2021 California Medi-Cal Managed Care Formulary

(List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER WHEN YOU PARTICIPATE IN A MEDI-CAL MANAGED CARE PLAN OFFERED BY KAISER PERMANENTE.

This prescription drug formulary was updated on 09/01/2021 and is effective as of September 07, 2021. This formulary document is subject to change and may vary depending on your health plan. For more recent information or questions about which drug formulary applies to your plan, visit kp.org/formulary or call our Member Service Contact Center 24 hours a day, seven days a week (closed holidays). 1-800-464-4000 English (and over 150 languages), 1-800-788-0616 Spanish, 1-800-757-7585 Chinese dialects and 711 TTY for the deaf or hard of hearing.

What is the Kaiser Permanente California Medi-Cal Managed Care Formulary? The California Medi-Cal Managed Care Formulary is a list of covered drugs chosen by a group of Kaiser Permanente doctors and pharmacists known as the Pharmacy and Therapeutics Committee. The Committee meets regularly to evaluate and select drugs that are safe and effective for our members. This Formulary meets the requirements outlined under state law, regulations, and guidance for Medi-Cal Managed Care plans.

What drugs are covered? Kaiser Permanente covers brand, generic and specialty drugs listed on the California Medi-Cal Managed Care Formulary as long as the drug is medically necessary, the prescription is filled at a Kaiser Permanente, or an affiliated pharmacy, and other coverage rules are followed.

If you are prescribed a drug on the California Medi-Cal Managed Care Formulary, that drug will be covered under the terms of your drug benefit.

Getting an exception to the formulary Drugs not listed on the formulary are called non-formulary drugs. When a Kaiser Permanente doctor determines that a non-formulary drug is medically appropriate and necessary, that drug will be covered under the terms of your benefits (if you have a prescription drug benefit). If you do not have coverage for a certain type of prescription drug (for example, sexual dysfunction and infertility), you will be charged the full retail price for the drug.

You may consult with your doctor if an exception to the formulary is needed. You and your doctor are best able to determine your medication needs.

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 1 of 145 You may also contact Member Services, 24 hours a day, 7 days a week. If you wish to have a non- formulary drug that your doctor determines not to be medically necessary, you may file a grievance with Member Services.

Are there any restrictions on the drugs covered on the Formulary? Some covered drugs may have additional requirements or limits on coverage, such as Quantity Limits. For certain drugs, Kaiser Permanente may limit the amount of the drug dispensed to a certain days’ supply. Additionally, when there is a national shortage of a drug, we may limit the quantity of the drug dispensed.

What is a brand-name drug? Brand-name drugs are usually manufactured and sold by the drug company that originally researched and developed the drug. When the patent on a brand-name drug expires, other drug companies may manufacture and sell an FDA-approved generic version of the drug with the same active ingredient(s) at lower prices.

What is a generic drug? A generic drug is approved by the FDA as having the same active ingredient as the brand- name drug. Generally, generic drugs cost less than brand-name drugs.

What is a specialty drug? Specialty drugs are very high-cost drugs approved by the FDA that are on our formulary used to treat complex chronic conditions such as rheumatoid arthritis, multiple sclerosis, or cancer.

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 or require special handling) may not be eligible for mailing. Drugs cannot be mailed outside the United States.

You can order refills through our mail-order service online at kp.org/refill or by phone or mobile app. There is no extra charge for mail order. The appropriate cost share (according to your prescription drug benefit) will apply.

Please refer to your Evidence of Coverage for complete details of your prescription drug benefit.

Kaiser Permanente California Medi-Cal Managed Care Formulary Kaiser Permanente may add or remove drugs from the California Medi-Cal Managed Care Formulary during the year. These changes to the Formulary are based on new information or new drugs that become available. Specific medications used for the treatment of substance use disorders, HIV, blood factors, and anti-psychotics are “carved out” of the Kaiser formulary and must be billed to the State Medi-Cal system as fee-for-service. Intravenous solutions: Parenteral nutrition solutions (TPN), separately administered

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 2 of 145 intravenous lipids and other unlisted intravenous solutions are restricted to dispensing up to a 10 day supply following inpatient discharge from an acute care hospital.

How do I use the formulary? There are two ways to find your drug within the formulary:

Medical condition The formulary begins on page 4. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Drugs”. If you know what your drug is used for, look for the category name in the list that begins on page 4. Then look under the category name for your drug.

Alphabetical listing If you are not sure what category to look under, you should look for your drug in the index that begins on page 92. The index provides an alphabetical list of all the drugs included in this document. Look in the index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the index and find the name of your drug in the first column of the list.

The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g. ALBENZA) and generic drugs are listed in lower-case italics (e.g. amoxicillin)

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. Note: Some of these drugs may be available only in a clinic setting.

The second column, “Drug Tier,” will indicate what tier number the drug is in. Drugs on the California Medi-Cal Managed Care Formulary are all categorized as Tier 1.

The third column of the chart will indicate any requirements or limits for that drug: QL = Quantity Limits -For certain drugs, we may limit the amount of drug that you can receive. Additionally, when there is a national shortage of a drug, we may limit the quantity of the drug dispensed. LD = Limited-distribution drugs can only be obtained at certain specialty pharmacies. To locate a specialty pharmacy, refer to your electronic member guidebook at kp.org/eguidebook (under the facility directory) or contact Member Services. OTC = Over-the-Counter Please refer to your electronic member guidebook at kp.org/eguidebook for a complete listing of network pharmacies available to you or contact Member Services.

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 3 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits INTELENCE TABS 25 MG ANTI-INFECTIVE AGENTS 1 ANTHELMINTICS [etravirine] ALBENZA TABS 200 MG INVIRASE TABS 500 MG 1 1 [albendazole] [saquinavir mesylate] BILTRICIDE TABS 600 ISENTRESS CHEW 100 1 MG [praziquantel] MG [raltegravir 1 ivermectin tabs 3 mg 1 potassium] ISENTRESS CHEW 25 ANTI-HIV AGENTS MG [raltegravir 1 abacavir sulfate tabs 300 1 potassium] mg ISENTRESS HD TABS abacavir sulfate- 600 MG [raltegravir 1 1 lamivudine tabs 600-300 potassium] mg ISENTRESS TABS 400 abacavir-lamivudine- MG [raltegravir 1 1 zidovudine tabs 300-150- potassium] 300 mg KALETRA SOLN 400-100 APTIVUS CAPS 250 MG 1 MG/5ML [lopinavir- 1

[tipranavir] ritonavir] BIKTARVY TABS 50-200- KALETRA TABS 100-25 25 MG [bictegravir- 1 1 MG [lopinavir-ritonavir] emtricitabine-tenofovir KALETRA TABS 200-50 alafenamide fumarate] 1 MG [lopinavir-ritonavir] CIMDUO TABS 300-300 lamivudine soln 10 MG [lamivudine- 1 1 mg/ml tenofovir disoproxil lamivudine tabs 150 mg 1 fumarate] COMPLERA TABS 200- lamivudine tabs 300 mg 1 lamivudine-zidovudine 25-300 MG 1 [emtricitabine-rilpivirine- 1 tabs 150-300 mg LEXIVA TABS 700 MG tenofovir disoproxil 1 fumarate] [fosamprenavir calcium] CRIXIVAN CAPS 200 MG nevirapine er tb24 400 1 1 [indinavir sulfate] mg CRIXIVAN CAPS 400 MG nevirapine susp 50 1 1 [indinavir sulfate] mg/5ml didanosine cap 125mg 1 nevirapine tabs 200 mg 1 NORVIR SOLN 80 MG/ML DOVATO TABS 50-300 1 MG [dolutegravir 1 [ritonavir] PREZISTA TABS 150 MG sodium-lamivudine] 1 EDURANT TABS 25 MG [darunavir ethanolate] 1 PREZISTA TABS 600 MG [rilpivirine hcl] 1 EMTRIVA SOLN 10 [darunavir ethanolate] 1 PREZISTA TABS 75 MG MG/ML [emtricitabine] 1 FUZEON SOLR 90 MG [darunavir ethanolate] 1 QL - 30 day(s) PREZISTA TABS 800 MG [enfuvirtide] 1 INTELENCE TABS 100 [darunavir ethanolate] 1 MG [etravirine] RESCRIPTOR TABS 100 INTELENCE TABS 200 MG [delavirdine 1 1 MG [etravirine] mesylate]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 4 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits RESCRIPTOR TABS 200 zidovudine syrp 50 1 MG [delavirdine 1 mg/5ml mesylate] zidovudine tabs 300 mg 1 SELZENTRY TABS 150 1 ANTIBACTERIALS MG [maraviroc] amikacin sulfate soln SELZENTRY TABS 25 1 1 500 mg/2ml MG [maraviroc] amoxicillin caps 250 mg 1 SELZENTRY TABS 300 1 amoxicillin caps 500 mg 1 MG [maraviroc] amoxicillin chew 125 mg 1 SELZENTRY TABS 75 1 1 MG [maraviroc] amoxicillin chew 250 mg amoxicillin susr 125 stavudine caps 15 mg 1 1 mg/5ml stavudine caps 20 mg 1 amoxicillin susr 200 1 1 stavudine caps 30 mg mg/5ml stavudine caps 40 mg 1 amoxicillin susr 250 1 STRIBILD TABS 150-150- mg/5ml 200-300 MG [elvitegravir- amoxicillin susr 400 1 1 cobicistat-emtricitabine- mg/5ml tenofovir df] amoxicillin-pot SYMFI LO TABS 400-300- clavulanate chew 200- 1 300 MG [efavirenz- 1 28.5 mg lamivudine-tenofovir amoxicillin-pot disoproxil fumarate] clavulanate chew 400-57 1 SYMFI TABS 600-300-300 mg MG [efavirenz- 1 amoxicillin-pot lamivudine-tenofovir clavulanate susr 200- 1 disoproxil fumarate] 28.5 mg/5ml SYMTUZA TABS 800-150- amoxicillin-pot 200-10 MG [darunavir- 1 clavulanate susr 250- 1 cobicistat-emtricitabine- 62.5 mg/5ml tenofovir alafenamide] amoxicillin-pot TIVICAY TABS 50 MG 1 clavulanate susr 400-57 1 [dolutegravir sodium] mg/5ml TRIUMEQ TABS 600-50- amoxicillin-pot 300 MG [abacavir- 1 clavulanate susr 600- 1 dolutegravir-lamivudine] 42.9 mg/5ml VIDEX SOLR 2 GM 1 amoxicillin-pot [didanosine] clavulanate tabs 250-125 1 VIDEX SOLR 4 GM 1 mg [didanosine] amoxicillin-pot VIRACEPT TABS 250 MG 1 clavulanate tabs 500-125 1 [nelfinavir mesylate] mg VIRACEPT TABS 625 MG 1 amoxicillin-pot [nelfinavir mesylate] clavulanate tabs 875-125 1 VIRAMUNE SUSP 50 1 mg MG/5ML [nevirapine] amp-sulbacta inj 1.5gm 1 ZIAGEN SOLN 20 MG/ML 1 ampicillin cap 250mg 1 [abacavir sulfate] ampicillin caps 500 mg 1 zidovudine caps 100 mg 1 ampicillin sodium solr 1 1 gm

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 5 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits ampicillin sodium solr 10 BICILLIN L-A SUSP 1 gm 1200000 UNIT/2ML 1 ampicillin sodium solr [penicillin g benzathine] 1 125 mg BICILLIN L-A SUSP ampicillin sodium solr 2 2400000 UNIT/4ML 1 1 gm [penicillin g benzathine] ampicillin sodium solr BICILLIN L-A SUSP 1 250 mg 600000 UNIT/ML 1 ampicillin sodium solr [penicillin g benzathine] 1 CAYSTON SOLR 75 MG QL - 30 500 mg 1 ampicillin sus 125/5ml 1 [aztreonam lysine] day(s),LD ampicillin sus 250/5ml 1 cefaclor caps 250 mg 1 ampicillin-sulbactam cefaclor caps 500 mg 1 sodium solr 1.5 (1-0.5) 1 cefadroxil caps 500 mg 1 gm cefazolin sodium solr 1 1 ampicillin-sulbactam 1 gm sodium solr 15 (10-5) gm cefazolin sodium solr 10 1 ampicillin-sulbactam 1 gm sodium solr 3 (2-1) gm cefazolin sodium solr 20 1 AUGMENTIN SUSR 125- gm 31.25 MG/5ML cefazolin sodium solr 1 1 [amoxicillin & pot 500 mg clavulanate] CEFAZOLIN SODIUM- AVELOX SOLN 400 DEXTROSE SOLN 1-4 1 MG/250ML [moxifloxacin 1 GM/50ML-% [cefazolin hcl in sodium chloride] sodium-dextrose] AZACTAM IN DEXTROSE CEFAZOLIN SODIUM- SOLN 1 GM/50ML 1 DEXTROSE SOLR 1-4 1 [aztreonam-dextrose] GM-%(50ML) [cefazolin AZACTAM IN DEXTROSE sodium-dextrose] SOLN 2 GM/50ML 1 cefdinir susr 125 mg/5ml 1 [aztreonam-dextrose] cefdinir susr 250 mg/5ml 1 azithromycin solr 500 1 cefepime hcl solr 1 gm 1 mg cefepime hcl solr 2 gm 1 azithromycin susr 100 1 CEFEPIME-DEXTROSE mg/5ml SOLR 1-5 GM-%(50ML) 1 azithromycin susr 200 1 [cefepime hcl-dextrose] mg/5ml CEFEPIME-DEXTROSE azithromycin tabs 250 1 SOLR 2-5 GM-%(50ML) 1 mg [cefepime hcl-dextrose] azithromycin tabs 500 1 cefixime caps 400 mg 1 mg cefotaxime sodium inj azithromycin tabs 600 1 1 10gm mg cefotaxime sodium solr aztreonam solr 1 gm 1 1 1 gm aztreonam solr 2 gm 1 cefotaxime sodium solr bacitracin solr 50000 1 1 2 gm unit cefotaxime sodium solr 1 500 mg

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 6 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits cefotetan disodium solr ceftriaxone sodium solr 1 1 1 gm 500 mg cefotetan disodium solr CEFTRIAXONE SODIUM- 1 2 gm DEXTROSE SOLR 1-3.74 1 CEFOTETAN DISODIUM- GM-%(50ML) [ceftriaxone DEXTROSE SOLR 1-3.58 sodium and dextrose] 1 GM-%(50ML) [cefotetan CEFTRIAXONE SODIUM- disodium and dextrose] DEXTROSE SOLR 2-2.22 1 CEFOTETAN DISODIUM- GM-%(50ML) [ceftriaxone DEXTROSE SOLR 2-2.08 sodium and dextrose] 1 GM-%(50ML) [cefotetan cefuroxime axetil tabs 1 disodium and dextrose] 250 mg cefoxitin sodium solr 1 cefuroxime axetil tabs 1 1 gm 500 mg cefoxitin sodium solr 10 cefuroxime sodium solr 1 1 gm 1.5 gm cefoxitin sodium solr 2 cefuroxime sodium solr 1 1 gm 7.5 gm CEFOXITIN SODIUM- cefuroxime sodium solr 1 DEXTROSE SOLR 1-4 750 mg 1 GM-%(50ML) [cefoxitin cephalexin caps 250 mg 1 sodium and dextrose] cephalexin caps 500 mg 1 CEFOXITIN SODIUM- cephalexin susr 125 DEXTROSE SOLR 2-2.2 1 1 mg/5ml GM-%(50ML) [cefoxitin cephalexin susr 250 1 sodium and dextrose] mg/5ml cefpodoxime proxetil 1 cephalexin tabs 500 mg 1 susr 100 mg/5ml chloramphenicol sod cefpodoxime proxetil 1 1 succinate solr 1 gm susr 50 mg/5ml CIPRO SUSR 250 cefpodoxime proxetil 1 MG/5ML (5%) 1 tabs 100 mg [ciprofloxacin] cefpodoxime proxetil 1 CIPRO SUSR 500 tabs 200 mg MG/5ML (10%) 1 ceftazidime solr 6 gm 1 [ciprofloxacin] CEFTIN SUSR 125 ciprofloxacin hcl tabs 1 MG/5ML [cefuroxime 1 250 mg axetil] ciprofloxacin hcl tabs ceftriaxone sodium in 1 1 500 mg dextrose soln 20 mg/ml ciprofloxacin hcl tabs ceftriaxone sodium in 1 1 750 mg dextrose soln 40 mg/ml ciprofloxacin in d5w soln ceftriaxone sodium solr 1 1 200 mg/100ml 1 gm ciprofloxacin in d5w soln ceftriaxone sodium solr 1 1 400 mg/200ml 10 gm clarithromycin susr 125 ceftriaxone sodium solr 1 1 mg/5ml 2 gm clarithromycin susr 250 ceftriaxone sodium solr 1 1 mg/5ml 250 mg

