Denver/Boulder, Mountain & Northern Colorado Commercial HMO Drug

Denver/Boulder, Mountain & Northern Colorado Commercial HMO Drug Formulary

The following is a listing of the drugs on the Denver/Boulder, Mountain & Northern Colorado Commercial HMO drug Formulary. This formulary applies only to outpatient drugs provided to members for self- administration, and does not apply to medications used in inpatient settings or medications administered in a doctor’s office or infusion center. The listing does not provide information regarding the specific coverage, limitations or quotas an individual member may have. Many members have specific exclusions, copays, or coinsurances that are not reflected in the formulary.

Kaiser Permanente has many brand and generic medications on the formulary. In most cases, a generic equivalent is used when available. Members will be notified when a generic equivalent is dispensed. If a member requests a brand name when a generic equivalent is routinely used, the member will pay the difference in price between the generic equivalent and the requested brand plus the appropriate copay. Kaiser Permanente may implement programs, such as a therapeutic interchange program, to promote safe and effective drug therapy. In these cases the prescribing provider and member are notified prior to a change occurring.

How to use this Formulary document Products available in a generic form are listed by their generic name in italics. With the exception of drugs where multiple branded products exist, medications only available as a brand name product are listed in all CAPITAL letters.

Please remember that this list is subject to change and will be updated at least quarterly. Any product not found in this listing or in subsequent updates, will be considered a non-preferred drug.

You can search the list by using the index, by using the “Find” function in Adobe Reader, or by therapeutic drug category.

All dosage forms and strengths for a particular drug listed may not be formulary. Some drugs are available in more than one dosage form (example: tablet and injectable). Not all dosage forms of drugs are covered under the prescription drug benefit. Drugs that have at least one dosage form as an injectable on formulary are noted with an asterisk (*). Drugs that have certain strengths or forms (e.g., tablet, gel capsule, liquid) that are only available as brand drugs are subject to the brand cost share.

Restrictions on medication coverage: Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:  Restricted to specialty: A drug that needs to be written by a physician specialized in the treatment of certain conditions for the drug to be covered under the patient’s pharmacy benefit.  Prior authorization: Some drugs require specific medical criteria be met prior to dispensing the drug for the patient’s pharmacy benefit.  Quantity Limits or Quotas: For certain drugs, Kaiser Permanente limits the amount of medication dispensed to a specific days supply or quantity per copay. For example, Tarceva® is limited to a 30-day supply. In addition, when there is a national shortage of a drug, we may limit the quantity of the drug dispensed per prescription per copayment.

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 1 -  Restricted to Benefit: Some drugs are not covered unless the individual prescription benefit specifically covers such medications. For example, Viagra® and other drugs for sexual dysfunction are not covered unless the prescription benefit specifically covers them.  Step therapy: Some medications require a similar therapy be attempted first. For example, before lansoprazole can be dispensed, a drug such as omeprazole must be tried first.  Restricted to a specific age: Some medications may be restricted to a certain age or age range.  Medication Exception Process: Upon request, Kaiser Permanente may make an exception to our coverage rules. The following are examples of exception requests: o Request to cover a drug that is not on our preferred product list o Request to waive coverage restrictions or limitations  Generally Kaiser Permanente will only approve requests for an exception if the alternative drugs included on the plan’s preferred product list, or existing utilization restrictions, would not be as effective in treating a condition or would cause adverse medical effects.

Key: * (asterisk) = A drug where at least one of the dosage forms is an injectable. Some patients have a specific self-injectable coinsurance.  (diamond) = A drug that is designated as a Specialty drug which may process at a Specialty tier of the individual prescription drug benefit, where applicable. † (dagger) = Certain strengths or forms of the drug (e.g., tablet, gel, liquid) are only available as brand drugs and are subject to the brand cost share.  (triangle/delta) = This drug is only covered for benefit if your Evidence of Coverage states that contraceptives are covered at $0. Otherwise, this drug requires a medical necessity review to be covered for benefit. MD = A drug that is required to be written by a physician specialized in the treatment of certain conditions. PA = A drug that requires specific medical criteria be met prior to dispensing for prescription benefit. QL = A drug that has a quantity limit or is limited to a specific day supply. RB = A drug that is restricted to a certain benefit for coverage. ST = A drug that requires another class of medications be attempted prior to dispensing for prescription benefit. AG = A drug that is restricted to a specific age range. NC = A drug that is specifically excluded under certain benefit plans.

This list of drugs should not be used to determine benefit issues such as prescription copay amounts. If you have questions about prescription benefits, please call Kaiser Permanente Member Services at 1-888-681-7878.

The medications on this list are subject to change at any time throughout the year

Drug Name Drug Tier Requirements/Limits ANTI-INFECTIVE AGENTS ANTHELMINTICS ALBENZA Brand BILTRICIDE Brand ANTI-INFECTIVE AGENTS ANTIBACTERIALS amoxicillin Generic/Brand † amoxicillin & potassium Generic/Brand † clavulanate

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 2 - Drug Name Drug Tier Requirements/Limits ampicillin Generic * AVELOX Brand * AZACTAM Brand * azithromycin Generic * bacitracin Generic bacitracin & polymyxin B Generic CAYSTON Brand * cefazolin sodium Generic * cefdinir Generic cefepime Generic * cefotaxime sodium Generic/Brand * † cefotetan Generic * ceftazidime Generic/Brand * † ceftriaxone sodium Generic * cefuroxime axetil Generic/Brand † cefuroxime sodium Generic * cephalexin Generic CIPRODEX Brand ciprofloxacin hcl Generic/Brand * † clarithromycin Generic clindamycin hcl Generic/Brand † clindamycin palmitate Generic hydrochloride clindamycin phosphate Generic/Brand * † dicloxacillin sodium Generic doxycycline hyclate Generic * doxycycline monohydrate Generic erythromycin base Generic/Brand † erythromycin ethylsuccinate Generic/Brand † erythromycin lactobionate Generic/Brand * † GANTRISIN Brand gentamicin sulfate Generic * INVANZ Brand * levofloxacin Generic* minocycline hcl Generic neomycin sulfate Generic penicillin g potassium Generic * penicillin g procaine Generic * penicillin g sodium Generic * penicillin v potassium Generic piperacillin-tazobactam Generic/Brand * †

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 3 - Drug Name Drug Tier Requirements/Limits PRIMAXIN I.M. Brand * streptomycin sulfate Generic * sulfamethoxazole-trimethoprim Generic * sulfasalazine Generic SUPRAX Brand TAZICEF Brand * tetracycline hcl Generic/Brand † tobramycin nebulization solution Generic  tobramycin sulfate Generic/Brand * † TROBICIN Brand * VANCOCIN ISO- Brand * OSMOTIC DEXTROSE vancomycin hcl Generic/Brand *  ZYVOX Brand *  ANTI-INFECTIVE AGENTS ANTIFUNGALS AMBISOME Brand * amphotericin b Generic * ANCOBON Brand CANCIDAS Brand * fluconazole Generic * fluconazole in nacl Generic * griseofulvin microsize Generic/Brand † griseofulvin ultramicrosize Generic ketoconazole Generic nystatin Generic voriconazole Generic/Brand * † ANTI-INFECTIVE AGENTS ANTIMYCOBACTERIALS dapsone Generic ethambutol hcl Generic isoniazid Generic pyrazinamide Generic rifampin Generic * ANTI-INFECTIVE AGENTS ANTIPROTOZOALS atovaquone Generic  atovaquone-proguanil Generic chloroquine phosphate Generic DARAPRIM Brand hydroxychloroquine sulfate Generic

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 4 - Drug Name Drug Tier Requirements/Limits mefloquine hcl Generic MEPRON Brand metronidazole Generic * paromomycin sulfate Generic pentamidine isethionate Generic/Brand * † primaquine phosphate Generic ANTI-INFECTIVE AGENTS ANTIVIRALS abacavir Generic/Brand † abacavir &lamivudine & Generic  zidovudine acyclovir Generic * adefovir Generic  amantadine hcl Generic APTIVUS Brand  ATRIPLA Brand  COMPLERA Brand  CRIXIVAN Brand didanosine Generic/Brand † EDURANT Brand  EMTRIVA Brand entecavir Generic  EPZICOM Brand  famciclovir Generic foscarnet sodium Generic * ganciclovir Generic * HARVONI Brand  MD INTELENCE Brand  INVIRASE Brand  ISENTRESS Brand  KALETRA Brand  lamivudine Generic/Brand † lamivudine & zidovudine Generic LEXIVA Brand  nevirapine Generic/Brand † NORVIR Brand PEGASYS Brand * QL PREZISTA Brand RESCRIPTOR Brand REYATAZ Brand  ribavirin Generic

