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2020 Kaiser Permanente Federal Employees Health Benefit FEHB Drug Formulary

Northern California Region Member Service Contact Center 24hours aday,7 days a week.Closedholidays. 1-800-464-4000 711 TTY

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2020 Kaiser Permanente Federal Employees Health Benefit (FEHB) Drug Formulary Northern California Region This document contains information about the drugs we cover when you participate in a Federal Employees Health Benefits (FEHB) plan offered by Kaiser Permanente (Plan). This formulary is effective February 4, 2020. Benefits described in this formulary are effective January 1 – December 31, 2020. What is the Kaiser Permanente FEHB Drug Formulary? A formulary is a list of drugs determined to be safe and effective for our members by our Pharmacy and Therapeutics Committee. Use of formulary drugs enables Kaiser Permanente to provide high quality care to you and your family at reasonable costs. Kaiser Permanente continually updates the formulary throughout the year based on new medical evidence, considering the recommendations of appropriate physician experts. How much will I pay for covered drugs? The cost-sharing you will pay for most drugs depends on:  The tier in which your drug is categorized, and  Whether your drug is included in our formulary. Preferred drugs are included in our formulary. Non- preferred drugs are not included in our formulary. Below is the copayment you pay for up to a 30-day supply of prescription drugs at a Plan pharmacy. You pay only two copayments for up to a 100-day supply for most drugs dispensed through our mail order program.

Drug Tier Type High Option Standard Option Basic Option Tier 1 Generic drugs $10 $15 $15 Tier 2 Preferred brand-name drugs $40 $50 $60 Tier 3 Non-preferred brand-name drugs $40 $50 $60 Tier 4 Specialty drugs $100 $150 $200

You pay 50% of our allowed amount for fertility and sexual dysfunction. Some drugs may be covered at no cost sharing, such as cessation medications, women’s contraceptive drugs and devices and drugs required by ACA. Specific coverage information, including limitations and exclusions, is described in your FEHB brochure (RI 73-003), see Section 5(f) Prescription drug benefits. To get a copy of your FEHB brochure or if you have questions, please visit our website at kp.org/feds or call Member Services at 1-800-464-4000, 24 hours a day, 7 days a week (closed holidays). For TTY for the hearing/speech impaired, call 711.

2020 Kaiser Permanente Federal Employees Health Benefit Formulary Page 1 (Northern California Region)

We define tiers as follows:  Tier 1. Generic drugs are produced and sold under their generic names after the patent on the brand- name drug expires. Although the price is usually lower, the quality of generic drugs is the same as brand- name drugs. Generic drugs are also just as effective as brand-name drugs. The U.S. Food and Drug Administration (FDA) requires that a generic drug contain the same active drug ingredient in the same amount as the brand-name drug.  Tier 2. Brand-name drugs are produced and sold under the original manufacturer's brand name. Preferred brand-name drugs are listed on our drug formulary.  Tier 3. Non-preferred brand-name drugs are not listed on our drug formulary and are not covered unless approved through the exception process.  Tier 4. Specialty drugs are high-cost drugs that are on our specialty drug list. Kaiser Permanente adopts the model used by most Medicare plans to determine which drugs are in the specialty tier. What drugs are eligible to be mailed from the mail order pharmacy? Most drugs can be mailed from our mail order pharmacy. Some drugs (for example, drugs that are extremely high cost, require special handling or requested to be mailed outside the state of California) may not be eligible for mailing. We provide up to a 100-day supply for most drugs when dispensed through our mail order program for two copayments. How do I use the FEHB Drug Formulary? Our formulary drugs are listed in this formulary by medical condition and alphabetically. We consider drugs not listed on our formulary to be “non-preferred drugs”. You may pay higher cost-sharing for non-formulary drugs that are medically necessary. The cost-sharing you pay and other coverage information is determined by the outpatient prescription drug benefit in your FEHB brochure (RI 73-003, see Section 5(f) Prescription drug benefits). Formulary Drugs by Medical Condition The formulary begins on page 4. The drugs in this formulary are grouped into categories depending on the type of medical condition that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Agents.” If you know the medical condition your drug is used for, simply look for the category name in the list. Then look under the category name for your drug. Formulary Drugs by Alphabetical Listing If you are not sure what category to look under, the Index starting on page 25, provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed. Look in the Index to find the drug name and the page number where you can locate coverage information. Turn to the page listed in the Index and find the name of the drug on the list. If you are using a computer to

2020 Kaiser Permanente Federal Employees Health Benefit Formulary Page 2 (Northern California Region) view this document, you also use the search function (Ctrl F) to find the medication by name. Columns on Medical Condition and Alphabetical Listings There are three columns in the attached chart.  The first column lists the drug name. Brand-name drugs are capitalized (e.g. ALBENZA) and generic drugs are listed in lower-case italics (e.g. amoxicillin). Some drugs include different dosage forms and strengths. All dosage forms and strengths for a particular drug listed may not be on the Formulary. Some drugs have multiple dosage forms. In such cases, some dosages may be on the Formulary and others not. Some of these drugs may be available only in a clinic setting.  The second column indicates drug tier. Some drugs may have more than one tier listed in this column. This means that the amount you pay may vary based on the dosage or the way the drug is administered. You will find cost-sharing for your drug in your FEHB brochure. To get a copy of your FEHB brochure or if you have questions, please visit our website at kp.org/feds or call Member Services at 1-800-464-4000 (TTY 711), 24 hours a day, 7 days a week (closed holidays).  The third column indicates additional requirements or limits on coverage. These requirements and limits may include:

QL = Quantity Limit. For certain drugs, we may limit the amount of the drug you can receive. Additionally, when there is a national shortage of a drug, we may limit the quantity of the drug dispensed.

Does the FEHB Drug Formulary ever change? Yes, Kaiser Permanente continually updates the formulary based on new medical evidence, considering the recommendations of appropriate physician experts and notifies our doctors, pharmacists, and other clinicians about any changes. If a change in the formulary affects any of your prescriptions, your doctor or pharmacist will let you know. Our online formulary at kp.org/formulary is updated on a regular basis. To get updated information about the drugs covered by Kaiser Permanente or if you have questions, please visit our website at kp.org/feds or call Member Services at 1-800-464-4000, 24 hours a day, 7 days a week (closed holidays). For TTY for the hearing/speech impaired, call 711.

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Formulary Drugs by Medical Condition

Drug Requirement / Drug Requirement / Name of drug Name of drug Tier Limits Tier Limits ANTI-INFECTIVE AGENTS CEFTRIAXONE 1 ANTHELMINTICS SODIUM IN DEXTROSE ALBENZA 4 CEFTRIAXONE 2 BILTRICIDE 2 SODIUM-DEXTROSE 1 cefuroxime axetil 1 ANTIBACTERIALS cefuroxime sodium 1, 2 amikacin sulfate 1 cephalexin 1 amoxicillin 1 CHLORAMPHENICOL 1 amoxicillin & pot SOD SUCCINATE 1, 2 clavulanate ciprofloxacin hcl 1 ampicillin & sulbactam 1 ciprofloxacin in d5w 1 sodium clarithromycin 1 ampicillin sodium 1 CLEOCIN IN D5W 2 AVELOX 2 clindamycin hcl 1 AZACTAM IN clindamycin palmitate 2 1 DEXTROSE hydrochloride azithromycin 1, 2 clindamycin phosphate 1 aztreonam 1 CUBICIN 4 BICILLIN L-A 2 demeclocycline hcl 1 CAYSTON 4 QL dicloxacillin sodium 1 cefaclor 1 doxycycline 1 cefadroxil 1 (monohydrate) cefazolin sodium 1 doxycycline hyclate 1 CEFAZOLIN SODIUM- ERYTHROCIN 1 1, 2 DEXTROSE LACTOBIONATE cefdinir 1 FLUCONAZOLE IN 1 cefepime hcl 1 SODIUM CHLORIDE CEFEPIME-DEXTROSE 2 gentamicin in saline 1 cefixime 1 gentamicin sulfate 1 cefotaxime sodium 1 INVANZ 2 cefotetan disodium 1 levofloxacin 1 CEFOTETAN levofloxacin in d5w 1 2 DISODIUM-DEXTROSE linezolid 1 cefoxitin sodium 1 meropenem 1 CEFOXITIN SODIUM- 2 minocycline hcl 1 DEXTROSE moxifloxacin hcl 1 cefpodoxime proxetil 1 nafcillin sodium 1 ceftazidime 1 NAFCILLIN SODIUM IN 2 ceftriaxone sodium 1 DEXTROSE neomycin sulfate 1 2020 Kaiser Permanente Federal Employees Health Benefit Formulary Page 4 (Northern California Reg)

Drug Requirement / Drug Requirement / Name of drug Name of drug Tier Limits Tier Limits OXACILLIN SODIUM IN 2 terbinafine hcl 1 DEXTROSE voriconazole 1, 2 PENICILLIN G POT IN 2 ANTIMYCOBACTERIALS DEXTROSE CAPASTAT SULFATE 2 penicillin g potassium 1 cycloserine 1 PENICILLIN G 1 PROCAINE dapsone 1 PENICILLIN G SODIUM 1 ethambutol hcl 1 penicillin v potassium 1 isoniazid 1 piperacillin sodium- PRIFTIN 2 1 tazobactam sodium pyrazinamide 1 PRIMAXIN IV 2 rifabutin 1 STREPTOMYCIN 1 rifampin 1 SULFATE TRECATOR 2 SULFADIAZINE 1 ANTIPROTOZOALS sulfamethoxazole- 1 ALINIA 2 trimethoprim atovaquone 4 sulfasalazine 1 atovaquone-proguanil 1 SYNERCID 2 hcl tetracycline hcl 1 chloroquine phosphate 1 tobramycin 1, 4 COARTEM 2 tobramycin sulfate 1 DARAPRIM 2 QL vancomycin hcl 1, 2 hydroxychloroquine 1 VANCOMYCIN HCL IN sulfate 2 DEXTROSE KRINTAFEL 2 XIFAXAN 4 QL mefloquine hcl 1 ZINACEF IN STERILE 2 metronidazole 1 WATER metronidazole in nacl 1, 2 ZOSYN 2 NEBUPENT 2 ANTIFUNGALS paromomycin sulfate 1 ABELCET 2 PRIMAQUINE 2 AMPHOTERICIN B 1 PHOSPHATE CANCIDAS 4 ANTIVIRALS fluconazole 1 abacavir sulfate 1, 2 fluconazole in dextrose 1 abacavir sulfate- 1 fluconazole in nacl 1 lamivudine flucytosine 4 abacavir sulfate- 1 griseofulvin microsize 1 lamivudine-zidovudine griseofulvin acyclovir 1 1 ultramicrosize acyclovir sodium 1 ketoconazole 1 adefovir dipivoxil 4 nystatin 1 APTIVUS 2 nystatin (mouth-throat) 1 atazanavir sulfate 1

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Drug Requirement / Drug Requirement / Name of drug Name of drug Tier Limits Tier Limits ATRIPLA 2 ritonavir 1, 2 BIKTARVY 2 SELZENTRY 2 cidofovir 1 SOVALDI 4 QL CIMDUO 1 stavudine 1 COMPLERA 2 STRIBILD 2 CRIXIVAN 2 SYMFI 1 DAKLINZA 4 QL SYMTUZA 2 DESCOVY 2 SYNAGIS 4 didanosine 1, 2 tenofovir disoproxil 1 DOVATO 2 fumarate EDURANT 2 TIVICAY 2 1 TRIUMEQ 2 EMTRIVA 2 TRUVADA 2 entecavir 1, 2 valacyclovir hcl 1 EPCLUSA 4 QL valganciclovir hcl 1, 2 QL EVOTAZ 2 VIRACEPT 2 famciclovir 1 VIRAZOLE 2 fosamprenavir 1 voriconazole 1 FOSCAVIR 2 VOSEVI 4 QL FUZEON 2 QL zidovudine 1, 2 ganciclovir sodium 1 URINARY ANTI-INFECTIVES GENVOYA 2 methenamine hippurate 1 HARVONI 4 QL nitrofurantoin 1 nitrofurantoin INTELENCE 2 1, 2 INVIRASE 2 macrocrystal nitrofurantoin monohyd ISENTRESS 2 1 macro JULUCA 2 trimethoprim 1 KALETRA 2 ANTIHISTAMINE DRUGS lamivudine 1 FIRST GENERATION ANTIHISTAMINES lamivudine (hbv) 1 cyproheptadine hcl 1 lamivudine-zidovudine 1 diphenhydramine hcl 1 nevirapine 1 promethazine hcl 1 ODEFSEY 2 ANTINEOPLASTIC AGENTS oseltamivir phosphate 1, 2 ANTINEOPLASTIC AGENTS PEGASYS 4 QL abiraterone acetate 4 QL PREVYMIS 4 QL ABRAXANE 2 PREZCOBIX 2 ADCETRIS 2 PREZISTA 2 AFINITOR 4 QL RELENZA DISKHALER 2 ALECENSA 4 QL RESCRIPTOR 2 ALIMTA 2 ribavirin (hepatitis c) 1 ALKERAN 2 RIMANTADINE HCL 1 2020 Kaiser Permanente Federal Employees Health Benefit Formulary Page 6 (Northern California Reg)

