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Future Formulary Changes

Updated 07/30/2021

Applies to: Employer group plan 2021 closed formularies

KEY: PA=prior authorization; ST=step therapy; QL=quantity limit

Generic name Brand name Change Effective Posted date date /lamivudine/tenofovir DF Symfi Lo, Symfi Remove from 10/01/2021 07/30/2021 the formulary (generic available) Etravirine Intelence Remove from 10/01/2021 07/30/2021 the formulary (generic available) Lopinavir/ritonavir Kaletra Remove from 10/01/2021 07/30/2021 the formulary (generic available) tablets, alprazolam ER Ativan tablets, Doral tablets, Add quantity limit 10/01/2021 07/30/2021 tablets, alprazolam orally disintegrating Halcion tablets, Klonopin for tablets, alprazolam oral concentrate, tablets, Restoril capsules, dipotassium tablets, Tranxene-T tablets, Valium naïve therapy tablets, clonazepam orally tablets, Xanax tablets, Xanax limited to the disintegrating tablets, oral XR tablets lesser of: 15 concentrate, diazepam oral solution, tablets/capsules/ diazepam tablets, tablets, doses or a 14 capsules, oral day supply concentrate, lorazepam tablets, oral syrup, capsules, tablets, capsules, tablets Diclofenac gel 1% Voltaren gel 1% Move to 10/01/2021 07/30/2021 excluded (over- the-counter alternative available) Mometasone furoate/formoterol Dulera Add quantity limit 10/01/2021 07/30/2021 of 1 inhaler per 24 days Budesonide/formoterol fumarate Symbicort Add quantity limit 10/01/2021 07/30/2021 of 1 inhaler per 24 days Emtricitabine/tenofovir alafenamide Descovy Add PA 10/01/2021 07/30/2021

Updated 07/30/2021

Generic name Brand name Change Effective Posted date date Glycopyrronium tosylate Qbrexza Add quantity limit 10/01/2021 07/30/2021 of 30 pads per 30 days Berotralstat Orladeyo Add quantity limit 10/01/2021 07/30/2021 of 30 capsules per 30 days Cenobamate Xcopri Add quantity limit 10/01/2021 07/30/2021 of 60 tablets per 30 days Brivaracetam Brivact Add quantity limit 10/01/2021 07/30/2021 of 60 tablets per 30 days, add quantity limit of 600 mL per 30 days Valbenazine Ingrezza Limited to 08/30/2021 06/30/2021 Kaiser Permanente Pharmacies Cyclosporine ophthalmic Restasis Remove from 07/01/2021 04/30/2021 the formulary

Pimecrolimus 1% cream Elidel Remove from 07/01/2021 04/30/2021 the formulary (brand only generic available) Potassium chloride ER K-Tab Remove from 07/01/2021 04/30/2021 the formulary (brand only generic available) Metronidazole gel 0.75% Vandazole Remove from 07/01/2021 04/30/2021 the formulary (brand only generic available) Brinzolamide suspension 1% Azopt Remove from 07/01/2021 04/30/2021 the formulary (brand only generic available)

Updated 07/30/2021

Generic name Brand name Change Effective Posted date date Lapatinib ditosylate Tykerb Remove from 07/01/2021 04/30/2021 the formulary (brand only generic available) Plecanatide Trulance Add quantity 07/01/2021 04/30/2021 limit of 30 tablets per 30 days Tegaserod Zelnorm Add quantity 07/01/2021 04/30/2021 limit of 60 tablets per 30 days Prucalopride Motegrity Add quantity 07/01/2021 04/30/2021 limit of 30 tablets per 30 days Diazepam Valtoco Add PA 07/01/2021 04/30/2021

Avatrombopag Doptelet Limited to 07/01/2021 04/30/2021 Kaiser Permanente Pharmacies Filgrastim Nivestym Limited to 07/01/2021 04/30/2021 Kaiser Permanente Pharmacies Ponatinib Iclusig Limited to 07/01/2021 04/30/2021 Kaiser Permanente Pharmacies Teriparatide Brand Teriparatide Limited to 07/01/2021 04/30/2021 Kaiser Permanente Pharmacies Dalfampridine Brand Ampyra Limited to 07/01/2021 04/30/2021 Kaiser Permanente Pharmacies