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 7 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits clarithromycin tabs 250 doxycycline hyclate 1 1 mg caps 100 mg clarithromycin tabs 500 doxycycline hyclate 1 1 mg caps 50 mg CLEOCIN IN D5W SOLN doxycycline hyclate tabs 1 300 MG/50ML 100 mg 1 [clindamycin phosphate doxycycline hyclate tabs 1 in d5w] 20 mg CLEOCIN IN D5W SOLN doxycycline 600 MG/50ML 1 1 monohydrate susr 25 [clindamycin phosphate mg/5ml in d5w] doxycycline CLEOCIN IN D5W SOLN monohydrate tabs 100 1 900 MG/50ML 1 mg [clindamycin phosphate doxycycline 1 in d5w] monohydrate tabs 50 mg [Clindamycin Phosphate] ERYTHROCIN CLEOCIN PHOSPHATE 1 LACTOBIONATE SOLR 1 SOLN 300 MG/2ML 500 MG [erythromycin [Clindamycin Phosphate] lactobionate] CLEOCIN PHOSPHATE 1 FIRVANQ SOLR 25 1 SOLN 900 MG/6ML MG/ML [vancomycin hcl] [Clindamycin Palmitate FIRVANQ SOLR 50 1 Hydrochloride] CLEOCIN 1 MG/ML [vancomycin hcl] SOLR 75 MG/5ML fluconazole in sodium clindamycin hcl caps 1 chloride soln 100-0.9 1 150 mg mg/50ml-% clindamycin hcl caps 1 FORTAZ IN D5W SOLN 1- 300 mg 5 GM/50ML-% 1 clindamycin palmitate 1 [ceftazidime sodium in hcl solr 75 mg/5ml d5w] clindamycin phosphate FORTAZ IN D5W SOLN 2- 1 soln 300 mg/2ml 5 GM/50ML-% 1 CLINDAMYCIN [ceftazidime sodium in PHOSPHATE SOLN 600 d5w] 1 MG/4ML [clindamycin FORTAZ SOLR 500 MG 1 phosphate] [ceftazidime] clindamycin phosphate gentamicin in saline soln 1 1 soln 9000 mg/60ml 0.8-0.9 mg/ml-% CUBICIN SOLR 500 MG gentamicin in saline soln 1 1 [daptomycin] 0.9-0.9 mg/ml-% demeclocycline hcl tabs gentamicin in saline soln 1 1 150 mg 1-0.9 mg/ml-% demeclocycline hcl tabs gentamicin in saline soln 1 1 300 mg 1.2-0.9 mg/ml-% dicloxacillin sodium gentamicin in saline soln 1 1 caps 250 mg 1.4-0.9 mg/ml-% dicloxacillin sodium gentamicin in saline soln 1 1 caps 500 mg 1.6-0.9 mg/ml-% [Doxycycline Hyclate] gentamicin in saline soln 1 1 DOXY 100 SOLR 100 MG 2-0.9 mg/ml-%

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 8 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits gentamicin sulfate soln OXACILLIN SODIUM IN 1 10 mg/ml DEXTROSE SOLN 1 1 gentamicin sulfate soln GM/50ML [oxacillin 1 40 mg/ml sodium in dextrose] INVANZ SOLR 1 GM OXACILLIN SODIUM IN 1 DEXTROSE SOLN 2 [ertapenem sodium] 1 levofloxacin in d5w soln GM/50ML [oxacillin 1 250 mg/50ml sodium in dextrose] levofloxacin in d5w soln oxacillin sodium solr 1 1 1 500 mg/100ml gm levofloxacin in d5w soln OXACILLIN SODIUM 1 750 mg/150ml SOLR 2 GM [oxacillin 1 levofloxacin soln 25 sodium] 1 mg/ml PENICILLIN G POT IN DEXTROSE SOLN 20000 levofloxacin tabs 250 mg 1 1 levofloxacin tabs 500 mg 1 UNIT/ML [penicillin g pot levofloxacin tabs 750 mg 1 in dextrose] PENICILLIN G POT IN linezolid soln 600 1 DEXTROSE SOLN 40000 mg/300ml 1 UNIT/ML [penicillin g pot linezolid susr 100 1 in dextrose] mg/5ml PENICILLIN G POT IN meropenem solr 1 gm 1 DEXTROSE SOLN 60000 1 meropenem solr 500 mg 1 UNIT/ML [penicillin g pot MINOCIN SOLR 100 MG 1 in dextrose] [minocycline hcl] penicillin g potassium minocycline hcl caps 1 1 solr 20000000 unit 100 mg penicillin g potassium minocycline hcl caps 50 1 1 solr 5000000 unit mg penicillin g procaine minocycline hcl caps 75 1 1 susp 600000 unit/ml mg penicillin g sodium solr moxifloxacin hcl tabs 1 1 5000000 unit 400 mg penicillin v potassium 1 NAFCILLIN SODIUM IN solr 125 mg/5ml DEXTROSE SOLN 1 penicillin v potassium 1 1 GM/50ML [nafcillin solr 250 mg/5ml sodium in dextrose] penicillin v potassium 1 NAFCILLIN SODIUM IN tabs 250 mg DEXTROSE SOLN 2 penicillin v potassium 1 1 GM/100ML [nafcillin tabs 500 mg sodium in dextrose] [Penicillin G Potassium] nafcillin sodium solr 1 1 PFIZERPEN SOLR 1 gm 20000000 UNIT nafcillin sodium solr 10 1 piperacillin sod- gm tazobactam so solr 2.25 1 nafcillin sodium solr 2 1 (2-0.25) gm gm piperacillin sod- neomycin sulfate tabs 1 tazobactam so solr 3.375 1 500 mg (3-0.375) gm

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 9 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits piperacillin sod- tobramycin nebu 300 1 tazobactam so solr 4.5 1 mg/5ml (4-0.5) gm tobramycin sulfate soln 1 piperacillin sod- 10 mg/ml tazobactam so solr 40.5 1 tobramycin sulfate soln 1 (36-4.5) gm 80 mg/2ml PRIMAXIN IV SOLR 250- tobramycin sulfate solr 1 250 MG [imipenem- 1 1.2 gm cilastatin] vancomycin hcl caps 1 PRIMAXIN IV SOLR 500- 125 mg 500 MG [imipenem- 1 vancomycin hcl caps 1 cilastatin] 250 mg PRIMSOL SOLN 50 VANCOMYCIN HCL IN MG/5ML [trimethoprim 1 DEXTROSE SOLN 1-5 hcl] GM/200ML-% 1 streptomycin sulfate solr 1 [vancomycin hcl- 1 gm dextrose] sulfadiazine tabs 500 mg 1 VANCOMYCIN HCL IN sulfamethoxazole- DEXTROSE SOLN 500-5 trimethoprim soln 400-80 1 MG/100ML-% 1 mg/5ml [vancomycin hcl- sulfamethoxazole- dextrose] vancomycin hcl solr 1 trimethoprim susp 200- 1 1 40 mg/5ml gm vancomycin hcl solr 10 sulfamethoxazole- 1 trimethoprim tabs 400-80 1 gm vancomycin hcl solr 5 mg 1 sulfamethoxazole- gm 1 vancomycin hcl solr 500 trimethoprim tabs 800- 1 160 mg mg sulfasalazine tabs 500 XIFAXAN TABS 550 MG 1 1 QL - 30 day(s) mg [rifaximin] sulfasalazine tbec 500 ZITHROMAX PACK 1 GM 1 1 mg [azithromycin] [Cefixime] SUPRAX SUSR ZOSYN SOLN 2-0.25 1 100 MG/5ML GM/50ML [piperacillin 1 SYNERCID SOLR 150- sodium-tazobactam 350 MG [quinupristin- 1 sodium in dextrose] dalfopristin] ZOSYN SOLN 3-0.375 [Ceftazidime] TAZICEF GM/50ML [piperacillin 1 1 SOLR 1 GM sodium-tazobactam [Ceftazidime] TAZICEF sodium in dextrose] 1 ZYVOX SUSR 100 SOLR 2 GM 1 TETRACYCLINE HCL MG/5ML [linezolid] ZYVOX TABS 600 MG CAPS 250 MG 1 1 [tetracycline hcl] [linezolid] TETRACYCLINE HCL ANTIFUNGALS CAPS 500 MG 1 ABELCET SUSP 5 MG/ML 1 [tetracycline hcl] [amphotericin b lipid] TOBI PODHALER CAPS 1 28 MG [tobramycin]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 10 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits AMBISOME SUSR 50 MG SPORANOX SOLN 10 1 [amphotericin b 1 MG/ML [itraconazole] liposome] terbinafine hcl tabs 250 1 amphotericin b solr 50 mg 1 mg VFEND IV SOLR 200 MG 1 CANCIDAS SOLR 50 MG [voriconazole] 1 [caspofungin acetate] voriconazole tabs 200 1 CANCIDAS SOLR 70 MG mg 1 [caspofungin acetate] voriconazole tabs 50 mg 1 fluconazole in dextrose 1 ANTIHEPATITIS C AGENTS inj dex 200 HARVONI TABS 45-200 fluconazole in dextrose 1 MG [ledipasvir- 1 QL - 30 day(s) soln 400 mg/200ml sofosbuvir] fluconazole in nacl inj 1 HARVONI TABS 90-400 nacl 200 MG [ledipasvir- 1 QL - 30 day(s) fluconazole in nacl inj 1 sofosbuvir] nacl 400 PEG-INTRON REDIPEN fluconazole in sodium KIT 120 RP 1 QL - 30 day(s) chloride soln 200-0.9 1 [peginterferon alfa-2b] mg/100ml-% PEG-INTRON REDIPEN fluconazole in sodium KIT 150 RP 1 QL - 30 day(s) chloride soln 400-0.9 1 [peginterferon alfa-2b] mg/200ml-% PEGASYS PROCLICK fluconazole susr 10 1 SOLN 135 MCG/0.5ML 1 QL - 30 day(s) mg/ml [peginterferon alfa-2a] fluconazole susr 40 1 PEGASYS PROCLICK mg/ml SOLN 180 MCG/0.5ML 1 QL - 30 day(s) fluconazole tabs 100 mg 1 [peginterferon alfa-2a] fluconazole tabs 150 mg 1 PEGASYS SOLN 180 fluconazole tabs 200 mg 1 MCG/0.5ML 1 QL - 30 day(s) fluconazole tabs 50 mg 1 [peginterferon alfa-2a] flucytosine caps 250 mg 1 PEGASYS SOLN 180 flucytosine caps 500 mg 1 MCG/ML [peginterferon 1 QL - 30 day(s) alfa-2a] griseofulvin microsize 1 PEGINTRON KIT 50 susp 125 mg/5ml MCG/0.5ML 1 QL - 30 day(s) griseofulvin microsize 1 [peginterferon alfa-2b] tabs 500 mg 1 griseofulvin ribavirin caps 200 mg SOVALDI PACK 150 MG ultramicrosize tabs 125 1 1 QL - 30 day(s) mg [sofosbuvir] SOVALDI PACK 200 MG griseofulvin 1 QL - 30 day(s) ultramicrosize tabs 250 1 [sofosbuvir] SOVALDI TABS 200 MG mg 1 QL - 30 day(s) itraconazole caps 100 [sofosbuvir] 1 SOVALDI TABS 400 MG mg 1 QL - 30 day(s) ketoconazole tabs 200 [sofosbuvir] 1 mg ANTIMYCOBACTERIALS nystatin susp 100000 CAPASTAT SULFATE 1 unit/ml SOLR 1 GM 1 nystatin tabs 500000 unit 1 [capreomycin sulfate]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 11 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits cycloserine caps 250 mg 1 KRINTAFEL TABS 150 dapsone tabs 100 mg 1 MG [tafenoquine 1 dapsone tabs 25 mg 1 succinate] ethambutol hcl tabs 100 mefloquine hcl tabs 250 1 1 mg mg ethambutol hcl tabs 400 METRONIDAZOLE IN 1 NACL SOLN 5-0.79 mg 1 isoniazid soln 100 mg/ml 1 MG/ML-% [metronidazole in nacl] isoniazid syrp 50 mg/5ml 1 METRONIDAZOLE IN isoniazid tabs 100 mg 1 NACL SOLN 500-0.74 1 isoniazid tabs 300 mg 1 MG/100ML-% PRETOMANID TABS 200 1 [metronidazole in nacl] MG [pretomanid] metronidazole tabs 250 PRIFTIN TABS 150 MG 1 1 mg [rifapentine] metronidazole tabs 500 pyrazinamide tabs 500 1 1 mg mg NEBUPENT SOLR 300 rifabutin caps 150 mg 1 MG [pentamidine 1 [Isoniazid & Rifampin] isethionate] RIFAMATE CAPS 150- 1 paromomycin sulfate 1 300 MG caps 250 mg rifampin caps 150 mg 1 PENTAM SOLR 300 MG rifampin caps 300 mg 1 [pentamidine 1 rifampin solr 600 mg 1 isethionate] TRECATOR TABS 250 PRIMAQUINE 1 PHOSPHATE TABS 26.3 MG [ethionamide] 1 ANTIPROTOZOALS (15 Base) MG ALINIA SUSR 100 [primaquine phosphate] 1 MG/5ML [nitazoxanide] ANTIVIRALS ALINIA TABS 500 MG acyclovir caps 200 mg 1 1 acyclovir sodium inj [nitazoxanide] 1 atovaquone susp 750 1000mg 1 acyclovir sodium soln 50 mg/5ml 1 atovaquone-proguanil mg/ml 1 acyclovir susp 200 hcl tabs 250-100 mg 1 atovaquone-proguanil mg/5ml 1 hcl tabs 62.5-25 mg acyclovir tabs 400 mg 1 chloroquine phosphate 1 1 acyclovir tabs 800 mg tabs 250 mg adefovir dipivoxil tabs 10 1 chloroquine phosphate 1 mg tabs 500 mg atazanavir sulfate caps 1 COARTEM TABS 20-120 150 mg MG [artemether- 1 atazanavir sulfate caps 1 lumefantrine] 200 mg DARAPRIM TABS 25 MG atazanavir sulfate caps 1 1 [pyrimethamine] 300 mg hydroxychloroquine BARACLUDE SOLN 0.05 1 1 sulfate tabs 200 mg MG/ML [entecavir] cidofovir soln 75 mg/ml 1

