SAVELLA Non-Preferred 1 riluzole RILUTEK Generic 3 sodium oxybate XYREM Non-Preferred QRM 3 tetrabenazine XENAZINE Non-Preferred Opioid Antagonists 1 naloxone NARCAN Generic 1 naltrexone REVIA Generic Psychotherapeutic Agents 1 amitriptyline ELAVIL Generic 1 amitriptyline & perphenazine TRIAVIL Generic 1 amoxapine ASENDIN Generic 2 aripiprazole ABILIFY Preferred Brand 3 asenapine SAPHRIS Non-Preferred 1 bupropion WELLBUTRIN Generic 1 bupropion extended-release WELLBUTRIN XL Generic 3 bupropion hydrobromide APLENZIN Non-Preferred 1 bupropion sustained-release WELLBUTRIN SR Generic 1 chlordiazepoxide & amitriptyline LIMBITROL DS Generic 1 chlorpromazine THORAZINE Generic 1 citalopram CELEXA Generic 1 clomipramine ANAFRANIL Generic 1 clozapine CLOZARIL Generic 3 clozapine FAZACLO Non-Preferred 1 desipramine NORPRAMIN Generic desvenlafaxine base extended 1 PRISTIQ Generic release 1 doxepin SINEQUAN Generic 1 duloxetine CYMBALTA Generic 1 escitalopram LEXAPRO Generic 1 fluoxetine PROZAC Generic 3 fluoxetine PROZAC WEEKLY Non-Preferred 3 fluoxetine SARAFEM Non-Preferred 1 fluphenazine PROLIXIN Generic 1 fluvoxamine LUVOX Generic 1 haloperidol HALDOL Generic 3 iloperidone FANAPT Non-Preferred 1 imipramine TOFRANIL Generic 1 imipramine pamoate TOFRANIL-PM Generic *Multi-Choice Formulary is for medications covered at Network Pharmacies. Please see HMO Formulary for medications covered at KP Pharmacies* **All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.** Kaiser Permanente of Georgia Multi Choice Formulary 19 Kaiser Permanente of Georgia Multi Choice Formulary ST = Step Therapy, QRM = Physician Review, QL = Quantity Limit, Age = Age Restriction Restrictions Tier Generic Name Brand Name Coverage Status 3 isocarboxazid MARPLAN Non-Preferred 3 levomilnacipran FETZIMA Non-Preferred 1 lithium carbonate capsule LITHIUM CARBONATE Generic 1 lithium carbonate extended release LITHOBID Generic 1 lithium citrate CIBALITH-S Generic 1 loxapine LOXITANE Generic 3 lurasidone LATUDA Non-Preferred 1 maprotiline LUDIOMIL Generic 1 mirtazapine REMERON Generic 1 nefazodone SERZONE Generic 1 nortriptyline PAMELOR Generic 1 olanzapine ZYPREXA Generic 1 olanzapine & fluoxetine hcl SYMBYAX Generic 1 olanzapine orally disintegrating ZYPREXA ZYDIS Generic 3 paliperidone INVEGA Non-Preferred 1 paroxetine PAXIL Generic 3 paroxetine extended-release PAXIL CR Non-Preferred 3 paroxetine mesylate PEXEVA Non-Preferred 1 perphenazine TRILAFON Generic 1 phenelzine NARDIL Generic 3 pimozide ORAP Non-Preferred 3 protriptyline VIVACTIL Non-Preferred 1 quetiapine SEROQUEL Generic 3 quetiapine extended-release SEROQUEL XR Non-Preferred 1 risperidone RISPERDAL Generic 3 risperidone orally disintegrating RISPERDALM-TAB Non-Preferred 1 sertraline ZOLOFT Generic 1 thioridazine MELLARIL Generic 1 thiothixene NAVANE Generic 1 tranylcypromine sulfate PARNATE Generic 1 trazodone DESYREL Generic 3 trazodone extended-release OLEPTRO Non-Preferred 1 trifluoperazine STELAZINE Generic 3 trimipramine SURMONTIL Non-Preferred 1 venlafaxine EFFEXOR Generic 1 venlafaxine extended-release EFFEXOR XR Generic QL 3 vilazodone VIIBRYD Non-Preferred 3 vortioxetine BRINTELLIX Non-Preferred 1 ziprasidone GEODON Generic Diabetic Supplies Diabetic Supplies ONE TOUCH ULTRA TEST 3 blood sugar diagnostic Non-Preferred QL STRIPS ONE TOUCH VERIO TEST 1 blood sugar diagnostic Preferred Brand QL STRIPS QL 3 blood sugar diagnostic ACCU-CHEK TEST STRIPS Non-Preferred QL 3 blood sugar diagnostic ASCENSIA TEST STRIPS Non-Preferred *Multi-Choice Formulary is for medications covered at Network Pharmacies. Please see HMO Formulary for medications covered at KP Pharmacies* **All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.** Kaiser Permanente of Georgia Multi Choice Formulary 20 Kaiser Permanente of Georgia Multi Choice Formulary ST = Step Therapy, QRM = Physician Review, QL = Quantity Limit, Age = Age Restriction Restrictions Tier Generic Name Brand Name Coverage Status QL 3 blood sugar diagnostic FREESTYLE TEST STRIPS Non-Preferred QL 3 blood sugar diagnostic PRODIGY TEST STRIPS Non-Preferred QL 3 blood-glucose meter ONE TOUCH ULTRA 2 Non-Preferred QL 1 blood-glucose meter ONE TOUCH VERIO IQ Preferred Brand QL 3 blood-glucose meter ACCU-CHEK Non-Preferred QL 3 blood-glucose meter ASCENSIA BREEZE Non-Preferred QL 3 blood-glucose meter FREESTYLE SYSTEM Non-Preferred ONE TOUCH ULTRA 3 blood-glucose meter Non-Preferred QL SMART QL 3 blood-glucose meter ONE TOUCH ULTRAMINI Non-Preferred QL 3 blood-glucose meter PRODIGY Non-Preferred QL 1 syringe with needle,disposable BD INSULIN SYRINGE Generic Electrolytic, Caloric and Water Balance Acidifying and Alkalinizing Agents citric acid, sodium citrate, & 3 CYTRA-3 Non-Preferred potassium citrate 1 potassium citrate UROCIT-K Generic 2 potassium citrate & citric acid POLYCITRA-K Preferred Brand 3 sodium citrate & citric acid BICITRA Non-Preferred Ammonia Detoxicants 3 carglumic acid CARBAGLU Non-Preferred QRM 3 glycerol phenylbutyrate RAVICTI Non-Preferred 3 sodium phenylbutyrate BUPHENYL Non-Preferred 3 lactulose CHRONULAC Non-Preferred 1 lactulose ENULOSE Generic 3 lactulose KRISTALOSE Non-Preferred Diuretics 1 amiloride MIDAMOR Generic 1 amiloride & hydrochlorothiazide MODURETIC Generic 1 bumetanide BUMEX Generic 1 chlorothiazide DIURIL Generic 1 chlorthalidone HYGROTON Generic 3 ethacrynic acid EDECRIN Non-Preferred 1 furosemide LASIX Generic 1 hydrochlorothiazide MICROZIDE Generic 1 indapamide LOZOL Generic 1 metolazone ZAROXOLYN Generic QL 3 tolvaptan SAMSCA Non-Preferred 1 torsemide DEMADEX Generic 3 triamterene DYRENIUM Non-Preferred 1 triamterene & hydrochlorothiazide DYAZIDE Generic 1 triamterene & hydrochlorothiazide MAXZIDE Generic Ion-Removing Agnets 3 lanthanum carbonate FOSRENOL Non-Preferred 1 sevelamer carbonate RENVELA Generic 3 sevelamer hcl RENAGEL Non-Preferred 2 sodium polystyrene sulfonate SPS Preferred Brand *Multi-Choice Formulary is for medications covered at Network Pharmacies. Please see HMO Formulary for medications covered at KP Pharmacies* **All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.** Kaiser Permanente of Georgia Multi Choice Formulary 21 Kaiser Permanente of Georgia Multi Choice Formulary ST = Step Therapy, QRM = Physician Review, QL = Quantity Limit, Age = Age Restriction Restrictions Tier Generic Name Brand Name Coverage Status Replacement Products 2 calcium acetate ELIPHOS Preferred Brand 1 calcium acetate PHOSLO Generic 2 calcium acetate PHOSLYRA Preferred Brand potassium bicarbonate & potassium 1 K-LYTE/CL Generic chloride 1 potassium chloride K-DUR Generic 1 potassium chloride K-TAB Generic 2 potassium chrloide powder KLOR-CON 20 MEQ Preferred Brand 1 potassium gluconate KAON Generic 2 potassium phosphate PHOSPHA Preferred Brand 3 potassium phosphate, monobasic K-PHOS NEUTRAL Non-Preferred 2 potassium phosphate, monobasic K-PHOS ORIGINAL Preferred Brand Uricosuric Agents 1 colchicine & probenecid COL-BENEMID Generic 1 probenecid BENEMID Generic Enzymes Enzymes 2 dornase alfa PULMOZYME Preferred Brand Eye, Ear, Nose and Throat (EENT) Anti-infectives 3 azithromycin (ophth) AZASITE Non-Preferred 1 bacitracin & polmyxin B (ophth) POLYSPORIN Generic 1 bacitracin (ophth) AK-TRACIN Generic 3 besilfoxacin BESIVANCE Non-Preferred 1 chlorhexidine (mouth-throat) PERIDEX Generic 3 ciprofloxacin (ophth) ointment CILOXAN Non-Preferred 1 ciprofloxacin (ophth) solution CILOXAN Generic 1 erythromycin (ophth) ROMYCIN Generic 3 ganciclovir (ophth) ZIRGAN Non-Preferred 2 gatifloxacin (ophth) ZYMAXID Preferred Brand 1 gentamicin (ophth) GENTAK Generic 1 levofloxacin (ophth) QUIXIN Generic 3 moxifloxacin (ophth) VIGAMOX Non-Preferred 2 natamycin NATACYN Preferred Brand neomycin, bacitracin & polymyxin b 1 NEO-POLYCIN Generic (ophth) neomycin, polymycin b & gramicidin 1 NEOSPORIN Generic (ophth) 1 ofloxacin (ophth) OCUFLOX Generic 1 ofloxacin (otic) FLOXIN Generic 1 polymyxin b & trimethoprim (ophth) POLYTRIM Generic sulfacetamide sodium (ophth) 1 SULFAC Generic ointment sulfacetamide sodium (ophth) 1 BLEPH-10 Generic solution 2 tobramycin sulfate (ophth) ointment TOBREX Preferred Brand *Multi-Choice Formulary is for medications covered at Network Pharmacies. Please see HMO Formulary for medications covered at KP Pharmacies* **All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.** Kaiser Permanente of Georgia Multi Choice Formulary 22 Kaiser Permanente of Georgia Multi Choice Formulary ST = Step Therapy, QRM = Physician Review, QL = Quantity Limit, Age = Age Restriction Restrictions Tier Generic Name Brand Name Coverage Status 1 tobramycin sulfate (ophth) solution TOBREX Generic 1 trifluridine VIROPTIC Generic Anti-Inflammatory Agents bacitracin, neomycin, polymyxin B & 1 NEO-POLYCIN HC Generic hydrocortisone (ophth) 3 beclomethasone dipropionate (nasal) QNASL Non-Preferred beclomethasone dipropionate 3 BECONASE AQ Non-Preferred monohydrate (nasal) 3 bromfenac (ophth) XIBROM Non-Preferred 1 budesonide (nasal) RHINOCORT AQUA Generic 3 ciclesonide (nasal) OMNARIS Non-Preferred ciprofloxacin & dexamethasone 2 CIPRODEX Preferred Brand (ophth) 3 ciprofloxacin & hydrocortisone (otic) CIPRO HC Non-Preferred 2 cyclosporine (ophth) RESTASIS Preferred Brand 1 dexamethasone (ophth) solution DECADRON Generic 2 dexamethasone (ophth) suspension MAXIDEX Preferred Brand 1 diclofenac sodium (ophth) VOLTAREN Generic 3 difluprednate DUREZOL Non-Preferred 3 fluocinolone acetonide (otic) DERMOTIC Non-Preferred 1 fluorometholone (ophth) FML Generic 3 fluorometholone (ophth) FML FORTE Non-Preferred 2 fluorometholone acetate FLAREX Preferred Brand 1 flurbiprofen (ophth) OCUFEN Generic 3 fluticasone furoate VERAMYST Non-Preferred 2 gentamicin & prednisolone PRED-G Preferred Brand 1 hydrocortisone & acetic acid (otic) ACETASOL HC Generic 1 ketorolac (ophth) ACULAR Generic 1 ketorolac (ophth) ACULAR LS Generic 3 loteprednol ALREX Non-Preferred 3 loteprednol LOTEMAX Non-Preferred 3 loteprednol & tobramycin ZYLET Non-Preferred 3 mometasone (nasal) NASONEX Non-Preferred neomycin, colistin, hydrocortisone & 2 CORTISPORIN-TC Preferred Brand thonzonium (otic) neomycin, polymyxin B & 1 MAXITROL Generic dexamethasone (ophth) neomycin, polymyxin B & 1 CORTISPORIN Generic hydrocortisone (ophth) neomycin, polymyxin B & 1 CORTISPORIN Generic hydrocortisone (otic) 3 nepafenac NEVANAC Non-Preferred 1 prednisolone acetate (ophth) OMNIPRED Generic 1 prednisolone acetate (ophth) PRED FORTE Generic 2 prednisolone acetate (ophth) PRED MILD Preferred Brand prednisolone sodium phosphate 3 INFLAMASE FORTE Non-Preferred (ophth)