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 5 - Drug Name Drug Tier Requirements/Limits rimantadine hydrochloride Generic/Brand † SELZENTRY Brand  SOVALDI Brand  QL stavudine Generic STRIBILD Brand  SUSTIVA Brand SYNAGIS Brand * TAMIFLU Brand TIVICAY Brand TRUVADA Brand  VALCYTE Brand  VICTRELIS Brand * QL VIRACEPT Brand  VIREAD Brand  zidovudine Generic/Brand † ANTI-INFECTIVE AGENTS URINARY ANTI-INFECTIVES methenamine hippurate Generic nitrofurantoin macrocrystal Generic nitrofurantoin monohyd macro Generic PRIMSOL Brand/Generic trimethoprim Generic ANTIHISTAMINE DRUGS ANTIHISTAMINE DRUGS cyproheptadine hcl Generic* diphenhydramine hcl Generic * promethazine hcl Generic* ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS ABRAXANE Brand * AFINITOR Brand  QL anastrozole Generic AVASTIN Brand * bicalutamdie Generic BICNU W/DILUENT Brand * ABSOLUTE ETHANOL bleomycin sulfate Generic * capecitabine Generic carboplatin Generic * CEENU Brand cisplatin Generic *

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 6 - Drug Name Drug Tier Requirements/Limits cyclophosphamide Generic * cytarabine Generic * dacarbazine Generic * dactinomycin Generic * daunorubicin hcl Generic * docetaxel Generic * doxorubicin hcl Generic * EMCYT Brand  QL ERBITUX Brand * etoposide Generic * exemestane Generic FEMARA Brand fludarabine phosphate Generic * fluorouracil Generic/Brand * † flutamide Generic GEMZAR Brand * GLEEVEC Brand  QL HERCEPTIN Brand * HEXALEN Brand  hydroxyurea Generic idarubicin hcl Generic * ifosfamide Generic * ifosfamide & mesna Generic * IMBRUVICA Brand  QL INTRON-A Brand * QL INTRON-A W/DILUENT Brand * QL LEUKERAN Brand leuprolide acetate Generic/Brand * † LUPRON DEPOT Brand * LUPRON DEPOT-PED Brand * LYSODREN Brand  QL MATULANE Brand  QL megestrol acetate Generic melphalan Generic/Brand * † mercaptopurine Generic methotrexate sodium Generic * mitomycin Generic * mitoxantrone hcl Generic * MUSTARGEN Brand * MYLERAN Brand NEXAVAR Brand  QL

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 7 - Drug Name Drug Tier Requirements/Limits paclitaxel Generic * pentostatin Generic * RITUXAN Brand * SPRYCEL Brand  QL SUTENT Brand  QL TABLOID Brand tamoxifen citrate Generic TARCEVA Brand  QL TASIGNA Brand  QL temozolomide Generic *  QL thiotepa Generic * topotecan Generic * TORISEL Brand * tretinoin Generic  QL TYKERB Brand  QL VIDAZA Brand * vinblastine sulfate Generic * vincristine sulfate Generic * vinorelbine tartrate Generic * VOTRIENT Brand  QL XALKORI Brand  QL XTANDI Brand  QL ZELBORAF Brand  QL ZOLADEX Brand * ZYDELIG Brand  QL ZYTIGA Brand  QL AUTONOMIC DRUGS ANTICHOLINERGIC AGENTS atropine sulfate Generic * ATROVENT HFA Brand benztropine mesylate Generic * clidinium / chlordiazepoxide Generic dicyclomine hcl Generic/Brand * † glycopyrrolate Generic * ipratropium bromide Generic propantheline bromide Generic scopolamine hydrobromide Generic/Brand * † SPIRIVA RESPIMAT Brand trihexyphenidyl hcl Generic AUTONOMIC DRUGS AUTONOMIC DRUGS, MISCELLANEOUS

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 8 - Drug Name Drug Tier Requirements/Limits DIBENZYLINE Brand AUTONOMIC DRUGS PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS bethanechol chloride Generic donepezil hydrochloride Generic ENLON Brand * galantamine hydrobromide Generic neostigmine methylsulfate Generic * pilocarpine hcl (oral) Generic/Brand † pyridostigmine bromide Generic/Brand † AUTONOMIC DRUGS SKELETAL MUSCLE RELAXANTS ANECTINE Brand * baclofen Generic cyclobenzaprine hcl Generic dantrolene sodium Generic/Brand * † methocarbamol Generic/Brand * † tizanidine Generic AUTONOMIC DRUGS SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS ergoloid mesylates Generic phentolamine mesylate Generic * AUTONOMIC DRUGS SYMPATHOMIMETIC (ADRENERGIC) AGENTS ADVAIR DISKUS Brand albuterol Generic albuterol sulfate Generic COMBIVENT RESPIMAT Brand DULERA Brand ephedrine sulfate (pressors) Generic * EPIPEN 2-PAK Brand * EPIPEN-JR 2-PAK Brand * FORADIL AEROLIZER Brand metaproterenol sulfate Generic phenylephrine hcl (pressors) Generic * SEREVENT DISKUS Brand STRIVERDI RESPIMAT Brand terbutaline sulfate Generic * BLOOD FORMATION, COAGULATION, AND THROMBOSIS COAGULANTS AND ANTICOAGULANTS ACTIVASE Brand *

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 9 - Drug Name Drug Tier Requirements/Limits AGGRENOX Brand aminocaproic acid Generic * anagrelide hcl Generic clopidogrel Generic dipyridamole Generic fondaparinux Generic * BRILINTA Brand enoxaparin sodium Generic * EFFIENT Brand heparin sodium (porcine) Generic * pentoxifylline Generic tranexamic acid Generic * PRADAXA Brand warfarin sodium Generic BLOOD FORMATION, COAGULATION AND THROMBOSIS HEMATOPOIETIC AGENTS PROCRIT Brand *  QL ZARXIO Brand *  QL BLOOD FORMATION, COAGULATION AND THROMBOSIS HEMOSTATICS HELIXATE FS Brand * HUMATE-P Brand * KOGENATE FS Brand * RECOMBINATE Brand * REFACTO Brand * BLOOD FORMATION, COAGULATION AND THROMBOSIS IRON PREPARATIONS DEXFERRUM Brand * INFED Brand * VENOFER Brand * CARDIOVASCULAR DRUGS ALPHA-ADRENERGIC BLOCKING AGENTS doxazosin mesylate Generic prazosin hcl Generic terazosin hcl Generic CARDIOVASCULAR DRUGS ANTILIPEMIC AGENTS atorvastatin Generic cholestyramine Generic colestipol hcl Generic fenofibrate Generic

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 10 - Drug Name Drug Tier Requirements/Limits gemfibrozil Generic lovastatin Generic pravastatin sodium Generic simvastatin Generic CARDIOVASCULAR DRUGS BETA-ADRENERGIC BLOCKING AGENTS acebutolol Generic atenolol Generic/Brand * † carvedilol Generic labetalol hcl Generic * metoprolol succinate Generic metoprolol tartrate Generic * propranolol hcl Generic * sotalol hcl Generic CARDIOVASCULAR DRUGS CALCIUM-CHANNEL BLOCKING AGENTS amlodipine besylate Generic diltiazem hcl Generic * nifedipine Generic nimodipine Generic verapamil hcl Generic * CARDIOVASCULAR DRUGS CARDIAC DRUGS amiodarone hcl Generic * digoxin Generic * disopyramide phosphate Generic/Brand † dopamine hcl Generic * flecainide acetate Generic lidocaine hcl (cardiac) Generic * procainamide hcl Generic * propafenone hcl Generic quinidine gluconate Generic quinidine sulfate Generic TIKOSYN Brand CARDIOVASCULAR DRUGS HYPOTENSIVE AGENTS acetazolamide Generic* clonidine hcl Generic hydralazine hcl Generic methazolamide Generic methyldopa Generic