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 12 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits DAKLINZA TABS 30 MG FOSCAVIR SOLN 6000 [daclatasvir 1 MG/250ML [foscarnet 1 dihydrochloride] sodium] DAKLINZA TABS 60 MG ganciclovir sodium solr 1 [daclatasvir 1 500 mg dihydrochloride] GENVOYA TABS 150- DESCOVY TABS 200-25 150-200-10 MG MG [emtricitabine- [elvitegravir-cobicistat- 1 1 tenofovir alafenamide emtricitabine-tenofovir fumarate] alafenamide] didanosine cpdr 200 mg 1 JULUCA TABS 50-25 MG didanosine cpdr 250 mg 1 [dolutegravir sodium- 1 didanosine cpdr 400 mg 1 rilpivirine hcl] efavirenz caps 200 mg 1 lamivudine tabs 100 mg 1 efavirenz caps 50 mg 1 ODEFSEY TABS 200-25- 25 MG [emtricitabine- efavirenz tabs 600 mg 1 1 rilpivirine-tenofovir efavirenz-emtricitab- alafenamide fumarate] tenofovir tabs 600-200- 1 oseltamivir phosphate 300 mg 1 caps 30 mg emtricitabine caps 200 1 oseltamivir phosphate mg 1 caps 45 mg emtricitabine-tenofovir 1 oseltamivir phosphate df tabs 100-150 mg 1 caps 75 mg emtricitabine-tenofovir 1 oseltamivir phosphate df tabs 133-200 mg 1 susr 6 mg/ml emtricitabine-tenofovir 1 PREVYMIS SOLN 240 df tabs 167-250 mg 1 QL - 30 day(s) MG/12ML [letermovir] emtricitabine-tenofovir 1 PREVYMIS SOLN 480 df tabs 200-300 mg 1 QL - 30 day(s) MG/24ML [letermovir] entecavir tabs 0.5 mg 1 PREVYMIS TABS 240 MG 1 QL - 30 day(s) entecavir tabs 1 mg 1 [letermovir] EPCLUSA TABS 200-50 PREVYMIS TABS 480 MG 1 QL - 30 day(s) MG [sofosbuvir- 1 QL - 30 day(s) [letermovir] velpatasvir] PREZCOBIX TABS 800- EPCLUSA TABS 400-100 150 MG [darunavir- 1 MG [sofosbuvir- 1 QL - 30 day(s) cobicistat] velpatasvir] RELENZA DISKHALER EPIVIR HBV SOLN 5 AEPB 5 MG/BLISTER 1 MG/ML [lamivudine 1 [zanamivir] (hbv)] RETROVIR SOLN 10 EPIVIR HBV TABS 100 1 1 MG/ML [zidovudine] MG [lamivudine (hbv)] rimantadine hcl tabs 100 1 EVOTAZ TABS 300-150 mg MG [atazanavir sulfate- 1 ritonavir tabs 100 mg 1 cobicistat] SYNAGIS SOLN 100 1 famciclovir tabs 500 mg 1 MG/ML [palivizumab] fosamprenavir calcium SYNAGIS SOLN 50 1 1 tabs 700 mg MG/0.5ML [palivizumab]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 13 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits TAMIFLU CAPS 30 MG NITROFURANTOIN 1 [oseltamivir phosphate] MACROCRYSTAL CAPS 1 TAMIFLU CAPS 45 MG 25 MG [nitrofurantoin 1 [oseltamivir phosphate] macrocrystal] TAMIFLU CAPS 75 MG NITROFURANTOIN 1 MACROCRYSTAL CAPS [oseltamivir phosphate] 1 TAMIFLU SUSR 6 MG/ML 50 MG [nitrofurantoin 1 [oseltamivir phosphate] macrocrystal] tenofovir disoproxil nitrofurantoin monohyd 1 1 fumarate tabs 300 mg macro caps 100 mg TIVICAY PD TBSO 5 MG nitrofurantoin susp 25 1 1 [dolutegravir sodium] mg/5ml TIVICAY TABS 10 MG trimethoprim tabs 100 1 1 [dolutegravir sodium] mg TIVICAY TABS 25 MG 1 ANTIHISTAMINE DRUGS [dolutegravir sodium] FIRST GENERATION ANTIHISTAMINES TRIZIVIR TABS 300-150- cyproheptadine hcl syrp 300 MG [abacavir 1 1 2 mg/5ml sulfate-lamivudine- cyproheptadine hcl tabs 1 zidovudine] 4 mg valacyclovir hcl tabs 1 diphenhydramine hcl 1 1 gm soln 50 mg/ml valacyclovir hcl tabs 500 promethazine hcl soln 25 1 1 mg mg/ml VALCYTE SOLR 50 promethazine hcl tabs 1 MG/ML [valganciclovir 1 QL - 30 day(s) 12.5 mg hcl] promethazine hcl tabs 25 valganciclovir hcl tabs 1 1 mg 450 mg [Promethazine Hcl] VEKLURY SOLN 100 1 PROMETHEGAN SUPP 1 MG/20ML [remdesivir] 12.5 MG VEKLURY SOLR 100 MG 1 [Promethazine Hcl] [remdesivir] PROMETHEGAN SUPP 1 VIRAZOLE SOLR 6 GM 1 25 MG [ribavirin] ANTINEOPLASTIC AGENTS voriconazole solr 200 mg 1 ANTINEOPLASTIC AGENTS VOSEVI TABS 400-100- abiraterone acetate tabs 100 MG [sofosbuvir- 1 QL - 30 day(s) 1 QL - 30 day(s) 250 mg velpatasvir-voxilaprevir] ABRAXANE SUSR 100 URINARY ANTI-INFECTIVES MG [paclitaxel protein- 1 MACRODANTIN CAPS 25 bound particles] MG [nitrofurantoin 1 ADCETRIS SOLR 50 MG 1 macrocrystal] [brentuximab vedotin] methenamine hippurate AFINITOR TABS 10 MG 1 1 QL - 30 day(s) tabs 1 gm [everolimus] NITROFURANTOIN ALECENSA CAPS 150 MACROCRYSTAL CAPS 1 QL - 30 day(s) 1 MG [alectinib hcl] 100 MG [nitrofurantoin ALIMTA SOLR 500 MG 1 macrocrystal] [pemetrexed disodium]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 14 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits ALKERAN TABS 2 MG capecitabine tabs 500 1 1 QL - 30 day(s) [melphalan] mg ALUNBRIG TABS 180 MG CAPRELSA TABS 100 1 QL - 30 day(s) 1 QL - 30 day(s) [brigatinib] MG [vandetanib] ALUNBRIG TABS 30 MG CAPRELSA TABS 300 1 QL - 30 day(s) 1 QL - 30 day(s) [brigatinib] MG [vandetanib] ALUNBRIG TABS 90 MG 1 1 QL - 30 day(s) carmustine solr 100 mg [brigatinib] cisplatin soln 100 ALUNBRIG TBPK 90 & 1 1 QL - 30 day(s) mg/100ml 180 MG [brigatinib] cisplatin soln 50 1 anastrozole tabs 1 mg 1 mg/50ml ARRANON SOLN 5 cladribine soln 10 1 1 MG/ML [nelarabine] mg/10ml AVASTIN SOLN 100 COMETRIQ (100 MG 1 MG/4ML [bevacizumab] DAILY DOSE) KIT 80 & 20 QL - 30 1 AVASTIN SOLN 400 MG [cabozantinib s- day(s),LD 1 MG/16ML [bevacizumab] malate] azacitidine susr 100 mg 1 COMETRIQ (140 MG DAILY DOSE) KIT 3 x 20 QL - 30 BENDEKA SOLN 100 1 MG/4ML [bendamustine 1 QL - 30 day(s) MG & 80 MG day(s),LD hcl] [cabozantinib s-malate] COMETRIQ (60 MG bicalutamide tabs 50 mg 1 QL - 30 BICNU SOLR 100 MG DAILY DOSE) KIT 20 MG 1 1 day(s),LD [carmustine] [cabozantinib s-malate] bleomycin sulfate solr 15 COPIKTRA CAPS 15 MG 1 1 QL - 30 day(s) unit [duvelisib] bleomycin sulfate solr 30 COPIKTRA CAPS 25 MG 1 1 QL - 30 day(s) unit [duvelisib] BLINCYTO SOLR 35 COSMEGEN SOLR 0.5 1 QL - 30 day(s) 1 MCG [blinatumomab] MG [dactinomycin] BRUKINSA CAPS 80 MG COTELLIC TABS 20 MG 1 QL - 30 day(s) 1 QL - 30 day(s) [zanubrutinib] [cobimetinib fumarate] CABOMETYX TABS 20 CYCLOPHOSPHAMIDE MG [cabozantinib s- 1 QL - 30 day(s) CAPS 25 MG 1 malate] [cyclophosphamide] CABOMETYX TABS 40 CYCLOPHOSPHAMIDE MG [cabozantinib s- 1 QL - 30 day(s) CAPS 50 MG 1 malate] [cyclophosphamide] cyclophosphamide solr CABOMETYX TABS 60 1 MG [cabozantinib s- 1 QL - 30 day(s) 1 gm cyclophosphamide solr malate] 1 CALQUENCE CAPS 100 2 gm 1 QL - 30 day(s) cyclophosphamide solr MG [acalabrutinib] 1 CAMPTOSAR SOLN 100 500 mg 1 CYRAMZA SOLN 100 MG/5ML [irinotecan hcl] 1 QL - 30 day(s) CAMPTOSAR SOLN 40 MG/10ML [ramucirumab] 1 CYRAMZA SOLN 500 MG/2ML [irinotecan hcl] 1 QL - 30 day(s) capecitabine tabs 150 MG/50ML [ramucirumab] 1 QL - 30 day(s) cytarabine (pf) soln 100 mg 1 mg/ml

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 15 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits cytarabine (pf) soln 20 1 QL - 30 day(s) 1 everolimus tabs 7.5 mg mg/ml exemestane tabs 25 mg 1 cytarabine soln 20 mg/ml 1 fludarabine phosphate 1 dacarbazine solr 100 mg 1 solr 50 mg 1 fluorouracil soln 1 dacarbazine solr 200 mg 1 DACOGEN SOLR 50 MG gm/20ml 1 fluorouracil soln 2.5 [decitabine] 1 DARZALEX SOLN 100 gm/50ml 1 QL - 30 day(s) fluorouracil soln 5 MG/5ML [daratumumab] 1 DARZALEX SOLN 400 gm/100ml 1 QL - 30 day(s) fluorouracil soln 500 MG/20ML [daratumumab] 1 daunorubicin hcl soln 20 mg/10ml 1 mg/4ml flutamide caps 125 mg 1 DOCETAXEL (NON- fulvestrant soln 250 1 QL - 30 day(s) ALCOHOL) SOLN 160 1 QL - 30 day(s) mg/5ml MG/8ML [docetaxel] GAZYVA SOLN 1000 DOCETAXEL (NON- MG/40ML 1 QL - 30 day(s) ALCOHOL) SOLN 20 1 QL - 30 day(s) [obinutuzumab] MG/ML [docetaxel] gemcitabine hcl solr 200 1 docetaxel conc 80 mg 1 mg/4ml GEMZAR SOLR 1 GM 1 DOXIL INJ 2 MG/ML [gemcitabine hcl] [doxorubicin hcl 1 GLEOSTINE CAPS 10 1 liposomal] MG [lomustine] doxorubicin hcl GLEOSTINE CAPS 100 1 1 liposomal inj 2 mg/ml MG [lomustine] doxorubicin hcl soln 2 GLEOSTINE CAPS 40 1 1 mg/ml MG [lomustine] doxorubicin hcl solr 10 GLEOSTINE CAPS 5 MG 1 1 mg [lomustine] doxorubicin hcl solr 50 HALAVEN SOLN 1 1 mg MG/2ML [eribulin 1 EMCYT CAPS 140 MG mesylate] [estramustine phosphate 1 QL - 30 day(s) HERCEPTIN SOLR 150 1 QL - 30 day(s) sodium] MG [trastuzumab] ERBITUX SOLN 100 HEXALEN CAPS 50 MG 1 1 QL - 30 day(s) MG/50ML [cetuximab] [altretamine] ERBITUX SOLN 200 HYCAMTIN CAPS 0.25 1 1 QL - 30 day(s) MG/100ML [cetuximab] MG [topotecan hcl] ERIVEDGE CAPS 150 HYCAMTIN CAPS 1 MG 1 QL - 30 day(s) 1 QL - 30 day(s) MG [vismodegib] [topotecan hcl] erlotinib hcl tabs 100 mg 1 QL - 30 day(s) hydroxyurea caps 500 1 erlotinib hcl tabs 150 mg 1 QL - 30 day(s) mg IBRANCE CAPS 100 MG erlotinib hcl tabs 25 mg 1 QL - 30 day(s) 1 QL - 30 day(s) ERWINAZE SOLR 10000 [palbociclib] IBRANCE CAPS 125 MG UNIT [asparaginase 1 1 QL - 30 day(s) erwinia chrysanthemi] [palbociclib] IBRANCE CAPS 75 MG etoposide caps 50 mg 1 1 QL - 30 day(s) everolimus tabs 2.5 mg 1 QL - 30 day(s) [palbociclib] everolimus tabs 5 mg 1 QL - 30 day(s)

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 16 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits IBRANCE TABS 100 MG ISTODAX (OVERFILL) 1 QL - 30 day(s) [palbociclib] SOLR 10 MG 1 IBRANCE TABS 125 MG [romidepsin] 1 QL - 30 day(s) [palbociclib] IXEMPRA KIT SOLR 15 1 QL - 30 day(s) IBRANCE TABS 75 MG MG [ixabepilone] 1 QL - 30 day(s) [palbociclib] IXEMPRA KIT SOLR 45 1 QL - 30 day(s) IDAMYCIN PFS SOLN 10 MG [ixabepilone] 1 MG/10ML [idarubicin hcl] JAKAFI TABS 10 MG 1 QL - 30 day(s) IDAMYCIN PFS SOLN 20 [ruxolitinib phosphate] 1 MG/20ML [idarubicin hcl] JAKAFI TABS 15 MG 1 QL - 30 day(s) idarubicin hcl soln 5 [ruxolitinib phosphate] 1 mg/5ml JAKAFI TABS 20 MG 1 QL - 30 day(s) IFOSFAMIDE SOLR 1 GM [ruxolitinib phosphate] 1 [ifosfamide] JAKAFI TABS 25 MG 1 QL - 30 day(s) imatinib mesylate tabs [ruxolitinib phosphate] 1 100 mg JAKAFI TABS 5 MG 1 QL - 30 day(s) imatinib mesylate tabs [ruxolitinib phosphate] 1 400 mg JEVTANA SOLN 60 1 IMBRUVICA CAPS 140 MG/1.5ML [cabazitaxel] 1 QL - 30 day(s) MG [ibrutinib] KADCYLA SOLR 100 MG IMBRUVICA CAPS 70 MG [ado-trastuzumab 1 QL - 30 day(s) 1 QL - 30 day(s) [ibrutinib] emtansine] IMBRUVICA TABS 140 KADCYLA SOLR 160 MG 1 QL - 30 day(s) MG [ibrutinib] [ado-trastuzumab 1 QL - 30 day(s) IMBRUVICA TABS 280 emtansine] 1 QL - 30 day(s) MG KANJINTI SOLR 420 MG [ibrutinib] 1 IMBRUVICA TABS 420 [trastuzumab-anns] 1 QL - 30 day(s) MG [ibrutinib] KEYTRUDA SOLN 100 IMBRUVICA TABS 560 MG/4ML 1 QL - 30 day(s) 1 QL - 30 day(s) MG [ibrutinib] [pembrolizumab] KYPROLIS SOLR 10 MG INTRON A SOLN 1 QL - 30 day(s) 10000000 UNIT/ML 1 QL - 30 day(s) [carfilzomib] KYPROLIS SOLR 30 MG [interferon alfa-2b] 1 QL - 30 day(s) INTRON A SOLN 6000000 [carfilzomib] UNIT/ML 1 QL - 30 day(s) KYPROLIS SOLR 60 MG [interferon alfa- 1 QL - 30 day(s) 2b] [carfilzomib] INTRON A SOLR LENVIMA (10 MG DAILY 10000000 UNIT 1 QL - 30 day(s) DOSE) CPPK 10 MG 1 QL - 30 day(s) [interferon alfa-2b] [lenvatinib mesylate] INTRON A SOLR LENVIMA (12 MG DAILY 18000000 UNIT 1 QL - 30 day(s) DOSE) CPPK 3 x 4 MG 1 [interferon alfa-2b] [lenvatinib mesylate] INTRON A SOLR LENVIMA (14 MG DAILY 50000000 UNIT 1 QL - 30 day(s) DOSE) CPPK 10 & 4 MG 1 QL - 30 day(s) [interferon alfa-2b] [lenvatinib mesylate] IRESSA TABS 250 MG LENVIMA (20 MG DAILY 1 QL - 30 day(s) [gefitinib] DOSE) CPPK 2 x 10 MG 1 QL - 30 day(s) irinotecan hcl soln 500 [lenvatinib mesylate] 1 LENVIMA (24 MG DAILY mg/25ml 1 QL - 30 day(s) DOSE) CPPK 2 x 10 MG