Index of Drugs

ADCIRCA ...... 14 8 ADDERALL...... 16 ADDERALL XR ...... 16 8-MOP ...... 38 adefovir dipivoxil ...... 6 ADEMPAS ...... 14 A ADOXA ...... 4 ADRENACLICK ...... 10 abacavir sulfate & lamivudine ...... 6 ADVAIR DISKUS ...... 35 abacavir sulfate solution ...... 6 ADVICOR ...... 11 abacavir sulfate tablet ...... 6 AFINITOR ...... 8 abacavir, lamivudine & zidovudine ...... 6 aflcaftadine ...... 24 abatacept ...... 32 AGGRENOX ...... 10 ABILIFY ...... 19 AGRYLIN ...... 10 abiraterone ...... 7 AKNE-MYCIN ...... 35 ABSTRAL ...... 15 AK-TRACIN ...... 22 acamprosate ...... 19 albendazole ...... 4 acarbose ...... 29 ALBENZA ...... 4 ACCOLATE ...... 34 albuterol nebulizer solution ...... 9 ACCU-CHEK ...... 20, 21 albuterol sulfate ...... 9, 10 ACCU-CHEK TEST STRIPS ...... 20 albuterol sulfate & ipratropium ...... 10 ACCUNEB ...... 9 albuterol sulfate tablet ...... 10 ACCUPRIL ...... 13 alclometasone dipropionate ...... 36 ACCURETIC ...... 13 ALDACTAZIDE ...... 13 ACCUTANE ...... 38 ALDACTONE ...... 13 acebutolol ...... 14 ALDARA ...... 38 ACEON...... 13 ALDOMET ...... 12 acetaminophen & codeine ...... 14 ALDORIL-25 ...... 12 acetaminophen, caffeine, & dihydrocodine ...... 14 alendronate ...... 33 ACETASOL HC ...... 23 alendronate & cholecalciferol ...... 33 acetazolamide ...... 24 alfuzosin hcl ...... 9 acetic acid ...... 23, 25 ALINIA ...... 6 acetylcysteine ...... 32 aliskiren ...... 12 acitretin ...... 37 aliskiren & amlodipine ...... 12 ACLOVATE ...... 36 aliskiren & hydrochlorothiazide...... 12 ACTEMRA ...... 34 aliskiren & valsartan ...... 12 ACTHAR ...... 32 aliskiren, amlodipine & hydrochlorothiazide ...... 12 ACTIGALL ...... 26 alitretinoin ...... 37 ACTIMMUNE ...... 33 ALKERAN ...... 8 ACTIQ ...... 15 allopurinol ...... 33 ACTIVELLA ...... 31 almotriptan ...... 17 ACTONEL ...... 34 ALOCRIL ...... 24 ACTOPLUS MET ...... 31 ALOMIDE ...... 24 ACTOS...... 31 ALORA ...... 31 ACULAR...... 23 alosetron ...... 25 ACULAR LS ...... 23 ALPHAGAN ...... 24 acyclovir ...... 6, 35 ALPHAGAN P ...... 24 ACZONE ...... 38 alprazolam ...... 18 ADALAT CC ...... 12 alprazolam extended-release...... 18 adalimumab ...... 33 alprazolam orally disintegrating ...... 18 adapalene ...... 37 ALREX ...... 23 Kaiser Permanente of Georgia Multi Choice Formulary 40 Kaiser Permanente of Georgia Multi Choice Formulary ALTABAX ...... 36 ANDROXY ...... 27 ALTACE ...... 13 ANGELIQ ...... 31 ALTOPREV ...... 11 ANSAID ...... 15 aluminum chloride hexahydrate...... 37 ANTABUSE ...... 33 ALVESCO ...... 35 anthralin ...... 37 amantadine ...... 18 antipyrine & benzocaine ...... 25 AMARYL ...... 30 ANUSOL-HC...... 37 AMBIEN ...... 19 ANZEMET ...... 25 AMBIEN CR ...... 19 APEXICON...... 36 ambrisentan ...... 13 APIDRA ...... 30 amcinonide ...... 36 apixaban ...... 10 AMERGE ...... 17 APLENZIN ...... 19 AMICAR ...... 10 apraclonidine...... 25 amiloride ...... 21 aprepitant ...... 25 amiloride & hydrochlorothiazide ...... 21 APRESOLINE ...... 12 aminocaproic acid ...... 10 APRI ...... 27 aminophylline ...... 38 APTIOM ...... 17 AMINOPHYLLINE ...... 38 APTIVUS ...... 7 amiodarone...... 12 ARALEN ...... 6 AMITIZA ...... 26 ARANESP ...... 10 amitriptyline ...... 19 ARAVA ...... 33 amitriptyline & perphenazine ...... 19 arformoterol ...... 10 amlodipine ...... 11, 12 ARICEPT ...... 9 amlodipine & atorvastatin ...... 11 ARICEPT ODT ...... 9 amlodipine & benazepril ...... 11 ARIMIDEX ...... 7 amlodipine & olmesartan ...... 11 aripiprazole ...... 19 amlodipine & valsartan ...... 11 ARIXTRA ...... 10 amlodipine, olmesartan & hydrochlorothiazide ...... 11 armodafinil ...... 16 amlodipine, valsartan & hydrochlorothiazide ...... 11 ARMOUR THYROID...... 32 ammonium lactate ...... 37, 38 AROMASIN ...... 8 amoxapine ...... 19 ARTANE ...... 18 amoxicillin ...... 2, 4, 25 ARTHROTEC ...... 15 amoxicillin & clavulanate potassium ...... 4 artificial tear insert ...... 25 amoxicillin & clavulanate potassium extended-release ...... 4 ASCENSIA BREEZE ...... 21 amoxicillin, clarithromycin, & lansoprazole ...... 25 ASCENSIA TEST STRIPS ...... 20 AMOXIL ...... 4 asenapine...... 19 amphetamine & dextroamphetamine ...... 16 ASENDIN ...... 19 amphetamine & dextroamphetamine extended-release ...... 16 ASMANEX ...... 35 AMPICILLIN ...... 4 aspirin & dipyridamole ...... 10 ampicillin sodium ...... 4 ASTELIN ...... 24 AMPYRA ...... 33 ASTEPRO ...... 24 AMRIX ...... 9 ATACAND ...... 12, 13 AMTURNIDE ...... 12 ATACAND HCT ...... 13 AMYTHYST ...... 28 ATARAX ...... 18 ANAFRANIL ...... 19 atazanavir sulfate ...... 6 anagrelide ...... 10 ATELVIA ...... 34 anakinra ...... 33 atenolol ...... 14 ANALPRAM HC ...... 37 atenolol & chlorthalidone ...... 14 ANAPROX ...... 16 ATIVAN ...... 18 anastrozole ...... 7 atomoxetine ...... 19 ANCOBON ...... 5 atorvastatin ...... 11 ANDRODERM ...... 27 atovaquone ...... 6 ANDROGEL ...... 27 atovaquone & proguanil ...... 6 ANDROID 10 ...... 27 ATRIPLA ...... 6

Kaiser Permanente of Georgia Multi Choice Formulary 41 Kaiser Permanente of Georgia Multi Choice Formulary atropine ...... 8, 25 BALZIVA ...... 28 atropine sulfate ...... 8 BANZEL ...... 17 ATROPINE SULFATE ...... 8 BARACLUDE ...... 6 ATROVENT ...... 9 BD INSULIN SYRINGE ...... 21 ATROVENTHFA ...... 9 becaplermin ...... 38 AUBAGIO ...... 34 beclomethasone dipropionate ...... 23, 34 AUGMENTIN ...... 4 beclomethasone dipropionate (nasal) ...... 23 AUGMENTIN XR ...... 4 beclomethasone dipropionate monohydrate (nasal) ...... 23 auranofin ...... 26 BECONASE AQ ...... 23 AURODEX ...... 25 bedaquiline...... 33 AUVI-Q ...... 10 benazepril ...... 11, 12 AVALIDE ...... 13 benazepril & hydrochlorothiazide ...... 12 AVAPRO ...... 13 BENEMID ...... 22 AVAR ...... 37 BENICAR ...... 13 AVC ...... 36 BENICAR HCT ...... 13 AVELOX ...... 5 BENTYL ...... 8 AVIANE...... 28 BENZACLIN ...... 35 AVINZA ...... 15 BENZAMYCIN ...... 35 AVLOSULFON ...... 5 benzonatate ...... 34 AVODART ...... 33 benzoyl peroxide & erythromycin ...... 35 AVONEX ...... 33 benzoyl peroxide & hydrocortisone ...... 36 AXERT ...... 17 benztropine ...... 18 AXID ...... 26 bepotastine ...... 24 AXIRON ...... 27 BEPREVE ...... 24 axitinib ...... 7 besilfoxacin ...... 22 AYGESTIN ...... 32 BESIVANCE ...... 22 AZASAN ...... 33 BETAGAN ...... 24 AZASITE ...... 22 betamethasone dipropionate (topical) ...... 36 azathioprine ...... 33 betamethasone dipropionate augmented ...... 36 azelaic acid ...... 37 betamethasone valerate ...... 36 azelaic acid (acne) ...... 37 BETAPACE...... 14 azelastine ...... 24 BETAPACE AF ...... 14 azelastine & fluticasone ...... 24 BETASERON] ...... 33 azelastine (ophth) ...... 24 betaxolol ...... 14, 24 AZELEX ...... 37 betaxolol hcl ...... 24 azelstine...... 24 bethanechol chloride ...... 9 AZILECT ...... 18 BETIMOL...... 24 azilsartan...... 12 BETOPTIC ...... 24 azithromycin ...... 4, 22 BETOPTIC S ...... 24 azithromycin (ophth) ...... 22 bexarotene ...... 7, 38 AZOPT ...... 24 bexarotene (topical) ...... 38 AZOR ...... 11 BEYAZ ...... 28 AZULFIDINE ...... 5 BIAXIN ...... 4 BIAXIN XL ...... 4 bicalutamide ...... 7 B BICITRA ...... 21 B & O SUPPRETTES ...... 16 BIDIL ...... 13 bacitracin (ophth) ...... 22 bimatoprost ...... 24 bacitracin, polymyxin, neomycin & hydrocortisone ...... 36 bismuth subcitrate & metronidazole ...... 4 baclofen...... 9 bisoprol & hydrochlorothiazide ...... 14 BACTRIM DS ...... 5 bisoprolol ...... 14 BACTROBAN ...... 35 BLEPH-10 ...... 22 BACTROBAN NASAL ...... 35 BLEPHAMIDE ...... 24 balsalazide ...... 25 BLOCADREN...... 14