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 11 - Drug Name Drug Tier Requirements/Limits minoxidil Generic reserpine Generic CARDIOVASCULAR DRUGS RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS captopril Generic lisinopril Generic lisinopril & hydrochlorothiazide Generic losartan Generic losartan & hydrochlorothiazide Generic spironolactone Generic spironolactone & Generic hydrochlorothiazide CARDIOVASCULAR DRUGS VASODILATING AGENTS ADCIRCA Brand epoprostenol sodium Generic * isosorbide dinitrate Generic/Brand † isosorbide mononitrate Generic LETAIRIS Brand  QL OPSUMIT Brand  QL nitroglycerin Generic/Brand * † sildenafil citrate (pulmonary Generic hypertention) TRACLEER Brand  QL VENTAVIS Brand  QL CENTRAL NERVOUS SYSTEM AGENTS ANALGESICS AND ANTIPYRETICS acetaminophen w/ codeine Generic butorphanol tartrate Generic * choline & mag salicylate Generic codeine phosphate Generic etodolac Generic fentanyl transdermal system Generic fentanyl citrate Generic * flurbiprofen Generic hydrocodone-acetaminophen Generic hydromorphone hcl Generic * ibuprofen Generic INDOCIN IV Brand * indomethacin Generic/Brand † ketoprofen Generic

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 12 - Drug Name Drug Tier Requirements/Limits ketorolac Generic * meloxicam Generic methadone hcl Generic morphine sulfate Generic/Brand * † nabumetone Generic naproxen Generic oxycodone hcl Generic oxycodone w/ acetaminophen Generic/Brand † salsalate Generic * SUBOXONE Brand sufentanil citrate Generic * sulindac Generic tramadol hcl Generic CENTRAL NERVOUS SYSTEM AGENTS ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL

STIMULANTS amphetamine-dextroamphetamine Generic/Brand † dextroamphetamine sulfate Generic methylphenidate hcl Generic methylphenidate hcl extended Generic phentermine hcl Generic RB QSYMIA Brand RB, PA CENTRAL NERVOUS SYSTEM AGENTS ANTICONVULSANTS carbamazepine Generic/Brand † CELONTIN Brand divalproex sodium Generic divalproex sodium sprinkles Generic ethosuximide Generic FELBATOL Brand felbamate Generic/Brand † gabapentin Generic lamotrigine Generic levetiracetam Generic levetiracetam extended Generic magnesium sulfate Generic * oxcarbazepine Generic † phenobarbital Generic * phenytoin Generic/Brand † phenytoin sodium Generic * phenytoin sodium extended Generic

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 13 - Drug Name Drug Tier Requirements/Limits primidone Generic topiramate Generic topiramate sprinkle Generic valproate sodium Generic * valproic acid Generic/Brand † zonisamide Generic CENTRAL NERVOUS SYSTEM AGENTS ANTIMIGRAINE AGENTS butalbital & acetaminophen Generic butalbital, acetaminophen & Generic caffeine CAFERGOT Brand QL dihydroergotamine mesylate Generic/Brand * † ERGOMAR Brand QL naratriptan Generic* QL rizatriptan Generic* QL sumatriptan Generic* QL CENTRAL NERVOUS SYSTEM AGENTS ANXIOLYTICS, SEDATIVES, AND HYPNOTICS buspirone hcl Generic droperidol Generic * hydroxyzine hcl Generic * zolpidem tartrate Generic CENTRAL NERVOUS SYSTEM AGENTS BENZODIAZEPINES alprazolam Generic chlordiazepoxide Generic clonazepam Generic DIASTAT ACUDIAL Brand DIASTAT PEDIATRIC Brand diazepam Generic/Brand * † lorazepam Generic * midazolam Generic * oxazepam Generic/Brand † temazepam Generic triazolam Generic CENTRAL NERVOUS SYSTEM AGENTS CENTRAL NERVOUS SYSTEM AGENTS, MISCELLANEOUS CAMPRAL Brand carbidopa-levodopa Generic * COMTAN Brand

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 14 - Drug Name Drug Tier Requirements/Limits NAMENDA Brand NAMENDA TITRATION PAK Brand pramipexole dihydrochloride Generic RILUTEK Brand ropinirole hydrochloride Generic SAVELLA Brand PA selegiline hcl Generic CENTRAL NERVOUS SYSTEM AGENTS OPIATE ANTAGONISTS naloxone hcl Brand/Generic * † naltrexone hcl Generic CENTRAL NERVOUS SYSTEM AGENTS PSYCHOTHERAPEUTIC AGENTS ABILIFY Brand amitriptyline hcl Generic bupropion hcl Generic chlorpromazine hcl Generic * citalopram hydrobromide Generic clomipramine hcl Generic clozapine Generic desipramine hcl Generic doxepin hcl Generic duloxetine hcl Generic fluoxetine hcl Generic fluphenazine decanoate Generic * fluphenazine hcl Generic * fluvoxamine maleate Generic GEODON Brand haloperidol Generic haloperidol decanoate Generic * haloperidol lactate Generic * imipramine hcl Generic lithium carbonate Generic lithium citrate Generic loxapine succinate Generic mirtazapine Generic nefazodone hcl Generic nortriptyline hcl Generic ORAP Brand paroxetine hcl Generic perphenazine Generic

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 15 - Drug Name Drug Tier Requirements/Limits phenelzine sulfate Generic prochlorperazine edisylate Generic * prochlorperazine maleate Generic risperidone Generic/Brand † SEROQUEL Brand sertraline hcl Generic thioridazine hcl Generic thiothixene Generic tranylcypromine sulfate Generic trazodone hcl Generic trifluoperazine hcl Generic venlafaxine hcl Generic ZYPREXA Brand ELECTROLYTIC, CALORIC, AND WATER BALANCE ACIDIFYING AND ALKALINIZING AGENTS citric acid monohydrate Generic potassium citrate (alkalinizer) Generic potassium citrate-citric acid Generic sodium acetate Generic * sodium bicarbonate Generic * sodium citrate & citric acid Generic ELECTROLYTIC, CALORIC, AND WATER BALANCE AMMONIA DETOXICANTS lactulose Generic ELECTROLYTIC, CALORIC, AND WATER BALANCE DIURETICS amiloride & hydrochlorothiazide Generic amiloride hcl Generic bumetanide Generic chlorothiazide Generic chlorthalidone Generic DYRENIUM Brand ethacrynate sodium Generic * furosemide Generic * hydrochlorothiazide Generic metolazone Generic torsemide Generic triamterene & Generic hydrochlorothiazide ELECTROLYTIC, CALORIC, AND WATER BALANCE ION-REMOVING AGENTS

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 16 - Drug Name Drug Tier Requirements/Limits RENAGEL Brand RENVELA Brand sodium polystyrene sulfonate Generic ELECTROLYTIC, CALORIC, AND WATER BALANCE IRRIGATING SOLUTIONS acetic acid Generic lactated ringer's (irrigation) Generic* ringer's irrigation Generic* sodium chloride (gu irrigant) Generic* water for irrigation, sterile Generic* ELECTROLYTIC, CALORIC, AND WATER BALANCE REPLACEMENT PREPARATIONS calcium acetate Generic calcium chloride (dihydrate) Generic* calcium gluconate Generic* electrolyte concentrate solution Generic* ELIPHOS Brand K-PHOS Brand * potassium phosphate dibasic monobasic w/sodium phosphate Generic * monobasic potassium acetate Generic * potassium chloride Generic/Brand * † potassium chloride Generic microencapsulated crystals cr potassium phosphate dibasic Generic * sodium phosphate Generic* zinc (trace metals) Generic * ELECTROLYTIC, CALORIC, AND WATER BALANCE URICOSURIC AGENTS probenecid Generic ENZYMES ENZYMES ADAGEN Brand * PULMOZYME Brand  QL ERECTILE DYSFUNCTION PHOSPHODIESTERACE-5 ENZYME INHIBITOR sildenafil Generic RB CIALIS Brand RB ERECTILE DYSFUNCTION PROSTAGLANDIN VASODILATORS