Drug Requirement / Drug Requirement / Name of drug Name of drug Tier Limits Tier Limits ALUNBRIG 4 QL fulvestrant 4 QL anastrozole 1 GAZYVA 4 QL ARRANON 2 gemcitabine hcl 1, 2 AVASTIN 4 GLEOSTINE 2, 4 azacitidine 1 HALAVEN 2 BENDEKA 2, 4 QL HERCEPTIN 4 QL bicalutamide 1 HEXALEN 4 QL bleomycin sulfate 1 hydroxyurea 1 BLINCYTO 4 QL IBRANCE 4 QL CABOMETYX 4 QL idarubicin hcl 1 CAMPTOSAR 1 ifosfamide 1 capecitabine 1 QL imatinib mesylate 1 QL CAPRELSA 2 QL IMBRUVICA 4 QL carmustine 1, 2 INTRON A 4 QL cisplatin 1 IRESSA 4 QL cladribine 1 ISTODAX (OVERFILL) 2 COPIKTRA 4 QL IXEMPRA KIT 2, 4 QL COTELLIC 4 QL JAKAFI 4 QL cyclophosphamide 1 JEVTANA 2 CYRAMZA 4 QL KADCYLA 4 QL cytarabine 1 KANJINTI 4 dacarbazine 1 KEYTRUDA 4 QL DACOGEN 2 KYPROLIS 4 QL LENVIMA (10 MG DAILY dactinomycin 1, 2 4 QL DOSE) DARZALEX 4 QL letrozole 1 daunorubicin hcl 1 LEUKERAN 4 DEPOCYT 2 1, 2, leuprolide acetate 1, 2 DOCETAXEL QL 4 LONSURF 4 QL doxorubicin hcl 1 LORBRENA 4 QL LUPRON DEPOT (3- doxorubicin hcl liposomal 1, 2 2 MONTH) EMCYT 2 QL LUPRON DEPOT (4- 2 ERBITUX 2 MONTH) ERIVEDGE 4 QL LUPRON DEPOT (6- 2 erlotinib hcl 4 QL MONTH) ERWINAZE 2 LUPRON DEPOT-PED 2 etoposide 1 (1-MONTH) LUPRON DEPOT-PED exemestane 1 2 fludarabine phosphate 1 (3-MONTH) LYNPARZA 4 QL fluorouracil 1 LYSODREN 2 QL flutamide 1 MARQIBO 4 QL

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Drug Requirement / Drug Requirement / Name of drug Name of drug Tier Limits Tier Limits MATULANE 4 QL VELCADE 2 megestrol acetate 1 VENCLEXTA 2, 4 QL MEKINIST 4 QL VINCRISTINE SULFATE 1 melphalan hcl 1 vinorelbine tartrate 1 mercaptopurine 1, 4 QL VOTRIENT 4 QL methotrexate sodium 1 VYXEOS 4 QL mitomycin 1 XALKORI 4 QL mitoxantrone hcl 1 XTANDI 4 QL MUSTARGEN 2 YONDELIS 4 QL MVASI 4 ZANOSAR 2 MYLERAN 2 ZEJULA 4 QL NEXAVAR 4 QL ZELBORAF 4 QL NINLARO 4 QL ZYDELIG 4 QL ODOMZO 4 QL ZYKADIA 4 QL OPDIVO 4 QL AUTONOMIC DRUGS oxaliplatin 1 ANTICHOLINERGIC AGENTS 1 atropine sulfate 1, 2 pentostatin 1 ATROVENT HFA 2 BELLADONNA PERJETA 4 QL 2 ALKALOIDS-OPIUM POMALYST 4 QL hcl- 1 REVLIMID 4 QL clidinium RITUXAN 4 dicyclomine hcl 1 RYDAPT 4 QL DONNATAL 1 SPRYCEL 4 QL glycopyrrolate 1, 2 STIVARGA 4 QL hyoscyamine sulfate 1, 2 SUTENT 4 QL ipratropium bromide 1 SYLVANT 4 QL ipratropium bromide 1 TABLOID 2 (nasal) TAFINLAR 4 QL PROPANTHELINE 1 TAGRISSO 4 QL BROMIDE tamoxifen citrate 1 SPIRIVA RESPIMAT 2 TARGRETIN 4 AUTONOMIC DRUGS, MISCELLANEOUS TASIGNA 4 QL CHANTIX 2 TECENTRIQ 4 QL 1 temozolomide 1 nicotine polacrilex 1, 2 TENIPOSIDE 2 PARASYMPATHOMIMETIC (CHOLINERGIC) thiotepa 4 AGENTS topotecan hcl 1, 2 QL bethanechol chloride 1 TORISEL 2 donepezil hydrochloride 1 TRISENOX 4 QL ENLON 1 galantamine TYKERB 4 QL 1 UNITUXIN 4 QL hydrobromide 2020 Kaiser Permanente Federal Employees Health Benefit Formulary Page 8 (Northern California Reg)

Drug Requirement / Drug Requirement / Name of drug Name of drug Tier Limits Tier Limits neostigmine SEREVENT DISKUS 2 1, 2 methylsulfate STRIVERDI RESPIMAT 2 PHYSOSTIGMINE 2 terbutaline sulfate 1 SALICYLATE BLOOD DERIVATIVES pilocarpine hcl (oral) 1 BLOOD DERIVATIVES pyridostigmine bromide 1, 2 albumin, human 1 SKELETAL MUSCLE RELAXANTS PLASMANATE 2 atracurium besylate 1 BLOOD FORMATION, COAGULATION, AND baclofen 1, 2 THROMBOSIS cisatracurium besylate 1 ANTIANEMIA DRUGS cyclobenzaprine hcl 1 INFED 2 dantrolene sodium 1, 2 polysaccharide iron 1 methocarbamol 1 complex PANCURONIUM PROFERRIN ES 2 1 BROMIDE PROFERRIN-FORTE 2 QUELICIN 2 VENOFER 2 rocuronium bromide 1 ANTIHEMORRHAGIC AGENTS tizanidine hcl 1 ADVATE 2 QL vecuronium bromide 1 AFSTYLA 2 QL SYMPATHOLYTIC (ADRENERGIC BLOCKING) ALPHANINE SD 2 QL AGENTS aminocaproic acid 1 1, 2 QL BENEFIX 2 QL mesylate ELOCTATE 2 QL ERGOMAR 1 GELFOAM SPONGE 2 guanfacine hcl 1 SIZE 100 phenoxybenzamine hcl 4 HELIXATE FS 2 QL phentolamine mesylate 1 HEMLIBRA 2 QL SYMPATHOMIMETIC (ADRENERGIC) AGENTS HEMOFIL M 2 QL ADVAIR DISKUS 1, 2 HUMATE-P 2 QL albuterol sulfate 1 IDELVION 2 QL dobutamine hcl 1 KCENTRA 2 dobutamine in d5w 1 NOVOSEVEN RT 2 dopamine hcl 1 PRAXBIND 2 dopamine in d5w 1 PROFILNINE 2 QL ephedrine sulfate PROTAMINE SULFATE 1 1, 2 (pressors) RECOTHROM 2 epinephrine 1, 2 tranexamic acid 1 EPINEPHRINE 1 XYNTHA 2 QL ipratropium-albuterol 1 ANTITHROMBOTIC AGENTS METAPROTERENOL ACTIVASE 2 1 SULFATE anagrelide hcl 1 midodrine hcl 1 ANGIOMAX 2 norepinephrine bitartrate 1 ARGATROBAN 2 2020 Kaiser Permanente Federal Employees Health Benefit Formulary Page 9 (Northern California Reg)

Drug Requirement / Drug Requirement / Name of drug Name of drug Tier Limits Tier Limits aspirin-dipyridamole 1, 2 rosuvastatin calcium 1 BRILINTA 2 simvastatin 1 clopidogrel bisulfate 1 BETA-ADRENERGIC BLOCKING AGENTS EFFIENT 2 atenolol 1 heparin (porcine) in 1, 2 atenolol & chlorthalidone 1 sodium chloride bisoprolol & HEPARIN SOD 1 1, 2 hydrochlorothiazide (PORCINE) IN D5W bisoprolol fumarate 1 heparin sodium (porcine) 1 BREVIBLOC IN NACL 2 heparin sodium (porcine) 1, 2 carvedilol 1 lock flush esmolol hcl 1 INTEGRILIN 2 labetalol hcl 1 LOVENOX 1 QL metoprolol succinate 1 PRADAXA 2 PROFILNINE 2 metoprolol tartrate 1 REOPRO 2 propranolol hcl 1 THROMBATE III 2 sotalol hcl 1 TNKASE 2 sotalol hcl (afib/afl) 1 warfarin sodium 1 CALCIUM-CHANNEL BLOCKING AGENTS HEMATOPOIETIC AGENTS amlodipine besylate 1 LEUKINE 2 QL CLEVIPREX 2 NEUPOGEN 4 QL diltiazem hcl 1 diltiazem hcl coated PROCRIT 2 QL 1 PROMACTA 4 QL beads ZARXIO 4 QL nicardipine hcl 1 HEMORRHEOLOGIC AGENTS nifedipine 1 pentoxifylline 1 nimodipine 1 CARDIOVASCULAR DRUGS verapamil hcl 1 ALPHA-ADRENERGIC BLOCKING AGENTS CARDIAC DRUGS doxazosin mesylate 1 adenosine 1 prazosin hcl 1 amiodarone hcl 1 tamsulosin hcl 1 digoxin 1, 2 terazosin hcl 1 disopyramide phosphate 1, 2 ANTILIPEMIC AGENTS dofetilide 1 atorvastatin calcium 1 flecainide acetate 1 cholestyramine 1 ibutilide fumarate 1 LIDOCAINE HCL cholestyramine light 1 1 (CARDIAC) colestipol hcl 1 lidocaine in d5w 1 fenofibrate 1 MEXILETINE HCL 1 gemfibrozil 1 milrinone lactate 1 lovastatin 1 milrinone lactate in 1 pravastatin sodium 1 dextrose 2020 Kaiser Permanente Federal Employees Health Benefit Formulary Page 10 (Northern California Reg)

Drug Requirement / Drug Requirement / Name of drug Name of drug Tier Limits Tier Limits procainamide hcl 1 isosorbide mononitrate 1 propafenone hcl 1 nitroglycerin 1, 2 quinidine gluconate 1, 2 nitroglycerin in d5w 1, 2 QUINIDINE SULFATE 1 PAPAVERINE HCL 2 HYPOTENSIVE AGENTS sildenafil citrate 1 QL CARDENE IV 2 sildenafil citrate clonidine 1 (pulmonary 1 QL clonidine hcl 1 hypertension) hydralazine hcl 1 tadalafil 1 QL hydrochlorothiazide 1 TRACLEER 4 QL methyldopa 1 treprostinil 2, 4 QL minoxidil 1 vardenafil hcl 1 QL VENTAVIS 4 QL nitroprusside sodium 1 CENTRAL NERVOUS SYSTEM AGENTS RESERPINE 2 RENIN-ANGIOTENSIN-ALDOSTERONE ANALGESICS AND ANTIPYRETICS acetaminophen w/ SYSTEM INHIBITORS 1 codeine benazepril hcl 1 alfentanil hcl 1 enalaprilat 1 buprenorphine hcl 1 ENTRESTO 2 buprenorphine hcl- lisinopril 1 1 QL naloxone hcl dihydrate lisinopril & 1 butorphanol tartrate 1 hydrochlorothiazide choline & mag salicylate 1 losartan potassium 1 losartan potassium & CODEINE SULFATE 1 1 hydrochlorothiazide etodolac 1 spironolactone 1 fentanyl 1 QL spironolactone & fentanyl citrate 1, 2 1 hydrochlorothiazide hydrocodone- 1 valsartan 1 acetaminophen valsartan- hydromorphone hcl 1, 2 QL 1 hydrochlorothiazide ibuprofen 1 SCLEROSING AGENTS indomethacin 1 ETHAMOLIN 2 indomethacin sodium 1 sodium tetradecyl sulfate 1 INFUMORPH 200 2 VARITHENA 2 ketorolac tromethamine 1 VASODILATING AGENTS MECLOFENAMATE 1 alprostadil 1 SODIUM ambrisentan 1, 4 QL 1 CAVERJECT 2 meloxicam 1 dipyridamole 1 meperidine hcl 1 DIPYRIDAMOLE 1 methadone hcl 1, 2 isosorbide dinitrate 1 morphine sulfate 1, 2