Updated 07/30/2021

Generic name Brand name Change Effective Posted date date Emtricitabine/tenofovir disoproxil fumarate Truvada Remove from 04/01/2021 01/29/2021 the formulary and remove from ACA status (brand only generic available) sulfate, acetaminophen/codeine, Tylenol/codeine, Dvorah, Add PA 04/01/2021 01/29/2021 codeine/chlorpheniramine ER, tramadol, Tuxarin ER, Ultracet, Ultram, tramadol/acetaminophen Qdolo Mesalamine Pentasa Add PA 04/01/2021 01/29/2021

Nitazoxanide Alinia Remove from 04/01/2021 01/29/2021 the formulary (brand only generic available) Lapatinib ditosylate Tykerb Remove from 04/01/2021 01/29/2021 the formulary (brand only generic available) Abiraterone acetate tablet 500 mg Zytiga Remove from 04/01/2021 01/29/2021 the formulary (brand only generic available) Efavirenz/emtricitabine/tenofovir Atripla Remove from 01/01/2021 11/16/2020 the formulary (brand only generic available) Emtricitabine Emtriva Remove from 01/01/2021 11/16/2020 the formulary (brand only generic available) Buprenorphine/naloxone Suboxone, Zubsolv, Bunavail Add quantity 01/01/2021 11/16/2020 limit of a 30 day supply per fill

Updated 07/30/2021

Generic name Brand name Change Effective Posted date date Acetaminophen//dihydrocodeine, Abstral, Actiq, Apadaz, Arymo Add quantity 01/01/2021 10/30/2020 acetaminophen/codeine, ER, Ascomp/Codeine, limit of a 30 day belladonna/opium, Belbuca, Butrans, Conzip, supply per fill benzhydrocodone/acetaminophen, Dilaudid, Dolophine, buprenorphine, Duragesic, Dvorah, Embeda, /acetaminophen/caffeine/codeine Endocet, Exalgo, Fentora, , butalbital//caffeine/codeine, Fioricet/Codeine, butorphanol tartrate, codeine sulfate, Fiorinal/Codeine, Hysingla ER, fentanyl, hydrocodone bitartrate ER, Ibudone, Ionsys, Kadian, hydrocodone bitartrate/acetaminophen, Lazanda, Lorcet, Lorcet HD, hydrocodone/acetaminophen, Lorcet Plus, Lortab, hydrocodone/ibuprofen, hydromorphone, Methadose, Morphabond ER, hydromorphone ER, levorphanol tartrate, MS Contin, Nalocet, Norco, meperidine, methadone, morphine sulfate, Nucynta, Nucynta ER, Opana, morphine sulfate ER, opium, oxycodone, Oxaydo, Oxycontin, Panlor, oxycodone ER, Percocet, Primlev, Prolate, oxycodone/acetaminophen, Roxicodone, Subsys, Trezix, oxycodone/aspirin, oxycodone/ibuprofen, Tylenol/Codeine, Ultracet, pentazocine/naloxone, tramadol, tramadol Ultram, Xtampza ER, Zohydro ER, tramadol/acetaminophen ER Alprazolam, alprazolam ER, alprazolam Ativan, Diastat Acudial, Add quantity 01/01/2021 10/30/2020 ODT, alprazolam XR, , Diastat Pediatric, Doral, limit of a 30 day chlordiazepoxide/clidinium , Halcion, Klonopin, Librax, supply per fill chlordiazepoxide/amitriptyline, , Onfi, Restoril, Sympazan, clonazepam, clonazepam ODT, Tranxene T, Valium, Valtoco, clorazepate dipotassium, diazepam, Xanax, Xanax XR estazolam, flurazepam, lorazepam, midazolam, oxazepam, quazepam, temazepam, triazolam , , tartrate, Ambien, Ambien CR, Edluar, Add quantity 01/01/2021 10/30/2020 zolpidem tartrate ER Intermezzo, Zolpimist limit of a 30 day supply per fill Ibrutinib 140 mg capsule Imbruvica Add quantity 01/01/2021 10/30/2020 limit of 90 capsules per 30 days Albuterol Ventolin, ProAir Remove from 01/01/2021 10/30/2020 the formulary (brand only generic available) Fluticasone/salmeterol Advair Remove from 01/01/2021 10/30/2020 the formulary (brand only generic available)