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 17 - Drug Name Drug Tier Requirements/Limits alprostadil Generic/Brand * † RB EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS ANTI-INFECTIVES bacitracin-polymyxin b (ophth) Generic erythromycin (ophth) Generic gentamicin sulfate (ophth) Generic ofloxacin (ophth) Generic ofloxacin (otic) Generic polymyxin b-trimethoprim Generic sodium sulfacetamide Generic & phenylephrine tobramycin sulfate (ophth) Generic/Brand † trifluridine Generic ZYMAXID Brand EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS ANTI-INFLAMMATORY AGENTS CIPRODEX Brand COLY-MYCIN S OTIC Brand dexamethasone sodium phosphate Generic/Brand † (ophth) diclofenac (ophth) Generic flunisolide (nasal) Generic fluorometholone (ophth) Generic/Brand † flurbiprofen sodium Generic fluticasone propionate (nasal) Generic ketorolac (ophth) Generic LOTEMAX Brand MAXIDEX Brand neomycin-polymycin- Generic dexamethasone neomycin-polymyxin- Generic hydrocortisone (ophth) neomycin-polymyxin- Generic hydrocortisone (otic) PRED-G Brand prednisolone acetate (ophth) Generic prednisolone sodium phosphate Generic (ophth) RESTASIS Brand † sulfacetamide sod-prednisolone Generic/Brand † EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 18 - Drug Name Drug Tier Requirements/Limits ANTIALLERGIC AGENTS azelastine Generic cromolyn sodium (ophth) Generic EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS EENT DRUGS, MISCELLANEOUS acetic acid (otic) Generic acetic acid-aluminum acetate Generic betaxolol hcl Generic brimonidine tartrate Generic dorzolamide Generic dorzolamide/timolol Generic EYLEA Brand* latanoprost Generic levobunolol hcl Generic LACRISERT Brand LUCENTIS Brand* MACUGEN Brand * PHOSPHOLINE IODIDE Brand pilocarpine hcl Generic/Brand † timolol maleate (ophth) Generic VISUDYNE Brand * EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS LOCAL ANESTHETICS benzocaine & antipyrine Generic lidocaine hcl (mouth-throat) Generic proparacaine hcl Generic tetracaine hcl (ophth) Generic EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS MYDRIATICS atropine sulfate (ophthalmic) Generic CYCLOMYDRIL Brand cyclopentolate hcl Generic homatropine hbr Generic/Brand † ISOPTO HYOSCINE Brand tropicamide Generic EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS VASOCONSTRICTORS ADRENALIN Brand * phenylephrine hcl (ophth) Generic GASTROINTESTINAL DRUGS ANTI-INFLAMMATORY AGENTS

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 19 - Drug Name Drug Tier Requirements/Limits balsalazide Generic mesalamine Generic/Brand † GASTROINTESTINAL DRUGS ANTIDIARRHEA AGENTS diphenoxylate w/ atropine Generic paregoric Generic GASTROINTESTINAL DRUGS ANTIEMETICS dimenhydrinate Generic * dronabinol Generic EMEND Brand ondansetron Generic * ondansetron hcl Generic * prochlorperazine Generic * TRANSDERM-SCOP Brand GASTROINTESTINAL DRUGS ANTIULCER AGENTS AND ACID SUPPRESSANTS cimetidine hcl Generic famotidine Generic * famotidine in nacl Generic * misoprostol Generic omeprazole Generic pantoprazole Generic ranitidine hcl Generic * sucralfate Generic GASTROINTESTINAL DRUGS DIGESTANTS CREON Brand PANCRELIPASE Brand ZENPEP Brand GASTROINTESTINAL DRUGS GI DRUGS, MISCELLANEOUS LINZESS Brand PA metoclopramide hcl Generic * peg 3350-kcl-sod bicarb-sod Generic chloride-sod sulfate ursodiol Generic GOLD COMPOUNDS GOLD COMPOUNDS MYOCHRYSINE Brand * RIDAURA Brand

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 20 - Drug Name Drug Tier Requirements/Limits HEAVY METAL ANTAGONISTS HEAVY METAL ANTAGONISTS CHEMET Brand CUPRIMINE Brand QL deferoxamine mesylate Generic * DEPEN Brand QL EXJADE Brand  QL pysostigmine salicylate Generic * HORMONES AND SYNTHETIC SUBSTITUTES ADRENALS ARISTOSPAN INTRA- Brand * ARTICULAR ARISTOSPAN Brand * INTRALESIONAL ASMANEX Brand betamethasone acetate- Generic * betamethasone sodium phosphate Budesonide Respules Generic cortisone acetate Generic dexamethasone Generic/Brand * † dexamethasone sodium phosphate Generic * ENTOCORT EC Brand FLOVENT HFA Brand fludrocortisone acetate Generic hydrocortisone Generic/Brand * † KENALOG-10 Brand * KENALOG-40 Brand * methylprednisolone Generic * methylprednisolone acetate Generic * methylprednisolone sod succ Generic * prednisolone Generic prednisone Generic QVAR Brand SOLU-CORTEF Brand * HORMONES AND SYNTHETIC SUBSTITUTES ANDROGENS ANADROL-50 Brand ANDRODERM Brand danazol Generic METHITEST Brand TESTOSTERONE Brand *

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 21 - Drug Name Drug Tier Requirements/Limits testosterone cypionate Generic * TESTRED Brand HORMONES AND SYNTHETIC SUBSTITUTES CONTRACEPTIVES desogestrel-ethinyl estradiol Generic ELLA Brand ethynodiol diacetate & ethinyl Generic estradiol JOLESSA Brand  levonorgestrel & eth estradiol Generic levonorgestrel-ethinyl estradiol Generic (triphasic) NEXPLANON Brand * norethindrone Generic norethin acetate & estradiol-Fe Generic norethindrone & mestranol Generic/Brand † norethindrone & ethinyl estradiol Generic/Brand † norethindrone acetate & ethinyl Generic estradiol norethindrone-eth estradiol Generic/Brand † (triphasic) norgestimate-ethinyl estradiol Generic norgestimate-ethinyl estradiol Generic (triphasic) NUVARING Brand HORMONES AND SYNTHETIC SUBSTITUTES DIABETIC AGENTS acarbose Generic glimepiride Generic glipizide Generic glyburide Generic GLUCAGON EMERGENCY Brand * KIT HUMALOG Brand * humulin 70/30 Generic * humulin n Generic * humulin r Generic * HUMULIN R U-500 Brand * (CONCENTRATED) LANTUS Brand * PA metformin hcl Generic

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 22 - Drug Name Drug Tier Requirements/Limits pioglitazone Generic tolbutamide Generic HORMONES AND SYNTHETIC SUBSTITUTES ESTROGENS AND ANTIESTROGENS clomiphene citrate Generic RB DEPO-ESTRADIOL Brand * estradiol Generic/Brand * † estradiol valerate Generic * estrogens with methyltestosterone Generic ESTRING Brand estropipate Generic OSPHENA Brand RB PREMARIN INJECTION Brand * PREMARIN W/APPLICATOR Brand raloxifene Generic* † VAGIFEM Brand HORMONES AND SYNTHETIC SUBSTITUTES FOLLICLE STIMULATING HORMONES / LUTENIZING HORMONES BRAVELLE Brand * RB MENOPUR Brand * RB HORMONES AND SYNTHETIC SUBSTITUTES GONADOTROPINS chorionic gonadotropin Generic * RB FACTREL Brand * SYNAREL Brand HORMONES AND SYNTHETIC SUBSTITUTES PARATHYROID calcitonin (salmon) Generic/Brand * † HORMONES AND SYNTHETIC SUBSTITUTES PITUITARY ACTHAR HP Brand *  PA, QL desmopressin acetate Generic desmopressin acetate refrigerated Generic desmopressin acetate spray Generic desmopressin acetate spray Generic refrigerated vasopressin Generic * HORMONES AND SYNTHETIC SUBSTITUTES PROGESTINS medroxyprogesterone acetate Generic/Brand * † norethindrone acetate Generic

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 23 - Drug Name Drug Tier Requirements/Limits progesterone Generic HORMONES AND SYNTHETIC SUBSTITUTES SOMATOTROPIN AGONISTS AND ANTAGONISTS OMNITROPE Brand PA PREFILLED CARTRIDGE HORMONES AND SYNTHETIC SUBSTITUTES THYROID AND ANTITHYROID AGENTS levothyroxine sodium Generic liothyronine sodium Generic methimazole Generic potassium iodide Generic propylthiouracil Generic thyroid Generic INTRAVENOUS SOLUTIONS DEXTROSE dextrose 5% in water Generic * dextrose 5% in nacl 0.2% Generic * dextrose 5% in nacl 0.45% Generic * dextrose 5% in nacl 0.9% Generic * dextrose 10% in water Generic * dextrose 5% in lactated ringer’s Generic * INTRAVENOUS SOLUTIONS MISCELLANEOUS sterile water Generic * ringer’s injection Generic * lactated ringer’s Generic * sodium bicarbonate Generic * mannitol injection Generic * INTRAVENOUS SOLUTIONS NUTRITIONAL PRODUCTS amino acid solutions Generic * dextrose high concentration Generic * in water INTRALIPID Brand * LIPOSYN III Brand * INTRAVENOUS SOLUTIONS SODIUM CHLORIDE (NACL, SALINE) nacl 0.45%, ½ normal saline Generic * nacl 0.9%, normal saline Generic * nacl 3% Generic * nacl 5% Generic *