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 17 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits & 4 MG [lenvatinib LUPRON DEPOT-PED (3- mesylate] MONTH) KIT 30 MG 1 letrozole tabs 2.5 mg 1 (PED) [leuprolide acetate LEUKERAN TABS 2 MG (cpp) (3 month)] 1 LYNPARZA TABS 100 [chlorambucil] 1 QL - 30 day(s) leuprolide acetate kit 1 MG [olaparib] 1 LYNPARZA TABS 150 mg/0.2ml 1 QL - 30 day(s) LONSURF TABS 15-6.14 MG [olaparib] 1 QL - 30 day(s) LYSODREN TABS 500 MG [trifluridine-tipiracil] 1 QL - 30 day(s) LONSURF TABS 20-8.19 MG [mitotane] 1 QL - 30 day(s) MG [trifluridine-tipiracil] MARQIBO SUSP 5 LORBRENA TABS 100 MG/31ML [vincristine 1 QL - 30 day(s) 1 QL - 30 day(s) MG [lorlatinib] sulfate liposome] LORBRENA TABS 25 MG MATULANE CAPS 50 MG 1 QL - 30 day(s) 1 QL - 30 day(s) [lorlatinib] [procarbazine hcl] megestrol acetate susp LUPRON DEPOT (1- 1 MONTH) KIT 3.75 MG 1 40 mg/ml megestrol acetate susp [leuprolide acetate] 1 LUPRON DEPOT (1- 400 mg/10ml megestrol acetate tabs MONTH) KIT 7.5 MG 1 1 [leuprolide acetate] 20 mg megestrol acetate tabs LUPRON DEPOT (3- 1 MONTH) KIT 11.25 MG 40 mg 1 [leuprolide acetate (3 MEKINIST TABS 0.5 MG month)] [trametinib dimethyl 1 QL - 30 day(s) LUPRON DEPOT (3- sulfoxide] MONTH) KIT 22.5 MG MEKINIST TABS 2 MG 1 [leuprolide acetate (3 [trametinib dimethyl 1 QL - 30 day(s) month)] sulfoxide] LUPRON DEPOT (4- melphalan hcl solr 50 mg 1 MONTH) KIT 30 MG mercaptopurine tabs 50 1 1 [leuprolide acetate (4 mg month)] methotrexate sodium 1 LUPRON DEPOT (6- (pf) soln 50 mg/2ml MONTH) KIT 45 MG 1 METHOTREXATE [leuprolide acetate (6 SODIUM SOLN 50 1 month)] MG/2ML [methotrexate LUPRON DEPOT-PED (1- sodium] MONTH) KIT 11.25 MG 1 methotrexate sodium 1 [leuprolide acetate (cpp)] solr 1 gm LUPRON DEPOT-PED (1- methotrexate tabs 2.5 1 MONTH) KIT 15 MG 1 mg [leuprolide acetate (cpp)] mitomycin solr 20 mg 1 LUPRON DEPOT-PED (1- mitomycin solr 40 mg 1 MONTH) KIT 7.5 MG 1 mitomycin solr 5 mg 1 [leuprolide acetate (cpp)] mitoxantrone hcl conc LUPRON DEPOT-PED (3- 1 25 mg/12.5ml MONTH) KIT 11.25 MG 1 MUSTARGEN SOLR 10 (PED) [leuprolide acetate MG [mechlorethamine 1 (cpp) (3 month)] hcl]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 18 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits MVASI SOLN 100 REVLIMID CAPS 10 MG 1 QL - 30 day(s) MG/4ML [bevacizumab- 1 [lenalidomide] awwb] REVLIMID CAPS 15 MG 1 QL - 30 day(s) MYLERAN TABS 2 MG [lenalidomide] 1 [busulfan] REVLIMID CAPS 2.5 MG 1 QL - 30 day(s) NEXAVAR TABS 200 MG [lenalidomide] 1 QL - 30 day(s) [sorafenib tosylate] REVLIMID CAPS 20 MG 1 QL - 30 day(s) NINLARO CAPS 2.3 MG [lenalidomide] 1 QL - 30 day(s) [ixazomib citrate] REVLIMID CAPS 25 MG 1 QL - 30 day(s) NINLARO CAPS 3 MG [lenalidomide] 1 QL - 30 day(s) [ixazomib citrate] REVLIMID CAPS 5 MG 1 QL - 30 day(s) NINLARO CAPS 4 MG [lenalidomide] 1 QL - 30 day(s) [ixazomib citrate] RITUXAN SOLN 100 1 ODOMZO CAPS 200 MG MG/10ML [rituximab] 1 QL - 30 day(s) [sonidegib phosphate] RITUXAN SOLN 500 1 ONCASPAR SOLN 750 MG/50ML [rituximab] 1 UNIT/ML [pegaspargase] romidepsin solr 10 mg 1 OPDIVO SOLN 100 ROZLYTREK CAPS 100 1 QL - 30 day(s) 1 QL - 30 day(s) MG/10ML [nivolumab] MG [entrectinib] OPDIVO SOLN 40 ROZLYTREK CAPS 200 1 QL - 30 day(s) 1 QL - 30 day(s) MG/4ML [nivolumab] MG [entrectinib] oxaliplatin soln 100 RYDAPT CAPS 25 MG 1 1 QL - 30 day(s) mg/20ml [midostaurin] oxaliplatin soln 50 SARCLISA SOLN 100 1 1 QL - 30 day(s) mg/10ml MG/5ML [isatuximab-irfc] paclitaxel conc 300 1 SARCLISA SOLN 500 mg/50ml MG/25ML [isatuximab- 1 QL - 30 day(s) PADCEV SOLR 20 MG irfc] [enfortumab vedotin- 1 SPRYCEL TABS 100 MG 1 QL - 30 day(s) ejfv] [dasatinib] PADCEV SOLR 30 MG SPRYCEL TABS 140 MG 1 QL - 30 day(s) [enfortumab vedotin- 1 [dasatinib] ejfv] SPRYCEL TABS 20 MG 1 QL - 30 day(s) pentostatin inj 10mg 1 [dasatinib] PERJETA SOLN 420 SPRYCEL TABS 50 MG 1 QL - 30 day(s) 1 QL - 30 day(s) MG/14ML [pertuzumab] [dasatinib] POMALYST CAPS 1 MG SPRYCEL TABS 70 MG 1 QL - 30 day(s) 1 QL - 30 day(s) [pomalidomide] [dasatinib] POMALYST CAPS 2 MG SPRYCEL TABS 80 MG 1 QL - 30 day(s) 1 QL - 30 day(s) [pomalidomide] [dasatinib] POMALYST CAPS 3 MG STIVARGA TABS 40 MG 1 QL - 30 day(s) 1 QL - 30 day(s) [pomalidomide] [regorafenib] POMALYST CAPS 4 MG SUTENT CAPS 12.5 MG 1 QL - 30 day(s) 1 QL - 30 day(s) [pomalidomide] [sunitinib malate] PROLEUKIN SOLR SUTENT CAPS 25 MG 1 QL - 30 day(s) 22000000 UNIT 1 QL - 30 day(s) [sunitinib malate] [aldesleukin] SUTENT CAPS 37.5 MG 1 QL - 30 day(s) PURIXAN SUSP 2000 [sunitinib malate] MG/100ML 1 QL - 30 day(s) SUTENT CAPS 50 MG 1 QL - 30 day(s) [mercaptopurine] [sunitinib malate]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 19 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits SYLVANT SOLR 100 MG TRISENOX SOLN 12 1 QL - 30 day(s) [siltuximab] MG/6ML [arsenic 1 QL - 30 day(s) SYLVANT SOLR 400 MG trioxide] 1 QL - 30 day(s) [siltuximab] TUKYSA TABS 150 MG 1 QL - 30 day(s) TABLOID TABS 40 MG [tucatinib] 1 [thioguanine] TUKYSA TABS 50 MG 1 QL - 30 day(s) TAFINLAR CAPS 50 MG [tucatinib] 1 QL - 30 day(s) [dabrafenib mesylate] TYKERB TABS 250 MG 1 QL - 30 day(s) TAFINLAR CAPS 75 MG [lapatinib ditosylate] 1 QL - 30 day(s) [dabrafenib mesylate] UNITUXIN SOLN 17.5 1 QL - 30 day(s) TAGRISSO TABS 40 MG MG/5ML [dinutuximab] 1 QL - 30 day(s) [osimertinib mesylate] VELCADE SOLR 3.5 MG 1 TAGRISSO TABS 80 MG [bortezomib] 1 QL - 30 day(s) [osimertinib mesylate] VENCLEXTA STARTING tamoxifen citrate tabs 10 PACK TBPK 10 & 50 & 1 QL - 30 day(s) 1 mg 100 MG [venetoclax] tamoxifen citrate tabs 20 VENCLEXTA TABS 10 1 1 QL - 30 day(s) mg MG [venetoclax] TARGRETIN CAPS 75 VENCLEXTA TABS 100 1 1 QL - 30 day(s) MG [bexarotene] MG [venetoclax] TASIGNA CAPS 150 MG VENCLEXTA TABS 50 1 QL - 30 day(s) 1 QL - 30 day(s) [nilotinib hcl] MG [venetoclax] TASIGNA CAPS 200 MG vinblastine sulfate soln 1 1 QL - 30 day(s) 1 [nilotinib hcl] mg/ml TAXOTERE INJ vincristine sulfate soln 1 1 1 80MG/2ML [docetaxel] mg/ml TECENTRIQ SOLN 1200 vinorelbine tartrate soln 1 QL - 30 day(s) 1 MG/20ML [atezolizumab] 10 mg/ml temozolomide caps 100 vinorelbine tartrate soln 1 1 mg 50 mg/5ml temozolomide caps 140 VOTRIENT TABS 200 MG 1 1 QL - 30 day(s) mg [pazopanib hcl] temozolomide caps 180 VYXEOS SUSR 44-100 1 mg MG [daunorubicin- 1 QL - 30 day(s) temozolomide caps 20 cytarabine liposome] 1 XALKORI CAPS 200 MG mg 1 QL - 30 day(s) temozolomide caps 250 [crizotinib] 1 XALKORI CAPS 250 MG mg 1 QL - 30 day(s) temozolomide caps 5 mg 1 [crizotinib] TENIPOSIDE SOLN 10 XGEVA SOLN 120 1 1 QL - 30 day(s) MG/ML [teniposide] MG/1.7ML [denosumab] XTANDI CAPS 40 MG thiotepa solr 15 mg 1 1 QL - 30 day(s) [Etoposide] TOPOSAR [enzalutamide] 1 XTANDI TABS 40 MG SOLN 100 MG/5ML 1 QL - 30 day(s) topotecan hcl solr 4 mg 1 [enzalutamide] TORISEL SOLN 25 XTANDI TABS 80 MG 1 1 QL - 30 day(s) MG/ML [temsirolimus] [enzalutamide] TREANDA SOLR 100 MG YERVOY SOLN 200 1 1 [bendamustine hcl] MG/40ML [ipilimumab] tretinoin caps 10 mg 1 QL - 30 day(s)

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 20 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits YERVOY SOLN 50 CHLORDIAZEPOXIDE- 1 MG/10ML [ipilimumab] CLIDINIUM CAPS 5-2.5 1 YONDELIS SOLR 1 MG MG [chlordiazepoxide 1 QL - 30 day(s) [trabectedin] hcl-clidinium bromide] ZANOSAR SOLR 1 GM CUVPOSA SOLN 1 1 1 [streptozocin] MG/5ML [glycopyrrolate] ZEJULA CAPS 100 MG dicyclomine hcl caps 10 1 QL - 30 day(s) 1 [niraparib tosylate] mg ZELBORAF TABS 240 dicyclomine hcl soln 10 1 QL - 30 day(s) 1 MG [vemurafenib] mg/5ml ZYDELIG TABS 100 MG dicyclomine hcl tabs 20 1 QL - 30 day(s) 1 [idelalisib] mg ZYDELIG TABS 150 MG DONNATAL ELIX 16.2 1 QL - 30 day(s) MG/5ML [phenobarbital- [idelalisib] 1 ZYKADIA CAPS 150 MG hyoscyamine-atropine- 1 QL - 30 day(s) [ceritinib] scopolamine] ZYKADIA TABS 150 MG DONNATAL TABS 16.2 1 QL - 30 day(s) MG [phenobarbital- [ceritinib] 1 ZYTIGA TABS 500 MG hyoscyamine-atropine- 1 QL - 30 day(s) [abiraterone acetate] scopolamine] glycopyrrolate soln 0.2 AUTONOMIC DRUGS 1 ANTICHOLINERGIC AGENTS mg/ml glycopyrrolate soln 0.4 atropine sulfate inj 1 1 1mg/ml mg/2ml glycopyrrolate soln 1 ATROPINE SULFATE 1 SOLN 0.4 MG/ML 1 mg/5ml glycopyrrolate soln 4 [atropine sulfate] 1 ATROPINE SULFATE mg/20ml SOLN 8 MG/20ML 1 glycopyrrolate tabs 1 mg 1 [atropine sulfate] glycopyrrolate tabs 2 mg 1 ATROPINE SULFATE HYOSCYAMINE SULFATE ER TB12 0.375 SOSY 0.5 MG/5ML 1 1 [atropine sulfate] MG [hyoscyamine ATROVENT HFA AERS sulfate] 17 MCG/ACT HYOSCYAMINE 1 SULFATE SUBL 0.125 [ipratropium bromide 1 hfa] MG [hyoscyamine BELLADONNA sulfate] ALKALOIDS-OPIUM HYOSCYAMINE SULFATE TABS 0.125 SUPP 16.2-30 MG 1 1 [belladonna alkaloids & MG [hyoscyamine opium] sulfate] BELLADONNA HYOSCYAMINE SULFATE TBDP 0.125 ALKALOIDS-OPIUM 1 SUPP 16.2-60 MG 1 MG [hyoscyamine [belladonna alkaloids & sulfate] opium] HYOSYNE ELIX 0.125 BENTYL SOLN 10 MG/ML MG/5ML [hyoscyamine 1 1 [dicyclomine hcl] sulfate]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 21 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits HYOSYNE SOLN 0.125 galantamine MG/ML [hyoscyamine 1 hydrobromide er cp24 16 1 sulfate] mg ipratropium bromide galantamine 1 soln 0.02 % hydrobromide er cp24 24 1 ipratropium bromide mg 1 soln 0.03 % GALANTAMINE LEVSIN SOLN 0.5 MG/ML HYDROBROMIDE ER 1 1 [hyoscyamine sulfate] CP24 8 MG [galantamine propantheline bromide hydrobromide] 1 tabs 15 mg galantamine SPIRIVA RESPIMAT hydrobromide tabs 12 1 AERS 2.5 MCG/ACT mg 1 galantamine [tiotropium bromide 1 monohydrate] hydrobromide tabs 4 mg STIOLTO RESPIMAT galantamine 1 AERS 2.5-2.5 MCG/ACT hydrobromide tabs 8 mg 1 [tiotropium bromide- GUANIDINE HCL TABS 1 olodaterol hcl] 125 MG [guanidine hcl] AUTONOMIC DRUGS, MISCELLANEOUS MESTINON SOLN 60 CHANTIX CONTINUING MG/5ML [pyridostigmine 1 MONTH PAK TABS 1 MG 1 bromide] [varenicline tartrate] MESTINON TBCR 180 CHANTIX STARTING MG [pyridostigmine 1 MONTH PAK TABS 0.5 bromide] 1 MG X 11 & 1 MG X 42 neostigmine [varenicline tartrate] methylsulfate soln 0.5 1 CHANTIX TABS 0.5 MG mg/ml 1 [varenicline tartrate] NEOSTIGMINE CHANTIX TABS 1 MG METHYLSULFATE SOLN 1 [varenicline tartrate] 10 MG/10ML 1 PARASYMPATHOMIMETIC (CHOLINERGIC) [neostigmine AGENTS methylsulfate] bethanechol chloride PHYSOSTIGMINE 1 SALICYLATE SOLN 1 tabs 10 mg 1 bethanechol chloride MG/ML [physostigmine 1 tabs 25 mg salicylate] bethanechol chloride pilocarpine hcl tabs 5 1 1 tabs 5 mg mg bethanechol chloride pyridostigmine bromide 1 1 tabs 50 mg er tbcr 180 mg pyridostigmine bromide donepezil hcl tabs 10 mg 1 1 DONEPEZIL HCL TABS 5 tabs 60 mg MG [donepezil 1 REGONOL SOLN 10 hydrochloride] MG/2ML [pyridostigmine 1 donepezil hcl tbdp 10 mg 1 bromide] donepezil hcl tbdp 5 mg 1 SKELETAL MUSCLE RELAXANTS [Edrophonium Chloride] atracurium besylate soln 1 1 ENLON SOLN 10 MG/ML 100 mg/10ml atracurium besylate soln 1 50 mg/5ml