Updated 07/30/2021

Generic name Brand name Change Effective Posted date date Amphetamine and dextroamphetamine Adderall XR Remove from 01/01/2021 10/30/2020 ER the formulary (brand only generic available) Corticotropin Acthar Limited to 01/01/2021 10/30/2020 Kaiser Permanente Pharmacies Eliglustat Cerdelga Limited to 01/01/2021 10/30/2020 Kaiser Permanente Pharmacies Abacavir, abacavir/lamivudine, Aptivus, Atripla, Biktarvy, Limited to 01/01/2021 10/30/2020 abacavir/lamivudine/zidovudine, Cimduo, Combivir, Kaiser atazanavir, didanosine, efavirenz, Complera, Crixivan, Permanente efavirenz/emtricitabine/tenofovir Delstrigo, Descovy, Dovato, Pharmacies disoproxil fumarate, Edurant, Emtriva, Epivir, efavirenz/lamivudine/tenofovir disoproxil Epivir HBV, Epzicom, fumarate, emtricitabine, Evotaz, Fuzeon, Genvoya, emtricitabine/tenofovir disoproxil Intelence, Invirase, Isentress, fumarate, fosamprenavir, lamivudine, Isentress HD, Juluca, lamivudine/zidovudine, Kaletra,, Lexiva, Odefsey, lopinavir/ritonavir, nevirapine, nevirapine Pifeltro, Prezcobix, Prezista, ER, norvir, ritonavir, stavudine, tenofovir Rescriptor, Retrovir, disoproxil fumarate, zidovudine Reyataz, Rukobia, Selzentry, Stribild, Sustiva, Symfi, Symfi Lo, Symtuza, Temixys, Tivicay, Triumeq, Trizivir, Truvada, Tybost, Videx , Videx EC, Viracept, Viramune, Viramune XR, Viread, Zerit, Ziagen Tretinoin Retin-A Remove from 01/01/2021 10/30/2020 the formulary (brand only generic available) Insulin NPH, insulin regular, insulin U- Humulin N, Humulin R, Remove from 01/01/2021 10/30/2020 500 insulin 70/30 Humulin U-500, Humulin the formulary 70/30 Methylnaltrexone Relistor subcutaneous Add PA 10/01/2020 08/13/2020

Updated 07/30/2021

Generic name Brand name Change Effective Posted date date Codeine sulfate; hydromorphone; Endocet; Lorcet; Lortab Update short 10/01/2020 08/13/2020 levorphanol; morphine sulfate; acting opioid oxycodone IR; quantity limit for oxycodone/acetaminophen; ≤7 days history oxycodone/aspirin; tramadol; of use. Now tramadol/acetaminophen; limited to 5 day buprenorphine sublingual; supply in acetaminophen/codeine; addition to hydrocodone/acetaminophen maximum quantity of 42 units or 210mLs for age >21 years; 18 units or 90mLs for age <21 years. Colchicine Colcrys Remove from 10/01/2020 08/13/2020 the formulary (brand only generic available) Sucralfate Carafate suspension Remove from 10/01/2020 08/13/2020 the formulary (brand only generic available) Tazarotene Tazorac Cream 0.1% Remove from 10/01/2020 08/13/2020 the formulary (brand only generic available) Mesalamine Lialda Remove from 10/01/2020 08/13/2020 the formulary (brand only generic available) Metformin oral solution Riomet Remove from 10/01/2020 08/13/2020 the formulary (brand only generic available) Proglycem suspension Diazoxide Remove from 10/01/2020 08/13/2020 the formulary (brand only generic available)

Updated 07/30/2021