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 24 - Drug Name Drug Tier Requirements/Limits IRRIGATION SOLUTIONS IRRIGATION SOLUTIONS sterile water Generic * sodium chloride 0.9% Generic * lactated ringer’s Generic * ringer’s irrigation Generic * acetic acid 0.25% Generic irrigation solution G Generic glycine 1.5% Generic sorbitol urologic 3% Generic * MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS acetylcysteine Generic alendronate sodium Generic/Brand † allopurinol Generic ARALAST Brand * AVONEX Brand * PA, QL azathioprine Generic BOTOX Brand * bromocriptine mesylate Generic bupivacaine hcl Generic * bupivacaine w/ epinephrine Generic* cabergoline Generic CEREZYME Brand * QL colchicine Generic cyclosporine modified Generic CYSTAGON Brand DIDRONEL Brand disulfiram Generic/Brand † ELMIRON Brand ENBREL Brand * QL ENBREL SURECLICK Brand * QL ETHYOL Brand * EXTAVIA Generic* QL finasteride Generic FIRAZYR Brand *  QL GILENYA Brand  PA, QL glatiramer acetate Generic * PA, QL HUMIRA Brand *  QL ketamine hcl Generic * KINERET Brand * QL

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 25 - Drug Name Drug Tier Requirements/Limits leflunomide Generic leucovorin calcium Generic * levocarnitine (metabolic Generic * modifiers) lidocaine hcl (local anesth.) Generic * mesna Generic * mycophenolate mofetil Generic/Brand † OCTREOTIDE ACETATE Brand/Generic *  QL ORENCIA Brand *  QL pamidronate disodium Generic * REMICADE Brand * REVLIMID Brand  QL RIMSO-50 Brand * SANDIMMUNE Brand SENSIPAR Brand  QL sirolimus Generic  QL SORIATANE Brand tacrolimus Generic/Brand * † tamsulosin Generic THALOMID Brand  QL THIOLA Brand VPRIV Brand *  QL ZEMAIRA Brand * ZOMETA Brand * OXYTOCICS OXYTOCICS methylergonovine maleate Generic * HEMABATE Brand * oxytocin Generic * RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORY AGENTS cromolyn sodium Generic/Brand † montelukast sodium Generic RESPIRATORY TRACT AGENTS RESPIRATORY AGENTS, MISCELLANEOUS acetylcysteine Generic benzonatate Generic guaifenesin / codeine Generic hydrocodone / chlorpheniramine Generic hydrocodone / homatropine Generic ipratropium bromide (nasal) Generic

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 26 - Drug Name Drug Tier Requirements/Limits sodium chloride (inhalant) Generic sterile water Generic SERUMS, TOXOIDS, AND VACCINES SERUMS GAMUNEX-C Brand * HYPERRHO S/D Brand * HYPERTET S/D Brand * immune globulin (human) iv Brand * IMOGAM RABIES-HT Brand * NABI-HB Brand * RESPIGAM Brand * VARIZIG Brand * RHOPHYLAC Brand * SERUMS, TOXOIDS, AND VACCINES TOXOIDS ADACEL Brand * DECAVAC Brand * DIPTHERIA/TETANUS Brand * TOXOID INFANRIX Brand * SERUMS, TOXOIDS, AND VACCINES VACCINES ACTHIB Brand * ATTENUVAX Brand * GARDASIL Brand * HAVRIX Brand * HIBERIX Brand * IMOVAX RABIES (H.D.C.V.) Brand * IPOL INACTIVATED IPV Brand * MENACTRA Brand * MENOMUNE-A/C/Y/W-135 Brand * MERUVAX II W/DILUENT 10 Brand * DOSE MUMPSVAX W/DILUENT 10 Brand * DOSE PEDIARIX Brand * PEDVAX HIB Brand * PREVNAR 13 Brand * PROQUAD Brand * RABAVERT Brand * RECOMBIVAX HB Brand *

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 27 - Drug Name Drug Tier Requirements/Limits ROTARIX Brand * ROTATEQ Brand * THERACYS Brand * TICE BCG Brand * VAQTA Brand * VARIVAX Brand * ZOSTAVAX Brand * SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) BACTROBAN NASAL Brand benzoyl peroxide-erythromycin Generic gel ciclopirox olamine Generic clindamycin phosphate (topical) Generic/Brand † clindamycin phosphate vaginal Generic/Brand † clotrimazole troche Generic erythromycin (acne aid) Generic/Brand † gentamicin sulfate (topical) Generic iodoquinol / hydrocortisone Generic ketoconazole (topical) Generic metronidazole (topical) Generic metronidazole vaginal Generic mupirocin Generic/Brand † nystatin Generic permethrin Generic selenium sulfide Generic silver sulfadiazine Generic terbinafine hcl Generic SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE) alclometasone dipropionate Generic ANALPRAM-HC Brand aug betamethasone dipropionate Generic betamethasone dipropionate Generic (topical) betamethasone valerate Generic CARMOL-HC Brand clotrimazole-betamethasone Generic clobetasol propionate Generic CORDRAN TAPE Brand desonide Generic

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 28 - Drug Name Drug Tier Requirements/Limits desoximetasone Generic fluocinolone acetonide Generic fluocinonide Generic fluocinonide emulsified base Generic halobetasol Generic hydrocortisone (intrarectal) Generic hydrocortisone (rectal) Generic/Brand † hydrocortisone (topical) Generic/Brand † hydrocortisone butyrate Generic/ Brand † LOCOID LIPOCREAM Brand mometasone furoate Generic nystatin-triamcinolone Generic PROCTOFOAM-HC Brand SKIN AND MUCOUS MEMBRANE AGENTS CELL STIMULANTS AND PROLIFERANTS tretinoin Generic SKIN AND MUCOUS MEMBRANE AGENTS SKIN AND MUCOUS MEMBRANE AGENTS, MISCELLANEOUS 8-MOP CAPSULE Brand aluminum chloride Generic/Brand † AZELEX Brand calcipotriene Generic DIFFERIN Brand DRITHO-SCALP Brand FINACEA Brand fluorouracil (topical) Generic/Brand † imiquimod Generic isotretinoin Generic lidocaine Generic/Brand † lidocaine hcl Generic* lidocaine-prilocaine Generic OXSORALEN ULTRA Brand para-aminobenzoic acid Generic podofilox Generic/Brand † PROTOPIC Brand PSORIATEC Brand SANTYL Brand sulfacetamide sodium Generic TAZORAC Brand trypsin, balsam peru & castor Generic oil

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 29 - Drug Name Drug Tier Requirements/Limits VECTICAL Brand XERAC AC Brand SMOOTH MUSCLE RELAXANTS SMOOTH MUSCLE RELAXANTS oxybutynin chloride Generic/Brand † theophylline Generic/Brand † trospium Generic VITAMINS VITAMINS AQUASOL A Brand * calcitriol Generic cyanocobalamin Generic * DRISDOL Brand folic acid Generic * phytonadione Generic * pyridoxine Generic * thiamine Generic *

INDEX OF DRUGS Kaiser Permanente Commercial Comprehensive Formulary Index

adefovir 5 ADRENALIN 19 8 ADVAIR DISKUS 9 8-MOP 29 AFINITOR 6 AGGRENOX 10 ALBENZA 2 A albuterol 9 ABILIFY 15 albuterol sulfate 9 ABRAXANE 6 alclometasone dipropionate 28 acarbose 22 alendronate sodium 25 acebutolol 11 allopurinol 25 ACETADOTE 25 alprazolam 14 acetaminophen w/ codeine 12 alprostadil 18 acetazolamide 11 aluminum chloride 29 acetic acid 17, 19 amantadine hcl 5 acetic acid (otic) 19 AMBISOME 4 acetic acid 0.25% 25 amiloride & hydrochlorothiazide 16 acetic acid-aluminum acetate 19 amiloride hcl 16 acetylcysteine 26 amino acid solutions 24 ACTHAR HP 23 aminocaproic acid 10 ACTHIB 27 amiodarone hcl 11 ACTIVASE 9 amitriptyline hcl 15 acyclovir 5 amlodipine besylate 11 ADACEL 27 amoxicillin 2 ADAGEN 17 amoxicillin & potassium clavulanate 2 ADCIRCA 12 amphetamine-dextroamphetamine 13 amphotericin b 4