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 22 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits 1 vecuronium bromide baclofen tabs 10 mg 1 baclofen tabs 20 mg 1 solr 10 mg cisatracurium besylate vecuronium bromide 1 1 (pf) soln 10 mg/5ml solr 20 mg cisatracurium besylate SYMPATHOLYTIC (ADRENERGIC BLOCKING) 1 (pf) soln 200 mg/20ml AGENTS cisatracurium besylate dihydroergotamine 1 1 soln 20 mg/10ml mesylate soln 1 mg/ml cyclobenzaprine hcl tabs [Ergotamine Tartrate] 1 1 10 mg ERGOMAR SUBL 2 MG cyclobenzaprine hcl tabs guanfacine hcl tabs 1 mg 1 1 5 mg guanfacine hcl tabs 2 mg 1 dantrolene sodium caps MIGRANAL SOLN 4 1 100 mg MG/ML 1 dantrolene sodium caps [dihydroergotamine 1 25 mg mesylate] dantrolene sodium caps phenoxybenzamine hcl 1 1 50 mg caps 10 mg GABLOFEN SOLN 10000 phentolamine mesylate 1 1 MCG/20ML [baclofen] solr 5 mg GABLOFEN SOLN 20000 1 SYMPATHOMIMETIC (ADRENERGIC) AGENTS MCG/20ML [baclofen] albuterol sulfate hfa aers GABLOFEN SOLN 40000 1 1 108 (90 base) mcg/act MCG/20ML [baclofen] albuterol sulfate nebu GABLOFEN SOSY 10000 1 1 (2.5 mg/3ml) 0.083% MCG/20ML [baclofen] albuterol sulfate nebu (5 GABLOFEN SOSY 20000 1 1 mg/ml) 0.5% MCG/20ML [baclofen] albuterol sulfate nebu GABLOFEN SOSY 40000 1 1 0.63 mg/3ml MCG/20ML [baclofen] albuterol sulfate nebu GABLOFEN SOSY 50 1 1 1.25 mg/3ml MCG/ML [baclofen] albuterol sulfate nebu 1 methocarbamol tabs 500 1 2.5 mg/0.5ml mg albuterol sulfate syrp 2 1 methocarbamol tabs 750 1 mg/5ml mg albuterol sulfate tabs 2 1 pancuronium bromide 1 mg soln 1 mg/ml albuterol sulfate tabs 4 1 QUELICIN SOLN 20 mg MG/ML [succinylcholine 1 dobutamine hcl soln 250 1 chloride] mg/20ml rocuronium bromide 1 DOBUTAMINE IN D5W soln 100 mg/10ml SOLN 1-5 MG/ML-% 1 rocuronium bromide 1 [dobutamine in d5w] soln 50 mg/5ml DOBUTAMINE IN D5W RYANODEX SUSR 250 1 SOLN 2 MG/ML 1 MG [dantrolene sodium] [dobutamine in d5w] tizanidine hcl tabs 2 mg 1 dopamine hcl inj 1 tizanidine hcl tabs 4 mg 1 80mg/ml

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 23 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits dopamine hcl soln 160 1 1 midodrine hcl tabs 5 mg mg/ml norepinephrine bitartrate 1 DOPAMINE HCL SOLN soln 1 mg/ml 40 MG/ML [dopamine 1 SEREVENT DISKUS hcl] AEPB 50 MCG/DOSE 1 dopamine hcl soln 80 1 [salmeterol xinafoate] mg/ml STRIVERDI RESPIMAT DOPAMINE IN D5W AERS 2.5 MCG/ACT 1 SOLN 0.8-5 MG/ML-% 1 [olodaterol hcl] [dopamine in d5w] terbutaline sulfate inj 1 DOPAMINE IN D5W 1mg/ml SOLN 1.6-5 MG/ML-% 1 terbutaline sulfate soln 1 1 [dopamine in d5w] mg/ml DOPAMINE IN D5W terbutaline sulfate tabs 1 SOLN 3.2-5 MG/ML-% 1 2.5 mg [dopamine in d5w] terbutaline sulfate tabs 5 1 EPHEDRINE SULFATE mg SOLN 50 MG/ML 1 VENTOLIN HFA AERS [ephedrine sulfate 108 (90 Base) MCG/ACT 1 (pressors)] [albuterol sulfate] epinephrine hcl inj 1 [Fluticasone-salmeterol] 1mg/ml WIXELA INHUB AEPB 1 EPINEPHRINE PF SOLN 1 100-50 MCG/DOSE 1 MG/ML [epinephrine] [Fluticasone-salmeterol] epinephrine soaj 0.15 1 WIXELA INHUB AEPB 1 mg/0.15ml 250-50 MCG/DOSE EPINEPHRINE SOLN 30 1 [Fluticasone-salmeterol] MG/30ML [epinephrine] WIXELA INHUB AEPB 1 EPINEPHRINE SOSY 1 1 500-50 MCG/DOSE MG/10ML [epinephrine] BLOOD DERIVATIVES EPIPEN 2-PAK SOAJ 0.3 BLOOD DERIVATIVES MG/0.3ML 1 [epinephrine ALBUMIN HUMAN SOLN 1 (anaphylaxis)] 25 % [albumin, human] EPIPEN JR 2-PAK SOAJ ALBURX SOLN 5 % 0.15 MG/0.3ML 1 1 [albumin, human] [epinephrine ALBUTEIN SOLN 25 % (anaphylaxis)] 1 [albumin, human] ipratropium-albuterol 1 BUMINATE SOLN 5 % soln 0.5-2.5 (3) mg/3ml 1 [albumin, human] isoproterenol hcl soln 1 PLASMANATE SOLN 5 % 0.2 mg/ml 1 [plasma protein fraction] metaproterenol sulfate 1 syrp 10 mg/5ml BLOOD FORMATION, COAGULATION, AND metaproterenol sulfate THROMBOSIS 1 tabs 10 mg ANTIANEMIA DRUGS metaproterenol sulfate INFED SOLN 50 MG/ML 1 1 tabs 20 mg [iron dextran] midodrine hcl tabs 10 PROFERRIN-FORTE 1 TABS 12-1 MG [iron mg 1 midodrine hcl tabs 2.5 heme polypeptide-folic 1 mg acid]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 24 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits VENOFER SOLN 20 (recombinant) single 1 MG/ML [iron sucrose] chain] ANTIHEMORRHAGIC AGENTS AFSTYLA KIT 2500 UNIT [antihemophilic factor ADVATE SOLR 1000 1 QL - 30 day(s) UNIT [antihemophilic (recombinant) single factor (rcmb) 1 QL - 30 day(s) chain] plasma/albumin free AFSTYLA KIT 3000 UNIT [antihemophilic factor (rahf-pfm)] 1 QL - 30 day(s) ADVATE SOLR 1500 (recombinant) single UNIT [antihemophilic chain] factor (rcmb) 1 QL - 30 day(s) AFSTYLA KIT 500 UNIT [antihemophilic factor plasma/albumin free 1 QL - 30 day(s) (rahf-pfm)] (recombinant) single ADVATE SOLR 2000 chain] UNIT [antihemophilic ALPHANATE/VWF factor (rcmb) 1 QL - 30 day(s) COMPLEX/HUMAN SOLR 1000 UNIT plasma/albumin free 1 (rahf-pfm)] [antihemophilic ADVATE SOLR 250 UNIT factor/von willebrand [antihemophilic factor factor complex (human)] 1 QL - 30 day(s) (rcmb) plasma/albumin ALPHANATE/VWF free (rahf-pfm)] COMPLEX/HUMAN SOLR 1500 UNIT ADVATE SOLR 3000 1 UNIT [antihemophilic [antihemophilic factor (rcmb) 1 factor/von willebrand plasma/albumin free factor complex (human)] (rahf-pfm)] ALPHANINE SD SOLR ADVATE SOLR 4000 1000 UNIT [coagulation 1 QL - 30 day(s) UNIT [antihemophilic factor ix] factor (rcmb) 1 QL - 30 day(s) ALPHANINE SD SOLR plasma/albumin free 1500 UNIT [coagulation 1 QL - 30 day(s) (rahf-pfm)] factor ix] ADVATE SOLR 500 UNIT ALPHANINE SD SOLR [antihemophilic factor 500 UNIT [coagulation 1 QL - 30 day(s) 1 QL - 30 day(s) (rcmb) plasma/albumin factor ix] aminocaproic acid soln free (rahf-pfm)] 1 AFSTYLA KIT 1000 UNIT 250 mg/ml [antihemophilic factor BENEFIX KIT 1000 UNIT 1 QL - 30 day(s) (recombinant) single [coagulation factor ix 1 chain] (recombinant)] AFSTYLA KIT 1500 UNIT BENEFIX KIT 2000 UNIT [antihemophilic factor [coagulation factor ix 1 1 QL - 30 day(s) (recombinant) single (recombinant)] chain] BENEFIX KIT 250 UNIT AFSTYLA KIT 2000 UNIT [coagulation factor ix 1 [antihemophilic factor (recombinant)] 1 (recombinant) single BENEFIX KIT 3000 UNIT chain] [coagulation factor ix 1 AFSTYLA KIT 250 UNIT (recombinant)] 1 QL - 30 day(s) [antihemophilic factor

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 25 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits BENEFIX KIT 500 UNIT GELFOAM SPONGE SIZE [coagulation factor ix 1 50 MISC [gelatin 1 (recombinant)] absorbable] ELOCTATE SOLR 1000 HELIXATE FS KIT 250 UNIT [antihemophilic UNIT [antihemophilic 1 QL - 30 day(s) 1 QL - 30 day(s) factor (rcmb) fc fusion factor (recombinant) protein(bdd-rfviiifc)] (rfviii)] ELOCTATE SOLR 1500 HEMLIBRA SOLN 105 UNIT [antihemophilic MG/0.7ML [emicizumab- 1 QL - 30 day(s) 1 QL - 30 day(s) factor (rcmb) fc fusion kxwh] protein(bdd-rfviiifc)] HEMLIBRA SOLN 150 ELOCTATE SOLR 2000 MG/ML [emicizumab- 1 QL - 30 day(s) UNIT [antihemophilic kxwh] 1 QL - 30 day(s) factor (rcmb) fc fusion HEMLIBRA SOLN 30 protein(bdd-rfviiifc)] MG/ML [emicizumab- 1 QL - 30 day(s) ELOCTATE SOLR 250 kxwh] UNIT [antihemophilic HEMLIBRA SOLN 60 1 QL - 30 day(s) factor (rcmb) fc fusion MG/0.4ML [emicizumab- 1 QL - 30 day(s) protein(bdd-rfviiifc)] kxwh] ELOCTATE SOLR 3000 HEMOFIL M INJ 220-400 UNIT [antihemophilic 1 QL - 30 day(s) 1 QL - 30 day(s) [antihemophilic factor factor (rcmb) fc fusion (human)] protein(bdd-rfviiifc)] HEMOFIL M SOLR 1000 ELOCTATE SOLR 4000 UNIT [antihemophilic 1 UNIT [antihemophilic 1 QL - 30 day(s) factor (human)] factor (rcmb) fc fusion HEMOFIL M SOLR 1700 protein(bdd-rfviiifc)] UNIT [antihemophilic 1 ELOCTATE SOLR 500 factor (human)] UNIT [antihemophilic 1 QL - 30 day(s) HEMOFIL M SOLR 500 factor (rcmb) fc fusion UNIT [antihemophilic 1 protein(bdd-rfviiifc)] factor (human)] ELOCTATE SOLR 5000 HUMATE-P SOLR 1000- UNIT [antihemophilic 1 QL - 30 day(s) 2400 UNIT factor (rcmb) fc fusion [antihemophilic 1 QL - 30 day(s) protein(bdd-rfviiifc)] factor/von willebrand ELOCTATE SOLR 6000 factor complex (human)] UNIT [antihemophilic 1 QL - 30 day(s) HUMATE-P SOLR 250- factor (rcmb) fc fusion 600 UNIT [antihemophilic 1 QL - 30 day(s) protein(bdd-rfviiifc)] factor/von willebrand ELOCTATE SOLR 750 factor complex (human)] UNIT [antihemophilic 1 QL HUMATE-P SOLR 500- factor (rcmb) fc fusion 1200 UNIT protein(bdd-rfviiifc)] [antihemophilic 1 QL - 30 day(s) GELFILM FILM [gelatin 1 factor/von willebrand adsorbable (ophth)] factor complex (human)] GELFOAM SPONGE IDELVION SOLR 1000 MISC 12-7 MM [gelatin 1 UNIT [coagulation factor 1 QL - 30 day(s) absorbable] ix recomb albumin GELFOAM SPONGE SIZE fusion protein (rix-fp)] 100 MISC [gelatin 1 IDELVION SOLR 2000 1 QL - 30 day(s) absorbable] UNIT [coagulation factor

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 26 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits ix recomb albumin factor (rcmb) fusion protein (rix-fp)] plasma/albumin free IDELVION SOLR 250 (rahf-pfm)] UNIT [coagulation factor KOVALTRY SOLR 500 1 QL - 30 day(s) ix recomb albumin UNIT [antihemophilic fusion protein (rix-fp)] factor (rcmb) 1 QL - 30 day(s) IDELVION SOLR 500 plasma/albumin free UNIT [coagulation factor (rahf-pfm)] 1 QL - 30 day(s) ix recomb albumin MONONINE SOLR 1000 fusion protein (rix-fp)] UNIT [coagulation factor 1 QL - 30 day(s) KCENTRA KIT 500 UNIT ix] [prothrombin complex 1 NOVOSEVEN RT SOLR 1 concentrate human] MG [coagulation factor 1 KOATE SOLR 1000 UNIT viia (recombinant)] [antihemophilic factor 1 NOVOSEVEN RT SOLR 2 (human)] MG [coagulation factor 1 KOATE-DVI SOLR 250 viia (recombinant)] UNIT [antihemophilic 1 NOVOSEVEN RT SOLR 5 factor (human)] MG [coagulation factor 1 KOATE-DVI SOLR 500 viia (recombinant)] UNIT [antihemophilic 1 NOVOSEVEN RT SOLR 8 factor (human)] MG [coagulation factor 1 KOGENATE FS KIT 1000 viia (recombinant)] UNIT [antihemophilic PHENOL LIQD 89 % 1 QL - 30 day(s) 1 QL - 30 day(s) factor (recombinant) [phenol] (rfviii)] PRAXBIND SOLN 2.5 1 KOGENATE FS KIT 2000 GM/50ML [idarucizumab] UNIT [antihemophilic PROFILNINE SOLR 1000 1 QL - 30 day(s) 1 factor (recombinant) UNIT [factor ix complex] (rfviii)] PROFILNINE SOLR 1500 1 KOGENATE FS KIT 500 UNIT [factor ix complex] UNIT [antihemophilic PROFILNINE SOLR 500 1 QL - 30 day(s) 1 QL - 30 day(s) factor (recombinant) UNIT [factor ix complex] (rfviii)] protamine sulfate soln 1 KOVALTRY SOLR 1000 10 mg/ml UNIT [antihemophilic RECOMBINATE SOLR factor (rcmb) 1 QL - 30 day(s) 1241-1800 UNIT 1 QL - 30 day(s) plasma/albumin free [antihemophilic factor (rahf-pfm)] (recombinant) (rfviii)] KOVALTRY SOLR 2000 RECOMBINATE SOLR UNIT [antihemophilic 1801-2400 UNIT 1 QL - 30 day(s) factor (rcmb) 1 QL - 30 day(s) [antihemophilic factor plasma/albumin free (recombinant) (rfviii)] (rahf-pfm)] RECOMBINATE SOLR KOVALTRY SOLR 250 220-400 UNIT 1 QL - 30 day(s) UNIT [antihemophilic [antihemophilic factor factor (rcmb) 1 QL - 30 day(s) (recombinant) (rfviii)] plasma/albumin free RECOMBINATE SOLR (rahf-pfm)] 401-800 UNIT KOVALTRY SOLR 3000 1 QL - 30 day(s) 1 QL - 30 day(s) [antihemophilic factor UNIT [antihemophilic (recombinant) (rfviii)]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 27 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits RECOMBINATE SOLR ACD-A NOCLOT-50 801-1240 UNIT SOLN 0.73-2.45-2.2 1 QL - 30 day(s) [antihemophilic factor GM/100ML 1 (recombinant) (rfviii)] [anticoagulant citrate RECOTHROM SOLR dextrose solution a] 20000 UNIT [thrombin 1 ACTIVASE SOLR 100 MG 1 (recombinant)] [alteplase] RECOTHROM SOLR ACTIVASE SOLR 50 MG 1 5000 UNIT [thrombin 1 [alteplase] (recombinant)] AGGRENOX CP12 25-200 THROMBIN-JMI KIT MG [aspirin- 1 1 20000 UNIT [thrombin] dipyridamole] THROMBIN-JMI SOLR anagrelide hcl caps 0.5 1 1 20000 UNIT [thrombin] mg THROMBIN-JMI SOLR 1 1 anagrelide hcl caps 1 mg 5000 UNIT [thrombin] ANGIOMAX SOLR 250 tranexamic acid soln 1 MG [bivalirudin 1 1000 mg/10ml trifluoroacetate] tranexamic acid tabs 650 1 ARGATROBAN IN mg SODIUM CHLORIDE WILATE KIT 1000-1000 SOLN 125-0.9 MG/125ML- 1 UNIT [antihemophilic % 1 [argatroban in sodium factor/von willebrand chloride] factor complex (human)] ARGATROBAN SOLN 250 1 WILATE KIT 500-500 MG/2.5ML [argatroban] UNIT [antihemophilic aspirin-dipyridamole er 1 1 factor/von willebrand cp12 25-200 mg factor complex (human)] BRILINTA TABS 90 MG 1 XYNTHA KIT 1000 UNIT [ticagrelor] [antihemophilic factor CATHFLO ACTIVASE 1 QL - 30 day(s) 1 (rcmb) moroctocog SOLR 2 MG [alteplase] alfa(bdd-rfviii,mor)] clopidogrel bisulfate 1 XYNTHA KIT 2000 UNIT tabs 75 mg [antihemophilic factor EFFIENT TABS 10 MG 1 1 (rcmb) moroctocog [prasugrel hcl] alfa(bdd-rfviii,mor)] EFFIENT TABS 5 MG 1 XYNTHA KIT 250 UNIT [prasugrel hcl] [antihemophilic factor heparin sodium 1 QL - 30 day(s) 1 (rcmb) moroctocog (porcine) lock flush soln alfa(bdd-rfviii,mor)] HEPARIN (PORCINE) IN XYNTHA KIT 500 UNIT NACL SOLN 1000-0.9 [antihemophilic factor 1 QL - 30 day(s) UT/500ML-% [heparin 1 (rcmb) moroctocog (porcine) in sodium alfa(bdd-rfviii,mor)] chloride] XYNTHA SOLOFUSE KIT HEPARIN (PORCINE) IN 3000 UNIT NACL SOLN 2000-0.9 [antihemophilic factor 1 QL - 30 day(s) UNIT/L-% [heparin 1 (rcmb) moroctocog (porcine) in sodium alfa(bdd-rfviii,mor)] chloride] ANTITHROMBOTIC AGENTS HEPARIN (PORCINE) IN 1 NACL SOLN 25000-0.45