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Drug Requirement / Drug Requirement / Name of drug Name of drug Tier Limits Tier Limits nabumetone 1 1 nalbuphine hcl 1 phenytoin sodium 1 phenytoin sodium naproxen 1 1 NEOPROFEN 2 extended OFIRMEV 2 1 OPANA 2 SABRIL 4 QL oxycodone hcl 1 1 oxycodone w/ valproate sodium 1 1 QL acetaminophen valproic acid 1 salsalate 1 ANTIMANIC AGENTS sufentanil citrate 1 LITHIUM 2 sulindac 1 lithium carbonate 1 hcl 1 ANTIMIGRAINE AGENTS tramadol-acetaminophen 1 CAFERGOT 1, 2 ULTIVA 2 naratriptan hcl 1 ANOREXIGENIC AGENTS AND RESPIRATORY rizatriptan benzoate 1 AND CEREBRAL STIMULANTS sumatriptan 1 amphetamine- 1 sumatriptan succinate 1 dextroamphetamine ANTIPARKINSONIAN AGENTS caffeine citrate 1 amantadine hcl 1 dexmethylphenidate hcl 1 APOKYN 4 QL dextroamphetamine 1 sulfate benztropine mesylate 1 methylphenidate hcl 1, 2 bromocriptine mesylate 1 VYVANSE 2 cabergoline 1 ANTICONVULSANTS carbidopa 1, 2 BANZEL 4 carbidopa-levodopa 1, 2 1 CARBIDOPA- CELONTIN 2 LEVODOPA- 1 ENTACAPONE 1 entacapone 1 divalproex sodium 1 pramipexole 1 EQUETRO 2 dihydrochloride ethosuximide 1 rasagiline mesylate 1 1 ropinirole hydrochloride 1 fosphenytoin sodium 1 SELEGILINE HCL 1 gabapentin 1 trihexyphenidyl hcl 1 lamotrigine 1, 2 ANXIOLYTICS, SEDATIVES, AND HYPNOTICS levetiracetam 1 1 QL LEVETIRACETAM IN 2 buspirone hcl 1 NACL chlordiazepoxide hcl 1 magnesium sulfate 1, 2 dipotassium 1 oxcarbazepine 1 DIASTAT ACUDIAL 1

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Drug Requirement / Drug Requirement / Name of drug Name of drug Tier Limits Tier Limits 1 clozapine 1 droperidol 1 desipramine hcl 1 hydroxyzine hcl 1 doxepin hcl 1 hydroxyzine pamoate 1 duloxetine hcl 1 1 QL escitalopram oxalate 1 hcl 1 hcl 1 NEMBUTAL 1 fluphenazine decanoate 1 1 QL fluphenazine hcl 1 1 fluvoxamine maleate 1 PHENOBARBITAL 2 haloperidol 1 SODIUM haloperidol decanoate 1 PRECEDEX 2 haloperidol lactate 1 1 QL imipramine hcl 1 tartrate 1 QL INVEGA SUSTENNA 2, 4 CENTRAL NERVOUS SYSTEM AGENTS, loxapine succinate 1 MISCELLANEOUS mirtazapine 1 acamprosate calcium 1 NEFAZODONE HCL 1 flumazenil 1 nortriptyline hcl 1 guanfacine hcl (adhd) 1 olanzapine 1 memantine hcl 1, 2 ORAP 1, 2 riluzole 1 paroxetine hcl 1 selegiline hcl 1 perphenazine 1 GENERAL PERPHENAZINE- 1 BREVITAL SODIUM 2 AMITRIPTYLINE 1 phenelzine sulfate 1 FORANE 2 prochlorperazine 1 ketamine hcl 1 prochlorperazine 1 1 edisylate OPIATE ANTAGONISTS prochlorperazine 1 escitalopram oxalate 1 maleate naloxone hcl 1, 2 protriptyline hcl 1 naltrexone hcl 1 quetiapine fumarate 1 NALTREXONE HCL 2 RISPERDAL CONSTA 2, 4 QL PSYCHOTHERAPEUTIC AGENTS risperidone 1 amitriptyline hcl 1 sertraline hcl 1 aripiprazole 1 thioridazine hcl 1 ARISTADA 4 thiothixene 1 bupropion hcl 1 tranylcypromine sulfate 1 chlorpromazine hcl 1 trazodone hcl 1 citalopram hydrobromide 1 trifluoperazine hcl 1 clomipramine hcl 1 trimipramine maleate 1

2020 Kaiser Permanente Federal Employees Health Benefit Formulary Page 13 (Northern California Reg)

Drug Requirement / Drug Requirement / Name of drug Name of drug Tier Limits Tier Limits PEDIATRIC SMALL venlafaxine hcl 1 2 ziprasidone hcl 1 MASK PENLET II BLOOD CONTRACEPTIVES (FOAMS, DEVICES) 2 SAMPLER CONTRACEPTIVES (FOAMS, DEVICES) POLYFIN QR INFUSION WIDE-SEAL 2 2 SET 42" DIAPHRAGM 60 DIAGNOSTIC AGENTS DEVICES DIAGNOSTIC AGENTS DEVICES ACETEST 2 AEROCHAMBER PLUS 2 FLO-VU SMALL adenosine (diagnostic) 1 AEROTRACH PLUS 2 ALBUSTIX 2 ALLERGIST SYRINGE 2 CANDIN 2 ASSESS FULL RANGE CHEMSTRIP 9 2 2 PEAK METER CHIRHOSTIM 2 BAYER BREEZE 2 CONRAY 2 2 CONTROL CORTROSYN 2 BD CATHETER TIP 2 CREON 2 SYRINGE CYSTOGRAFIN 2 BD DISP NEEDLE 2 DIASTIX 2 BD DISP NEEDLES 2 E-Z-CAT DRY 2 BD ECLIPSE SYRINGE 2 EOVIST 2 BD FILTER NEEDLE/5 fluorescein sodium 2 1 MICRON injection BD HYPODERMIC fluorescein sodium 2 1 NEEDLE topical BD INSULIN SYRINGE 1, 2 fluorescein w/ 1 BD LANCET DEVICE 2 benoxinate BD LANCET 2 GADAVIST 2 ULTRAFINE 33G GASTROGRAFIN 2 BD LUER-LOK 2 INDIGO CARMINE 2 SYRINGE KETO-DIASTIX 2 BD PEN NEEDLE MINI 2 U/F LEXISCAN 2 BD SAFETYGLIDE LUMASON 2 2 SYRINGE/NEEDLE MAGNEVIST 2 BD SYRINGE 2 METOPIRONE 2 BLUNT PLASTIC MULTIHANCE 2 2 CANNULA OMNIPAQUE 2 DISPOSABLE POWER 2 ONETOUCH ULTRA 2 INSUFLON 2 BLUE OMNITROPE PEN 5 INJ THYROGEN 2 2 DEVICE TUBERSOL 2 ONETOUCH ULTRA 2 ELECTROLYTIC, CALORIC, AND WATER MINI BALANCE ALKALINIZING AGENTS 2020 Kaiser Permanente Federal Employees Health Benefit Formulary Page 14 (Northern California Reg)

Drug Requirement / Drug Requirement / Name of drug Name of drug Tier Limits Tier Limits potassium citrate SODIUM EDECRIN 2 1 (alkalinizer) torsemide 1 potassium citrate-citric triamterene & 1 1 acid hydrochlorothiazide SODIUM ACETATE 2 ION-REMOVING AGENTS sodium bicarbonate 1, 2 sevelamer carbonate 1, 2 sodium citrate & citric sodium polystyrene 1 1 acid sulfonate AMMONIA DETOXICANTS IRRIGATING SOLUTIONS lactulose 1 acetic acid 1 lactulose DIANEAL LOW 1 2 (encephalopathy) CALCIUM/4.25% DEX LITHOSTAT 2 ringer's irrigation 1 sodium phenylbutyrate 1, 4 QL sodium chloride (gu 1 CALORIC AGENTS irrigant) AMINOSYN II 1, 2 water for irrigation, 1 CLINIMIX E/DEXTROSE sterile 2 (2.75/10) REPLACEMENT PREPARATIONS CLINIMIX E/DEXTROSE calcium acetate 2 1, 2 (2.75/5) (phosphate binder) CLINIMIX E/DEXTROSE calcium chloride 2 1 (4.25/25) (dihydrate) CLINIMIX E/DEXTROSE 2 calcium gluconate 1 (5/15) CHROMIC CHLORIDE 2 CLINIMIX E/DEXTROSE 2 COPPER CHLORIDE 2 (5/20) dextrose in lactated CLINIMIX/DEXTROSE 1 2 ringers (4.25/10) dextrose in ringers 1 CLINIMIX/DEXTROSE 2 dextrose w/ sodium (4.25/25) 1, 2 chloride dextrose 1, 2 hetastarch in sodium 1 INTRALIPID 2 chloride PHENEX-1 2 HEXTEND 2 DIURETICS K-PHOS 2 amiloride & KCL-LACTATED 1 2 hydrochlorothiazide RINGERS-D5W bumetanide 1 LACTATED RINGERS 2 chlorthalidone 1 LMD IN D5W 2 ethacrynic acid 1, 4 LMD IN NACL 2 furosemide 1 MAGNESIUM SULFATE 2 hydrochlorothiazide 1 IN D5W indapamide 1 potassium acetate 1 mannitol 1 potassium bicarbonate 1 metolazone 1 potassium chloride 1, 2

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Drug Requirement / Drug Requirement / Name of drug Name of drug Tier Limits Tier Limits potassium chloride in bacitracin-polymyxin b 1 1 dextrose (ophth) potassium chloride in gluconate 1 dextrose & sodium 1, 2 (mouth-throat) chloride ciprofloxacin hcl (ophth) 1 potassium chloride in 1 erythromycin (ophth) 1 nacl gatifloxacin (ophth) 1 potassium chloride gentamicin sulfate microencapsulated 1 1 (ophth) crystals er moxifloxacin hcl (ophth) 1 potassium phosphates 1 NATACYN 2 ringer's 1 neomycin-bacitracin zn- 1 SELENIUM 2 polymyxin sodium chloride 1 NEOMYCIN- sodium phosphates POLYMYXIN- 1 (sodium phosphate 1 GRAMICIDIN dibasic & monobasic) ofloxacin (ophth) 1 trace minerals (cr-cu-mn- 1, 2 ofloxacin (otic) 1 zn) polymyxin b-trimethoprim 1 ZINC CHLORIDE 2 sulfacetamide sodium URICOSURIC AGENTS 1 (ophth) colchicine w/ 1 tobramycin (ophth) 1, 2 probenecid 1 TRIFLURIDINE 1 ENZYMES ANTI-INFLAMMATORY AGENTS ENZYMES BLEPHAMIDE 1, 2 ALDURAZYME 2 CIPRODEX 2 ARALAST NP 4 QL DEXAMETHASONE 1 CEREZYME 4 SODIUM PHOSPHATE ELAPRASE 4 QL diclofenac sodium 1 ELITEK 2 (ophth) FABRAZYME 4 QL FLUNISOLIDE 1 HYLENEX 2 fluorometholone (ophth) 1, 2 LUMIZYME 4 QL flurbiprofen sodium 1 NAGLAZYME 4 QL fluticasone propionate 1 PULMOZYME 4 QL (nasal) ketorolac tromethamine STRENSIQ 4 QL 1 VIMIZIM 4 QL (ophth) neomycin-polymy- VORAXAZE 4 QL 1 dexameth VPRIV 4 neomycin-polymyxin-hc 1 EYE, EAR, NOSE, AND THROAT (EENT) (otic) PREPARATIONS PRED MILD 1, 2 ANTI-INFECTIVES RESTASIS 2 BACITRACIN 1 RETISERT 2

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Drug Requirement / Drug Requirement / Name of drug Name of drug Tier Limits Tier Limits ANTIALLERGIC AGENTS tetracaine hcl (ophth) 1 azelastine hcl 1 MYDRIATICS cromolyn sodium (ophth) 1 ATROPINE SULFATE 1, 2 olopatadine hcl 1 CYCLOMYDRIL 1 ANTIGLAUCOMA AGENTS cyclopentolate hcl 1 acetazolamide 1 homatropine hbr 1 acetazolamide sodium 1 tropicamide 1 betaxolol hcl (ophth) 1 VASOCONSTRICTORS phenylephrine hcl brimonidine tartrate 1 1 dorzolamide hcl 1 (mydriatic) dorzolamide hcl-timolol GASTROINTESTINAL DRUGS 1 maleate ANTI-INFLAMMATORY AGENTS latanoprost 1 balsalazide disodium 1 levobunolol hcl 1 mesalamine 1, 2 LUMIGAN 2 ANTIDIARRHEA AGENTS methazolamide 1 bismuth subsalicylate 1 diphenoxylate w/ MIOCHOL-E 2 1 MIOSTAT 2 atropine MITOSOL 2 ANTIEMETICS PHOSPHOLINE IODIDE 2 AKYNZEO 2 QL pilocarpine hcl 1 dronabinol 1 timolol maleate (ophth) 1 EMEND 2 QL fosaprepitant EENT DRUGS, MISCELLANEOUS 1 dimeglumine acetic acid (otic) 1 meclizine hcl 1 ACETIC ACID- 1 ondansetron 1 ALUMINUM ACETATE apraclonidine hcl 1, 2 ondansetron hcl 1 BSS 2 scopolamine 1, 2 EYLEA 4 ANTIULCER AGENTS AND ACID SUPPRESSANTS HEALON5 2 CIMETIDINE HCL 1 LUCENTIS 4 QL famotidine 1 MACUGEN 2 FAMOTIDINE PHOTREXA- 1 PREMIXED PHOTREXA VISCOUS 2 KIT misoprostol 1 VISUDYNE 2 omeprazole 1 LOCAL ANESTHETICS pantoprazole sodium 1, 2 AKTEN 2 ranitidine hcl 1 C-TOPICAL 2 sucralfate 1, 2 lidocaine hcl (mouth- CATHARTICS AND LAXATIVES 1 throat) castor oil 1 proparacaine hcl 1 peg 3350-kcl-sod bicarb- 1 sod chloride-sod sulfate 2020 Kaiser Permanente Federal Employees Health Benefit Formulary Page 17 (Northern California Reg)