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 30 - ampicillin 3 bleomycin sulfate 6 ANADROL-50 21 BOTOX 25 anagrelide hcl 10 BRAVELLE 23 ANALPRAM-HC 28 BRILINTA 10 anastrozole 6 brimonidine tartrate 19 ANCOBON 4 bromocriptine mesylate 25 ANDRODERM 21 budesonide respules 21 ANECTINE 9 bumetanide 16 APTIVUS 5 bupivacaine hcl 25 AQUASOL A 30 bupivacaine w/ epinephrine 25 ARALAST 25 bupropion hcl 15 ARISTOSPAN INTRA-ARTICULAR 21 buspirone hcl 14 ARISTOSPAN INTRALESIONAL 21 butalbital & acetaminophen 14 ASMANEX 21 butalbital, acetaminophen & caffeine 14 atenolol 11 butorphanol tartrate 12 atorvastatin 10 atovaquone 4 atovaquone-proguanil 4 C ATRIPLA 5 cabergoline 25 atropine sulfate 8, 19 CAFERGOT 14 atropine sulfate (ophthalmic) 19 calcipotriene 29 ATROVENT HFA 8 calcitonin (salmon) 23 ATTENUVAX 27 calcitriol 30 aug betamethasone dipropionate 28 calcium acetate 17 avacavir 5 calcium chloride (dihydrate) 17 avacavir & lamivudine & zidovudine 5 calcium gluconate 17 AVASTIN 6 CAMPRAL 14 AVELOX 3 CANCIDAS 4 AVONEX 25 capecitabine 6 AZACTAM 3 captopril 12 azathioprine 25 carbamazepine 13 azelastine 19 carbidopa-levodopa 14 azelastine 19 carboplatin 6 AZELEX 29 CARMOL-HC 28 azithromycin 3 carvedilol 11 CAYSTON 3 B CEENU 6 cefazolin sodium 3 bacitracin 3, 18 cefdinir 3 bacitracin & polymyxin B 3 cefepime 3 bacitracin-polymyxin b (ophth) 18 cefotaxime sodium 3 baclofen 9 cefotetan 3 BACTROBAN 28 ceftazidime 3 BACTROBAN NASAL 28 ceftriaxone sodium 3 balsalazide 20 cefuroxime axetil 3 benzocaine & antipyrine 19 cefuroxime sodium 3 benzonatate 26 CELONTIN 13 benzoyl peroxide-erythromycin 28 cephalexin 3 benztropine mesylate 8 CEREZYME 25 betamethasone acetate 21 CHEMET 21 betamethasone dipropionate (topical) 28 chlordiazepoxide 14 betamethasone sodium phosphate 21 chloroquine phosphate 4 betamethasone valerate 28 chlorothiazide 16 betaxolol hcl 19 chlorpromazine hcl 15 bethanechol chloride 9 chlorthalidone 16 bicalutamide 6 cholestyramine 10 BICNU W/DILUENT ABSOLUTE ETHANOL 6 choline & mag salicylate 12 BILTRICIDE 2 chorionic gonadotropin 23

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 31 - CIALIS 17 DECAVAC 27 ciclopirox olamine 28 deferoxamine mesylate 21 cimetidine hcl 20 DEPEN 21 CIPRODEX 3, 18 DEPO-ESTRADIOL 23 ciprofloxacin hcl 3 desipramine hcl 15 cisplatin 6 desmopressin acetate 23 citalopram hydrobromide 15 desmopressin acetate refrigerated 23 citric acid monohydrate 16 desmopressin acetate spray 23 clarithromycin 3 desmopressin acetate spray refrigerated 23 clidinium / chlordiazepoxide 8 desogestrel-ethinyl estradiol 22 clindamycin hcl 3 desonide 28 clindamycin palmitate hydrochloride 3 desoximetasone 29 clindamycin phosphate 3, 28 dexamethasone 18, 21 clindamycin phosphate (topical) 28 dexamethasone sodium phosphate 18, 21 clindamycin phosphate vaginal 28 dexamethasone sodium phosphate (ophth) 18 clobetasol propionate 28 DEXFERRUM 10 clomiphene citrate 23 dextroamphetamine sulfate 13 clomipramine hcl 15 dextrose 10% in water 24 clonazepam 14 dextrose 5% in lactated ringer’s 24 clonidine hcl 11 dextrose 5% in nacl 0.2% 24 clopidogrel 10 dextrose 5% in nacl 0.45% 24 clotrimazole 28 dextrose 5% in nacl 0.9% 24 clotrimazole-betamethasone 28 dextrose 5% in water 24 clozapine 15 dextrose high concentration 24 codeine phosphate 12 DIASTAT ACUDIAL 14 colchicine 25 DIASTAT PEDIATRIC 14 colestipol hcl 10 diazepam 14 COLY-MYCIN S OTIC 18 DIBENZYLINE 9 COMBIVENT RESPIMAT 9 diclofenac (ophth) 18 COMPLERA 5 dicloxacillin sodium 3 COMTAN 14 dicyclomine hcl 8 CORDRAN 28 didanosine 5 CORDRAN TAPE 28 DIDRONEL 25 cortisone acetate 21 DIFFERIN 29 CREON 20 digoxin 11 CRIXIVAN 5 dihydroergotamine mesylate 14 cromolyn sodium 19, 26 diltiazem hcl 11 cromolyn sodium (ophth) 19 dimenhydrinate 20 CUPRIMINE 21 diphenhydramine hcl 6 cyanocobalamin 30 diphenoxylate w/ atropine 20 cyclobenzaprine hcl 9 DIPTHERIA/TETANUS TOXOID 27 CYCLOMYDRIL 19 dipyridamole 10 cyclopentolate hcl 19 disopyramide phosphate 11 cyclophosphamide 7 disulfiram 25 cyclosporine modified 25 divalproex sodium 13 cyproheptadine hcl 6 divalproex sodium sprinkles 13 CYSTAGON 25 docetaxel 7 cytarabine 7 donepezil hydrochloride 9 dopamine hcl 11 dorzolamide 19 D dorzolamide/timolol 19 dacarbazine 7 doxazosin mesylate 10 dactinomycin 7 doxepin hcl 15 danazol 21 doxorubicin hcl 7 dantrolene sodium 9 doxycycline hyclate 3 dapsone 4 doxycycline monohydrate 3 DARAPRIM 4 DRISDOL 30 daunorubicin hcl 7 DRITHO-SCALP 29