Kaiser Permanente of Georgia Multi Choice Formulary 42 Kaiser Permanente of Georgia Multi Choice Formulary blood sugar diagnostic ...... 20, 21 calcipotriene ...... 36, 38 blood-glucose meter ...... 21 calcipotriene & betamethasone ...... 36 boceprevir ...... 6 calcitonin salmon ...... 32 BONIVA ...... 33 calcitriol ...... 38, 39 bosentan ...... 13 calcitriol (topical) ...... 38 BOSULIF ...... 7 calcium acetate ...... 22 bosutinib ...... 7 CAMILA ...... 28 BREO ELLIPTA ...... 35 CAMPRAL ...... 19 BRETHINE ...... 10 CANASA ...... 25 BREVICON ...... 28 candesartan ...... 12, 13 BRILINTA ...... 10 candesartan & hydrochlorothiazide ...... 13 brimonidine ...... 24, 38 capecitabine ...... 7 brimonidine (topical) ...... 38 CAPEX SHAMPOO ...... 36 brimonidine tartrate ...... 24 CAPOTEN ...... 13 BRINTELLIX ...... 20 CAPOZIDE ...... 13 brinzolamide ...... 24 CAPRELSA ...... 8 bromfenac (ophth) ...... 23 captopril ...... 13 bromocriptine ...... 18 captopril & hydrochlorothiazide ...... 13 BROVANA ...... 10 CARAC ...... 38 budesonide ...... 23, 27, 34 CARAFATE ...... 26 budesonide & formoterol ...... 34 carbachol ...... 24 budesonide (nasal) ...... 23 CARBAGLU ...... 21 bumetanide ...... 21 carbamazepine ...... 16, 17 BUMEX ...... 21 carbamazepine extended-release cap...... 17 BUPHENYL ...... 21 carbamazepine extended-release tab ...... 17 buprenorphine ...... 14 CARBATROL...... 17 buprenorphine & naloxone film ...... 14 carbidopa ...... 18 buprenorphine transdermal...... 14 carbidopa & levodopa ...... 18 bupropion ...... 19 carbidopa & levodopa extended release ...... 18 bupropion extended-release ...... 19 carbidopa, levodopa, & entacapone ...... 18 bupropion hydrobromide ...... 19 carbinoxamine maleate ...... 4 bupropion sustained-release ...... 19 CARDENE ...... 12 BUSPAR ...... 18 CARDIZEM ...... 11 buspirone ...... 18 CARDIZEM CD ...... 11 busulfan ...... 7 CARDIZEM LA ...... 11 butalbital & acetaminophen ...... 14 CARDURA ...... 10 butalbital, acetaminophen, & caffeine ...... 14 carglumic acid ...... 21 butalbital, acetaminophen, caffeine, & codeine ...... 15 carisoprodol ...... 9, 15 butalbital, aspirin, & caffeine ...... 15 carisoprodol, aspirin, & codeine ...... 15 butalbital, aspirin, caffeine, & codeine ...... 15 carisoprodol/aspirin ...... 9 butenafine ...... 35 CARMOL ...... 37 butoconazole nitrate (vaginal) ...... 35 CARMOL HC ...... 37 butorphanol tartrate ...... 15 carteolol (ophth)...... 24 BUTRANS ...... 14 CARTIA XT ...... 11 BYDUREON ...... 30 carvedilol...... 14 BYETTA ...... 30 carvedilol phosphate ...... 14 BYSTOLIC ...... 14 CASODEX ...... 7 CATAFLAM ...... 15 CATAPRES ...... 12 C CATAPRES-TTS ...... 12 cabergoline ...... 18 CECLOR ...... 4 CADUET ...... 11 CEDAX ...... 4 CAFERGOT ...... 9 CEENU ...... 8 CALAN SR ...... 12 cefaclor ...... 4

Kaiser Permanente of Georgia Multi Choice Formulary 43 Kaiser Permanente of Georgia Multi Choice Formulary cefadroxil ...... 4 citric acid, sodium citrate, & potassium citrate ...... 21 cefdinir ...... 4 CLARAVIS ...... 38 cefditoren ...... 4 clarithromycin ...... 4, 25 cefixime ...... 4 clarithromycin extended-release ...... 4 cefpodoxime ...... 4 CLEOCIN ...... 4, 35 cefprozil ...... 4 CLEOCIN HCL...... 4 ceftibuten ...... 4 CLEOCIN PEDIATRIC ...... 4 CEFTIN ...... 4 CLEOCIN T ...... 35 cefuroxime axetil ...... 4 clidinium & chlordiazepoxide...... 26 CEFZIL ...... 4 CLIMARA DIS ...... 31 CELEBREX ...... 15 CLIMARA PRO ...... 31 celecoxib ...... 15 CLINDAGEL ...... 35 CELEXA ...... 19 clindamycin & benzoyl peroxide...... 35 CELLCEPT ...... 33 clindamycin & tretinoin ...... 38 CELONTIN ...... 17 clindamycin hcl ...... 4 CENESTIN ...... 31 clindamycin palmitate ...... 4 cephalexin ...... 4 clindamycin phosphate (topical) ...... 35 ceritinib ...... 7 clindamyinc phosphate (vaginal) ...... 35 cevimeline hcl ...... 9 CLINORIL ...... 16 CHANTIX ...... 9 clobazam ...... 17 CHEMET ...... 27 clobetasol propionate ...... 36 CHERATUSSIN AC ...... 34 clobetasol propionate emollient ...... 36 chlorambucil ...... 7 clobetasol propionate emulsion ...... 36 chlordiazepoxide...... 18, 19, 26 CLOBEX ...... 36 chlordiazepoxide & amitriptyline ...... 19 clocortolone pivalate ...... 36 chlorhexidine (mouth-throat) ...... 22 CLODERM ...... 36 chloroquine phosphate ...... 6 clomipramine ...... 19 chlorothiazide ...... 21 clonazepam ...... 17 chlorphenirmine, phenylephrine & pyrilamine ...... 4 clonidine ...... 12 chlorpromazine...... 19 clonidine extended-release ...... 12 chlorpropamide ...... 30 clonidine transdermal ...... 12 CHLORPROPAMIDE ...... 30 clopidogrel ...... 10 chlorthalidone ...... 14, 21 clorazepate ...... 18 chlorzoxazone ...... 9 clotrimazole ...... 35 cholestyramine ...... 11 clotrimazole & betametmethasone ...... 35 cholestyramine light ...... 11 clozapine ...... 19 CHRONULAC ...... 21 CLOZARIL ...... 19 CIBALITH-S ...... 20 codeine ...... 14, 15, 34 ciclesonide ...... 23, 35 CODEINE SULF ...... 15 ciclesonide (nasal) ...... 23 COGENTIN...... 18 ciclopirox ...... 35 COLAZAL ...... 25 cilostazol ...... 10 COL-BENEMID ...... 22 CILOXAN ...... 22 colchicine ...... 22, 33 cimetidine ...... 25 colchicine & probenecid ...... 22 cinacalcet ...... 33 COLCRYS ...... 33 CIPRO ...... 4, 23 colesevelam ...... 11 CIPRO HC ...... 23 COLESTID ...... 11 CIPRODEX ...... 23 colestipol ...... 11 ciprofloxacin ...... 4, 22, 23 collagenase...... 38 ciprofloxacin & dexamethasone (ophth) ...... 23 COLYTE...... 26 ciprofloxacin & hydrocortisone (otic) ...... 23 COMBIPATCH ...... 31 ciprofloxacin (ophth) ointment ...... 22 COMBIVENT RESPIMAT ...... 10 ciprofloxacin (ophth) solution ...... 22 COMBIVIR ...... 6 citalopram ...... 19 COMBUNOX ...... 16

Kaiser Permanente of Georgia Multi Choice Formulary 44 Kaiser Permanente of Georgia Multi Choice Formulary COMPAZINE...... 25 CYTOXAN ...... 7 COMPLERA...... 6 CYTRA-3 ...... 21 COMTAN ...... 18 CONCERTA ...... 16 D CONDYLOX ...... 38 conjugated estrogens & bazedoxifene ...... 31 D.H.E.45 ...... 9 conjugated estrogens & medroxyprogesterone acetate ...... 31 dabigatran ...... 10 COPAXONE ...... 33 dalfampridine ...... 33 CORDRAN ...... 36 DALIRESP ...... 35 COREG ...... 14 DALMANE ...... 18 COREG CR ...... 14 dalteparin ...... 10 CORGARD ...... 14 danazol ...... 27 CORTEF...... 27 DANOCRINE ...... 27 CORTENEMA ...... 37 DANTRIUM ...... 9 corticotropin ...... 32 dantrolene sodium ...... 9 CORTIFOAM ...... 37 dapagliflozin ...... 30 cortisone acetate ...... 27 dapsone ...... 5, 38 CORTISPORIN ...... 23, 36 dapsone (topical) ...... 38 CORTISPORIN-TC ...... 23 DARAPRIM ...... 6 CORTONE ACETATE ...... 27 darbepoetin alfa ...... 10 CORZIDE ...... 14 darifenacin ...... 38 COSOPT ...... 24 darunavir ethanolate ...... 6 COUMADIN ...... 10 dasatinib ...... 8 COVERA-HS ...... 12 DAYPRO ...... 16 COZAAR ...... 13 DAYTRANA ...... 16 CREON ...... 26 DDAVP ...... 32 CRESTOR ...... 11 DECADRON ...... 23, 27 CRIXIVAN ...... 6 DECLOMYCIN ...... 4 crizotinib ...... 7 deferasirox ...... 27 cromolyn sodium...... 24, 34 deferiprone ...... 27 cromolyn sodium (ophth) ...... 24 delavirdine mesylate ...... 6 crotamiton ...... 35 DEMADEX ...... 21 CRYSELLE...... 29 demeclocycline ...... 4 CUPRIMINE ...... 27 DEMEROL ...... 15 CUTIVATE ...... 36 DENAVIR ...... 36 CYCLESSA...... 27 DEPAKENE ...... 17 cyclobenzaprine ...... 9 DEPAKOTE ...... 17 cyclobenzaprine extended-release...... 9 DEPAKOTE ER ...... 17 CYCLOCORT ...... 36 DEPAKOTE SPRINKLE ...... 17 cyclophosphamide ...... 7 DEPEN ...... 27 cycloserine ...... 5 DEPO-TESTOSTERONE ...... 27 CYCLOSET ...... 18 DERMA-SMOOTHE/FS OIL ...... 36 cyclosporine ...... 23, 33 DERMATOP ...... 37 cyclosporine (ophth) ...... 23 DERMOTIC ...... 23 cyclosporine, modified ...... 33 desipramine ...... 19 CYMBALTA ...... 19 desmopressin (non-refrigerated) ...... 32 cyproheptadine ...... 4 desmopressin acetate ...... 32 CYSTAGON ...... 33 DESOGEN ...... 27 cysteamine ...... 33 desogestrel & ethinyl estradiol ...... 27 cysteamine delayed-release ...... 33 desogestrel & ethinyl estradiol (biphasic) ...... 27 cysteamine immediate-release ...... 33 desogestrel & ethinyl estradiol (triphasic) ...... 27 CYTOMEL ...... 32 desonide ...... 36 CYTOTEC ...... 26 DESOWEN...... 36 CYTOVENE ...... 6 desoximetasone ...... 36

Kaiser Permanente of Georgia Multi Choice Formulary 45 Kaiser Permanente of Georgia Multi Choice Formulary DESOXYN ...... 16 dipyridamole ...... 10 desvenlafaxine ...... 19 DISALCID ...... 16 DESYREL ...... 20 disopyramide...... 12 DETROL ...... 38 disopyramide controlled-release ...... 12 DETROL LA ...... 38 disulfiram ...... 33 dexamethasone ...... 23, 24, 27 DITROPAN...... 38 dexamethasone (ophth) solution ...... 23 DITROPAN XL ...... 38 dexamethasone (ophth) suspension...... 23 DIURIL ...... 21 DEXEDRINE ...... 16 divalproex sodium ...... 17 dexmethylphenidate ...... 16 divalproex sodium capsule ...... 17 dexmethylphenidate extended-release ...... 16 divalproex sodium extended release ...... 17 dextroamphetamine sulfate ...... 16 DIVIGEL ...... 31 dextroamphetamine sulfate extended-release ...... 16 dofetilide...... 12 dextromethorphan & quinidine ...... 19 dolasetron ...... 25 DEXTROSTAT ...... 16 DOLOPHINE ...... 15 DIABETA ...... 30 dolutegravir ...... 6 DIAMOX ...... 24 donepezil ...... 9 DIAMOX SEQUELS ...... 24 DONNATAL ...... 26 DIASTAT ...... 17 dornase alfa ...... 22 DIASTAT ACUDIAL ...... 17 DORYX ...... 4 diazepam ...... 17, 18 dorzolamide ...... 24 DIBENZYLINE ...... 9 dorzolamide & timolol ...... 24 diclofenac epolamine ...... 38 DOSTINEX ...... 18 diclofenac potassium ...... 15 DOVONEX ...... 38 diclofenac sodium ...... 15, 23, 38 doxazosin ...... 10 diclofenac sodium & misoprostol ...... 15 doxepin ...... 19, 37, 38 diclofenac sodium (actinic keratosis) ...... 38 doxepin (antipuritic) ...... 37, 38 diclofenac sodium (ophth) ...... 23 doxercalciferol...... 39 diclofenac sodium extended release ...... 15 doxycycline ...... 4, 38 dicloxacillin ...... 4 doxycycline (rosacea) ...... 38 dicyclomine ...... 8 doxycycline hyclate ...... 4 didanosine ...... 6 doxycycline monohydrate ...... 4 didanosine solution ...... 6 DRISDOL ...... 39 DIDRONEL ...... 33 DRITHOCREME HP ...... 37 difenoxin & atropine ...... 25 DRITHO-SCALP ...... 37 DIFFERIN ...... 37 dronabinol ...... 25 DIFICID ...... 5 dronedarone ...... 12 diflorasone diacetate ...... 36 drospirenone & estradiol ...... 31 DIFLUCAN ...... 5 drospirenone & ethinyl estradiol ...... 28 diflunisal ...... 15 drospirenone & ethinyl estradiol w/ folate ...... 28 DIFLUNISAL ...... 15 DROXIA ...... 8 difluprednate ...... 23 DUAC ...... 35 digoxin ...... 12 DUAVEE ...... 31 dihydroergotamine mesylate ...... 9 DUETACT ...... 31 DILANTIN ...... 17 DULERA ...... 35 DILAUDID...... 15 duloxetine ...... 19 diltiazem ...... 11 DUONEB ...... 10 diltiazem extended-release ...... 11 DURAGESIC ...... 15 DIOVAN ...... 13 DUREZOL ...... 23 DIOVAN HCT ...... 13 DURICEF ...... 4 DIPENTUM ...... 25 dutasteride ...... 33 diphenoxylate & atropine ...... 25 dutasteride & tamsulosin ...... 33 DIPROLENE ...... 36 DYAZIDE ...... 21 DIPROSONE ...... 36 DYMISTA...... 24