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 28 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits UT/250ML-% [heparin sodium (porcine) lock (porcine) in sodium flush] chloride] INTEGRILIN SOLN 20 1 HEPARIN LOCK FLUSH MG/10ML [eptifibatide] SOLN 1 UNIT/ML INTEGRILIN SOLN 75 1 1 [heparin sodium MG/100ML [eptifibatide] (porcine) lock flush] LOVENOX SOLN 100 HEPARIN LOCK FLUSH MG/ML [enoxaparin 1 QL - 30 day(s) SOLN 10 UNIT/ML 1 sodium] [heparin sodium LOVENOX SOLN 120 (porcine) lock flush] MG/0.8ML [enoxaparin 1 QL - 30 day(s) HEPARIN SOD sodium] (PORCINE) IN D5W LOVENOX SOLN 150 SOLN 100 UNIT/ML 1 MG/ML [enoxaparin 1 QL - 30 day(s) [heparin sod (porcine) in sodium] d5w] LOVENOX SOLN 30 HEPARIN SOD MG/0.3ML [enoxaparin 1 QL - 30 day(s) (PORCINE) IN D5W sodium] SOLN 25000-5 UT/500ML- 1 LOVENOX SOLN 300 % [heparin sod (porcine) MG/3ML [enoxaparin 1 QL - 30 day(s) in d5w] sodium] HEPARIN SOD LOVENOX SOLN 40 (PORCINE) IN D5W MG/0.4ML [enoxaparin 1 QL - 30 day(s) SOLN 40-5 UNIT/ML-% 1 sodium] [heparin sod (porcine) in LOVENOX SOLN 60 d5w] MG/0.6ML [enoxaparin 1 QL - 30 day(s) HEPARIN SODIUM sodium] (PORCINE) PF SOLN LOVENOX SOLN 80 5000 UNIT/0.5ML 1 MG/0.8ML [enoxaparin 1 QL - 30 day(s) [heparin sodium sodium] (porcine)] PRADAXA CAPS 110 MG HEPARIN SODIUM [dabigatran etexilate 1 (PORCINE) SOLN 1000 1 mesylate] UNIT/ML [heparin PRADAXA CAPS 150 MG sodium (porcine)] [dabigatran etexilate 1 HEPARIN SODIUM mesylate] (PORCINE) SOLN 10000 1 PRADAXA CAPS 75 MG UNIT/ML [heparin [dabigatran etexilate 1 sodium (porcine)] mesylate] HEPARIN SODIUM THROMBATE III SOLR (PORCINE) SOLN 20000 1 500 UNIT [antithrombin 1 UNIT/ML [heparin iii (human)] sodium (porcine)] TNKASE KIT 50 MG 1 HEPARIN SODIUM [tenecteplase] (PORCINE) SOLN 5000 warfarin sodium tabs 1 1 1 UNIT/ML [heparin mg sodium (porcine)] warfarin sodium tabs 10 1 HEPARIN SODIUM LOCK mg FLUSH SOLN 100 1 warfarin sodium tabs 2 1 UNIT/ML [heparin mg

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 29 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits warfarin sodium tabs 2.5 PROMACTA TABS 25 MG 1 1 QL - 30 day(s) mg [eltrombopag olamine] warfarin sodium tabs 3 PROMACTA TABS 50 MG 1 1 QL - 30 day(s) mg [eltrombopag olamine] warfarin sodium tabs 4 PROMACTA TABS 75 MG 1 1 QL - 30 day(s) mg [eltrombopag olamine] warfarin sodium tabs 5 ZARXIO SOSY 300 1 mg MCG/0.5ML [filgrastim- 1 QL - 30 day(s) warfarin sodium tabs 6 sndz] 1 mg ZARXIO SOSY 480 warfarin sodium tabs 7.5 MCG/0.8ML [filgrastim- 1 QL - 30 day(s) 1 mg sndz] HEMATOPOIETIC AGENTS HEMORRHEOLOGIC AGENTS ADAKVEO SOLN 100 pentoxifylline er tbcr 400 1 MG/10ML [crizanlizumab- 1 mg tmca] CARDIOVASCULAR DRUGS LEUKINE SOLR 250 MCG 1 QL - 30 day(s) ALPHA-ADRENERGIC BLOCKING AGENTS [sargramostim] doxazosin mesylate tabs NEUPOGEN SOSY 300 1 1 QL - 30 day(s) 1 mg MCG/0.5ML [filgrastim] doxazosin mesylate tabs NEUPOGEN SOSY 480 1 1 QL - 30 day(s) 2 mg MCG/0.8ML [filgrastim] doxazosin mesylate tabs NIVESTYM SOLN 300 1 1 QL - 30 day(s) 4 mg MCG/ML [filgrastim-aafi] doxazosin mesylate tabs 1 NIVESTYM SOLN 480 8 mg MCG/1.6ML [filgrastim- 1 QL - 30 day(s) prazosin hcl caps 1 mg 1 aafi] prazosin hcl caps 2 mg 1 NIVESTYM SOSY 300 prazosin hcl caps 5 mg 1 MCG/0.5ML [filgrastim- 1 tamsulosin hcl caps 0.4 aafi] 1 NIVESTYM SOSY 480 mg MCG/0.8ML [filgrastim- 1 terazosin hcl caps 1 mg 1 aafi] terazosin hcl caps 10 mg 1 PROCRIT SOLN 10000 terazosin hcl caps 2 mg 1 1 QL - 30 day(s) UNIT/ML [epoetin alfa] terazosin hcl caps 5 mg 1 PROCRIT SOLN 2000 1 QL - 30 day(s) ANTILIPEMIC AGENTS UNIT/ML [epoetin alfa] atorvastatin calcium PROCRIT SOLN 20000 1 1 QL - 30 day(s) tabs 10 mg UNIT/ML [epoetin alfa] atorvastatin calcium PROCRIT SOLN 3000 1 1 QL - 30 day(s) tabs 20 mg UNIT/ML [epoetin alfa] atorvastatin calcium PROCRIT SOLN 4000 1 1 QL - 30 day(s) tabs 40 mg UNIT/ML [epoetin alfa] atorvastatin calcium PROCRIT SOLN 40000 1 1 QL - 30 day(s) tabs 80 mg UNIT/ML [epoetin alfa] cholestyramine light PROMACTA PACK 25 MG 1 1 pack 4 gm [eltrombopag olamine] cholestyramine light 1 PROMACTA TABS 12.5 powd 4 gm/dose MG [eltrombopag 1 QL - 30 day(s) cholestyramine pack 4 1 olamine] gm

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 30 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits cholestyramine powd 4 bisoprolol- 1 gm/dose hydrochlorothiazide tabs 1 colestipol hcl gran 5 gm 1 2.5-6.25 mg colestipol hcl pack 5 gm 1 bisoprolol- colestipol hcl tabs 1 gm 1 hydrochlorothiazide tabs 1 ezetimibe tabs 10 mg 1 5-6.25 mg BREVIBLOC IN NACL fenofibrate tabs 160 mg 1 SOLN 2000 MG/100ML 1 1 fenofibrate tabs 54 mg [esmolol hcl-sodium gemfibrozil tabs 600 mg 1 chloride] lovastatin tabs 10 mg 1 BREVIBLOC IN NACL lovastatin tabs 20 mg 1 SOLN 2500 MG/250ML 1 lovastatin tabs 40 mg 1 [esmolol hcl-sodium pravastatin sodium tabs chloride] 1 10 mg carvedilol tabs 12.5 mg 1 pravastatin sodium tabs 1 carvedilol tabs 25 mg 1 20 mg carvedilol tabs 3.125 mg 1 pravastatin sodium tabs 1 carvedilol tabs 6.25 mg 1 40 mg ESMOLOL HCL SOLN pravastatin sodium tabs 1 100 MG/10ML [esmolol 1 80 mg hcl] rosuvastatin calcium labetalol hcl soln 5 1 1 tabs 10 mg mg/ml rosuvastatin calcium 1 labetalol hcl tabs 100 mg 1 tabs 20 mg labetalol hcl tabs 200 mg 1 rosuvastatin calcium 1 labetalol hcl tabs 300 mg 1 tabs 40 mg rosuvastatin calcium metoprolol succinate er 1 1 tabs 5 mg tb24 100 mg metoprolol succinate er simvastatin tabs 10 mg 1 1 tb24 200 mg simvastatin tabs 20 mg 1 metoprolol succinate er 1 simvastatin tabs 40 mg 1 tb24 25 mg simvastatin tabs 5 mg 1 metoprolol succinate er 1 simvastatin tabs 80 mg 1 tb24 50 mg BETA-ADRENERGIC BLOCKING AGENTS metoprolol tartrate soln 1 atenolol tabs 100 mg 1 5 mg/5ml metoprolol tartrate tabs atenolol tabs 25 mg 1 1 atenolol tabs 50 mg 1 100 mg atenolol-chlorthalidone metoprolol tartrate tabs 1 1 tabs 100-25 mg 25 mg atenolol-chlorthalidone metoprolol tartrate tabs 1 1 tabs 50-25 mg 50 mg bisoprolol fumarate tabs metoprolol- 1 10 mg hydrochlorothiazide tabs 1 bisoprolol fumarate tabs 100-50 mg 1 5 mg nadolol tabs 20 mg 1 bisoprolol- nadolol tabs 40 mg 1 hydrochlorothiazide tabs 1 nadolol tabs 80 mg 1 10-6.25 mg propranolol hcl er cp24 1 120 mg

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 31 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits propranolol hcl er cp24 CARDENE IV SOLN 40-5 1 160 mg MG/200ML-% 1 propranolol hcl er cp24 [nicardipine hcl in 1 60 mg dextrose] propranolol hcl er cp24 [Diltiazem Hcl Coated 1 80 mg Beads] CARTIA XT CP24 1 propranolol hcl soln 1 120 MG 1 mg/ml [Diltiazem Hcl Coated propranolol hcl soln 20 Beads] CARTIA XT CP24 1 1 mg/5ml 240 MG propranolol hcl tabs 10 [Diltiazem Hcl Coated 1 mg Beads] CARTIA XT CP24 1 propranolol hcl tabs 20 300 MG 1 CLEVIPREX EMUL 25 mg 1 propranolol hcl tabs 40 MG/50ML [clevidipine] 1 CLEVIPREX EMUL 50 mg 1 propranolol hcl tabs 60 MG/100ML [clevidipine] 1 diltiazem hcl er coated mg 1 propranolol hcl tabs 80 beads cp24 180 mg 1 diltiazem hcl er cp12 120 mg 1 sotalol hcl (af) tabs 120 mg 1 diltiazem hcl er cp12 60 mg 1 sotalol hcl (af) tabs 160 mg 1 diltiazem hcl er cp12 90 mg 1 sotalol hcl (af) tabs 80 mg 1 diltiazem hcl er cp24 120 mg 1 sotalol hcl tabs 120 mg 1 mg diltiazem hcl er cp24 180 sotalol hcl tabs 160 mg 1 1 sotalol hcl tabs 240 mg 1 mg diltiazem hcl er cp24 240 sotalol hcl tabs 80 mg 1 1 mg CALCIUM-CHANNEL BLOCKING AGENTS diltiazem hcl soln 125 amlodipine besylate tabs 1 1 mg/25ml 10 mg diltiazem hcl soln 25 amlodipine besylate tabs 1 1 mg/5ml 2.5 mg diltiazem hcl soln 50 amlodipine besylate tabs 1 1 mg/10ml 5 mg diltiazem hcl tabs 120 1 CARDENE IV SOLN 20- mg 0.86 MG/200ML-% 1 diltiazem hcl tabs 30 mg 1 [nicardipine hcl in diltiazem hcl tabs 60 mg 1 sodium chloride] CARDENE IV SOLN 20- diltiazem hcl tabs 90 mg 1 4.8 MG/200ML-% nicardipine hcl soln 2.5 1 1 [nicardipine hcl in mg/ml dextrose] nifedipine caps 10 mg 1 CARDENE IV SOLN 40- nifedipine caps 20 mg 1 0.83 MG/200ML-% nifedipine er osmotic 1 1 [nicardipine hcl in release tb24 30 mg sodium chloride] nifedipine er osmotic 1 release tb24 60 mg