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 32 - dronabinol 20 famotidine in nacl 20 droperidol 14 felbamate 13 DULERA 9 FELBATOL 13 duloxetine hcl 15 FEMARA 7 DYRENIUM 16 fenofibrate 10 fentanyl 12 fentanyl citrate 12 E fentanyl transdermal system 12 EDURANT 5 FINACEA 29 EFFIENT 10 finasteride 25 electrolyte-2 in invert sugar 17 FIRAZYR 25 ELIPHOS 17 flecainide acetate 11 ELLA 22 FLOVENT HFA 21 ELMIRON 25 fluconazole 4 EMCYT 7 fluconazole in nacl 4 EMEND 20 fludarabine phosphate 7 EMTRIVA 5 fludrocortisone acetate 21 ENBREL 25 flunisolide (nasal) 18 ENBREL SURECLICK 25 fluocinolone acetonide 29 ENLON 9 fluocinonide 29 enoxaparin sodium ) 10 fluocinonide emulsified base 29 entecavir 5 fluorometholone (ophth) 18 ENTOCORT EC 21 fluorouracil 7, 29 ephedrine sulfate (pressors) 9 fluorouracil (topical) 29 EPIPEN 2-PAK 9 fluoxetine hcl 15 EPIPEN-JR 2-PAK 9 fluphenazine decanoate 15 epoprostenol sodium 12 fluphenazine hcl 15 EPZICOM 5 flurbiprofen 12, 18 ERBITUX 7 flurbiprofen sodium 18 ergoloid mesylates 9 flutamide 7 ERGOMAR 14 fluticasone propionate 18 erythromycin (acne aid 28 fluticasone propionate (nasal) 18 erythromycin (ophth) 18 fluvoxamine maleate 15 erythromycin base 3 folic acid 30 erythromycin ethylsuccinate 3 fondaparinux 10 erythromycin lactobionate 3 FORADIL AEROLIZER 9 estradiol 22, 23 foscarnet sodium 5 estradiol valerate 23 furosemide 16 ESTRING 23 estrogens with methyltestosterone 23 G estropipate 23 ethacrynate sodium 16 gabapentin 13 ethambutol hcl 4 galantamine hydrobromide 9 ethosuximide 13 GAMUNEX-C 27 ethynodiol diacetate & ethinyl estradiol 22 ganciclovir 5 ETHYOL 25 GANTRISIN 3 etodolac 12 GARDASIL 27 etoposide 7 gemfibrozil 11 exemestane 7 GEMZAR 7 EXJADE 21 gentamicin sulfate 3, 18, 28 EXTAVIA 25 gentamicin sulfate (ophth) 18 EYLEA 19 gentamicin sulfate (topical) 28 GEODON 15 GILENYA 25 F glatiramer acetate 25 FACTREL 23 GLEEVEC 7 famciclovir 5 glimepiride 22 famotidine 20 glipizide 22

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 33 - GLUCAGON EMERGENCY KIT 22 IMOVAX RABIES (H.D.C.V.) 27 glyburide 22 INDOCIN IV 12 glycine 1.5% 25 indomethacin 12 glycopyrrolate 8 INFANRIX 27 griseofulvin microsize 4 INFED 10 griseofulvin ultramicrosize 4 INTELENCE 5 guaifenesin / codeine 26 INTRALIPID 24 INTRON-A 7 INTRON-A W/DILUENT 7 H INVANZ 3 halobetasol 29 INVIRASE 5 haloperidol 15 iodoquinol / hydrocortisone 28 haloperidol decanoate 15 IPOL INACTIVATED IPV 27 haloperidol lactate 15 ipratropium bromide 8, 26 HARVONI 5 ipratropium bromide (nasal) 26 HAVRIX 27 irrigation solution G 25 HELIXATE FS 10 ISENTRESS 5 HEMABATE 26 isoniazid 4 heparin sodium (porcine) 10 ISOPTO HYOSCINE 19 HERCEPTIN 7 isosorbide dinitrate 12 HEXALEN 7 isosorbide mononitrate 12 HIBERIX 27 isotretinoin 29 homatropine hbr 19 HUMALOG 22 J HUMATE-P 10 HUMIRA 25 JOLESSA 22 humulin 70/30 22 humulin n 22 humulin r 22 K HUMULIN R U-500 (CONCENTRATED) 22 KALETRA 5 hydralazine hcl 11 KENALOG-10 21 hydrochlorothiazide 12, 16 KENALOG-40 21 hydrocodone / chlorpheniramine 26 ketamine hcl 25 hydrocodone / homatropine 26 ketoconazole 4, 28 hydrocodone-acetaminophen 12 ketoconazole (topical) 28 hydrocortisone 21, 29 ketoprofen 12 hydrocortisone (intrarectal) 29 ketorolac 13, 18 hydrocortisone (rectal) 29 KINERET 25 hydrocortisone (topical) 29 KOGENATE FS 10 hydrocortisone butyrate 29 K-PHOS 17 hydromorphone hcl 12 hydroxychloroquine sulfate 4 hydroxyurea 7 L hydroxyzine hcl 14 labetalol hcl 11 HYPERRHO S/D 27 LACRISERT 19 HYPERTET S/D 27 lactated ringer’s 24, 25 lactated ringer's 17 I lactated ringer's (irrigation) 17 lactulose 16 ibuprofen 12 lamivudine 5 idarubicin hcl 7 lamivudine & zidovudine 5 ifosfamide 7 lamotrigine 13 ifosfamide & mesna 7 LANTUS 22 IMBRUVICA 7 latanoprost 19 imipramine hcl 15 leflunomide 26 imiquimod 29 LETAIRIS 12 immune globulin (human) iv 27 leucovorin calcium 26 IMOGAM RABIES-HT 27 LEUKERAN 7

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 34 - leuprolide acetate 7 methadone hcl 13 levetiracetam 13 methazolamide 11 levetiracetam extended 13 methenamine hippurate 6 levobunolol hcl 19 methimazole 24 levocarnitine (metabolic modifiers) 26 METHITEST 21 levofloxacin 3 methocarbamol 9 levonorgestrel & eth estradiol 22 methotrexate sodium 7 levonorgestrel-ethinyl estradiol (triphasic) 22 methyldopa 11 levothyroxine sodium 24 methylgonovine maleate 26 LEXIVA 5 methylphenidate hcl 13 lidocaine 11, 19, 26, 29 methylphenidate hcl extended 13 lidocaine hcl 11, 19, 26, 29 methylprednisolone 21 lidocaine hcl (cardiac) 11 methylprednisolone acetate 21 lidocaine hcl (local anesth.) 26 methylprednisolone sod succ 21 lidocaine hcl (mouth-throat) 19 metoclopramide hcl 20 lidocaine-prilocaine 29 metolazone 16 LINZESS 20 metoprolol succinate 11 liothyronine sodium 24 metoprolol tartrate 11 LIPOSYN 24 metronidazole 5, 28 LIPOSYN III 24 metronidazole (topical) 28 lisinopril 12 metronidazole vaginal 28 lisinopril & hydrochlorothiazide 12 midazolam 14 lithium carbonate 15 minocycline hcl 3 lithium citrate 15 minoxidil 12 LOCOID LIPOCREAM 29 mirtazapine 15 lorazepam 14 misoprostol 20 losartan 12 mitomycin 7 losartan & hydrochlorothiazide 12 mitoxantrone hcl 7 LOTEMAX 18 mometasone furoate 29 lovastatin 11 montelukast sodium 26 loxapine succinate 15 morphine sulfate 13 LUCENTIS 19 MUMPSVAX W/DILUENT 10 DOSE 27 LUPRON DEPOT 7 mupirocin 28 LUPRON DEPOT-PED 7 MUSTARGEN 7 LYSODREN 7 mycophenolate mofetil 26 MYLERAN 7 M MYOCHRYSINE 20 MACUGEN 19 N magnesium sulfate 13 mannitol injection 24 NABI-HB 27 MATULANE 7 nabumetone 13 MAXIDEX 18 nacl 0.45%, ½ normal saline 24 medroxyprogesterone acetate 23 nacl 0.9%, normal saline 24 mefloquine hcl 5 nacl 3% 24 megestrol acetate 7 nacl 5% 24 meloxicam 13 naloxone hcl 15 melphalan 7 naltrexone hcl 15 MENACTRA 27 NAMENDA 15 MENOMUNE-A/C/Y/W-135 27 NAMENDA TITRATION PAK 15 MENOPUR 23 naproxen 13 MEPRON 5 naratriptan 14 mercaptopurine 7 nefazodone hcl 15 MERUVAX II W/DILUENT 10 DOSE 27 neomycin sulfate 3 mesalamine 20 neomycin-polymycin-dexamethasone 18 mesna 7, 26 neomycin-polymyxin-hydrocortisone (ophth) 18 metaproterenol sulfate 9 neomycin-polymyxin-hydrocortisone (otic) 18 metformin hcl 22 neostigmine methylsulfate 9