Kaiser Permanente of Georgia Multi Choice Formulary 46 Kaiser Permanente of Georgia Multi Choice Formulary DYNACIN ...... 5 entecavir ...... 6 DYNACIRC ...... 11 ENTOCORT EC ...... 27 DYNACIRC CR ...... 11 ENULOSE...... 21 DYNAPEN ...... 4 enzalutamide ...... 8 dyphylline ...... 38 EPANOVA ...... 11 DYRENIUM ...... 21 epinastine (ophth) ...... 24 epinephrine ...... 10 EPIPEN ...... 10 E EPIPEN JR ...... 10 E.E.S...... 5 EPIVIR ...... 6 E.S.P ...... 4 EPIVIR HBV ...... 6 econazole nitrate...... 35 eplerenone ...... 13 ecothiophate ...... 24 epoetin alfa ...... 10 EDARBI ...... 12 EPOGEN ...... 10 EDECRIN ...... 21 eprosartan...... 13 EDLUAR ...... 18 eprosartan & hydrochlorothiazide ...... 13 EDURANT ...... 7 EPZICOM ...... 6 efavirenz ...... 6 EQUETRO ...... 17 efavirenz, emtricitab & tenofovir ...... 6 ergocalciferol ...... 39 EFFEXOR ...... 20 ergoloid mesylates ...... 9 EFFEXOR XR ...... 20 ergotamine & caffeine ...... 9, 17 EFUDEX ...... 38 erlotinib ...... 8 ELAVIL ...... 19 ERTACZO...... 36 ELDEPRYL ...... 18 ERYGEL ...... 35 ELESTAT ...... 24 ERYPED ...... 5 ELESTRIN GEL ...... 31 ERY-TAB ...... 5 eletriptan ...... 17 ERYTHROCIN ...... 5 ELIDEL ...... 38 ERYTHROMYCIN ...... 4 ELIMITE ...... 36 erythromycin & sulfisoxazole ...... 4 ELIPHOS ...... 22 erythromycin (acne acid) ...... 35 ELIQUIS ...... 10 erythromycin (ophth) ...... 22 ELLA ...... 29 erythromycin base ...... 4, 5 ELMIRON ...... 34 erythromycin base delayed-release ...... 5 ELOCON ...... 37 erythromycin ethylsuccinate ...... 5 eltrombopag ...... 10 erythromycin sterate ...... 5 elvitegravir, cobicistat, emtricitabine, & tenofovir ...... 6 escitalopram ...... 19 EMADINE ...... 24 eslicarbazepine ...... 17 EMCYT ...... 8 estazolam ...... 18 emedastine ...... 24 esterified estrogens ...... 31 EMEND...... 25 ESTRACE CREAM ...... 31 EMLA ...... 37 ESTRACE TAB ...... 31 EMSAM ...... 18 ESTRADERM ...... 31 emtricitabine ...... 6 estradiol ...... 27, 28, 29, 31, 32 emtricitabine & tenofovir ...... 6 estradiol & levonorgestrel ...... 31 emtricitabine, rilpivirine, & tenofovir ...... 6 estradiol & norethindrone ...... 31 EMTRIVA ...... 6 estradiol & norgestimate ...... 31 ENABLEX ...... 38 estradiol acetate ...... 31 enalapril ...... 13 estradiol acetate vaginal tablets ...... 31 enalapril & hydrochlorothiazide ...... 13 estradiol gel ...... 31 ENBREL ...... 33 estradiol transdermal ...... 31 enfuvirtide ...... 6 estradiol vaginal ...... 31 ENJUVIA ...... 32 estradiol valerate & dienogest ...... 28 enoxaparin ...... 10 estramustine ...... 8 entacapone ...... 18 ESTRATEST...... 31

Kaiser Permanente of Georgia Multi Choice Formulary 47 Kaiser Permanente of Georgia Multi Choice Formulary ESTRING ...... 31 FEMHRT ...... 32 estrogen,ester/me-testosterone ...... 31 FEMRING ...... 31 estrogens, conjugated ...... 31, 32 FEMTRACE ...... 31 estrogens, conjugated synthetic a ...... 31 fenofibrate ...... 11 estrogens, conjugated synthetic b ...... 32 fenofibrate, micronized ...... 11 estrogens, conjugated vaginal ...... 32 fenofibric acid ...... 11 estropipate ...... 32 fenoprofen calcium ...... 15 ESTROSTEP FE ...... 29 fentanyl film ...... 15 eszopiclone ...... 18 fentanyl intranasal ...... 15 etanercept ...... 33 fentanyl lozenge...... 15 ethacrynic acid ...... 21 fentanyl sublingual...... 15 ethambutol ...... 5 fentanyl tablet ...... 15 ethontoin ...... 17 fentanyl transdermal ...... 15 ethosuximide ...... 17 FENTORA ...... 15 ethynodiol diacetate & ethinyl estradiol ...... 28 FERRIPROX ...... 27 etidronate ...... 33 fesoterodine ...... 38 etodolac ...... 15 FETZIMA ...... 20 etonogestrel & ethinyl estradiol ...... 28 fidaxomicin ...... 5 etravirine ...... 6 filgrastim ...... 10 EULEXIN ...... 8 FINACEA ...... 37 EURAX ...... 35 fingolimod ...... 33 everolimus ...... 8, 33 FIORICET ...... 14, 15 EVISTA ...... 32 FIORICET W/ CODEINE ...... 15 EVOCLIN ...... 35 FIORINAL ...... 15 EVOXAC ...... 9 FIORINAL W/ CODEINE ...... 15 EXALGO ...... 15 FIRAZYR ...... 33 EXELDERM ...... 36 FLAGYL ...... 6 EXELON ...... 9 FLAGYL ER...... 6 exemestane ...... 8 FLAREX ...... 23 exenatide ...... 30 flavoxate ...... 38 exenatide extended-release ...... 30 FLAVOXATE ...... 38 EXFORGE ...... 11 flecainide ...... 12 EXFORGE HCT ...... 11 FLECTOR ...... 38 EXJADE ...... 27 FLEXERIL ...... 9 EXTAVIA ...... 33 FLOMAX ...... 9 ezetimibe ...... 11 FLORINEF ACETATE ...... 27 ezetimibe & simvastatin ...... 11 FLOVENT DISKUS AER ...... 35 ezogaine ...... 17 FLOVENT HFA ...... 35 FLOXIN ...... 22 fluconazole ...... 5 F flucytosine ...... 5 FACTIVE ...... 5 fludrocortisone ...... 27 famciclovir ...... 6 FLUMADINE ...... 7 FAMVIR ...... 6 fluocinolone acetonide ...... 23, 36 FANAPT...... 19 fluocinolone acetonide (otic)...... 23 FARXIGA ...... 30 fluocinonide ...... 36 FAZACLO ...... 19 fluocinonide emollient ...... 36 febuxostat ...... 33 FLUORABON BASIC ...... 34 felbamate ...... 17 FLUORITAB ...... 34 FELBATOL...... 17 fluorometholone (ophth) ...... 23 FELDENE...... 16 fluorometholone acetate ...... 23 felodipine ...... 11 FLUOROPLEX ...... 38 FEMARA ...... 8 fluorouracil (topical) ...... 38 FEMCON FE ...... 29 fluoxetine ...... 19, 20

Kaiser Permanente of Georgia Multi Choice Formulary 48 Kaiser Permanente of Georgia Multi Choice Formulary fluoxymesterone ...... 27 GEL-KAM ...... 34 fluphenazine ...... 19 gemfibrozil ...... 11 flurandrenolide ...... 36 gemifloxacin ...... 5 flurazepam ...... 18 GENTAK ...... 22 flurbiprofen ...... 15, 23 gentamicin & prednisolone ...... 23 flurbiprofen (ophth) ...... 23 gentamicin (ophth) ...... 22 flutamide ...... 8 gentamicin sulfate ...... 5, 35 fluticasone & salmeterol ...... 35 gentamicin sulfate (topical) ...... 35 fluticasone & vilanterol ...... 35 GENTROPIN ...... 32 fluticasone furoate ...... 23 GEODON ...... 20 fluticasone propionate ...... 35, 36 GIANVI ...... 28 fluticasone propionate (topical) ...... 36 GIAZO ...... 25 fluvastatin ...... 11 GILENYA ...... 33 fluvastatin extended-release ...... 11 glatiramer acetate ...... 33 fluvoxamine ...... 19 GLEEVEC ...... 8 FML ...... 23 glimepiride ...... 30, 31 FML FORTE ...... 23 glipizide...... 30 FOCALIN ...... 16 glipizide & metformin ...... 30 FOCALIN XR ...... 16 glipizide extended-release ...... 30 fondaparinux ...... 10 GLUCAGEN HYPOKIT ...... 30 FORADIL ...... 10 glucagon ...... 30 formoterol fumarate ...... 10 GLUCAGON EMERGENCY KIT ...... 30 FORTAMET ...... 30 GLUCOPHAGE ...... 30 FORTEO ...... 32 GLUCOPHAGE XR ...... 30 FORTESTA ...... 27 GLUCOTROL ...... 30 FORTICAL ...... 32 GLUCOTROL XL ...... 30 FOSAMAX ...... 33 GLUCOVANCE ...... 30 FOSAMAX PLUS D ...... 33 GLUMETZA ...... 30 fosamprenavir calcium...... 6 glyburide ...... 30 fosinopril ...... 13 glyburide & metformin ...... 30 fosinopril & hydrochlorothiazide ...... 13 glyburide micronized ...... 30 FOSRENOL ...... 21 glycerol phenylbutyrate ...... 21 FRAGMIN ...... 10 glycopyrrolate ...... 8 FREESTYLE SYSTEM ...... 21 GLYNASE ...... 30 FREESTYLE TEST STRIPS ...... 21 GLYSET ...... 30 FROVA ...... 17 golimumab ...... 33 frovatriptan ...... 17 GOLYTELY ...... 26 FURADANTIN ...... 7 granisetron ...... 25 furosemide ...... 21 GRIFULVIN V ...... 5 FUZEON ...... 6 griseofulvin microsize ...... 5 FYCOMPA ...... 17 griseofulvin ultramicrosize ...... 5 GRIS-PEG ...... 5 guaifenesin & codeine ...... 34 G guanfacine ...... 12, 19 gabapentin ...... 17 guanfacine extended-release ...... 19 GABITRIL ...... 17 GYNAZOLE-1 ...... 35 galantamine hydrobromide ...... 9 GYNODIOL...... 31 ganciclovir ...... 6, 22 ganciclovir (ophth) ...... 22 H GARAMYCIN ...... 5, 35 GASTROCROM ...... 34 halcinonide ...... 36 gatifloxacin (ophth) ...... 22 HALCION ...... 18 GATTEX ...... 26 HALDOL ...... 19 GAVILYTE-C ...... 26 HALFLYTELY ...... 26