Drug Requirement / Drug Requirement / Name of drug Name of drug Tier Limits Tier Limits SORBITOL 2 ANDROGENS CHOLELITHOLYTIC AGENTS ANDRODERM 1, 2 ursodiol 1 ANDROID 1 DIGESTANTS ANDROXY 1 CREON 2 danazol 1 PROKINETIC AGENTS cypionate 1 metoclopramide hcl 1 testosterone enanthate 1 GOLD COMPOUNDS ANTIDIABETIC AGENTS GOLD COMPOUNDS glimepiride 1 RIDAURA 2 glipizide 1 HEAVY METAL ANTAGONISTS glipizide-metformin hcl 1 HEAVY METAL ANTAGONISTS glyburide 1 BAL IN OIL 2 HUMALOG 2 CHEMET 2 HUMULIN 70/30 2 deferasirox 4 QL HUMULIN N 2 deferoxamine mesylate 1 HUMULIN R 2 DEPEN TITRATABS 2 JARDIANCE 2 HORMONES AND SYNTHETIC SUBSTITUTES LANTUS 2 ADRENALS metformin hcl 1 ASMANEX (120 2 pioglitazone hcl 1 METERED DOSES) TOLBUTAMIDE 1 betamethasone sod 1 ANTIHYPOGLYCEMIC AGENTS phosphate & acetate BAQSIMI TWO PACK 2 budesonide 1 GLUCAGEN 2 budesonide (inhalation) 1, 2 GLUCAGON 2 dexamethasone 1 EMERGENCY dexamethasone sodium 1 CONTRACEPTIVES phosphate desogestrel & ethinyl 1 FLOVENT HFA 2 fludrocortisone acetate 1 drospirenone-ethinyl 1 hydrocortisone 1 estradiol KENALOG 2 ELLA 2 methylprednisolone 1 ethynodiol diacet & eth 1 methylprednisolone estrad 1 etonogestrel-ethinyl acetate 1, 2 methylprednisolone sod estradiol 1, 2 levonorgestrel & eth succ 1 prednisolone 1 estradiol prednisolone sodium levonorgestrel 1 1 phosphate (emergency oc) levonorgestrel-eth prednisone 1 1 estradiol (triphasic) QVAR 2 MIRENA (52 MG) 2 SOLU-CORTEF 2

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Drug Requirement / Drug Requirement / Name of drug Name of drug Tier Limits Tier Limits NECON 10/11 (28) 1 ENDOMETRIN 2 NEXPLANON 2 HYDROXYPROGESTE 1 QL norethin acet & estrad-fe 1 RONE CAPROATE norethindrone & eth medroxyprogesterone 1 1 estradiol acetate norethindrone medroxyprogesterone 1 1 (contraceptive) acetate (contraceptive) norethindrone-eth norethindrone acetate 1 1 estradiol (triphasic) 1 norgestimate-ethinyl 1 progesterone micronized 1 estradiol SOMATROPIN AGONISTS-ANTAGONISTS norgestimate-ethinyl NORDITROPIN 1 1, 4 QL estradiol (triphasic) FLEXPRO OGESTREL 1 SEROSTIM 4 QL XULANE 1 THYROID AND ANTITHYROID AGENTS ESTROGENS AND ESTROGEN AGONISTS- levothyroxine sodium 1, 2 ANTAGONISTS liothyronine sodium 1 clomiphene citrate 1 methimazole 1 DEPO-ESTRADIOL 1 propylthiouracil 1 esterified estrogens & 1 methyltestosterone SSKI 2 estradiol 1 LOCAL ANESTHETICS estradiol vaginal 1, 2 LOCAL ANESTHETICS PREMARIN 2 bupivacaine hcl 1, 2 raloxifene hcl 1 bupivacaine in dextrose 1 bupivacaine w/ GONADOTROPINS 1, 2 epinephrine GONAL-F 2 chloroprocaine hcl 1, 2 MENOPUR 2 LIDOCAINE HCL NOVAREL 1 1, 2 (CARDIAC) PF OVIDREL 2 lidocaine hcl (local 1 SYNAREL 2 anesth.) PARATHYROID lidocaine w/ epinephrine 1, 2 calcitonin (salmon) 1 mepivacaine hcl 1 FORTEO 4 QL NAROPIN 2 PITUITARY TETRACAINE HCL 2 ACTHAR 4 MISCELLANEOUS THERAPEUTIC AGENTS DDAVP RHINAL TUBE 2 MISCELLANEOUS THERAPEUTIC AGENTS desmopressin acetate 1, 2 acetylcysteine 1 desmopressin acetate 1 acetylcysteine (antidote) 1 spray ACTIMMUNE 2 QL desmopressin acetate 1 spray refrigerated alendronate sodium 1 PROGESTINS allopurinol 1 DEPO-PROVERA 2 AVONEX 2, 4 QL 2020 Kaiser Permanente Federal Employees Health Benefit Formulary Page 19 (Northern California Reg)

Drug Requirement / Drug Requirement / Name of drug Name of drug Tier Limits Tier Limits azathioprine 1 REMICADE 4 BOTOX 2 RIMSO-50 2 BOTOX COSMETIC 2 SANDIMMUNE 2 BRIDION 2 sirolimus 1, 4 CERDELGA 4 QL sodium fluoride 1, 2 cinacalcet hcl 1 sodium fluoride (dental) 1, 2 CINRYZE 4 QL SOLIRIS 2 COLCHICINE 1 tacrolimus 1, 2 cyclosporine modified 1, 2 TAKHZYRO 4 QL (for microemulsion) THALOMID 4 QL CYSTADANE 2 QL THIOLA 4 CYSTAGON 2 QL TYSABRI 4 QL dexrazoxane hcl 1, 2 water for injection, sterile 1 disulfiram 1 XELJANZ 4 QL ELMIRON 2 zoledronic acid 1 ENBREL 4 QL OXYTOCICS ETIDRONATE 1 OXYTOCICS DISODIUM HEMABATE 2 EXTAVIA 1 QL methylergonovine 1 finasteride 1 maleate FUSILEV 2 MIFEPREX 2 glatiramer acetate 1 QL oxytocin 1 GRASTEK 2 PREPIDIL 2 HUMIRA 4 QL PHARMACEUTICAL AIDS icatibant acetate 4 QL PHARMACEUTICAL AIDS INFLECTRA 4 ALOE VERA 2 KALYDECO 4 QL ALPROSTADIL 2 KINERET 4 QL ATROPINE SULFATE 2 leflunomide 1 MONOHYDRATE leucovorin calcium 1 BIOTIN-D 2 levocarnitine (metabolic BORIC ACID 2 1 modifiers) CANTHARIDIN 2 mesna 1, 2 QL CARBAMAZEPINE 2 METHYLENE BLUE 1 CHLORPROMAZINE 2 mycophenolate mofetil 1 HCL MYOBLOC 2 2 octreotide acetate 1, 4 QL CLINDAMYCIN HCL 2 CLOBETASOL OPSUMIT 4 QL 2 ORENCIA 4 QL PROPIONATE 2 OTEZLA 4 QL COLLODION FLEXIBLE 2 pamidronate disodium 1 CYSTEAMINE HCL 2 RASUVO 2 DEXAMETHASONE 2 2020 Kaiser Permanente Federal Employees Health Benefit Formulary Page 20 (Northern California Reg)

Drug Requirement / Drug Requirement / Name of drug Name of drug Tier Limits Tier Limits ESTRADIOL 2 THYMOL 2 GLYCERIN 2 TRANEXAMIC ACID 2 GLYCOPYRROLATE 2 TRIAMCINOLONE 2 HALOPERIDOL 2 ACETONIDE HYDROCORTISONE 2 UREA 2 HYDROXOCOBALAMIN 2 ZINC SULFATE 2 HYDROXYPROGESTE RESPIRATORY TRACT AGENTS 2 RONE CAPROATE ANTI-INFLAMMATORY AGENTS INDOMETHACIN 2 ALVESCO 2 KETAMINE HCL 2 ASMANEX HFA 2 L-ARGININE 2 COMBIVENT 2 L-CITRULLINE 2 RESPIMAT L-ISOLEUCINE 2 cromolyn sodium 1 L-VALINE 2 montelukast sodium 1 LACTIC ACID 2 ANTITUSSIVES LACTOSE 2 benzonatate 1 LACTOSE guaifenesin-codeine 1 2 MONOHYDRATE phenylephrine- 1 LIDOCAINE HCL 2 chlorphen-dm METHADONE HCL 2 PHENYLHISTINE DH 2 METOCLOPRAMIDE PROMETHAZINE-DM 1 2 HCL MONOHYDRATE MUCOLYTIC AGENTS MORPHINE SULFATE 2 sodium chloride 1 NEOMYCIN SULFATE 2 (inhalant) PHENOBARBITAL 2 PULMONARY SURFACTANTS PLURONIC F127 2 CUROSURF 2 PODOPHYLLUM RESIN 2 SURVANTA 2 POLYETHYLENE RESPIRATORY AGENTS, MISCELLANEOUS 2 GLYCOL 400 ARALAST NP 4 QL PROGESTERONE 2 KALYDECO 4 QL MICRONIZED ORKAMBI 4 QL PROGESTERONE 2 STIOLTO RESPIMAT 2 WETTABLE SYMDEKO 4 QL PROPYLENE GLYCOL 2 VASODILATING QUINACRINE HCL 2 TRACLEER 4 QL SALICYLIC ACID 2 SERUMS, TOXOIDS, AND VACCINES SODIUM BENZOATE 2 SERUMS SORBITOL 2 ANTIVENIN SQUARIC ACID 2 LATRODECTUS 2 DIBUTYLESTER MACTANS SULFUR 2 CARIMUNE NF 2 PRECIPITATED TESTOSTERONE CROFAB 2 2 PROPIONATE DIGIFAB 2

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Drug Requirement / Drug Requirement / Name of drug Name of drug Tier Limits Tier Limits FLUVIRIN 2 ROTATEQ 2 GAMASTAN S/D 2 SHINGRIX 2 GAMMAGARD 2 TICE BCG 2 HIZENTRA 2 QL TWINRIX 2 HYPERRAB 2 TYPHIM VI 2 HYPERTET S/D 2 VARIVAX 2 MICRHOGAM ULTRA- VAXCHORA 2 2 FILTERED PLUS VIVOTIF 2 NABI-HB 2 YF-VAX 2 ODACTRA 2 ZOSTAVAX 2 TOXOIDS SKIN AND MUCOUS MEMBRANE AGENTS ADACEL 2 ANTI-INFECTIVES INFANRIX 2 benzoyl peroxide- 1, 2 TDVAX 2 erythromycin VACCINES clindamycin phosphate 1 ACTHIB 2 (topical) clindamycin phosphate AFLURIA 2 1 BEXSERO 2 vaginal clindamycin phosphate- ENGERIX-B 2 1 benzoyl peroxide FLUAD 2 clindamycin phosphate- FLUARIX 2 benzoyl peroxide 1 QUADRIVALENT (refrigerate) FLUBLOK 2 clotrimazole 1 FLUCELVAX 2 dakin's solution 1, 2 FLUMIST 2 erythromycin (acne aid) 1 QUADRIVALENT gentamicin sulfate FLUVIRIN 2 1 (topical) FLUZONE HIGH-DOSE 2 GENTIAN VIOLET 2 GARDASIL 2 iodoquinol-hc 1 GARDASIL 9 2 ketoconazole (topical) 1 HAVRIX 2 metronidazole (topical) 1 IMOVAX RABIES 2 metronidazole vaginal 1 IPOL 2 IXIARO 2 mupirocin 1 NEOMYCIN- KINRIX 2 1 POLYMYXIN B GU M-M-R II 2 nystatin (topical) 1 MENVEO 2 permethrin 1 PEDIARIX 2 selenium sulfide 1 PNEUMOVAX 23 2 silver sulfadiazine 1 PREVNAR 13 2 ANTI-INFLAMMATORY AGENTS PROQUAD 2 alclometasone RABAVERT 2 1 dipropionate ROTARIX 2 2020 Kaiser Permanente Federal Employees Health Benefit Formulary Page 22 (Northern California Reg)