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 35 - nevirapine 5 PEGASYS 5 NEXAVAR 7 penicillin g potassium 3 NEXPLANON 22 penicillin g procaine 3 nifedipine 11 penicillin g sodium 3 NIMODIPINE 11 penicillin v potassium 3 nitrofurantoin macrocrystal 6 pentamidine isethionate 5 nitrofurantoin monohyd macro 6 pentostatin 8 nitroglycerin 12 pentoxifylline 10 norethin acet & estrad-fe 22 permethrin 28 norethindrone 22 perphenazine 15 norethindrone & ethinyl estradiol 22 phenelzine sulfate 16 norethindrone & mestranol 22 phenobarbital 13 norethindrone acetate 23 phentermine hcl 13 norethindrone acetate & ethinyl estradiol 22 phentolamine mesylate 9 norethindrone-ethinyl estradiol (triphasic) 22 phenylephrine hcl (ophth) 19 norgestimate-ethinyl estradiol 22 phenylephrine hcl (pressors) 9 norgestimate-ethinyl estradiol (triphasic) 22 phenytoin 13 nortriptyline hcl 15 phenytoin sodium 13 NORVIR 5 phenytoin sodium extended 13 NUVARING 22 PHOSPHOLINE IODIDE 19 nystatin 4, 29 physostigmine salicylate 21 NYSTATIN 28 phytonadione 30 nystatin-triamcinolone 29 pilocarpine hcl 9, 19 pilocarpine hcl (oral) 9 pioglitazone 23 O piperacillin-tazobactam 3 OCTREOTIDE ACETATE 26 podofilox 29 ofloxacin (ophth) 18 polymyxin b-trimethoprim 18 ofloxacin (otic) 18 potassium acetate 17 omeprazole 20 potassium chloride 17 OMNITROPE PREFILLED CARTRIDGE 24 potassium chloride microencapsulated crystals cr 17 ondansetron 20 potassium citrate (alkalinizer) 16 ondansetron hcl 20 potassium citrate-citric acid 16 OPSUMIT 12 potassium iodide 24 ORAP 15 potassium phosphate dibasic 17 ORENCIA 26 potassium phosphate dibasic & monobasic w/ sodium OSPHENA 23 phosphate monobasic 17 oxazepam 14 PRADAXA 10 oxcarbazepine 13 pramipexole dihydrochloride 15 OXSORALEN ULTRA 29 pravastatin sodium 11 oxybutynin chloride 30 prazosin hcl 10 oxycodone hcl 13 PRED-G 18 oxycodone w/ acetaminophen 13 prednisolone 18, 21 oxytocin 26 prednisolone acetate (ophth) 18 prednisolone sodium phosphate 18 prednisolone sodium phosphate (ophth) 18 P prednisone 21 paclitaxel 8 PREMARIN INJECTION 23 pamidronate disodium 26 PREMARIN W/APPLICATOR 23 PANCRELIPASE 20 PREVNAR 13 27 pantoprazole 20 PREZISTA 5 para-aminobenzoic acid 29 PRIMAQUINE PHOSPHATE 5 paregoric 20 PRIMAXIN I.M. 4 paromomycin sulfate 5 primidone 14 paroxetine hcl 15 PRIMSOL 6 PEDIARIX 27 probenecid 17 PEDVAX HIB 27 procainamide hcl 11 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate 20 prochlorperazine 16, 20

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 36 - prochlorperazine edisylate 16 ROTATEQ 28 prochlorperazine maleate 16 PROCRIT 10 PROCTOFOAM-HC 29 S progesterone 24 salsalate 13 promethazine hcl 6 SANDIMMUNE 26 propafenone hcl 11 SANTYL 29 propantheline bromide 8 SAVELLA 15 proparacaine hcl 19 scopolamine hydrobromide 8 propranolol hcl 11 selegiline hcl 15 propylthiouracil 24 selenium sulfide 28 PROQUAD 27 SELZENTRY 6 PROTOPIC 29 SENSIPAR 26 PSORIATEC 29 SEREVENT DISKUS 9 PULMOZYME 17 SEROQUEL 16 pyrazinamide 4 sertraline hcl 16 pyridostigmine bromide 9 sildenafil 17 pyridoxine 30 sildenafil citrate (pulmonary hypertention) 12 silver sulfadiazine 28 Q simvastatin 11 sirolimus 26 QSYMIA 13 sodium acetate 16 quinidine gluconate 11 sodium bicarbonate 16, 24 quinidine sulfate 11 sodium chloride 17, 27 QVAR 21 sodium chloride (gu irrigant) 17 sodium chloride (inhalant) 27 sodium chloride 0.9% 25 R sodium citrate & citric acid 16 RABAVERT 27 sodium phosphate 17, 18, 21 raloxifene 23 sodium polystyrene sulfonate 17 ranitidine hcl 20 sodium sulfacetamide & phenylephrine 18 RECOMBINATE 10 SOLU-CORTEF 21 RECOMBIVAX HB 27 sorbitol urologic 3% 25 REFACTO 10 SORIATANE 26 REMICADE 26 sotalol hcl 11 RENAGEL 17 SOVALDI 6 RENVELA 17 SPIRIVA RESPIMAT 8 RESCRIPTOR 5 spironolactone 12 RESERPINE 12 spironolactone & hydrochlorothiazide 12 RESPIGAM 27 SPRYCEL 8 RESTASIS 18 stavudine 6 REVLIMID 26 sterile water 24, 25, 27 REYATAZ 5 streptomycin sulfate 4 RHOPHYLAC 27 STRIBILD 6 ribavirin (hepatitis c) 5 STRIVEDI RESPIMATS 9 RIDAURA 20 SUBOXONE 13 rifampin 4 sucralfate 20 RILUTEK 15 sufentanil citrate 13 rimantadine hydrochloride 6 sulfacetamide sodium 29 RIMSO-50 26 sulfacetamide sod-prednisolone 18 ringer’s injection 24 sulfamethoxazole-trimethoprim 4 ringer’s irrigation 25 sulfasalazine 4 ringer's irrigation 17 sulindac 13 risperidone 16 sumatriptan 14 RITUXAN 8 SUPRAX 4 rizatriptan 14 SUSTIVA 6 ropinirole hydrochloride 15 SUTENT 8 ROTARIX 28 SYNAGIS 6

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 37 - SYNAREL 23 trihexyphenidyl hcl 8 trimethoprim 6, 18 TROBICIN 4 T tropicamide 19 TABLOID 8 trospium 30 tacrolimus 26 TRUVADA 6 TAMIFLU 6 trypsin, balsam peru & castor 29 tamoxifen citrate 8 TYKERB 8 tamsulosin 26 TARCEVA 8 U TASIGNA 8 TAZICEF 4 ursodiol 20 TAZORAC 29 temazepam 14 temozolomide 8 V terazosin hcl 10 VAGIFEM 23 terbinafine hcl 28 VALCYTE 6 terbutaline sulfate 9 valproate sodium 14 TESTOSTERONE 21 valproic acid 14 testosterone cypionate 22 VANCOCIN ISO-OSMOTIC DEXTROSE 4 TESTRED 22 vancomycin hcl 4 tetracaine hcl (ophth) 19 VAQTA 28 tetracycline hcl 4 VARIVAX 28 THALOMID 26 VARIZIG 27 theophylline 30 vasopressin 23 THERACYS 28 VECTICAL 30 thiamine 30 venlafaxine hcl 16 THIOLA 26 VENOFER 10 thioridazine hcl 16 VENTAVIS 12 thiotepa 8 verapamil hcl 11 thiothixene 16 VICTRELIS 6 thyroid 24 VIDAZA 8 TICE BCG 28 VINBLASTINE SULFATE 8 TIKOSYN 11 vincristine sulfate 8 timolol maleate 19 vinorelbine tartrate 8 timolol maleate (ophth) 19 VIRACEPT 6 TIVICAY 6 VIREAD 6 tizanidine 9 VISUDYNE 19 tobramycin nebulization solution 4 voriconazole 4 tobramycin sulfate 4, 18 VOTRIENT 8 tobramycin sulfate (ophth) 18 VPRIV 26 tolbutamide 23 topiramate 14 topiramate sprinkle 14 W topotecan 8 warfarin sodium 10 TORISEL 8 water for irrigation, sterile 17 torsemide 16 TRACLEER 12 tramadol hcl 13 X tranexmic acid 10 XALKORI 8 TRANSDERM-SCOP 20 XERAC AC 30 tranylcypromine sulfate 16 XTANDI 8 trazodone hcl 16 tretinoin 8, 29 triamterene & hydrochlorothiazide 16 Z triazolam 14 trifluoperazine hcl 16 ZARXIO 10 trifluridine 18 ZELBORAF 8

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 38 - ZEMAIRA 26 zonisamide 14 ZENPEP 20 ZOSTAVAX 28 zidovudine 6 ZYDELIG 8 zinc (trace metals) 17 ZYMAXID 18 ZOLADEX 8 ZYPREXA 16 zolpidem tartrate 14 ZYTIGA 8 ZOMETA 26 ZYVOX 4

Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 39 -