Kaiser Permanente of Georgia Multi Choice Formulary 49 Kaiser Permanente of Georgia Multi Choice Formulary halobetasol propionate ...... 36 HYTRIN ...... 11 HALOG ...... 36 HYZAAR ...... 13 haloperidol ...... 19 HECTOROL ...... 39 I HELIDAC ...... 4 heparin ...... 10 ibandronate ...... 33 HEPARIN SODIUM ...... 10 ibrutinib ...... 8 HEPSERA ...... 6 ibuprofen ...... 15, 16 hexachlorophene ...... 35 icatibant ...... 33 HIPREX...... 7 ICLUSIG ...... 8 homatropine ...... 25, 34 ILARIS ...... 33 HUMALOG ...... 30 iloperidone ...... 19 HUMALOG MIX 50/50 ...... 30 imatinib mesylate ...... 8 HUMALOG MIX 75/25 ...... 30 IMBRUVICA...... 8 HUMATIN ...... 6 IMDUR ...... 13 HUMATROPE ...... 32 imipramine ...... 19 HUMIRA ...... 33 imipramine pamoate ...... 19 HUMULIN 50/50 ...... 30 imiquimod ...... 38 HUMULIN 70/30 ...... 30 IMITREX ...... 17 HUMULIN N ...... 30 IMURAN ...... 33 HUMULIN R...... 30 INCIVEK ...... 7 HYCAMTIN ...... 8 indapamide ...... 21 HYCODAN ...... 34 INDERAL ...... 14 HYDERGINE...... 9 INDERAL LA ...... 14 hydralazine ...... 12, 13 INDERIDE ...... 14 HYDREA ...... 8 indinavir sulfate ...... 6 hydrochlorothiazide ...... 11, 12, 13, 14, 21 INDOCIN ...... 15 hydrocodone ...... 15, 34 indomethacin ...... 15 hydrocodone & acetaminophen ...... 15 INFERGEN ...... 6 hydrocodone & chlorpheniramine ...... 34 INFLAMASE FORTE ...... 23 hydrocodone & homatropine ...... 34 ingenol mebutate ...... 38 hydrocodone & ibuprofen ...... 15 INLYTA ...... 7 hydrocortisone ...... 23, 27, 35, 36, 37 INNOPRAN XL ...... 14 hydrocortisone & acetic acid (otic) ...... 23 INSPRA ...... 13 hydrocortisone & pramoxine ...... 37 insulin aspart ...... 30 hydrocortisone (intrarectal) ...... 37 insulin aspart protamine & insulin aspart...... 30 hydrocortisone (rectal) ...... 37 insulin detemir...... 30 hydrocortisone (topical) ...... 37 insulin glargine,hum.rec.anlog ...... 30 hydrocortisone acetate & urea ...... 37 insulin glulisine ...... 30 hydrocortisone acetate (intrarectal) ...... 37 insulin isophane ...... 30 hydrocortisone butyrate ...... 37 insulin isophane & regular insulin ...... 30 hydrocortisone probutate ...... 37 insulin lispro ...... 30 hydrocortisone valerate ...... 37 insulin lispro protamine & insulin lispro ...... 30 hydromorphone oral suspension ...... 15 insulin regular ...... 30 hydromorphone tablet ...... 15 INTAL ...... 34 hydroxychloroquine sulfate ...... 6 INTELENCE ...... 6 hydroxyurea ...... 8 interferon alfacon-1 ...... 6 hydroxyzine hcl ...... 18 interferon beta-1a ...... 33 hydroxyzine pamoate ...... 18 interferon beta-1b ...... 33 HYGROTON ...... 21 interferon gamma-1b ...... 33 hyoscyamine sulfate ...... 8 INTROVALE ...... 28 HYPERCARE...... 37 INTUNIV ...... 19 HYPERSAL ...... 35 INVEGA ...... 20 HYTONE ...... 37 INVIRASE ...... 7

Kaiser Permanente of Georgia Multi Choice Formulary 50 Kaiser Permanente of Georgia Multi Choice Formulary INVOKANA ...... 30 KERLONE ...... 14 iodoquinol & hydrocortisone ...... 35 KETEK ...... 5 IOPIDINE ...... 25 ketoconazole ...... 5, 35 ipratropium bromide ...... 9 ketoconazole (topical) ...... 35 irbesartan ...... 13 ketoprofen ...... 15 irbesartan & hydrochlorothiazide...... 13 KETOPROFEN ...... 15 ISENTRESS ...... 7 ketorolac (ophth) ...... 23 isocarboxazid ...... 20 ketorolac tablet ...... 15 isoniazid...... 5 KINERET ...... 33 ISOPTIN SR ...... 12 KLARON ...... 36 ISOPTO ATROPINE ...... 25 KLONOPIN ...... 17 ISOPTO CARBACHOL ...... 24 KLOR-CON 20 MEQ ...... 22 ISOPTO CARPINE ...... 24 K-LYTE/CL ...... 22 ISOPTO HOMATROPINE ...... 25 KOMBIGLYZE XR ...... 31 ISOPTO HYOSCINE...... 25 KORLYM ...... 30 ISORDIL ...... 13 K-PHOS NEUTRAL ...... 22 isosorbide dinitrate ...... 13 K-PHOS ORIGINAL ...... 22 isosorbide dinitrate & hydralazine ...... 13 KRISTALOSE ...... 21 isosorbide mononitrate ...... 13 K-TAB ...... 22 isotretinoin ...... 38 KUVAN ...... 34 isradipine ...... 11 KWELL ...... 35 ISTALOL ...... 24 KYNAMRO ...... 11 itraconazole ...... 5 KYTRIL ...... 25 itraconazole (solution) ...... 5 ivacaftor ...... 35 L ivermectin...... 4 labetalol ...... 14 J LAC-HYDRIN ...... 37 lacosamide...... 17 JAKAFI ...... 8 LACRISERT ...... 25 JALYN ...... 33 lactic acid (ammonium lactate) ...... 38 JANUMET ...... 31 LACTINOL ...... 38 JANUVIA ...... 31 lactulose ...... 21 JENTADUETO ...... 30 LAMICTAL ...... 17 JUNEL ...... 28, 29 LAMICTAL XR ...... 17 JUNEL FE ...... 29 LAMISIL ...... 5 JUVISYNC ...... 31 lamivudine ...... 6 JUXTAPID...... 11 lamivudine & zidovudine ...... 6 lamotrigine ...... 17 lamotrigine extended-release ...... 17 K LANOXIN ...... 12 KADIAN ...... 15 lanthanum carbonate ...... 21 KALETRA ...... 6 LANTUS...... 30 KALYDECO ...... 35 lapatinib ...... 8 KAON ...... 22 LARIAM ...... 6 KAPVAY ...... 12 LASIX ...... 21 KARIVA ...... 27 LASTACAFT ...... 24 KAZANO ...... 30 latanoprost ...... 24 K-DUR ...... 22 LATUDA ...... 20 KEFLEX ...... 4 LAZANDA ...... 15 KELNOR ...... 28 LEENA ...... 29 KENALOG ...... 37 leflunomide...... 33 KEPPRA ...... 17 lenalidomide ...... 8 KEPPRA XR ...... 17 LESCOL ...... 11 Kaiser Permanente of Georgia Multi Choice Formulary 51 Kaiser Permanente of Georgia Multi Choice Formulary LESCOL XL ...... 11 liothyronine ...... 32 LESSINA ...... 28 liotrix ...... 32 LETAIRIS ...... 13 LIPITOR ...... 11 letrozole ...... 8 liraglutide ...... 30 leucovorin...... 33 lisdexamfetamine ...... 16 LEUCOVORIN ...... 33 lisinopril ...... 13 LEUKERAN ...... 7 lisinopril & hydrochlorothiazide ...... 13 LEUKINE ...... 10 LITHIUM CARBONATE ...... 20 leuprolide acetate ...... 8 lithium carbonate capsule ...... 20 levalbuterol nebulizer solution ...... 10 lithium carbonate extended release ...... 20 levalbuterol tartrate ...... 10 lithium citrate ...... 20 LEVAQUIN ...... 5 LITHOBID ...... 20 LEVATOL ...... 14 LIVALO ...... 11 LEVBID ...... 8 LO LOESTRIN FE ...... 29 LEVEMIR ...... 30 LO/OVRAL-28 ...... 29 levetiracetam ...... 17 LOCOID ...... 37 levetiracetam extended-release ...... 17 LOCOID LIPOCREAM ...... 37 levobunolol ...... 24 LODINE ...... 15 LEVO-DROMORAN ...... 15 LODOSYN ...... 18 levofloxacin ...... 5, 22 lodoxamide tromethamine ...... 24 levofloxacin (ophth) ...... 22 LOESTRIN 24 FE ...... 29 levomilnacipran ...... 20 LOESTRIN FE ...... 29 levonorgestrel...... 28, 31 LOFIBRA CAP ...... 11 levonorgestrel & ethinyl estradiol ...... 28 LOFIBRA TAB ...... 11 levonorgestrel & ethinyl estradiol (91-day) ...... 28 LOMOTIL ...... 25 levonorgestrel & ethinyl estradiol (continuous) ...... 28 lomustine ...... 8 levonorgestrel & ethinyl estradiol (triphasic) ...... 28 LONITEN ...... 12 LEVORA ...... 28 LOPID ...... 11 levorphanol ...... 15 lopinavir & ritonavir ...... 6 LEVOTHROID ...... 32 LOPRESSOR ...... 14 levothyroxine ...... 32 LOPRESSOR HCT ...... 14 LEVOXYL ...... 32 LOPROX ...... 35 LEVSIN ...... 8 lorazepam ...... 18 LEXAPRO ...... 19 losartan...... 13 LEXIVA ...... 6 losartan & hydrochlorothiazide ...... 13 LIALDA ...... 25 LOSEASONIQUE ...... 28 LIBRAX ...... 26 LOTEMAX ...... 23 LIBRIUM ...... 18 LOTENSIN ...... 12 LIDAMANTLE ...... 37 LOTENSIN HCT ...... 12 LIDEX ...... 36 loteprednol ...... 23 LIDEX-E ...... 36 loteprednol & tobramycin ...... 23 lidocaine ...... 25, 37 LOTREL ...... 11 lidocaine & hydrocortisone ...... 37 LOTRISONE ...... 35 lidocaine & prilocaine ...... 37 LOTRONEX ...... 25 lidocaine (mouth-throat) ...... 25 lovastatin ...... 11 LIDODERM ...... 37 lovastatine extended-release ...... 11 LIMBITROL DS ...... 19 LOVAZA ...... 11 linaclotide...... 26 LOVENOX ...... 10 linagliptin ...... 30 LOW-OGESTREL ...... 29 linagliptin & metformin ...... 30 loxapine ...... 20 lindane ...... 35 LOXITANE ...... 20 linezolid ...... 5 LOZOL ...... 21 LINZESS ...... 26 lubiprostone ...... 26 LIORESAL ...... 9 LUDIOMIL ...... 20

Kaiser Permanente of Georgia Multi Choice Formulary 52 Kaiser Permanente of Georgia Multi Choice Formulary LUFYLLIN ...... 38 mesalamine controlled-release ...... 25 LUMIGAN ...... 24 mesalamine suppository ...... 25 LUNESTA ...... 18 mesalamine suspension ...... 25 LUPRON ...... 8 mesalamine tablet ...... 25 lurasidone ...... 20 mesna ...... 33 LURIDE CHEW ...... 34 MESNEX...... 33 LURIDE DROPS ...... 34 MESTION ...... 9 LUVOX ...... 19 MESTION TIMESPAN ...... 9 LUXIQ ...... 36 METADATE CD ...... 16 LYPREL ...... 28 METADATE ER ...... 16 LYRICA ...... 17 METAGLIP ...... 30 LYSODREN ...... 8 metaxalone ...... 9 metformin ...... 30, 31 metformin extended-release ...... 30, 31 M methadone ...... 15 macitentan ...... 13 methamphetamine ...... 16 MACROBID ...... 7 methazolamide ...... 24 MACRODANTIN ...... 7 methenamine hippurate ...... 7 methenamine, sodium biphosphate, phenyl salicylate, mafenide acetate ...... 35 methylene blue, and hyoscyamine MALARONE ...... 6 ...... 7 METHERGINE malathion ...... 35 ...... 33 methimazole maprotiline ...... 20 ...... 32 METHITEST maraviroc ...... 7 ...... 27 methocarbamol MARINOL ...... 25 ...... 9 methotrexate sodium MARPLAN ...... 20 ...... 8 methoxsalen MATULANE ...... 8 ...... 38 methoxsalen, rapid MAVIK ...... 13 ...... 38 methscopolamine MAXAIR AUTOHALER ...... 10 ...... 9 methsuximide MAXALT ...... 17 ...... 17 methyldopa MAXALT MLT ...... 17 ...... 12 methyldopa & hydrochlorothiazide MAXIDEX ...... 23 ...... 12 methylergonovine maleate MAXITROL ...... 23 ...... 33 METHYLIN MAXZIDE ...... 21 ...... 16 methylphenidate meclofenamate ...... 15 ...... 16 methylphenidate extended-release MECLOMEN ...... 15 ...... 16 methylphenidate sustained release MEDROL ...... 27 ...... 16 methylphenidate transdermal patch medroxyprogesterone acetate ...... 31, 32 ...... 16 methylprednisolone mefenamic acid ...... 15 ...... 27 methyltestosterone mefloquine ...... 6 ...... 27 metipranolol MEGACE ...... 32 ...... 24 metoclopramide megestrol acetate ...... 32 ...... 26 metolazone MELLARIL ...... 20 ...... 21 metoprol & hydrochlorothiazide meloxicam ...... 15 ...... 14 metoprolol succinate melphalan ...... 8 ...... 14 metoprolol tartrate memantine ...... 19 ...... 14 METROCREAM M-END MAX D ...... 34 ...... 35 METROGEL MENEST ...... 31 ...... 35 METROGEL-VAGINAL MENOSTAR ...... 31 ...... 35 METROLOTION MENTAX ...... 35 ...... 35 metronidazole meperidine tablet ...... 15 ...... 4, 6, 35 metronidazole (topical) MEPHYTON ...... 39 ...... 35 metronidazole (vaginal) meprobamate ...... 18 ...... 35 metronidazole, tetracycline & bismuth subsalicylate MEPRON ...... 6 ...... 4 metronidazoleextended-release mercaptopurine ...... 8 ...... 6