Drug Requirement / Drug Requirement / Name of drug Name of drug Tier Limits Tier Limits betamethasone sulfacetamide sodium w/ 1 1, 2 dipropionate (topical) sulfur betamethasone SKIN AND MUCOUS MEMBRANE AGENTS, 1 dipropionate augmented MISCELLANEOUS betamethasone valerate 1 acitretin 1 QL clobetasol propionate 1, 2 adapalene 1, 2 CORDRAN 2 adapalene-benzoyl 1, 2 CORTISPORIN 2 peroxide AQUAPHOR desonide 1 2 ADVANCED THERAPY desoximetasone 1 BENZOIN 2 fluocinolone acetonide 1 benzoin compound 1 fluocinonide 1 calcipotriene 1 halobetasol propionate 1 1 hydrocortisone 1 (intrarectal) COSENTYX 4 QL hydrocortisone (topical) 1 DESITIN 2 hydrocortisone acetate diclofenac sodium 1 1 (rectal) (topical) mometasone furoate 1 DRITHO-CREME HP 2 nystatin-triamcinolone 1 fluorouracil (topical) 1, 2 triamcinolone acetonide imiquimod 1 1 (mouth) isotretinoin 1 QL triamcinolone acetonide LEVULAN KERASTICK 2 1 (topical) pimecrolimus 1, 2 ANTIPRURITICS AND LOCAL ANESTHETICS PODOCON 2 lidocaine 1 podofilox 1, 2 lidocaine hcl 1 SANTYL 2 lidocaine-prilocaine 1 SKYRIZI (150 MG 4 2 DOSE) PROCTOFOAM HC 1 STELARA 4 ASTRINGENTS tacrolimus (topical) 1 DRYSOL 2 TARGRETIN 2 XERAC AC 2 tazarotene 1, 2 CELL STIMULANTS AND PROLIFERANTS TREMFYA 4 KEPIVANCE 4 QL VECTICAL 1 RETIN-A MICRO 1 SMOOTH MUSCLE RELAXANTS tretinoin 1 GENITOURINARY SMOOTH MUSCLE DEPIGMENTING AND PIGMENTING AGENTS RELAXANTS 8-MOP 2 oxybutynin chloride 1 methoxsalen rapid 1 OXYTROL 2 OXSORALEN 2 solifenacin succinate 1 KERATOLYTIC AGENTS trospium chloride 1

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Drug Requirement / Drug Requirement / Name of drug Name of drug Tier Limits Tier Limits RESPIRATORY SMOOTH MUSCLE pediatric multivitamins 1 RELAXANTS w/fl pediatric vitamins acd w/ aminophylline 1 1 theophylline 1 fluoride THEOPHYLLINE IN VITAMIN B COMPLEX 2 D5W cyanocobalamin 1 VITAMINS FOLIC ACID 1 MULTIVITAMIN PREPARATIONS 1 b-complex w/ c & folic thiamine hcl 1 1 acid VITAMIN D INFUVITE ADULT 2 calcitriol 1 INFUVITE PEDIATRIC 2 ergocalciferol 1 ped multivitamins w/fl & 1 VITAMIN K ACTIVITY iron phytonadione 1, 2

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Formulary Drugs by Alphabetical Listing Index

adefovir dipivoxil ...... 6 8 adenosine ...... 11, 15 8-MOP ...... 25 adenosine (diagnostic) ...... 15 ADVAIR DISKUS ...... 9 A ADVATE ...... 10 AEROCHAMBER PLUS FLO-VU SMALL ...... 15 abacavir sulfate ...... 5, 6 AEROTRACH PLUS ...... 15 abacavir sulfate-lamivudine ...... 6 AFINITOR ...... 7 abacavir sulfate-lamivudine-zidovudine ...... 6 AFLURIA ...... 24 ABELCET ...... 5 AFSTYLA ...... 10 abiraterone acetate ...... 7 AKTEN ...... 18 ABRAXANE ...... 7 AKYNZEO ...... 19 acamprosate calcium ...... 14 ALBENZA ...... 4 acetaminophen w/ codeine ...... 12 albumin, human ...... 10 acetazolamide ...... 18 ALBUSTIX ...... 15 acetazolamide sodium ...... 18 albuterol sulfate ...... 9 ACETEST ...... 15 alclometasone dipropionate ...... 24 acetic acid ...... 16, 18 ALDURAZYME ...... 17 acetic acid (otic) ...... 18 ALECENSA ...... 7 ACETIC ACID-ALUMINUM ACETATE ...... 18 alendronate sodium ...... 21 acetylcysteine ...... 21 alfentanil hcl ...... 12 acetylcysteine (antidote) ...... 21 ALIMTA ...... 7 acitretin ...... 25 ALINIA...... 5 ACTHAR ...... 20 ALKERAN ...... 7 ACTHIB ...... 24 ALLERGIST SYRINGE ...... 15 ACTIMMUNE ...... 21 allopurinol ...... 21 ACTIVASE ...... 10 ALOE VERA ...... 22 acyclovir ...... 6 ALPHANINE SD ...... 10 acyclovir sodium ...... 6 alprazolam ...... 13 ADACEL ...... 24 alprostadil ...... 12 adapalene ...... 25 ALPROSTADIL ...... 22 adapalene-benzoyl peroxide ...... 25 ALUNBRIG ...... 7 ADCETRIS ...... 7 ALVESCO ...... 23 2020 Kaiser Permanente Federal Employees Health Benefit Formulary Page 25 (Northern California Reg)

amantadine hcl ...... 13 ATRIPLA ...... 6 ambrisentan ...... 12 atropine sulfate ...... 9 amikacin sulfate ...... 4 ATROPINE SULFATE ...... 18, 22 amiloride & hydrochlorothiazide ...... 16 ATROPINE SULFATE MONOHYDRATE ...... 22 aminocaproic acid ...... 10 ATROVENT HFA ...... 9 aminophylline ...... 26 AVASTIN ...... 7 AMINOSYN II ...... 16 AVELOX ...... 4 amiodarone hcl ...... 11 AVONEX ...... 21 amitriptyline hcl ...... 14 azacitidine ...... 7 amlodipine besylate ...... 11 AZACTAM IN DEXTROSE ...... 4 amoxicillin ...... 4 azathioprine ...... 21 amoxicillin & pot clavulanate ...... 4 azelastine hcl ...... 18 amphetamine-dextroamphetamine ...... 13 azithromycin ...... 4 AMPHOTERICIN B ...... 5 aztreonam ...... 4 ampicillin & sulbactam sodium ...... 4 ampicillin sodium ...... 4 B anagrelide hcl ...... 10 BACITRACIN ...... 17 anastrozole ...... 7 bacitracin-polymyxin b (ophth) ...... 17 ANDRODERM ...... 19 baclofen ...... 9 ANDROID ...... 20 BAL IN OIL ...... 19 ANDROXY ...... 20 balsalazide disodium ...... 19 ANGIOMAX ...... 10 BANZEL ...... 13 ANTIVENIN LATRODECTUS MACTANS ...... 23 BAQSIMI TWO PACK ...... 20 APOKYN ...... 13 BAYER BREEZE 2 CONTROL ...... 15 apraclonidine hcl ...... 18 b-complex w/ c & folic acid ...... 26 APTIVUS ...... 6 BD CATHETER TIP SYRINGE ...... 15 AQUAPHOR ADVANCED THERAPY ...... 25 BD DISP NEEDLE ...... 15 ARALAST NP ...... 17, 23 BD DISP NEEDLES ...... 15 ARGATROBAN ...... 10 BD ECLIPSE SYRINGE ...... 15 aripiprazole ...... 14 BD FILTER NEEDLE/5 MICRON ...... 15 ARISTADA ...... 14 BD HYPODERMIC NEEDLE ...... 15 ARRANON ...... 7 BD INSULIN SYRINGE ...... 15 ASMANEX (120 METERED DOSES) ...... 19 BD LANCET DEVICE ...... 15 ASMANEX HFA ...... 23 BD LANCET ULTRAFINE 33G ...... 15 aspirin-dipyridamole ...... 10 BD LUER-LOK SYRINGE ...... 15 ASSESS FULL RANGE PEAK METER ...... 15 BD PEN NEEDLE MINI U/F ...... 15 atazanavir sulfate ...... 6 BD SAFETYGLIDE SYRINGE/NEEDLE ...... 15 atenolol ...... 11 BD SYRINGE ...... 15 atenolol & chlorthalidone ...... 11 BELLADONNA ALKALOIDS-OPIUM ...... 9 atorvastatin calcium ...... 11 benazepril hcl ...... 11 atovaquone ...... 5 BENDEKA ...... 7 atovaquone-proguanil hcl ...... 5 BENEFIX ...... 10 atracurium besylate ...... 9 BENZOIN ...... 25 2020 Kaiser Permanente Federal Employees Health Benefit Formulary Page 26 (Northern California Reg)

benzoin compound ...... 25 butorphanol tartrate ...... 12 benzonatate ...... 23 benzoyl peroxide-erythromycin ...... 24 C benztropine mesylate ...... 13 cabergoline...... 13 betamethasone dipropionate (topical) ...... 25 CABOMETYX ...... 7 betamethasone dipropionate augmented ...... 25 CAFERGOT ...... 13 betamethasone sod phosphate & acetate ...... 19 caffeine citrate ...... 13 betamethasone valerate ...... 25 calcipotriene ...... 25 betaxolol hcl (ophth) ...... 18 calcitonin (salmon) ...... 20 bethanechol chloride ...... 9 calcitriol ...... 26 BEXSERO ...... 24 calcium acetate (phosphate binder) ...... 16 bicalutamide ...... 7 calcium chloride (dihydrate) ...... 16 BICILLIN L-A ...... 4 calcium gluconate ...... 16 BIKTARVY ...... 6 CAMPTOSAR ...... 7 BILTRICIDE ...... 4 CANCIDAS ...... 5 BIOTIN-D ...... 22 CANDIN ...... 15 bismuth subsalicylate ...... 19 CANTHARIDIN ...... 22 bisoprolol & hydrochlorothiazide ...... 11 CAPASTAT SULFATE ...... 5 bisoprolol fumarate ...... 11 capecitabine ...... 7 bleomycin sulfate ...... 7 CAPRELSA ...... 7 BLEPHAMIDE ...... 18 capsaicin...... 25 BLINCYTO ...... 7 carbamazepine ...... 13 BLUNT PLASTIC CANNULA ...... 15 CARBAMAZEPINE ...... 22 BORIC ACID ...... 22 carbidopa ...... 13 BOTOX ...... 21 carbidopa-levodopa ...... 13 BOTOX COSMETIC ...... 21 CARBIDOPA-LEVODOPA-ENTACAPONE...... 13 BREVIBLOC IN NACL ...... 11 CARDENE IV ...... 11 BREVITAL SODIUM ...... 14 CARIMUNE NF ...... 23 BRIDION ...... 21 carmustine ...... 7 BRILINTA ...... 10 carvedilol ...... 11 brimonidine tartrate ...... 18 castor oil ...... 19 bromocriptine mesylate ...... 13 CAVERJECT ...... 12 BSS ...... 18 CAYSTON ...... 4 budesonide ...... 19 cefaclor ...... 4 budesonide (inhalation) ...... 19 cefadroxil ...... 4 bumetanide ...... 16 cefazolin sodium ...... 4 bupivacaine hcl ...... 21 CEFAZOLIN SODIUM-DEXTROSE ...... 4 bupivacaine in dextrose ...... 21 cefdinir ...... 4 bupivacaine w/ epinephrine ...... 21 cefepime hcl ...... 4 buprenorphine hcl ...... 12 CEFEPIME-DEXTROSE ...... 4 buprenorphine hcl-naloxone hcl dihydrate ...... 12 cefixime ...... 4 bupropion hcl ...... 14 cefotaxime sodium ...... 4 buspirone hcl ...... 13 cefotetan disodium ...... 4 2020 Kaiser Permanente Federal Employees Health Benefit Formulary Page 27 (Northern California Reg)

CEFOTETAN DISODIUM-DEXTROSE ...... 4 citalopram hydrobromide ...... 14 cefoxitin sodium ...... 4 cladribine ...... 7 CEFOXITIN SODIUM-DEXTROSE ...... 4 clarithromycin ...... 4 cefpodoxime proxetil ...... 4 CLEOCIN IN D5W ...... 4 ceftazidime ...... 4 CLEVIPREX ...... 11 ceftriaxone sodium ...... 4 clindamycin hcl ...... 4 CEFTRIAXONE SODIUM IN DEXTROSE ...... 4 CLINDAMYCIN HCL ...... 22 CEFTRIAXONE SODIUM-DEXTROSE ...... 4 clindamycin palmitate hydrochloride ...... 4 cefuroxime axetil ...... 4 clindamycin phosphate ...... 4, 24 cefuroxime sodium ...... 4 clindamycin phosphate (topical) ...... 24 CELONTIN ...... 13 clindamycin phosphate vaginal ...... 24 cephalexin ...... 4 clindamycin phosphate-benzoyl peroxide ...... 24 CERDELGA ...... 21 clindamycin phosphate-benzoyl peroxide CEREZYME ...... 17 (refrigerate) ...... 24 CHANTIX ...... 9 CLINIMIX E/DEXTROSE (2.75/10) ...... 16 CHEMET ...... 19 CLINIMIX E/DEXTROSE (2.75/5) ...... 16 CHEMSTRIP 9 ...... 15 CLINIMIX E/DEXTROSE (4.25/25) ...... 16 CHIRHOSTIM ...... 15 CLINIMIX E/DEXTROSE (5/15) ...... 16 CHLORAMPHENICOL SOD SUCCINATE ...... 4 CLINIMIX E/DEXTROSE (5/20) ...... 16 chlordiazepoxide hcl ...... 9, 13 CLINIMIX/DEXTROSE (4.25/10) ...... 16 chlordiazepoxide hcl-clidinium bromide...... 9 CLINIMIX/DEXTROSE (4.25/25) ...... 16 chlorhexidine gluconate (mouth-throat) ...... 17 clobetasol propionate ...... 25 chloroprocaine hcl ...... 21 CLOBETASOL PROPIONATE ...... 22 chloroquine phosphate ...... 5 clomiphene citrate ...... 20 chlorpromazine hcl ...... 14 clomipramine hcl ...... 14 CHLORPROMAZINE HCL ...... 22 clonazepam ...... 13 chlorthalidone ...... 16 clonidine ...... 11 CHOLESTEROL ...... 22 clonidine hcl ...... 11 cholestyramine ...... 11 clopidogrel bisulfate ...... 10 cholestyramine light ...... 11 clorazepate dipotassium ...... 13 choline & mag salicylate ...... 12 clotrimazole ...... 24 CHROMIC CHLORIDE ...... 16 CLOTRIMAZOLE ...... 22 cidofovir ...... 6 clozapine ...... 14 CIMDUO ...... 6 COARTEM ...... 5 CIMETIDINE HCL ...... 19 CODEINE SULFATE ...... 12 cinacalcet hcl ...... 21 COLCHICINE ...... 21 CINRYZE ...... 21 colchicine w/ probenecid ...... 17 CIPRODEX ...... 18 colestipol hcl ...... 11 ciprofloxacin hcl ...... 4, 17 COLLODION FLEXIBLE ...... 22 ciprofloxacin hcl (ophth) ...... 17 COMBIVENT RESPIMAT ...... 23 ciprofloxacin in d5w ...... 4 COMPLERA ...... 6 cisatracurium besylate ...... 9 CONRAY ...... 15 cisplatin ...... 7 COPIKTRA ...... 7