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 32 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits nifedipine er osmotic LANOXIN PEDIATRIC 1 release tb24 90 mg SOLN 0.1 MG/ML 1 nifedipine er tb24 30 mg 1 [digoxin] lidocaine hcl (cardiac) pf nifedipine er tb24 60 mg 1 1 nimodipine caps 30 mg 1 sosy 100 mg/5ml verapamil hcl er tbcr 120 lidocaine hcl (cardiac) 1 1 mg sosy 50 mg/5ml verapamil hcl er tbcr 180 LIDOCAINE IN D5W 1 mg SOLN 4-5 MG/ML-% 1 verapamil hcl er tbcr 240 [lidocaine in d5w] 1 mg LIDOCAINE IN D5W verapamil hcl soln 2.5 SOLN 8-5 MG/ML-% 1 1 mg/ml [lidocaine in d5w] verapamil hcl tabs 120 mexiletine hcl caps 150 1 1 mg mg mexiletine hcl caps 200 verapamil hcl tabs 40 mg 1 1 mg verapamil hcl tabs 80 mg 1 mexiletine hcl caps 250 1 CARDIAC DRUGS mg adenosine inj 6mg/2ml 1 milrinone lactate in adenosine soln 12 1 dextrose soln 20-5 1 mg/4ml mg/100ml-% adenosine soln 6 mg/2ml 1 milrinone lactate in amiodarone hcl soln 150 1 dextrose soln 40-5 1 mg/3ml mg/200ml-% amiodarone hcl soln 900 milrinone lactate inj 1 1 mg/18ml 1mg/ml amiodarone hcl tabs 200 milrinone lactate soln 10 1 1 mg mg/10ml DIGOXIN SOLN 0.05 1 NORPACE CR CP12 100 MG/ML [digoxin] MG [disopyramide 1 digoxin soln 0.25 mg/ml 1 phosphate] digoxin tabs 125 mcg 1 NORPACE CR CP12 150 digoxin tabs 250 mcg 1 MG [disopyramide 1 disopyramide phosphate phosphate] 1 procainamide hcl soln caps 100 mg 1 disopyramide phosphate 100 mg/ml 1 procainamide hcl soln caps 150 mg 1 dofetilide caps 125 mcg 1 500 mg/ml propafenone hcl tabs dofetilide caps 250 mcg 1 1 150 mg dofetilide caps 500 mcg 1 propafenone hcl tabs flecainide acetate tabs 1 1 225 mg 100 mg propafenone hcl tabs flecainide acetate tabs 1 1 300 mg 150 mg quinidine gluconate er flecainide acetate tabs 1 1 tbcr 324 mg 50 mg QUINIDINE GLUCONATE ibutilide fumarate soln 1 1 SOLN 80 MG/ML 1 mg/10ml [quinidine gluconate]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 33 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits quinidine sulfate tabs 1 1 enalaprilat inj 1.25 mg/ml 200 mg ENTRESTO TABS 24-26 1 quinidine sulfate tabs 1 MG [sacubitril-valsartan] 300 mg ENTRESTO TABS 49-51 1 HYPOTENSIVE AGENTS MG [sacubitril-valsartan] ENTRESTO TABS 97-103 clonidine hcl tabs 0.1 mg 1 1 clonidine hcl tabs 0.2 mg 1 MG [sacubitril-valsartan] clonidine hcl tabs 0.3 mg 1 lisinopril tabs 10 mg 1 clonidine ptwk 0.1 lisinopril tabs 2.5 mg 1 1 mg/24hr lisinopril tabs 20 mg 1 clonidine ptwk 0.2 lisinopril tabs 30 mg 1 1 mg/24hr lisinopril tabs 40 mg 1 clonidine ptwk 0.3 1 lisinopril tabs 5 mg 1 mg/24hr lisinopril- hydralazine hcl soln 20 1 hydrochlorothiazide tabs 1 mg/ml 10-12.5 mg hydralazine hcl tabs 10 1 lisinopril- mg hydrochlorothiazide tabs 1 hydralazine hcl tabs 100 1 20-12.5 mg mg lisinopril- hydralazine hcl tabs 25 1 hydrochlorothiazide tabs 1 mg 20-25 mg hydralazine hcl tabs 50 losartan potassium tabs 1 1 mg 100 mg methyldopa tabs 250 mg 1 losartan potassium tabs 1 methyldopa tabs 500 mg 1 25 mg methyldopate hcl soln losartan potassium tabs 1 1 250 mg/5ml 50 mg 1 losartan potassium-hctz minoxidil tabs 10 mg 1 minoxidil tabs 2.5 mg 1 tabs 100-12.5 mg nitroprusside sodium losartan potassium-hctz 1 1 soln 25 mg/ml tabs 100-25 mg PROGLYCEM SUSP 50 losartan potassium-hctz 1 1 MG/ML [diazoxide] tabs 50-12.5 mg reserpine tab 0.1mg 1 ramipril caps 10 mg 1 reserpine tab 0.25mg 1 ramipril caps 2.5 mg 1 RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM ramipril caps 5 mg 1 spironolactone tabs 100 INHIBITORS 1 benazepril hcl tabs 10 mg 1 spironolactone tabs 25 mg 1 benazepril hcl tabs 20 mg 1 spironolactone tabs 50 mg 1 benazepril hcl tabs 40 mg 1 spironolactone-hctz tabs mg 1 benazepril hcl tabs 5 mg 1 25-25 mg captopril tabs 100 mg 1 valsartan tabs 160 mg 1 captopril tabs 12.5 mg 1 valsartan tabs 320 mg 1 captopril tabs 25 mg 1 valsartan tabs 40 mg 1 captopril tabs 50 mg 1 valsartan tabs 80 mg 1

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 34 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits valsartan- EDEX KIT 20 MCG QL - 8/30 hydrochlorothiazide tabs 1 [alprostadil 1 day(s) 160-12.5 mg (vasodilator)] valsartan- EDEX KIT 40 MCG QL - 8/30 hydrochlorothiazide tabs 1 [alprostadil 1 day(s) 160-25 mg (vasodilator)] valsartan- isosorbide dinitrate er 1 hydrochlorothiazide tabs 1 tbcr 40 mg 320-12.5 mg isosorbide dinitrate tabs 1 valsartan- 10 mg hydrochlorothiazide tabs 1 isosorbide dinitrate tabs 1 320-25 mg 20 mg valsartan- isosorbide dinitrate tabs 1 hydrochlorothiazide tabs 1 30 mg 80-12.5 mg isosorbide dinitrate tabs 1 SCLEROSING AGENTS 5 mg ETHAMOLIN SOLN 5 % isosorbide mononitrate 1 1 [ethanolamine oleate] er tb24 120 mg isosorbide mononitrate [Sodium Tetradecyl 1 Sulfate] SOTRADECOL 1 er tb24 30 mg SOLN 1 % isosorbide mononitrate 1 [Sodium Tetradecyl er tb24 60 mg LETAIRIS TABS 10 MG QL - 30 Sulfate] SOTRADECOL 1 1 SOLN 3 % [ambrisentan] day(s),LD VARITHENA FOAM 180 LETAIRIS TABS 5 MG QL - 30 1 MG/18ML [polidocanol 1 [ambrisentan] day(s),LD (laureth-9)] [Nitroglycerin] MINITRAN 1 VASODILATING AGENTS PT24 0.1 MG/HR alprostadil soln 500 [Nitroglycerin] MINITRAN 1 1 mcg/ml PT24 0.2 MG/HR QL - 30 [Nitroglycerin] MINITRAN ambrisentan tabs 10 mg 1 1 day(s),LD PT24 0.6 MG/HR QL - 30 [Nitroglycerin] NITRO-BID ambrisentan tabs 5 mg 1 1 day(s),LD OINT 2 % CAVERJECT SOLR 20 NITRO-DUR PT24 0.3 QL - 8/30 1 MCG [alprostadil 1 MG/HR [nitroglycerin] day(s) NITRO-DUR PT24 0.8 (vasodilator)] 1 CAVERJECT SOLR 40 MG/HR [nitroglycerin] QL - 8/30 MCG [alprostadil 1 NITROGLYCERIN ER day(s) (vasodilator)] CPCR 2.5 MG 1 dipyridamole soln 5 [nitroglycerin] 1 mg/ml NITROGLYCERIN ER dipyridamole tabs 25 mg 1 CPCR 6.5 MG 1 dipyridamole tabs 50 mg 1 [nitroglycerin] NITROGLYCERIN ER dipyridamole tabs 75 mg 1 CPCR 9 MG 1 EDEX KIT 10 MCG QL - 8/30 [nitroglycerin] [alprostadil 1 day(s) NITROGLYCERIN IN (vasodilator)] D5W SOLN 100-5 1 MCG/ML-% [nitroglycerin in d5w]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 35 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits NITROGLYCERIN IN treprostinil soln 200 1 D5W SOLN 200-5 mg/20ml 1 MCG/ML-% [nitroglycerin treprostinil soln 50 1 LD in d5w] mg/20ml NITROGLYCERIN IN TYVASO SOLN 0.6 QL - 30 1 D5W SOLN 400-5 MG/ML day(s),LD 1 [treprostinil] MCG/ML-% [nitroglycerin VENTAVIS SOLN 10 QL - 30 1 in d5w] MCG/ML [iloprost] day(s),LD nitroglycerin pt24 0.4 VENTAVIS SOLN 20 QL - 30 1 1 mg/hr MCG/ML [iloprost] day(s),LD nitroglycerin soln 5 1 CENTRAL NERVOUS SYSTEM AGENTS mg/ml ANALGESICS AND ANTIPYRETICS NITROSTAT SUBL 0.3 1 acetaminophen-codeine MG 1 [nitroglycerin] #2 tabs 300-15 mg NITROSTAT SUBL 0.4 1 acetaminophen-codeine MG 1 [nitroglycerin] #3 tabs 300-30 mg NITROSTAT SUBL 0.6 1 acetaminophen-codeine MG 1 [nitroglycerin] #4 tabs 300-60 mg PAPAVERINE HCL SOLN acetaminophen-codeine 30 MG/ML 1 1 [papaverine soln 120-12 mg/5ml hcl] alfentanil hcl soln 1000 REMODULIN SOLN 100 1 1 LD mcg/2ml MG/20ML [treprostinil] buprenorphine hcl soln REMODULIN SOLN 20 1 1 LD 0.3 mg/ml MG/20ML [treprostinil] buprenorphine hcl- REMODULIN SOLN 200 1 LD naloxone hcl subl 2-0.5 1 QL - 30 day(s) MG/20ML [treprostinil] mg REMODULIN SOLN 50 1 LD buprenorphine hcl- MG/20ML 1 QL - 30 day(s) [treprostinil] naloxone hcl subl 8-2 mg sildenafil citrate tabs 100 QL - 8/30 1 butorphanol tartrate soln day(s) 1 mg 1 mg/ml sildenafil citrate tabs 20 QL - 8/30 1 butorphanol tartrate soln day(s) 1 mg 2 mg/ml tadalafil (pah) tabs 20 1 CHOLINE-MAG mg TRISALICYLATE LIQD QL - 8/30 1 tadalafil tabs 10 mg 1 500 MG/5ML [choline & day(s) mag salicylate] QL - 8/30 tadalafil tabs 2.5 mg 1 CODEINE SULFATE day(s) TABS 15 MG [codeine 1 tadalafil tabs 20 mg 1 sulfate] QL - 8/30 tadalafil tabs 5 mg 1 CODEINE SULFATE day(s) TABS 30 MG [codeine 1 TRACLEER TABS 125 QL - 30 1 sulfate] MG [bosentan] day(s),LD CODEINE SULFATE TRACLEER TABS 62.5 QL - 30 1 TABS 60 MG [codeine 1 MG [bosentan] day(s),LD sulfate] treprostinil soln 100 1 LD DURAMORPH SOLN 0.5 mg/20ml MG/ML [morphine 1 treprostinil soln 20 1 LD sulfate] mg/20ml

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 36 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits DURAMORPH SOLN 1 hydromorphone hcl tabs 1 MG/ML [morphine 1 2 mg sulfate] hydromorphone hcl tabs 1 etodolac caps 200 mg 1 4 mg hydromorphone hcl tabs etodolac caps 300 mg 1 1 etodolac tabs 400 mg 1 8 mg [Ibuprofen] IBU TABS 400 etodolac tabs 500 mg 1 1 fentanyl citrate (pf) soct MG 1 [Ibuprofen] IBU TABS 600 100 mcg/2ml 1 FENTANYL CITRATE MG [Ibuprofen] IBU TABS 800 (PF) SOLN 100 MCG/2ML 1 1 [fentanyl citrate] MG ibuprofen susp 100 FENTANYL CITRATE 1 (PF) SOLN 500 mg/5ml 1 [Indomethacin] INDOCIN MCG/10ML [fentanyl 1 citrate] SUPP 50 MG indomethacin caps 25 fentanyl pt72 100 mcg/hr 1 QL - 30 day(s) 1 mg fentanyl pt72 12 mcg/hr 1 QL - 30 day(s) indomethacin caps 50 fentanyl pt72 25 mcg/hr 1 QL - 30 day(s) 1 mg fentanyl pt72 50 mcg/hr 1 QL - 30 day(s) indomethacin er cpcr 75 1 fentanyl pt72 75 mcg/hr 1 QL - 30 day(s) mg hydrocodone- INDOMETHACIN acetaminophen soln 7.5- 1 SODIUM SOLR 1 MG 1 325 mg/15ml [indomethacin sodium] hydrocodone- INFUMORPH 200 SOLN acetaminophen tabs 10- 1 200 MG/20ML (10 MG/ML) 325 mg [morphine sulfate for 1 hydrocodone- continuous acetaminophen tabs 5- 1 microinfusion] 325 mg INFUMORPH 500 SOLN hydrocodone- 500 MG/20ML (25 MG/ML) acetaminophen tabs 7.5- 1 [morphine sulfate for 1 325 mg continuous hydromorphone hcl liqd 1 microinfusion] 1 mg/ml ketorolac tromethamine hydromorphone hcl pf 1 1 soln 15 mg/ml soln 500 mg/50ml ketorolac tromethamine 1 HYDROMORPHONE HCL soln 30 mg/ml SOLN 1 MG/ML 1 QL - 30 day(s) ketorolac tromethamine 1 [hydromorphone hcl] soln 60 mg/2ml HYDROMORPHONE HCL [Hydrocodone- SOLN 2 MG/ML 1 acetaminophen] LORTAB 1 [hydromorphone hcl] ELIX 10-300 MG/15ML HYDROMORPHONE HCL meclofenamate sodium 1 SOLN 4 MG/ML 1 caps 100 mg [hydromorphone hcl] meclofenamate sodium 1 HYDROMORPHONE HCL caps 50 mg SUPP 3 MG 1 mefenamic acid caps 1 [hydromorphone hcl] 250 mg

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 37 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits meloxicam tabs 15 mg 1 MORPHINE SULFATE meloxicam tabs 7.5 mg 1 SOLN 10 MG/5ML 1 meperidine hcl soln 100 [morphine sulfate] 1 mg/ml MORPHINE SULFATE meperidine hcl soln 25 SOLN 10 MG/ML 1 1 mg/ml [morphine sulfate] meperidine hcl soln 50 MORPHINE SULFATE 1 mg/ml SOLN 15 MG/ML 1 methadone hcl soln 10 [morphine sulfate] 1 mg/5ml MORPHINE SULFATE METHADONE HCL SOLN SOLN 2 MG/ML 1 10 MG/ML [methadone 1 [morphine sulfate] hcl] MORPHINE SULFATE methadone hcl soln 5 SOLN 20 MG/5ML 1 1 mg/5ml [morphine sulfate] METHADONE HCL TABS MORPHINE SULFATE 1 10 MG [methadone hcl] SOLN 25 MG/ML 1 METHADONE HCL TABS [morphine sulfate] 1 5 MG [methadone hcl] MORPHINE SULFATE morphine sulfate SOLN 4 MG/ML 1 (concentrate) soln 100 1 [morphine sulfate] mg/5ml MORPHINE SULFATE morphine sulfate (pf) SOLN 5 MG/ML 1 1 soln 0.5 mg/ml [morphine sulfate] morphine sulfate (pf) MORPHINE SULFATE 1 soln 1 mg/ml SOLN 50 MG/ML 1 MORPHINE SULFATE [morphine sulfate] (PF) SOLN 10 MG/ML 1 MORPHINE SULFATE [morphine sulfate] SOLN 8 MG/ML 1 MORPHINE SULFATE [morphine sulfate] (PF) SOLN 2 MG/ML 1 MORPHINE SULFATE [morphine sulfate] SUPP 10 MG [morphine 1 MORPHINE SULFATE sulfate] (PF) SOLN 4 MG/ML 1 MORPHINE SULFATE [morphine sulfate] SUPP 20 MG [morphine 1 morphine sulfate er tbcr sulfate] 1 100 mg MORPHINE SULFATE morphine sulfate er tbcr SUPP 30 MG [morphine 1 1 15 mg sulfate] morphine sulfate er tbcr MORPHINE SULFATE 1 200 mg SUPP 5 MG [morphine 1 morphine sulfate er tbcr sulfate] 1 30 mg MORPHINE SULFATE morphine sulfate er tbcr TABS 15 MG [morphine 1 1 60 mg sulfate] MORPHINE SULFATE MORPHINE SULFATE SOLN 1 MG/ML 1 TABS 30 MG [morphine 1 [morphine sulfate] sulfate] nabumetone tabs 500 1 mg