Kaiser Permanente of Georgia Multi Choice Formulary 53 Kaiser Permanente of Georgia Multi Choice Formulary MEVACOR ...... 11 MS CONTIN ...... 15 mexiletine...... 12 MSIR ...... 15 MEXITIL ...... 12 MUCOMYST-10 ...... 32 MIACALCIN ...... 32 MULTAQ ...... 12 MICARDIS ...... 13 mupirocin ...... 35 MICARDIS HCT ...... 13 mupirocin calcium ...... 35 miconazole nitrate & zinc oxide ...... 35 MYAMBUTOL ...... 5 MICROGESTIN ...... 28, 29 MYCELEX ...... 35 MICROGESTIN FE ...... 29 MYCIFRADIN ...... 5 MICROZIDE ...... 21 MYCOBUTIN ...... 5 MIDAMOR ...... 21 MYCOLOG II ...... 37 midodrine hcl...... 10 mycophenolate mofetil ...... 33 MIFEPREX ...... 33 mycophenolate sodium ...... 33 mifepristone ...... 30, 33 MYCOSTATIN ...... 5 MIGERGOT ...... 17 MYFORTIC ...... 33 miglitol...... 30 MYLERAN ...... 7 MIGRANAL ...... 9 MYRBETRIQ...... 38 milnacipran ...... 19 MYSOLINE ...... 17 MILTOWN ...... 18 MINIPRESS ...... 11 N MINOCIN ...... 5 minocycline ...... 5 na sulfacetm/avobenzone/sulfur ...... 35 minoxidil ...... 12 nabumetone ...... 15 mirabegron ...... 38 nadolol ...... 14 MIRAPEX ...... 18 nadolol & bendroflumethiazide ...... 14 MIRAPEX ER ...... 18 nafarelin ...... 32 mirtazapine ...... 20 naftifine ...... 35 MIRVASO ...... 38 NAFTIN ...... 35 misoprostol ...... 15, 26 nalbuphine ...... 15 mitotane ...... 8 NALFON ...... 15 MOBIC ...... 15 naloxone ...... 14, 16, 19 modafinil ...... 16 naltrexone ...... 19 MODICON ...... 28 NAMENDA ...... 19 MODURETIC ...... 21 NAPRELAN ...... 16 moexipril ...... 13 NAPROSYN ...... 16 moexipril & hydrochlorothiazide ...... 13 naproxen ...... 16 mometasone & formoterol ...... 35 naproxen sodium ...... 16 mometasone (nasal) ...... 23 naratriptan ...... 17 mometasone furoate ...... 35, 37 NARCAN ...... 19 MONODOX ...... 4 NARDIL ...... 20 MONONESSA ...... 29 NASACORT AQ ...... 24 MONOPRIL ...... 13 NASONEX ...... 23 MONOPRIL HCT ...... 13 NATACYN ...... 22 montelukast ...... 34 natamycin ...... 22 morphine ...... 15 NATAZIA ...... 28 morphine beads ...... 15 nateglinide ...... 30 morphine extended-relase capsule ...... 15 NATROBA ...... 36 morphine extended-release tablet ...... 15 NAVANE ...... 20 MORPHINE SULFATE ...... 15 nebivolol ...... 14 MOTOFEN ...... 25 NECON ...... 28, 29 MOTRIN ...... 15 NECON 10/11 ...... 29 MOVIPREP ...... 26 nedocromil sodium (ophth) ...... 24 moxifloxacin ...... 5, 22 nefazodone ...... 20 moxifloxacin (ophth) ...... 22 nelfinavir mesylate ...... 7

Kaiser Permanente of Georgia Multi Choice Formulary 54 Kaiser Permanente of Georgia Multi Choice Formulary neomycin sulfate ...... 5 norelgestromin & ethinyl estradiol ...... 28 neomycin, bacitracin & polymyxin b (ophth) ...... 22 norethindrone ...... 28, 29, 31, 32 neomycin, colistin, hydrocortisone & thonzonium (otic) ...... 23 norethindrone & ethinyl estradiol...... 28, 29 neomycin, polymycin b & gramicidin (ophth) ...... 22 norethindrone & ethinyl estradiol (biphasic) ...... 29 NEO-POLYCIN ...... 22, 23 norethindrone & ethinyl estradiol (triphasic) ...... 29 NEO-POLYCIN HC ...... 23 norethindrone & ethinyl estradiol w/ ferrous fumarate ...... 29 NEORAL ...... 33 norethindrone acetate ...... 29, 32 NEOSPORIN ...... 22 norethindrone acetate & ethinyl estradiol...... 29, 32 neostigmine bromide ...... 9 norethindrone acetate & ethinyl estradiol w/ ferrous fumarate nepafenac ...... 23 ...... 29 NEPTAZANE ...... 24 norethindrone acetate & ethinyl estradiol w/ ferrous fumarate NESINA ...... 30 (biphasic) ...... 29 NEULASTA ...... 10 norethindrone-mestranol...... 29 NEUMEGA ...... 10 NORFLEX ...... 9 NEUPOGEN ...... 10 norfloxacin ...... 5 NEUPRO ...... 18 NORGESIC ...... 9 NEURONTIN ...... 17 norgestimate & ethinyl estradiol ...... 29 NEVANAC ...... 23 norgestimate & ethinyl estradiol (triphasic) ...... 29 nevirapine solution ...... 7 norgestrel & ethinyl estradiol ...... 29 nevirapine tablet ...... 7 NORINYL 1+35 ...... 28 NEXAVAR ...... 8 NORINYL 1+50 ...... 29 niacin...... 11, 39 NOROXIN ...... 5 niacin & lovastatin ...... 11 NORPACE ...... 12 NIACOR...... 39 NORPACE CR ...... 12 NIASPAN ...... 11 NORPRAMIN ...... 19 nicardipine ...... 12 NOR-QD ...... 28 nifedipine ...... 12 NORTREL ...... 28, 29 nifedipine extended-release ...... 12 NORTREL 7/7/7 ...... 29 nilotinib ...... 8 nortriptyline ...... 20 nimodipine ...... 12 NORVASC ...... 11 NIMOTOP ...... 12 NORVIR ...... 7 NIRAVAM ...... 18 NOVOLIN 70/30 ...... 30 nisoldipine...... 12 NOVOLIN N ...... 30 nitazoxanide...... 6 NOVOLIN R ...... 30 NITRO-BID ...... 13 NOVOLOG ...... 30 NITRO-DUR ...... 13, 14 NOVOLOG MIX 70/30 ...... 30 nitrofurantoin ...... 7 NOXAFIL ...... 5 nitrofurantoin macrocrystal ...... 7 NUBAIN ...... 15 nitrofurantoin monohydrate ...... 7 NUCYNTA ...... 16 nitroglycerin aerosol ...... 13 NUEDEXTA ...... 19 nitroglycerin solution ...... 13 NULYTELY ...... 26 nitroglycerin subligual ...... 13 NUTROPIN AQ ...... 32 nitroglycerin topical ointment ...... 13 NUVARING ...... 28 nitroglycerin transdermal patch ...... 13, 14 NUVIGIL ...... 16 NITROLINGUAL ...... 13 NYDRAZID ...... 5 NITROMIST ...... 13 nystatin ...... 5, 36, 37 NITROSTAT ...... 13 NYSTATIN ...... 36 nizatidine ...... 26 nystatin & triamcinolone ...... 37 NIZORAL ...... 5, 35 nystatin (topical) ...... 36 NOLVADEX ...... 8 NORA-BE ...... 28 O NORCO ...... 15 NORDETTE-28 ...... 28 OCELLA ...... 28 NORDITROPIN ...... 32 octreotide acetate ...... 33

Kaiser Permanente of Georgia Multi Choice Formulary 55 Kaiser Permanente of Georgia Multi Choice Formulary OCUFEN ...... 23 orphenadrine citrate ...... 9 OCUFLOX ...... 22 orphenadrine, aspirin, & caffeine ...... 9 OCUPRESS ...... 24 ORTHO EVRA ...... 28 ofloxacin (ophth) ...... 22 ORTHO TRI-CYCLEN ...... 29 ofloxacin (otic) ...... 22 ORTHO TRI-CYCLEN LO ...... 29 OGESTREL ...... 29 ORTHO-CEPT ...... 27 olanzapine ...... 20 ORTHO-CYCLEN ...... 29 olanzapine & fluoxetine hcl ...... 20 ORTHO-EST ...... 32 olanzapine orally disintegrating ...... 20 ORTHO-NOVUM ...... 29 OLEPTRO ...... 20 oseltamivir phosphate ...... 7 olmesartan ...... 11, 13 OSENI ...... 30 olmesartn & hydrochlorothiazide ...... 13 OSMOPREP ...... 26 olopatadine...... 24 ospemifene ...... 32 olopatadine (nasal)...... 24 OSPHENA ...... 32 olopatadine (ophth) ...... 24 OVCON-35 ...... 28 olsalazine ...... 25 OVCON-50 ...... 29 OLUX-E ...... 36 OVIDE ...... 35 OLYSIO ...... 7 OXANDRIN ...... 27 omalizumab ...... 35 oxandrolone ...... 27 omega-3 acid ethyl esters ...... 11 oxaprozin ...... 16 omega-3-carboxylic acid ...... 11 oxazepam ...... 18 OMNARIS ...... 23 oxcarbazepine ...... 17 OMNICEF...... 4 oxiconazole nitrate ...... 36 OMNIPRED ...... 23 OXISTAT ...... 36 OMNITROPE ...... 32 OXSORALEN-ULTRA ...... 38 ondansetron ...... 25 oxybutynin ...... 38 ondansetron (orally disentigrating) ...... 25 oxybutynin extended-release...... 38 ONE TOUCH ULTRA 2 ...... 21 oxybutynin transdermal ...... 38 ONE TOUCH ULTRA SMART ...... 21 oxycodone ...... 16 ONE TOUCH ULTRA TEST STRIPS ...... 20 oxycodone & acetaminophen ...... 16 ONE TOUCH ULTRAMINI ...... 21 oxycodone & aspirin ...... 16 ONE TOUCH VERIO IQ ...... 21 oxycodone & ibuprofen ...... 16 ONE TOUCH VERIO TEST STRIPS ...... 20 oxycodone controlled-release ...... 16 ONFI ...... 17 OXYCONTIN ...... 16 ONGLYZA ...... 31 oxymorphone ...... 16 ONSOLIS ...... 15 oxymorphone extended-release ...... 16 OPANA ...... 16 OXYTROL ...... 38 OPANA ER ...... 16 OPIUM ...... 16 P opium & belladonna alkaloids ...... 16 opium tincture ...... 16 PACERONE ...... 12 oprelvekin ...... 10 PALGIC ...... 4 OPSUMIT ...... 13 paliperidone ...... 20 OPTHETIC ...... 25 palivizumab ...... 7 OPTICROM ...... 24 PAMELOR ...... 20 OPTIPRANOLOL ...... 24 PAMINE...... 9 OPTIVAR...... 24 PANCREAZE ...... 26 ORACEA ...... 4, 38 pancrelipase (lipase-protease-amylase)...... 26 ORAP ...... 20 PANDEL ...... 37 ORAPRED...... 27 PANLOR SS ...... 14 ORAPRED ODT ...... 27 PANRETIN ...... 37 ORENCIA ...... 32 papaverine ...... 14 ORENITRAM ...... 14 PARAFON FORTE DSC ...... 9 ORINASE ...... 31 PARCOPA ...... 18