2020 Kaiser Permanente Federal Employees Health Benefit Formulary Page 28 (Northern California Reg)

COPPER CHLORIDE ...... 16 demeclocycline hcl ...... 4 CORDRAN ...... 25 DEPEN TITRATABS ...... 19 CORTISPORIN ...... 25 DEPOCYT ...... 7 CORTROSYN ...... 15 DEPO-ESTRADIOL ...... 20 COSENTYX ...... 25 DEPO-PROVERA ...... 21 COTELLIC ...... 7 DESCOVY ...... 6 CREON ...... 15, 19 desipramine hcl ...... 14 CRIXIVAN ...... 6 DESITIN ...... 25 CROFAB ...... 23 desmopressin acetate ...... 21 cromolyn sodium ...... 18, 23 desmopressin acetate spray ...... 21 cromolyn sodium (ophth) ...... 18 desmopressin acetate spray refrigerated ...... 21 C-TOPICAL ...... 18 desogestrel & ethinyl estradiol ...... 20 CUBICIN ...... 4 desonide ...... 25 CUROSURF ...... 23 desoximetasone ...... 25 cyanocobalamin ...... 26 dexamethasone ...... 19 cyclobenzaprine hcl ...... 9 DEXAMETHASONE ...... 18, 22 CYCLOMYDRIL ...... 18 dexamethasone sodium phosphate ...... 19 cyclopentolate hcl ...... 18 DEXAMETHASONE SODIUM PHOSPHATE ..... 18 cyclophosphamide ...... 7 dexmethylphenidate hcl ...... 13 cycloserine ...... 5 dexrazoxane hcl ...... 21 cyclosporine modified (for microemulsion) ...... 21 dextroamphetamine sulfate ...... 13 cyproheptadine hcl ...... 7 dextrose ...... 16, 17 CYRAMZA ...... 7 dextrose in lactated ringers ...... 16 CYSTADANE ...... 21 dextrose in ringers ...... 16 CYSTAGON ...... 21 dextrose w/ sodium chloride ...... 17 CYSTEAMINE HCL ...... 22 DIANEAL LOW CALCIUM/4.25% DEX ...... 16 CYSTOGRAFIN ...... 15 DIASTAT ACUDIAL ...... 13 cytarabine ...... 7 DIASTIX ...... 15 diazepam ...... 13 D diclofenac sodium (ophth) ...... 18 dacarbazine ...... 7 diclofenac sodium (topical) ...... 25 DACOGEN ...... 7 dicloxacillin sodium ...... 4 dactinomycin ...... 7 dicyclomine hcl ...... 9 DAKLINZA ...... 6 didanosine ...... 6 danazol ...... 20 DIGIFAB ...... 23 dantrolene sodium ...... 9 digoxin...... 11 dapsone ...... 5 dihydroergotamine mesylate ...... 9 DARAPRIM ...... 5 diltiazem hcl ...... 11 DARZALEX ...... 7 diltiazem hcl coated beads ...... 11 daunorubicin hcl ...... 7 diphenhydramine hcl ...... 7 DDAVP RHINAL TUBE ...... 21 diphenoxylate w/ atropine ...... 19 deferasirox ...... 19 dipyridamole ...... 12 deferoxamine mesylate ...... 19 DIPYRIDAMOLE ...... 12 2020 Kaiser Permanente Federal Employees Health Benefit Formulary Page 29 (Northern California Reg)

disopyramide phosphate ...... 11 ENGERIX-B ...... 24 DISPOSABLE POWER ...... 15 ENLON ...... 9 disulfiram ...... 21 entacapone ...... 13 divalproex sodium ...... 13 entecavir ...... 6 dobutamine hcl ...... 9 ENTRESTO ...... 11 dobutamine in d5w ...... 9 EOVIST ...... 15 DOCETAXEL ...... 7 EPCLUSA ...... 6 dofetilide ...... 11 ephedrine sulfate (pressors) ...... 9 donepezil hydrochloride ...... 9 epinephrine ...... 9 DONNATAL ...... 9 EPINEPHRINE ...... 9 dopamine hcl ...... 9 EQUETRO ...... 13 dopamine in d5w ...... 9 ERBITUX ...... 7 dorzolamide hcl ...... 18 ergocalciferol ...... 26 dorzolamide hcl-timolol maleate ...... 18 ERGOMAR ...... 9 DOVATO ...... 6 ERIVEDGE ...... 7 doxazosin mesylate ...... 10 erlotinib hcl ...... 7 doxepin hcl ...... 14 ERWINAZE ...... 7 doxorubicin hcl ...... 7 ERYTHROCIN LACTOBIONATE ...... 4 doxorubicin hcl liposomal ...... 7 erythromycin (acne aid) ...... 24 doxycycline (monohydrate) ...... 4 erythromycin (ophth) ...... 17 doxycycline hyclate ...... 4 escitalopram oxalate ...... 14 DRITHO-CREME HP ...... 25 esmolol hcl ...... 11 dronabinol ...... 19 esterified estrogens & methyltestosterone ...... 20 droperidol ...... 13 estradiol ...... 20 drospirenone-ethinyl estradiol ...... 20 ESTRADIOL ...... 22 DRYSOL ...... 25 estradiol vaginal ...... 20 duloxetine hcl ...... 14 ethacrynic acid ...... 16 ethambutol hcl ...... 5 E ETHAMOLIN ...... 12 EDURANT ...... 6 ethosuximide ...... 13 efavirenz ...... 6 ethynodiol diacet & eth estrad ...... 20 EFFIENT ...... 10 ETIDRONATE DISODIUM ...... 21 ELAPRASE ...... 17 etodolac ...... 12 ELITEK ...... 17 etomidate ...... 14 ELLA ...... 20 etonogestrel-ethinyl estradiol ...... 20 ELMIRON ...... 21 etoposide ...... 7 ELOCTATE ...... 10 EVOTAZ ...... 6 EMCYT ...... 7 exemestane ...... 7 EMEND ...... 19 EXTAVIA ...... 21 EMTRIVA ...... 6 EYLEA ...... 18 enalaprilat ...... 11 E-Z-CAT DRY ...... 15 ENBREL ...... 21 ENDOMETRIN ...... 21 2020 Kaiser Permanente Federal Employees Health Benefit Formulary Page 30 (Northern California Reg)

F FOLIC ACID ...... 26 FORANE ...... 14 FABRAZYME ...... 17 FORTEO ...... 20 famciclovir ...... 6 fosamprenavir calcium ...... 6 famotidine ...... 19 fosaprepitant dimeglumine ...... 19 FAMOTIDINE PREMIXED...... 19 FOSCAVIR ...... 6 felbamate ...... 13 fosphenytoin sodium ...... 13 fenofibrate ...... 11 fulvestrant ...... 7 fentanyl ...... 12 furosemide ...... 16 fentanyl citrate ...... 12 FUSILEV ...... 21 finasteride ...... 21 FUZEON ...... 6 flecainide acetate ...... 11 FLOVENT HFA ...... 19 G FLUAD ...... 24 FLUARIX QUADRIVALENT ...... 24 gabapentin ...... 13 FLUBLOK ...... 24 GADAVIST ...... 15 FLUCELVAX ...... 24 galantamine hydrobromide ...... 9 fluconazole ...... 5 GAMASTAN S/D ...... 23 fluconazole in dextrose ...... 5 GAMMAGARD ...... 23 fluconazole in nacl ...... 5 ganciclovir sodium ...... 6 FLUCONAZOLE IN SODIUM CHLORIDE ...... 4 GARDASIL ...... 24 flucytosine ...... 5 GARDASIL 9 ...... 24 fludarabine phosphate ...... 7 GASTROGRAFIN ...... 15 fludrocortisone acetate ...... 19 gatifloxacin (ophth) ...... 17 flumazenil ...... 14 GAZYVA ...... 7 FLUMIST QUADRIVALENT ...... 24 GELFOAM SPONGE SIZE 100 ...... 10 FLUNISOLIDE ...... 18 gemcitabine hcl ...... 7 fluocinolone acetonide ...... 25 gemfibrozil ...... 11 fluocinonide ...... 25 gentamicin in saline ...... 4 fluorescein sodium injection ...... 15 gentamicin sulfate ...... 4, 17, 24 fluorescein sodium topical ...... 15 gentamicin sulfate (ophth) ...... 17 fluorescein w/ benoxinate ...... 15 gentamicin sulfate (topical) ...... 24 fluorometholone (ophth) ...... 18 GENTIAN VIOLET ...... 24 fluorouracil ...... 7, 25 GENVOYA ...... 6 fluorouracil (topical) ...... 25 glatiramer acetate ...... 21 fluoxetine hcl ...... 14 GLEOSTINE ...... 7 fluphenazine decanoate ...... 14 glimepiride ...... 20 fluphenazine hcl ...... 14 glipizide ...... 20 flurbiprofen sodium ...... 18 glipizide-metformin hcl ...... 20 flutamide ...... 7 GLUCAGEN ...... 20 fluticasone propionate (nasal) ...... 18 GLUCAGON EMERGENCY ...... 20 FLUVIRIN ...... 23, 24 glyburide ...... 20 fluvoxamine maleate ...... 14 GLYCERIN ...... 22 FLUZONE HIGH-DOSE ...... 24 glycopyrrolate ...... 9 2020 Kaiser Permanente Federal Employees Health Benefit Formulary Page 31 (Northern California Reg)

GLYCOPYRROLATE ...... 22 HYDROCORTISONE ...... 22 GONAL-F ...... 20 hydrocortisone (intrarectal) ...... 25 GRASTEK ...... 21 hydrocortisone (topical) ...... 25 griseofulvin microsize ...... 5 hydrocortisone acetate (rectal) ...... 25 griseofulvin ultramicrosize ...... 5 hydromorphone hcl ...... 12 guaifenesin-codeine ...... 23 HYDROXOCOBALAMIN ...... 22 guanfacine hcl ...... 9, 14 hydroxychloroquine sulfate ...... 5 guanfacine hcl (adhd) ...... 14 HYDROXYPROGESTERONE CAPROATE .. 21, 22 hydroxyurea ...... 7 H hydroxyzine hcl ...... 13 HALAVEN ...... 7 hydroxyzine pamoate ...... 13 halobetasol propionate ...... 25 HYLENEX ...... 17 haloperidol ...... 14 hyoscyamine sulfate ...... 9 HALOPERIDOL ...... 22 HYPERRAB ...... 23 haloperidol decanoate ...... 14 HYPERTET S/D ...... 23 haloperidol lactate ...... 14 I HARVONI ...... 6 HAVRIX ...... 24 IBRANCE ...... 7 HEALON5 ...... 18 ibuprofen...... 12 HELIXATE FS ...... 10 ibutilide fumarate ...... 11 HEMABATE ...... 22 icatibant acetate ...... 21 HEMLIBRA ...... 10 idarubicin hcl ...... 7 HEMOFIL M ...... 10 IDELVION ...... 10 heparin (porcine) in sodium chloride ...... 10 ifosfamide ...... 7 HEPARIN SOD (PORCINE) IN D5W ...... 10 imatinib mesylate ...... 7 heparin sodium (porcine) ...... 10 IMBRUVICA ...... 7 heparin sodium (porcine) lock flush ...... 10 imipramine hcl ...... 14 HERCEPTIN ...... 7 imiquimod ...... 25 hetastarch in sodium chloride ...... 17 IMOVAX RABIES ...... 24 HEXALEN ...... 7 indapamide...... 16 HEXTEND ...... 17 INDIGO CARMINE ...... 15 HIZENTRA ...... 23 indomethacin ...... 12 homatropine hbr ...... 18 INDOMETHACIN ...... 22 HUMALOG ...... 20 indomethacin sodium ...... 12 HUMATE-P ...... 10 INFANRIX ...... 24 HUMIRA ...... 21 INFED ...... 10 HUMULIN 70/30 ...... 20 INFLECTRA ...... 21 HUMULIN N ...... 20 INFUMORPH 200 ...... 12 HUMULIN R ...... 20 INFUVITE ADULT ...... 26 hydralazine hcl ...... 11 INFUVITE PEDIATRIC ...... 26 hydrochlorothiazide ...... 11, 16 INSUFLON ...... 15 hydrocodone-acetaminophen ...... 12 INTEGRILIN ...... 10 hydrocortisone ...... 19, 25 INTELENCE ...... 6 2020 Kaiser Permanente Federal Employees Health Benefit Formulary Page 32 (Northern California Reg)