Kaiser Permanente of Georgia Multi Choice Formulary 56 Kaiser Permanente of Georgia Multi Choice Formulary paregoric ...... 25 PHENERGAN VC W/CODEINE ...... 34 PAREGORIC ...... 25 PHENERGAN W/ CODEINE ...... 34 paricalcitol ...... 39 phenobarbital ...... 18, 26 PARLODEL ...... 18 PHENOBARBITAL ...... 18 PARNATE ...... 20 phenobarbital and belladonna alkaloids ...... 26 paromomycin sulfate ...... 6 phenoxybenzamine ...... 9 paroxetine ...... 20 PHENYTEK ...... 17 paroxetine extended-release ...... 20 phenytoin sodium extended-release ...... 17 paroxetine mesylate ...... 20 phenytoin suspension ...... 17 PATADAY ...... 24 PHISOHEX ...... 35 PATANASE ...... 24 PHOSLO...... 22 PATANOL ...... 24 PHOSLYRA...... 22 PAVABID ...... 14 PHOSPHA ...... 22 PAXIL ...... 20 PHOSPHOLINE IODIDE ...... 24 PAXIL CR ...... 20 PHRENILIN ...... 14 pazopanib ...... 8 PHRENILIN FORTE ...... 14 PEDIAPRED ...... 27 phytonadione ...... 39 pediatric multivitamins w/ fluoride ...... 33 PICATO ...... 38 pediatric multivitamins w/ fluoride & iron ...... 33 pilocarpine ...... 9, 24 pediatric vitamins a, c, & d, w/ fluoride ...... 34 pilocarpine gel ...... 24 pediatric vitamins a, c, & d, w/ fluoride & iron ...... 34 PILOPINE HS ...... 24 PEGANONE ...... 17 pimecrolimus ...... 38 PEGASYS ...... 7 pimozide ...... 20 pegfilgrastim ...... 10 pindolol ...... 14 peginterferon alfa-2a ...... 7 pioglitazone ...... 30, 31 peginterferon-alfa 2b...... 7 pioglitazone & glimepiride ...... 31 PEG-INTRON ...... 7 pioglitazone & metformin ...... 31 pegvisomant ...... 32 pirbuterol acetate ...... 10 penbutolol ...... 14 piroxicam ...... 16 penciclovir ...... 36 pitavastatin ...... 11 penicillamine ...... 27 PLAN B ...... 28 penicillin v potassium ...... 5 PLAQUENIL ...... 6 PENLAC ...... 35 PLAVIX ...... 10 PENNSAID ...... 15 PLENDIL ...... 11 PENTASA ...... 25 PLETAL ...... 10 pentazocine & naloxone ...... 16 PLEXION ...... 37 pentosan polysulfate sodium ...... 34 PLEXION SCT ...... 37 pentoxifylline ...... 10 podofilox ...... 38 PEN-VEE K ...... 5 POLY HIST FORTE ...... 4 perampanel ...... 17 POLYCITRA-K ...... 21 PERCOCET ...... 16 polyethylene glycol-electrolyte solution ...... 26 PERCODAN ...... 16 polymyxin b & trimethoprim (ophth) ...... 22 PERIACTIN ...... 4 POLYSPORIN ...... 22 PERIDEX ...... 22 POLYTRIM ...... 22 perindopril ...... 13 POLY-VI-FLOR ...... 33 PERIOSTAT ...... 4 POLY-VI-FLOR W/IRON ...... 33 permethrin ...... 36 POMALYST ...... 8 perphenazine ...... 19, 20 ponatinib ...... 8 PERSANTINE ...... 10 PONSTEL ...... 15 PERTZYE ...... 26 posaconazole ...... 5 PEXEVA ...... 20 potassium bicarbonate & potassium chloride ...... 22 phenelzine ...... 20 potassium chloride ...... 22 PHENERGAN ...... 4, 34 potassium chrloide powder ...... 22 PHENERGAN VC...... 4, 34 potassium citrate ...... 21

Kaiser Permanente of Georgia Multi Choice Formulary 57 Kaiser Permanente of Georgia Multi Choice Formulary potassium citrate & citric acid ...... 21 PROCRIT ...... 10 potassium gluconate ...... 22 PROCTOCORT...... 37 potassium phosphate ...... 22 PROCTOFOAM ...... 37 potassium phosphate, monobasic ...... 22 PROCTOFOAM-HC...... 37 POTIGA ...... 17 PROCYSBI ...... 33 PRADAXA ...... 10 PRODIGY ...... 21 pramipexole ...... 18 PRODIGY TEST STRIPS ...... 21 pramipexole extended-release ...... 18 progesterone, micronized ...... 32 pramlintide acetate ...... 31 PROGRAF ...... 34 PRAMOSONE-E ...... 37 PROLIXIN ...... 19 pramoxine ...... 37 PROLOPRIM ...... 7 PRANDIMET ...... 31 PROMACTA ...... 10 PRANDIN ...... 31 promethazine ...... 4, 34 PRAVACHOL ...... 11 promethazine & codeine ...... 34 pravastatin ...... 11 promethazine & dextromethorphan ...... 34 prazosin ...... 11 promethazine & phenylephrine ...... 4 PRECOSE ...... 29 promethazine, phenylephrine & codeine ...... 34 PRED FORTE ...... 23 PROMETHAZINE-DM ...... 34 PRED MILD ...... 23 PROMETRIUM ...... 32 PRED-G ...... 23 propafenone ...... 12 prednicarbate ...... 37 propantheline bromide ...... 9 PREDNISOL ...... 24 proparacaine ...... 25 prednisolone ...... 23, 24, 27 propranolol ...... 14 PREDNISOLONE ...... 27 propranolol & hydrochlorothiazide ...... 14 prednisolone acetate...... 23, 27 propranolol extended-release ...... 14 prednisolone acetate (ophth) ...... 23 propranolol sustained-release ...... 14 prednisolone sodium phosphate ...... 23, 24, 27 propylthiouracil ...... 32 prednisolone sodium phosphate (ophth) ...... 23, 24 PROPYLTHIOURACIL ...... 32 prednisone ...... 27 PROSOM...... 18 PREDNISONE ...... 27 PROSTIGMIN ...... 9 PREFEST ...... 31 PROTOPIC ...... 38 pregabalin ...... 17 protriptyline ...... 20 PRELONE ...... 27 PROVENTIL HFA ...... 9 PREMARIN ...... 31, 32 PROVERA ...... 32 PREMARIN CREAM ...... 32 PROVIGIL ...... 16 PREMPHASE ...... 31 PROZAC ...... 19 PREMPRO ...... 31 PROZAC WEEKLY ...... 19 PREVIDENT ...... 34 PRUDOXIN ...... 38 PREVIDENT 5000 PLUS ...... 34 pseudoephedrine, brompheniramine & codeine ...... 34 PREVPAC ...... 25 PSORIATEC ...... 37 PREZISTA ...... 6 PULMICORT FLEXHALER ...... 34 PRIFTIN...... 6 PULMICORT RESPULES ...... 34 PRIMAQUINE ...... 6 PULMOZYME ...... 22 primaquine phosphate ...... 6 PURINETHOL ...... 8 primidone ...... 17 PYLERA...... 4 PRISTIQ ...... 19 pyrazinamide ...... 5 PROAIR HFA ...... 9 PYRAZINAMIDE ...... 5 PROAMATINE ...... 10 pyridostigmine ...... 9 PRO-BANTHINE ...... 9 pyrimethamine ...... 6 probenecid ...... 22 procarbazine ...... 8 Q PROCARDIA ...... 12 PROCARDIA XL ...... 12 QNASL ...... 23 prochlorperazine ...... 25 QUALAQUIN ...... 6

Kaiser Permanente of Georgia Multi Choice Formulary 58 Kaiser Permanente of Georgia Multi Choice Formulary QUESTRAN ...... 11 RETROVIR ...... 7 QUESTRAN LIGHT ...... 11 REVATIO ...... 14 quetiapine ...... 20 REVIA ...... 19 quetiapine extended-release ...... 20 REVLIMID ...... 8 QUINAGLUTE ...... 12 REYATAZ ...... 6 quinapril & hydrochlorothiazide ...... 13 RHINOCORT AQUA ...... 23 quinapril hcl ...... 13 ribavirin ...... 7 quinidine ...... 12, 19 RIDAURA ...... 26 quinidine gluconate ...... 12 rifabutin ...... 5 QUINIDINE SULFATE ...... 12 RIFADIN ...... 5 quinine sulfate ...... 6 RIFAMATE ...... 5 QUIXIN ...... 22 rifampin ...... 5 QVAR ...... 34 rifampin & isoniazid ...... 5 rifapentine ...... 6 rifaximin ...... 5 R rilpivirine ...... 6, 7 raloxifene hcl ...... 32 RILUTEK ...... 19 raltegravir ...... 7 riluzole ...... 19 ramelteon ...... 18 rimantadine ...... 7 ramipril ...... 13 rimexolone ...... 24 RANEXA ...... 12 riociguat ...... 14 ranitidine ...... 26 RIOMET ...... 30 ranolazine ...... 12 risedronate sodium ...... 34 RAPAFLO ...... 9 RISPERDAL ...... 20 RAPAMUNE ...... 34 RISPERDALM-TAB ...... 20 rasagiline ...... 18 risperidone ...... 20 RAVICTI ...... 21 risperidone orally disintegrating ...... 20 RAYOS ...... 27 RITALIN ...... 16 RAZADYNE ...... 9 RITALIN LA ...... 16 RAZADYNEER...... 9 RITALIN SR ...... 16 REBETOL ...... 7 ritonavir ...... 6, 7 REBIF ...... 33 rivaroxaban ...... 10 RECLIPSEN ...... 27 rivastigmine tartrate ...... 9 REGLAN ...... 26 rivastigmine tartrate (solution) ...... 9 REGRANEX ...... 38 rizatriptan ...... 17 RELAFEN ...... 15 rizatriptan orally disentigrating ...... 17 RELENZA ...... 7 ROBAXIN ...... 9 RELPAX ...... 17 ROBINUL...... 8 REMERON...... 20 ROBINULFORTE ...... 8 REMODULIN ...... 14 ROCALTROL ...... 39 RENAGEL ...... 21 roflumilast ...... 35 RENVELA ...... 21 ROMYCIN ...... 22 repaglinide ...... 31 ropinirole ...... 18 repaglinide & metformin ...... 31 ropinirole extended-release ...... 18 REQUIP ...... 18 ROSAC ...... 35 REQUIP XL ...... 18 ROSULA ...... 37 RESCRIPTOR...... 6 rosuvastatin...... 11 RESCULA ...... 25 rotigotine ...... 18 reserpine ...... 12 ROWASA ...... 25 RESTASIS ...... 23 ROXICET ...... 16 RESTORIL ...... 18 ROXICODONE ...... 16 retapamulin ...... 36 ROZEREM ...... 18 RETIN-A ...... 37 rufinamide ...... 17 RETIN-A MICRO ...... 37 ruxolitinib ...... 8

Kaiser Permanente of Georgia Multi Choice Formulary 59 Kaiser Permanente of Georgia Multi Choice Formulary RYTHMOL ...... 12 SILVADENE...... 36 RYTHMOL SR ...... 12 silver sulfadiazine ...... 36 simeprevir ...... 7 SIMPONI ...... 33 S simvastatin ...... 11, 31 SABRIL ...... 17 sinecatechins ...... 38 SAFYRAL ...... 28 SINEMET ...... 18 SAIZEN ...... 32 SINEMET CR...... 18 SALAGEN ...... 9 SINEQUAN ...... 19 salmeterol ...... 10, 35 SINGULAIR ...... 34 salsalate ...... 16 sirolimus ...... 34 SAMSCA ...... 21 SIRTURO ...... 33 SANCTURA ...... 38, 39 sitagliptin & metformin ...... 31 SANCTURA XR ...... 39 sitagliptin & simvastatin ...... 31 SANCUSO ...... 25 sitagliptin phosphate ...... 31 SANDIMMUNE ...... 33 SKELAXIN ...... 9 SANDOSTATIN ...... 33 sodium citrate & citric acid ...... 21 SANTYL ...... 38 sodium fluoride ...... 34 SAPHRIS ...... 19 sodium fluoride (dental) ...... 34 sapropterin dihydrochlorid ...... 34 sodium fluoride drops ...... 34 saquinavir mesylate...... 7 sodium oxybate ...... 19 SARAFEM ...... 19 sodium phenylbutyrate ...... 21 sargramostim ...... 10 sodium phosphates ...... 26 SAVELLA...... 19 sodium polystyrene sulfonate ...... 21 saxagliptin ...... 31 sofusbuvir ...... 7 scopolamine (ophth) ...... 25 SOLARAZE ...... 38 scopolamine hydrobromide ...... 25 solifenacin ...... 38 SEASONALE ...... 28 SOLODYN ...... 5 SEASONIQUE ...... 28 SOMA ...... 9, 15 SEB-PREV ...... 36 SOMA COMPOUND ...... 9, 15 SECTRAL ...... 14 SOMA COMPOUND W/ CODEINE ...... 15 selegiline ...... 18 somatropin ...... 32 selegiline transdermal ...... 18 SOMAVERT ...... 32 selenium sulfide ...... 36 SONATA ...... 18 SELSEB ...... 36 sorafenib tosylate ...... 8 SELSUN RX ...... 36 SORIATANE ...... 37 SELZENTRY ...... 7 SORILUX ...... 38 SENSIPAR ...... 33 sotalol ...... 14 SEPTRA ...... 5 SOVALDI ...... 7 SERAX ...... 18 SPECTAZOLE ...... 35 SEREVENT DISKUS ...... 10 SPECTRACEF ...... 4 SEROMYCIN ...... 5 spinosad ...... 36 SEROQUEL ...... 20 SPIRIVA...... 9 SEROQUEL XR ...... 20 spironolactone ...... 13 SEROSTIM ...... 32 spironolactone & hydrochlorothiazide...... 13 SERPASIL ...... 12 SPORANOX ...... 5 sertaconazole nitrate ...... 36 SPRINTEC ...... 29 sertraline ...... 20 SPRYCEL ...... 8 SERZONE ...... 20 SPS ...... 21 sevelamer carbonate ...... 21 STADOL ...... 15 sevelamer hcl ...... 21 STALEVO ...... 18 SIGNIFOR...... 33 stannous fluoride ...... 34 sildenafil ...... 14 STARLIX...... 30 silodosin ...... 9 stavudine ...... 7