INTRALIPID ...... 16 KEYTRUDA ...... 8 INTRON A ...... 7 KINERET ...... 22 INVANZ ...... 4 KINRIX ...... 24 INVEGA SUSTENNA ...... 14 K-PHOS ...... 17 INVIRASE ...... 6 KRINTAFEL ...... 5 iodoquinol-hc ...... 24 KYPROLIS ...... 8 IPOL ...... 24 ipratropium bromide ...... 9 L ipratropium bromide (nasal) ...... 9 labetalol hcl ...... 11 ipratropium-albuterol ...... 9 LACTATED RINGERS ...... 17 IRESSA ...... 7 LACTIC ACID ...... 22 ISENTRESS ...... 6 LACTOSE ...... 22 isoniazid ...... 5 LACTOSE MONOHYDRATE ...... 22 isosorbide dinitrate ...... 12 lactulose ...... 16 isosorbide mononitrate ...... 12 lactulose (encephalopathy) ...... 16 isotretinoin ...... 25 lamivudine ...... 6 ISTODAX (OVERFILL) ...... 7 lamivudine (hbv) ...... 6 ivermectin ...... 4 lamivudine-zidovudine ...... 6 IXEMPRA KIT ...... 7 lamotrigine ...... 13 IXIARO ...... 24 LANTUS ...... 20 L-ARGININE ...... 22 J latanoprost ...... 18 JAKAFI ...... 7 L-CITRULLINE ...... 22 JARDIANCE ...... 20 leflunomide ...... 22 JEVTANA ...... 8 LENVIMA (10 MG DAILY DOSE) ...... 8 JULUCA ...... 6 letrozole ...... 8 leucovorin calcium ...... 22 K LEUKERAN ...... 8 KADCYLA ...... 8 LEUKINE ...... 10 KALETRA ...... 6 leuprolide acetate ...... 8 KALYDECO ...... 22, 23 levetiracetam ...... 13 KANJINTI ...... 8 LEVETIRACETAM IN NACL ...... 13 KCENTRA ...... 10 levobunolol hcl ...... 18 KCL-LACTATED RINGERS-D5W ...... 17 levocarnitine (metabolic modifiers) ...... 22 KENALOG ...... 19 levofloxacin ...... 4 KEPIVANCE ...... 25 levofloxacin in d5w ...... 4 ketamine hcl ...... 14 levonorgestrel & eth estradiol ...... 20 KETAMINE HCL ...... 22 levonorgestrel (emergency oc) ...... 20 ketoconazole ...... 5, 24 levonorgestrel-eth estradiol (triphasic) ...... 20 ketoconazole (topical) ...... 24 levothyroxine sodium ...... 21 KETO-DIASTIX ...... 15 LEVULAN KERASTICK ...... 25 ketorolac tromethamine ...... 12, 18 LEXISCAN ...... 15 ketorolac tromethamine (ophth) ...... 18 lidocaine ...... 11, 18, 21, 25 2020 Kaiser Permanente Federal Employees Health Benefit Formulary Page 33 (Northern California Reg)

lidocaine hcl ...... 18, 21, 25 MAGNESIUM SULFATE IN D5W ...... 17 LIDOCAINE HCL ...... 11, 21, 23 MAGNEVIST ...... 15 LIDOCAINE HCL (CARDIAC) ...... 11, 21 mannitol ...... 16 LIDOCAINE HCL (CARDIAC) PF...... 21 MARQIBO ...... 8 lidocaine hcl (local anesth.) ...... 21 MATULANE ...... 8 lidocaine hcl (mouth-throat) ...... 18 meclizine hcl ...... 19 lidocaine in d5w ...... 11 MECLOFENAMATE SODIUM ...... 12 lidocaine w/ epinephrine ...... 21 medroxyprogesterone acetate ...... 21 lidocaine-prilocaine ...... 25 medroxyprogesterone acetate (contraceptive) .... 21 linezolid ...... 4 mefenamic acid ...... 12 liothyronine sodium ...... 21 mefloquine hcl ...... 5 lisinopril ...... 11 megestrol acetate ...... 8 lisinopril & hydrochlorothiazide ...... 11 MEKINIST ...... 8 L-ISOLEUCINE ...... 22 meloxicam ...... 12 LITHIUM ...... 13 melphalan hcl ...... 8 lithium carbonate ...... 13 memantine hcl ...... 14 LITHOSTAT ...... 16 MENOPUR ...... 20 LMD IN D5W ...... 17 MENVEO ...... 24 LMD IN NACL ...... 17 meperidine hcl ...... 12 LONSURF ...... 8 mepivacaine hcl ...... 21 lorazepam ...... 13 mercaptopurine ...... 8 LORBRENA ...... 8 meropenem ...... 4 losartan potassium ...... 11 mesalamine ...... 19 losartan potassium & hydrochlorothiazide ...... 11 mesna ...... 22 lovastatin ...... 11 METAPROTERENOL SULFATE...... 9 LOVENOX ...... 10 metformin hcl ...... 20 loxapine succinate ...... 14 methadone hcl ...... 12 LUCENTIS ...... 18 METHADONE HCL ...... 23 LUMASON ...... 15 methazolamide ...... 18 LUMIGAN ...... 18 methenamine hippurate ...... 6 LUMIZYME ...... 17 methimazole ...... 21 LUPRON DEPOT (3-MONTH) ...... 8 methocarbamol ...... 9 LUPRON DEPOT (4-MONTH) ...... 8 methotrexate sodium ...... 8 LUPRON DEPOT (6-MONTH) ...... 8 methoxsalen rapid ...... 25 LUPRON DEPOT-PED (1-MONTH) ...... 8 methyldopa ...... 11 LUPRON DEPOT-PED (3-MONTH) ...... 8 METHYLENE BLUE ...... 22 L-VALINE ...... 22 methylergonovine maleate ...... 22 LYNPARZA ...... 8 methylphenidate hcl ...... 13 LYSODREN ...... 8 methylprednisolone ...... 19 methylprednisolone acetate ...... 19 M methylprednisolone sod succ ...... 19 MACUGEN ...... 18 metoclopramide hcl ...... 19 magnesium sulfate ...... 13 METOCLOPRAMIDE HCL MONOHYDRATE ..... 23 2020 Kaiser Permanente Federal Employees Health Benefit Formulary Page 34 (Northern California Reg)

metolazone ...... 16 nafcillin sodium ...... 4 METOPIRONE ...... 15 NAFCILLIN SODIUM IN DEXTROSE...... 4 metoprolol succinate ...... 11 NAGLAZYME ...... 17 metoprolol tartrate ...... 11 nalbuphine hcl ...... 12 metronidazole ...... 5, 24 naloxone hcl ...... 14 metronidazole (topical) ...... 24 naltrexone hcl ...... 14 metronidazole in nacl ...... 5 NALTREXONE HCL ...... 14 metronidazole vaginal ...... 24 naproxen...... 12 MEXILETINE HCL ...... 11 naratriptan hcl ...... 13 MICRHOGAM ULTRA-FILTERED PLUS ...... 23 NAROPIN ...... 21 midazolam hcl ...... 13 NATACYN ...... 17 midodrine hcl ...... 9 NEBUPENT ...... 5 MIFEPREX ...... 22 NECON 10/11 (28) ...... 20 milrinone lactate ...... 11 NEFAZODONE HCL ...... 14 milrinone lactate in dextrose ...... 11 NEMBUTAL ...... 13 minocycline hcl ...... 4 neomycin sulfate ...... 4 minoxidil ...... 11 NEOMYCIN SULFATE ...... 23 MIOCHOL-E ...... 18 neomycin-bacitracin zn-polymyxin ...... 17 MIOSTAT ...... 18 neomycin-polymy-dexameth ...... 18 MIRENA (52 MG) ...... 20 NEOMYCIN-POLYMYXIN B GU ...... 24 mirtazapine ...... 14 NEOMYCIN-POLYMYXIN-GRAMICIDIN ...... 17 misoprostol ...... 19 neomycin-polymyxin-hc (otic) ...... 18 mitomycin ...... 8 NEOPROFEN ...... 12 MITOSOL ...... 18 neostigmine methylsulfate ...... 9 mitoxantrone hcl ...... 8 NEUPOGEN ...... 10 M-M-R II ...... 24 nevirapine ...... 6 mometasone furoate ...... 25 NEXAVAR ...... 8 montelukast sodium ...... 23 NEXPLANON ...... 20 morphine sulfate ...... 12 niacin ...... 26 MORPHINE SULFATE ...... 23 nicardipine hcl ...... 11 moxifloxacin hcl ...... 4, 17 nicotine ...... 9 moxifloxacin hcl (ophth) ...... 17 nicotine polacrilex ...... 9 MULTIHANCE ...... 15 nifedipine ...... 11 mupirocin ...... 24 nimodipine ...... 11 MUSTARGEN ...... 8 NINLARO ...... 8 MVASI ...... 8 nitrofurantoin ...... 6, 7 mycophenolate mofetil ...... 22 nitrofurantoin macrocrystal ...... 6 MYLERAN ...... 8 nitrofurantoin monohyd macro ...... 7 MYOBLOC ...... 22 nitroglycerin ...... 12 nitroglycerin in d5w ...... 12 N nitroprusside sodium ...... 11 NABI-HB ...... 23 NORDITROPIN FLEXPRO ...... 21 nabumetone ...... 12 norepinephrine bitartrate ...... 9 2020 Kaiser Permanente Federal Employees Health Benefit Formulary Page 35 (Northern California Reg)

norethin acet & estrad-fe ...... 20 oxaliplatin ...... 8 norethindrone & eth estradiol ...... 20 oxazepam ...... 13 norethindrone (contraceptive) ...... 20 oxcarbazepine ...... 13 norethindrone acetate ...... 21 OXSORALEN ...... 25 norethindrone-eth estradiol (triphasic) ...... 20 oxybutynin chloride ...... 26 norgestimate-ethinyl estradiol ...... 20 oxycodone hcl ...... 12 norgestimate-ethinyl estradiol (triphasic) ...... 20 oxycodone w/ acetaminophen ...... 12 nortriptyline hcl ...... 14 oxytocin...... 22 NOVAREL ...... 20 OXYTROL ...... 26 NOVOSEVEN RT ...... 10 nystatin ...... 5, 24, 25 P nystatin (mouth-throat) ...... 5 paclitaxel...... 8 nystatin (topical) ...... 24 pamidronate disodium ...... 22 nystatin-triamcinolone ...... 25 PANCURONIUM BROMIDE ...... 9 pantoprazole sodium ...... 19 O PAPAVERINE HCL ...... 12 octreotide acetate ...... 22 paromomycin sulfate ...... 5 ODACTRA ...... 23 paroxetine hcl ...... 14 ODEFSEY ...... 6 ped multivitamins w/fl & iron ...... 26 ODOMZO ...... 8 PEDIARIX ...... 24 OFIRMEV ...... 12 pediatric multivitamins w/fl ...... 26 ofloxacin (ophth) ...... 17 PEDIATRIC SMALL MASK ...... 15 ofloxacin (otic) ...... 17 pediatric vitamins acd w/ fluoride ...... 26 OGESTREL ...... 20 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate olanzapine ...... 14 ...... 19 olopatadine hcl ...... 18 PEGASYS ...... 6 omeprazole ...... 19 PENICILLIN G POT IN DEXTROSE ...... 5 OMNIPAQUE ...... 15 penicillin g potassium ...... 5 OMNITROPE PEN 5 INJ DEVICE ...... 15 PENICILLIN G PROCAINE ...... 5 ondansetron ...... 19 PENICILLIN G SODIUM ...... 5 ondansetron hcl ...... 19 penicillin v potassium ...... 5 ONETOUCH ULTRA BLUE...... 16 PENLET II BLOOD SAMPLER ...... 15 ONETOUCH ULTRA MINI...... 15 pentostatin ...... 8 OPANA ...... 12 pentoxifylline ...... 10 OPDIVO ...... 8 PERJETA ...... 8 OPSUMIT ...... 22 permethrin ...... 24 ORAP ...... 14 perphenazine ...... 14 ORENCIA ...... 22 PERPHENAZINE-AMITRIPTYLINE ...... 14 ORKAMBI ...... 23 phenelzine sulfate ...... 14 oseltamivir phosphate ...... 6 PHENEX-1 ...... 16 OTEZLA ...... 22 phenobarbital ...... 13 OVIDREL ...... 20 PHENOBARBITAL ...... 14, 23 OXACILLIN SODIUM IN DEXTROSE ...... 5 PHENOBARBITAL SODIUM ...... 14 2020 Kaiser Permanente Federal Employees Health Benefit Formulary Page 36 (Northern California Reg)

PHENOL ...... 25 pravastatin sodium ...... 11 phenoxybenzamine hcl ...... 9 PRAXBIND ...... 10 phentolamine mesylate ...... 9 prazosin hcl ...... 10 phenylephrine hcl (mydriatic) ...... 18 PRECEDEX ...... 14 phenylephrine-chlorphen-dm ...... 23 PRED MILD ...... 18 PHENYLHISTINE DH ...... 23 prednisolone ...... 19 phenytoin ...... 13 prednisolone sodium phosphate ...... 19 phenytoin sodium ...... 13 prednisone ...... 19 phenytoin sodium extended ...... 13 PREMARIN ...... 20 PHOSPHOLINE IODIDE ...... 18 PREPIDIL ...... 22 PHOTREXA-PHOTREXA VISCOUS KIT ...... 18 PREVNAR 13 ...... 24 PHYSOSTIGMINE SALICYLATE...... 9 PREVYMIS ...... 6 phytonadione ...... 26 PREZCOBIX ...... 6 pilocarpine hcl ...... 9, 18 PREZISTA ...... 6 pilocarpine hcl (oral) ...... 9 PRIFTIN ...... 5 pimecrolimus ...... 25 PRIMAQUINE PHOSPHATE ...... 5 pioglitazone hcl ...... 20 PRIMAXIN IV ...... 5 piperacillin sodium-tazobactam sodium ...... 5 primidone ...... 13 PLASMANATE ...... 10 probenecid ...... 17 PLURONIC F127 ...... 23 procainamide hcl ...... 11 PNEUMOVAX 23 ...... 24 prochlorperazine ...... 14 PODOCON ...... 25 prochlorperazine edisylate ...... 14 podofilox ...... 25 prochlorperazine maleate ...... 14 PODOPHYLLUM RESIN ...... 23 PROCRIT ...... 10 POLYETHYLENE GLYCOL 400 ...... 23 PROCTOFOAM HC ...... 25 POLYFIN QR INFUSION SET 42 ...... 15 PROFERRIN ES ...... 10 polymyxin b-trimethoprim ...... 17 PROFERRIN-FORTE ...... 10 polysaccharide iron complex ...... 10 PROFILNINE ...... 10 POMALYST ...... 8 progesterone ...... 21 potassium acetate ...... 17 progesterone micronized ...... 21 potassium bicarbonate ...... 17 PROGESTERONE MICRONIZED ...... 23 potassium chloride ...... 17 PROGESTERONE WETTABLE ...... 23 potassium chloride in dextrose ...... 17 PROMACTA ...... 10 potassium chloride in dextrose & sodium chloride promethazine hcl ...... 7 ...... 17 PROMETHAZINE-DM ...... 23 potassium chloride in nacl ...... 17 propafenone hcl ...... 11 potassium chloride microencapsulated crystals er PROPANTHELINE BROMIDE ...... 9 ...... 17 proparacaine hcl ...... 18 potassium citrate (alkalinizer) ...... 16 propofol ...... 14 potassium citrate-citric acid ...... 16 propranolol hcl ...... 11 potassium phosphates ...... 17 PROPYLENE GLYCOL ...... 23 PRADAXA ...... 10 propylthiouracil ...... 21 pramipexole dihydrochloride ...... 13 PROQUAD ...... 24

2020 Kaiser Permanente Federal Employees Health Benefit Formulary Page 37 (Northern California Reg)

PROTAMINE SULFATE ...... 10 ropinirole hydrochloride ...... 13 protriptyline hcl ...... 14 rosuvastatin calcium ...... 11 PULMOZYME ...... 17 ROTARIX ...... 24 pyrazinamide ...... 5 ROTATEQ ...... 24 pyridostigmine bromide ...... 9 RYDAPT ...... 8

Q S QUELICIN ...... 9 SABRIL ...... 13 quetiapine fumarate ...... 14 SALICYLIC ACID ...... 23 QUINACRINE HCL ...... 23 salsalate ...... 12 quinidine gluconate ...... 11 SANDIMMUNE ...... 22 QUINIDINE SULFATE ...... 11 SANTYL ...... 25 QVAR ...... 19 scopolamine ...... 19 selegiline hcl ...... 14 R SELEGILINE HCL ...... 13 RABAVERT ...... 24 SELENIUM ...... 17 raloxifene hcl ...... 20 selenium sulfide ...... 24 ranitidine hcl ...... 19 SELZENTRY ...... 6 rasagiline mesylate ...... 13 SEREVENT DISKUS ...... 9 RASUVO ...... 22 SEROSTIM ...... 21 RECOTHROM ...... 10 sertraline hcl ...... 14 RELENZA DISKHALER ...... 6 sevelamer carbonate ...... 16 REMICADE ...... 22 SHINGRIX ...... 24 REOPRO ...... 10 sildenafil citrate ...... 12 RESCRIPTOR ...... 6 sildenafil citrate (pulmonary hypertension) ...... 12 RESERPINE ...... 11 silver sulfadiazine ...... 24 RESTASIS ...... 18 simvastatin ...... 11 RETIN-A MICRO ...... 25 sirolimus ...... 22 RETISERT ...... 18 SKYRIZI (150 MG DOSE) ...... 25 REVLIMID ...... 8 SODIUM ACETATE ...... 16 ribavirin (hepatitis c) ...... 6 SODIUM BENZOATE ...... 23 RIDAURA ...... 19 sodium bicarbonate ...... 16 rifabutin ...... 5 sodium chloride ...... 16, 17, 23 rifampin ...... 5 sodium chloride (gu irrigant) ...... 16 riluzole ...... 14 sodium chloride (inhalant) ...... 23 RIMANTADINE HCL ...... 6 sodium citrate & citric acid ...... 16 RIMSO-50 ...... 22 SODIUM EDECRIN ...... 16 RISPERDAL CONSTA ...... 14 sodium fluoride ...... 22 risperidone ...... 14 sodium fluoride (dental) ...... 22 ritonavir ...... 6 sodium phenylbutyrate ...... 16 RITUXAN ...... 8 sodium phosphates (sodium phosphate dibasic & rizatriptan benzoate ...... 13 monobasic) ...... 17 rocuronium bromide ...... 9 sodium polystyrene sulfonate ...... 16 2020 Kaiser Permanente Federal Employees Health Benefit Formulary Page 38 (Northern California Reg)

sodium tetradecyl sulfate ...... 12 T solifenacin succinate ...... 26 TABLOID ...... 8 SOLIRIS ...... 22 tacrolimus ...... 22, 25 SOLU-CORTEF ...... 19 tacrolimus (topical) ...... 25 SORBITOL ...... 19, 23 tadalafil ...... 12 sotalol hcl ...... 11 TAFINLAR ...... 8 sotalol hcl (afib/afl) ...... 11 TAGRISSO ...... 8 SOVALDI ...... 6 TAKHZYRO ...... 22 SPIRIVA RESPIMAT ...... 9 tamoxifen citrate ...... 8 spironolactone ...... 12 tamsulosin hcl ...... 10 spironolactone & hydrochlorothiazide ...... 12 TARGRETIN ...... 8, 25 SPRYCEL ...... 8 TASIGNA ...... 8 SQUARIC ACID DIBUTYLESTER ...... 23 tazarotene ...... 25 SSKI ...... 21 TDVAX ...... 24 stavudine ...... 6 TECENTRIQ ...... 8 STELARA ...... 25 temazepam ...... 14 STIOLTO RESPIMAT ...... 23 temozolomide ...... 8 STIVARGA ...... 8 TENIPOSIDE ...... 8 STRENSIQ ...... 17 tenofovir disoproxil fumarate ...... 6 STREPTOMYCIN SULFATE ...... 5 terazosin hcl ...... 10 STRIBILD ...... 6 terbinafine hcl ...... 5 STRIVERDI RESPIMAT ...... 10 terbutaline sulfate ...... 10 sucralfate ...... 19 testosterone cypionate ...... 20 sufentanil citrate ...... 12 testosterone enanthate ...... 20 sulfacetamide sodium (ophth) ...... 18 TESTOSTERONE PROPIONATE ...... 23 sulfacetamide sodium w/ sulfur ...... 25 TETRACAINE HCL ...... 21 SULFADIAZINE ...... 5 tetracaine hcl (ophth) ...... 18 sulfamethoxazole-trimethoprim...... 5 tetracycline hcl ...... 5 sulfasalazine ...... 5 THALOMID ...... 22 SULFUR PRECIPITATED ...... 23 theophylline ...... 26 sulindac ...... 12 THEOPHYLLINE IN D5W ...... 26 sumatriptan ...... 13 thiamine hcl ...... 26 sumatriptan succinate ...... 13 THIOLA ...... 22 SURVANTA ...... 23 thioridazine hcl ...... 14 SUTENT ...... 8 thiotepa ...... 8 SYLVANT ...... 8 thiothixene ...... 14 SYMDEKO ...... 23 THROMBATE III ...... 10 SYMFI ...... 6 THYMOL ...... 23 SYMTUZA ...... 6 THYROGEN ...... 16 SYNAGIS ...... 6 TICE BCG ...... 24 SYNAREL ...... 20 timolol maleate (ophth) ...... 18 SYNERCID ...... 5 TIVICAY ...... 6 tizanidine hcl ...... 9 2020 Kaiser Permanente Federal Employees Health Benefit Formulary Page 39 (Northern California Reg)

TNKASE ...... 10 UNITUXIN ...... 8 tobramycin ...... 5, 18 UREA ...... 23 tobramycin (ophth) ...... 18 ursodiol ...... 19 tobramycin sulfate ...... 5 TOLBUTAMIDE ...... 20 V topiramate ...... 13 valacyclovir hcl ...... 6 topotecan hcl ...... 8 valganciclovir hcl ...... 6 TORISEL ...... 8 valproate sodium ...... 13 torsemide ...... 16 valproic acid ...... 13 trace minerals (cr-cu-mn-zn) ...... 17 valsartan ...... 12 TRACLEER ...... 12, 23 valsartan-hydrochlorothiazide ...... 12 tramadol hcl ...... 12 vancomycin hcl ...... 5 tramadol-acetaminophen ...... 12 VANCOMYCIN HCL IN DEXTROSE ...... 5 tranexamic acid ...... 10 vardenafil hcl ...... 12 TRANEXAMIC ACID ...... 23 VARITHENA ...... 12 tranylcypromine sulfate ...... 14 VARIVAX ...... 24 trazodone hcl ...... 14 VAXCHORA ...... 24 TRECATOR ...... 5 VECTICAL ...... 25 TREMFYA ...... 25 vecuronium bromide ...... 9 treprostinil ...... 12 VELCADE ...... 8 tretinoin ...... 25 VENCLEXTA ...... 8 TRIAMCINOLONE ACETONIDE ...... 23 venlafaxine hcl ...... 14 triamcinolone acetonide (mouth) ...... 25 VENOFER ...... 10 triamcinolone acetonide (topical) ...... 25 VENTAVIS ...... 12 triamterene & hydrochlorothiazide ...... 16 verapamil hcl ...... 11 trifluoperazine hcl ...... 14 VIMIZIM ...... 17 TRIFLURIDINE ...... 18 VINCRISTINE SULFATE ...... 8 trihexyphenidyl hcl ...... 13 vinorelbine tartrate ...... 8 trimethoprim ...... 7 VIRACEPT ...... 6 trimipramine maleate ...... 14 VIRAZOLE ...... 6 TRISENOX ...... 8 VISUDYNE ...... 18 TRIUMEQ ...... 6 VIVOTIF ...... 24 tropicamide ...... 18 VORAXAZE ...... 17 trospium chloride ...... 26 voriconazole ...... 5, 6 TRUVADA ...... 6 VOSEVI ...... 6 TUBERSOL ...... 16 VOTRIENT ...... 8 TWINRIX ...... 24 VPRIV ...... 17 TYKERB ...... 8 VYVANSE ...... 13 TYPHIM VI ...... 24 VYXEOS ...... 8 TYSABRI ...... 22 W U warfarin sodium ...... 10 ULTIVA ...... 12 water for injection, sterile ...... 22 2020 Kaiser Permanente Federal Employees Health Benefit Formulary Page 40 (Northern California Reg)

water for irrigation, sterile ...... 16 Z WIDE-SEAL DIAPHRAGM 60 ...... 15 ZANOSAR ...... 8 ZARXIO ...... 10 X ZEJULA ...... 9 XALKORI ...... 8 ZELBORAF ...... 9 XELJANZ ...... 22 zidovudine ...... 6 XERAC AC ...... 25 ZINACEF IN STERILE WATER ...... 5 XIFAXAN ...... 5 ZINC CHLORIDE ...... 17 XTANDI ...... 8 ZINC SULFATE ...... 23 XULANE ...... 20 ziprasidone hcl ...... 14 XYNTHA ...... 10 zoledronic acid ...... 22 zolpidem tartrate ...... 14 Y ZOSTAVAX ...... 24 YF-VAX ...... 24 ZOSYN ...... 5 YONDELIS ...... 8 ZYDELIG ...... 9 ZYKADIA ...... 9

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