Kaiser Permanente of Georgia Multi Choice Formulary 60 Kaiser Permanente of Georgia Multi Choice Formulary STELAZINE ...... 20 tamoxifen citrate ...... 8 STIMATE ...... 32 tamsulosin hcl ...... 9 STRATTERA ...... 19 TAPAZOLE ...... 32 STRIBILD ...... 6 tapentadol ...... 16 STROMECTOL ...... 4 TARCEVA ...... 8 SUBOXONE ...... 14 TARGRETIN ...... 7, 38 SUBUTEX ...... 14 TARKA ...... 12 succimer ...... 27 TASIGNA ...... 8 sucralfate ...... 26 TASMAR ...... 18 SULAR ...... 12 tazarotene ...... 38 sulconazole nitrate ...... 36 TAZORAC ...... 38 SULFAC ...... 22 TECFIDERA...... 33 sulfacetamide sodium & prednisolone ...... 24 TEGRETOL...... 16, 17 sulfacetamide sodium & sulfur ...... 37 TEGRETOL XR ...... 17 sulfacetamide sodium (acne) ...... 36 TEKAMLO ...... 12 sulfacetamide sodium (ophth) ointment ...... 22 TEKTURNA ...... 12 sulfacetamide sodium (ophth) solution ...... 22 TEKTURNA HCT ...... 12 sulfadiazine ...... 5, 36 telaprevir ...... 7 SULFADIAZINE ...... 5 telithromycin ...... 5 sulfamethoxazole & trimethoprim ...... 5 telmisartan ...... 13 SULFAMYLON ...... 35 telmisartan & hydrochlorothiazide ...... 13 sulfanilamide ...... 36 temazepam ...... 18 sulfasalazine ...... 5 TEMODAR ...... 8 sulindac ...... 16 TEMOVATE ...... 36 sumatriptan ...... 17 TEMOVATE E ...... 36 sunitinib malate ...... 8 temozolomide ...... 8 SUPRAX ...... 4 TENEX ...... 12 SURMONTIL ...... 20 tenofovir ...... 6, 7 SUSTIVA ...... 6 TENORETIC ...... 14 SUTENT ...... 8 TENORMIN...... 14 SYMAX ...... 8 TERAZOL 3 ...... 36 SYMAX DUOTAB ...... 8 TERAZOL 7 ...... 36 SYMBICORT ...... 34 terazosin ...... 11 SYMBYAX ...... 20 terbinafine ...... 5 SYMLIN ...... 31 terbutaline sulfate ...... 10 SYMMETREL ...... 18 terconazole ...... 36 SYNAGIS ...... 7 terconazole (vaginal) ...... 36 SYNALAR ...... 36 teriflunomide ...... 34 SYNAREL ...... 32 teriparatide ...... 32 SYNTHROID...... 32 TESSALON PERLES ...... 34 SYPRINE ...... 27 TESTIM ...... 27 syringe with needle,disposable ...... 21 testosterone ...... 27, 31 testosterone cypionate ...... 27 TESTRED T ...... 27 tetrabenazine ...... 19 TABLOID ...... 8 tetracycline ...... 4, 5 TACLONEX ...... 36 TETRACYCLINE ...... 5 tacrolimus ...... 34, 38 tetrahydrozoline ...... 25 tacrolimus (topical) ...... 38 TEVETEN ...... 13 tadalafil ...... 14 thalidomide ...... 34 TAGAMET ...... 25 THALOMID ...... 34 TALWIN NX ...... 16 theophylline ...... 38 TAMBOCOR ...... 12 thioguanine ...... 8 TAMIFLU ...... 7 thioridazine ...... 20

Kaiser Permanente of Georgia Multi Choice Formulary 61 Kaiser Permanente of Georgia Multi Choice Formulary thiothixene ...... 20 TRACLEER ...... 13 THORAZINE ...... 19 TRADJENTA ...... 30 thyroid ...... 32 tramadol ...... 16 THYROLAR ...... 32 tramadol & acetaminophen ...... 16 tiagabine ...... 17 tramadol extended-release ...... 16 TIAZAC ...... 11 TRANDATE ...... 14 ticagrelor ...... 10 trandolapril ...... 13 TICLID ...... 10 TRANSDERM-SCOP ...... 25 ticlopidine ...... 10 TRANXENE ...... 18 TIGAN ...... 25 tranylcypromine sulfate ...... 20 TIKOSYN ...... 12 TRAVATAN Z ...... 25 TILIA ...... 29 travoprost...... 25 timolol...... 14, 24, 25 trazodone ...... 20 TIMOPTIC ...... 25 trazodone extended-release ...... 20 TIMOPTIC-XE ...... 25 TRENTAL ...... 10 tiotropium ...... 9 treprostinil ...... 14 tipranavir ...... 7 tretinoin ...... 8, 37, 38 TIROSINT ...... 32 tretinoin microspheres ...... 37 TIVICAY ...... 6 TREXALL ...... 8 tizanidine ...... 9 triamcinolone acetonide (nasal) ...... 24 TOBI ...... 5 triamcinolone acetonide (topical) ...... 37 TOBI Podhaler ...... 5 triamterene ...... 21 TOBI PODHALER ...... 5 triamterene & hydrochlorothiazide ...... 21 TOBRADEX ...... 24 TRIAVIL ...... 19 tobramycin & dexamethasone ointment ...... 24 triazolam ...... 18 tobramycin & dexamethasone suspension ...... 24 TRIBENZOR ...... 11 tobramycin inhalation powder ...... 5 TRICOR ...... 11 tobramycin inhalation solution ...... 5 trientine ...... 27 tobramycin sulfate (ophth) ointment ...... 22 trifluoperazine ...... 20 tobramycin sulfate (ophth) solution ...... 23 trifluridine...... 23 TOBREX ...... 22, 23 trihexyphenidyl ...... 18 tocilizumab ...... 34 TRILAFON...... 20 tofacitinib ...... 34 TRILEPTAL ...... 17 TOFRANIL ...... 19 TRILIPIX ...... 11 TOFRANIL-PM ...... 19 trimethobenzamide ...... 25 tolazamide ...... 31 trimethoprim ...... 5, 7, 22 tolbutamide ...... 31 trimipramine ...... 20 tolcapone ...... 18 TRINESSA ...... 29 TOLECTIN 600...... 16 TRI-NORINYL ...... 29 TOLINASE ...... 31 TRI-SPRINTEC ...... 29 tolmetin sodium ...... 16 TRI-VI-FLOR ...... 34 tolterodine ...... 38 TRI-VI-FLOR W/IRON ...... 34 tolterodine extended-release ...... 38 TRIVORA ...... 28 tolvaptan ...... 21 TRIZIVIR ...... 6 TOPAMAX ...... 17 trospium ...... 38, 39 TOPAMAX SPRINKLE ...... 17 trospium extended-release ...... 39 TOPICORT ...... 36 TRUSOPT ...... 24 topiramate capsule ...... 17 TRUVADA ...... 6 topiramate tablet ...... 17 TUSSIONEX ...... 34 topotecan ...... 8 TWINJECT ...... 10 TOPROL XL ...... 14 TYKERB ...... 8 TORADOL ...... 15 TYLENOL W/ CODEINE ...... 14 torsemide ...... 21 TYZINE ...... 25 TOVIAZ ...... 38

Kaiser Permanente of Georgia Multi Choice Formulary 62 Kaiser Permanente of Georgia Multi Choice Formulary verapamil extended-release cap ...... 12 U verapamil sustained-release cap ...... 12 verapamil sustained-release tab ...... 12 UCERIS ...... 27 VEREGEN ...... 38 ulipristal ...... 29 VERELAN ...... 12 ULORIC ...... 33 VERELAN PM...... 12 ULTRACET ...... 16 VESANOID...... 8 ULTRAM ...... 16 VESICARE ...... 38 ULTRAM ER...... 16 VEXOL ...... 24 ULTRAVATE ...... 36 VFEND...... 5 UNIPHYL ...... 38 VICOPROFEN ...... 15 UNIRETIC ...... 13 VICTOZA ...... 30 UNITHROID ...... 32 VICTRELIS ...... 6 UNIVASC ...... 13 VIDEX ...... 6 urea ...... 37 VIDEX EC ...... 6 URECHOLINE ...... 9 vigabatrin ...... 17 URELLE ...... 7 VIGAMOX ...... 22 UROCIT-K ...... 21 VIIBRYD ...... 20 UROXATRAL ...... 9 vilazodone ...... 20 URSO ...... 26 VIMPAT ...... 17 URSO FORTE ...... 26 VIOKACE...... 26 ursodiol...... 26 VIRACEPT ...... 7 VIRAMUNE ...... 7 V VIREAD ...... 7 VIROPTIC ...... 23 VAGIFEM ...... 31 VISICOL ...... 26 valacyclovir ...... 7 VISKEN ...... 14 VALCYTE ...... 7 VISTARIL...... 18 valganciclovir ...... 7 VIVACTIL ...... 20 VALISONE ...... 36 VIVELLE-DOT ...... 31 VALIUM ...... 18 VOLTAREN ...... 15, 23, 38 valproate sodium ...... 17 VOLTAREN GEL ...... 38 valproic acid ...... 17 VOLTAREN XR ...... 15 valsartan ...... 11, 12, 13 voriconazole ...... 5 valsartan & hydrochlorothiazide ...... 11, 13 vorinostat ...... 8 VALTREX ...... 7 vortioxetine ...... 20 VALTURNA ...... 12 VOSOL ...... 25 VANCOCIN HCL ...... 5 VOSPIRE ER ...... 10 vancomycin hcl ...... 5 VOTRIENT ...... 8 vandetanib ...... 8 VUSION ...... 35 VANOS ...... 36 VYTONE ...... 35 VANOXIDE-HC ...... 36 VYTORIN ...... 11 VANTIN ...... 4 VYVANSE ...... 16 varenicline ...... 9 VASERETIC ...... 13 VASOTEC ...... 13 W VECTICAL...... 38 warfarin ...... 10 VELIVET ...... 27 WELCHOL ...... 11 VELTIN ...... 38 WELLBUTRIN...... 19 vemurafenib ...... 8 WELLBUTRIN SR ...... 19 venlafaxine ...... 20 WELLBUTRIN XL ...... 19 venlafaxine extended-release ...... 20 WESTCORT ...... 37 VENTOLIN HFA ...... 9 VERAMYST ...... 23 verapamil ...... 12 Kaiser Permanente of Georgia Multi Choice Formulary 63 Kaiser Permanente of Georgia Multi Choice Formulary ZESTRIL ...... 13 X ZETIA ...... 11 ZIAC ...... 14 XALATAN ...... 24 ZIAGEN ...... 6 XALKORI ...... 7 ZIANA ...... 38 XANAX ...... 18 zidovudine ...... 6, 7 XANAX XR ...... 18 zileuton ...... 34 XARELTO ...... 10 ziprasidone ...... 20 XELJANZ ...... 34 ZIRGAN ...... 22 XELODA ...... 7 ZITHROMAX ...... 4 XENAZINE ...... 19 ZOCOR...... 11 XIBROM ...... 23 ZOFRAN ...... 25 XIFAXAN ...... 5 ZOFRAN ODT ...... 25 XOLAIR ...... 35 ZOHYDRO ER...... 15 XOPENEX HFA ...... 10 ZOLINZA ...... 8 XOPENEX NEBULIZER ...... 10 zolipdem sublingual ...... 18 XTANDI ...... 8 zolmitriptan ...... 17, 18 XULANE...... 28 zolmitriptan orally disentigrating ...... 18 XYLOCAINE ...... 25, 37 ZOLOFT ...... 20 XYLOCAINE VISCOUS ...... 25 zolpidem ...... 19 XYREM ...... 19 zolpidem extended-release ...... 19 zolpidem oral spray ...... 19 Y ZOLPIMIST ...... 19 ZOMIG ...... 17, 18 YASMIN ...... 28 ZOMIG ZMT ...... 18 YAZ ...... 28 ZONALON ...... 37 ZONEGRAN ...... 17 Z zonisamide ...... 17 ZORBTIVE ...... 32 zafirlukast ...... 34 ZORTRESS ...... 33 zaleplon ...... 18 ZOVIA ...... 28 ZANAFLEX ...... 9 ZOVIRAX ...... 6, 35 zanamivir ...... 7 ZYCLARA ...... 38 ZANTAC ...... 26 ZYFLO ...... 34 ZARONTIN ...... 17 ZYKADIA ...... 7 ZAROXOLYN ...... 21 ZYLET ...... 23 ZEBETA ...... 14 ZYLOPRIM...... 33 ZELAPAR ...... 18 ZYMAXID ...... 22 ZELBORAF ...... 8 ZYPREXA ...... 20 ZEMPLAR ...... 39 ZYPREXA ZYDIS ...... 20 ZENPEP ...... 26 ZYTIGA ...... 7 ZERIT ...... 7 ZYVOX ...... 5 ZESTORETIC ...... 13

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