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 38 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits nabumetone tabs 750 ULTIVA SOLR 5 MG 1 1 mg [remifentanil hcl] nalbuphine hcl soln 10 ANOREXIGENIC AGENTS AND RESPIRATORY 1 mg/ml AND CEREBRAL STIMULANTS nalbuphine hcl soln 20 amphetamine- 1 mg/ml dextroamphet er cp24 10 1 naproxen sodium tabs mg 1 275 mg amphetamine- naproxen sodium tabs dextroamphet er cp24 15 1 1 550 mg mg naproxen susp 125 amphetamine- 1 mg/5ml dextroamphet er cp24 20 1 naproxen tabs 250 mg 1 mg naproxen tabs 375 mg 1 amphetamine- naproxen tabs 500 mg 1 dextroamphet er cp24 25 1 naproxen tbec 375 mg 1 mg NEOPROFEN SOLN 10 amphetamine- 1 dextroamphet er cp24 30 1 MG/ML [ibuprofen lysine] mg OFIRMEV SOLN 10 1 amphetamine- MG/ML [acetaminophen] dextroamphet er cp24 5 1 OPANA SOLN 1 MG/ML 1 mg [oxymorphone hcl] amphetamine- oxycodone hcl tabs 5 mg 1 dextroamphetamine tabs 1 oxycodone- 10 mg 1 acetaminophen tabs 10- amphetamine- 325 mg dextroamphetamine tabs 1 oxycodone- 12.5 mg 1 acetaminophen tabs 5- amphetamine- 325 mg dextroamphetamine tabs 1 oxycodone- 15 mg 1 acetaminophen tabs 7.5- amphetamine- 325 mg dextroamphetamine tabs 1 pentazocine-naloxone 1 20 mg hcl tabs 50-0.5 mg amphetamine- SALSALATE TABS 500 1 dextroamphetamine tabs 1 MG [salsalate] 30 mg SALSALATE TABS 750 1 amphetamine- MG [salsalate] dextroamphetamine tabs 1 sufentanil citrate soln 50 1 5 mg mcg/ml amphetamine- sulindac tabs 150 mg 1 dextroamphetamine tabs 1 sulindac tabs 200 mg 1 7.5 mg tramadol hcl tabs 50 mg 1 APTENSIO XR CP24 10 tramadol-acetaminophen MG 1 1 [methylphenidate tabs 37.5-325 mg hcl] ULTIVA SOLR 1 MG APTENSIO XR CP24 15 1 [remifentanil hcl] MG [methylphenidate 1 ULTIVA SOLR 2 MG hcl] 1 [remifentanil hcl]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 39 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits APTENSIO XR CP24 20 methylphenidate hcl er 1 MG [methylphenidate 1 (cd) cpcr 20 mg hcl] methylphenidate hcl er 1 APTENSIO XR CP24 30 (cd) cpcr 30 mg MG [methylphenidate 1 methylphenidate hcl er 1 hcl] (cd) cpcr 40 mg APTENSIO XR CP24 40 methylphenidate hcl er 1 MG [methylphenidate 1 (cd) cpcr 50 mg hcl] methylphenidate hcl er 1 APTENSIO XR CP24 50 (cd) cpcr 60 mg MG [methylphenidate 1 methylphenidate hcl er 1 hcl] tbcr 10 mg APTENSIO XR CP24 60 methylphenidate hcl er 1 MG [methylphenidate 1 tbcr 18 mg hcl] methylphenidate hcl er 1 caffeine citrate soln 60 1 tbcr 20 mg mg/3ml methylphenidate hcl er 1 dexmethylphenidate hcl 1 tbcr 27 mg er cp24 10 mg methylphenidate hcl er 1 dexmethylphenidate hcl 1 tbcr 36 mg er cp24 15 mg methylphenidate hcl er 1 dexmethylphenidate hcl 1 tbcr 54 mg er cp24 20 mg methylphenidate hcl 1 dexmethylphenidate hcl 1 tabs 10 mg er cp24 25 mg methylphenidate hcl 1 dexmethylphenidate hcl 1 tabs 20 mg er cp24 30 mg methylphenidate hcl 1 dexmethylphenidate hcl 1 tabs 5 mg er cp24 35 mg modafinil tabs 100 mg 1 dexmethylphenidate hcl 1 modafinil tabs 200 mg 1 er cp24 40 mg VYVANSE CAPS 10 MG dexmethylphenidate hcl 1 [lisdexamfetamine 1 er cp24 5 mg dimesylate] dexmethylphenidate hcl 1 VYVANSE CAPS 20 MG tabs 10 mg [lisdexamfetamine 1 dexmethylphenidate hcl 1 dimesylate] tabs 2.5 mg VYVANSE CAPS 30 MG dexmethylphenidate hcl 1 [lisdexamfetamine 1 tabs 5 mg dimesylate] dextroamphetamine 1 VYVANSE CAPS 40 MG sulfate er cp24 10 mg [lisdexamfetamine 1 dextroamphetamine 1 dimesylate] sulfate er cp24 15 mg VYVANSE CAPS 50 MG dextroamphetamine 1 [lisdexamfetamine 1 sulfate er cp24 5 mg dimesylate] dextroamphetamine 1 VYVANSE CAPS 60 MG sulfate tabs 10 mg [lisdexamfetamine 1 dextroamphetamine 1 dimesylate] sulfate tabs 5 mg methylphenidate hcl er 1 (cd) cpcr 10 mg

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 40 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits VYVANSE CAPS 70 MG divalproex sodium er 1 [lisdexamfetamine 1 tb24 250 mg dimesylate] divalproex sodium er 1 ANTICONVULSANTS tb24 500 mg BANZEL SUSP 40 MG/ML divalproex sodium tbec 1 1 [rufinamide] 125 mg BANZEL TABS 200 MG divalproex sodium tbec 1 1 [rufinamide] 250 mg BANZEL TABS 400 MG divalproex sodium tbec 1 1 [rufinamide] 500 mg BRIVIACT TABS 10 MG EQUETRO CP12 200 MG 1 [brivaracetam] [carbamazepine 1 BRIVIACT TABS 100 MG (antipsychotic)] 1 ethosuximide caps 250 [brivaracetam] 1 BRIVIACT TABS 25 MG mg 1 ethosuximide soln 250 [brivaracetam] 1 BRIVIACT TABS 50 MG mg/5ml 1 felbamate susp 600 [brivaracetam] 1 BRIVIACT TABS 75 MG mg/5ml 1 [brivaracetam] felbamate tabs 400 mg 1 carbamazepine chew 100 felbamate tabs 600 mg 1 1 mg fosphenytoin sodium 1 carbamazepine er cp12 1 soln 100 mg pe/2ml 100 mg fosphenytoin sodium 1 carbamazepine er cp12 soln 500 mg pe/10ml 1 200 mg gabapentin caps 100 mg 1 carbamazepine er cp12 1 gabapentin caps 300 mg 1 300 mg gabapentin caps 400 mg 1 carbamazepine er tb12 gabapentin soln 250 1 1 100 mg mg/5ml carbamazepine er tb12 1 gabapentin tabs 600 mg 1 200 mg gabapentin tabs 800 mg 1 carbamazepine er tb12 1 LAMICTAL STARTER KIT 400 mg 1 35 x 25 MG [lamotrigine] carbamazepine susp 100 1 LAMICTAL STARTER KIT mg/5ml 42 x 25 MG & 7 X 100 MG 1 carbamazepine tabs 200 1 [lamotrigine] mg LAMICTAL STARTER KIT CELONTIN CAPS 300 MG 1 84 x 25 MG & 14X100 MG 1 [methsuximide] [lamotrigine] clonazepam tabs 0.5 mg 1 lamotrigine chew 25 mg 1 clonazepam tabs 1 mg 1 lamotrigine chew 5 mg 1 clonazepam tabs 2 mg 1 lamotrigine tabs 100 mg 1 [Phenytoin Sodium 1 Extended] DILANTIN 1 lamotrigine tabs 150 mg CAPS 30 MG lamotrigine tabs 200 mg 1 [Phenytoin] DILANTIN lamotrigine tabs 25 mg 1 1 levetiracetam er tb24 500 INFATABS CHEW 50 MG 1 divalproex sodium csdr mg 1 125 mg

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 41 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits levetiracetam er tb24 750 phenytoin sodium 1 1 mg extended caps 100 mg LEVETIRACETAM IN phenytoin sodium soln 1 NACL SOLN 1000 50 mg/ml 1 MG/100ML [levetiracetam phenytoin susp 125 1 in sodium chloride] mg/5ml LEVETIRACETAM IN pregabalin caps 100 mg 1 NACL SOLN 1500 1 pregabalin caps 150 mg 1 MG/100ML [levetiracetam pregabalin caps 200 mg 1 in sodium chloride] pregabalin caps 225 mg 1 LEVETIRACETAM IN pregabalin caps 25 mg 1 NACL SOLN 500 1 MG/100ML [levetiracetam pregabalin caps 300 mg 1 in sodium chloride] pregabalin caps 50 mg 1 levetiracetam soln 100 pregabalin caps 75 mg 1 1 pregabalin soln 20 mg/ml 1 levetiracetam soln 500 mg/ml 1 mg/5ml primidone tab 50mg 1 levetiracetam tabs 1000 primidone tabs 250 mg 1 1 mg SABRIL PACK 500 MG QL - 30 1 levetiracetam tabs 250 day(s),LD 1 [vigabatrin] mg topiramate cpsp 15 mg 1 levetiracetam tabs 500 1 topiramate cpsp 25 mg 1 mg topiramate tabs 100 mg 1 levetiracetam tabs 750 1 topiramate tabs 200 mg 1 mg topiramate tabs 25 mg 1 MAGNESIUM SULFATE 1 SOLN 20 GM/500ML 1 topiramate tabs 50 mg valproate sodium soln [magnesium sulfate] 1 MAGNESIUM SULFATE 500 mg/5ml valproic acid caps 250 SOLN 4 GM/100ML 1 1 [magnesium sulfate] mg valproic acid soln 250 MAGNESIUM SULFATE 1 SOLN 4 GM/50ML 1 mg/5ml [Ethosuximide] ZARONTIN [magnesium sulfate] 1 MAGNESIUM SULFATE SOLN 250 MG/5ML SOLN 40 GM/1000ML 1 zonisamide caps 100 mg 1 [magnesium sulfate] zonisamide caps 25 mg 1 magnesium sulfate soln zonisamide caps 50 mg 1 1 50 % ANTIMANIC AGENTS oxcarbazepine susp 300 lithium carbonate caps 1 1 mg/5ml 150 mg oxcarbazepine tabs 150 1 LITHIUM CARBONATE mg CAPS 300 MG [lithium 1 oxcarbazepine tabs 300 1 carbonate] mg lithium carbonate caps 1 oxcarbazepine tabs 600 1 600 mg mg lithium carbonate er tbcr [Phenytoin] PHENYTOIN 1 1 300 mg INFATABS CHEW 50 MG lithium carbonate er tbcr 1 450 mg

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 42 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits LITHIUM CARBONATE sumatriptan succinate 1 TABS 300 MG [lithium 1 tabs 25 mg carbonate] sumatriptan succinate 1 LITHIUM SOLN 8 tabs 50 mg 1 MEQ/5ML [lithium] ANTIPARKINSONIAN AGENTS ANTIMIGRAINE AGENTS amantadine hcl caps 100 1 [Ergotamine W/ Caffeine] mg CAFERGOT TABS 1-100 1 amantadine hcl syrp 50 1 MG mg/5ml eletriptan hydrobromide APOKYN SOCT 30 1 tabs 20 mg MG/3ML [apomorphine 1 QL - 30 day(s) eletriptan hydrobromide hydrochloride] 1 tabs 40 mg benztropine mesylate 1 ergoloid mesylates tabs soln 1 mg/ml 1 1 mg benztropine mesylate 1 ergotamine-caffeine tabs tabs 0.5 mg 1 1-100 mg benztropine mesylate 1 ISOMETHEPTENE- tabs 1 mg DICHLORAL-APAP CAPS benztropine mesylate 1 65-100-325 MG 1 tabs 2 mg [isometheptene- bromocriptine mesylate 1 dichloralphenazone- caps 5 mg acetaminophen] bromocriptine mesylate 1 [Ergotamine W/ Caffeine] tabs 2.5 mg MIGERGOT SUPP 2-100 1 cabergoline tabs 0.5 mg 1 MG carbidopa tabs 25 mg 1 naratriptan hcl tabs 1 mg 1 carbidopa-levodopa er naratriptan hcl tabs 2.5 1 1 tbcr 25-100 mg mg carbidopa-levodopa er rizatriptan benzoate tabs 1 1 tbcr 50-200 mg 10 mg carbidopa-levodopa tabs rizatriptan benzoate tabs 1 1 10-100 mg 5 mg carbidopa-levodopa tabs rizatriptan benzoate tbdp 1 1 25-100 mg 10 mg carbidopa-levodopa tabs rizatriptan benzoate tbdp 1 1 25-250 mg 5 mg carbidopa-levodopa- sumatriptan soln 20 1 entacapone tabs 12.5-50- 1 mg/act 200 mg sumatriptan succinate 1 carbidopa-levodopa- refill soct 6 mg/0.5ml entacapone tabs 18.75- 1 sumatriptan succinate 1 75-200 mg soaj 6 mg/0.5ml carbidopa-levodopa- sumatriptan succinate 1 entacapone tabs 25-100- 1 soln 6 mg/0.5ml 200 mg sumatriptan succinate 1 carbidopa-levodopa- sosy 6 mg/0.5ml entacapone tabs 31.25- 1 sumatriptan succinate 1 125-200 mg tabs 100 mg

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 43 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits carbidopa-levodopa- rasagiline mesylate tabs 1 entacapone tabs 37.5- 1 0.5 mg 150-200 mg rasagiline mesylate tabs 1 carbidopa-levodopa- 1 mg entacapone tabs 50-200- 1 ropinirole hcl er tb24 12 1 200 mg mg DUOPA SUSP 4.63-20 ropinirole hcl er tb24 2 1 MG/ML [carbidopa- 1 mg levodopa] ropinirole hcl er tb24 4 1 ENTACAPONE TABS 200 1 mg MG [entacapone] ropinirole hcl er tb24 6 1 KYNMOBI FILM 10 MG mg [apomorphine 1 QL - 30 day(s) ropinirole hcl er tb24 8 1 hydrochloride] mg KYNMOBI FILM 15 MG ropinirole hcl tabs 0.25 1 [apomorphine 1 QL - 30 day(s) mg hydrochloride] ropinirole hcl tabs 0.5 1 KYNMOBI FILM 20 MG mg [apomorphine 1 QL - 30 day(s) ropinirole hcl tabs 1 mg 1 hydrochloride] ropinirole hcl tabs 2 mg 1 KYNMOBI FILM 25 MG ropinirole hcl tabs 3 mg 1 [apomorphine 1 QL - 30 day(s) ropinirole hcl tabs 4 mg 1 hydrochloride] ropinirole hcl tabs 5 mg 1 KYNMOBI FILM 30 MG [apomorphine 1 QL - 30 day(s) selegiline hcl tabs 5 mg 1 trihexyphenidyl hcl soln hydrochloride] 1 KYNMOBI TITRATION 0.4 mg/ml KIT KIT 10/15/20/25/30 trihexyphenidyl hcl tabs 1 QL - 30 day(s) 1 MG [apomorphine 2 mg trihexyphenidyl hcl tabs hydrochloride] 1 LODOSYN TABS 25 MG 5 mg 1 [carbidopa] ANXIOLYTICS, SEDATIVES, AND HYPNOTICS pramipexole alprazolam tabs 0.25 mg 1 QL - 30 day(s) dihydrochloride tabs 1 alprazolam tabs 0.5 mg 1 QL - 30 day(s) 0.125 mg alprazolam tabs 1 mg 1 QL - 30 day(s) pramipexole alprazolam tabs 2 mg 1 QL - 30 day(s) dihydrochloride tabs 1 buspirone hcl tabs 10 1 0.25 mg mg pramipexole buspirone hcl tabs 15 1 dihydrochloride tabs 0.5 1 mg mg buspirone hcl tabs 30 1 pramipexole mg 1 dihydrochloride tabs buspirone hcl tabs 5 mg 1 0.75 mg buspirone hcl tabs 7.5 pramipexole 1 mg dihydrochloride tabs 1 1 chlordiazepoxide hcl mg 1 caps 10 mg pramipexole chlordiazepoxide hcl dihydrochloride tabs 1.5 1 1 caps 25 mg mg

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 44 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits chlordiazepoxide hcl 1 QL - 30 day(s) 1 lorazepam tabs 0.5 mg caps 5 mg lorazepam tabs 1 mg 1 clorazepate dipotassium 1 lorazepam tabs 2 mg 1 QL - 30 day(s) tabs 15 mg midazolam hcl (pf) soln clorazepate dipotassium 1 1 10 mg/2ml tabs 3.75 mg midazolam hcl (pf) soln 2 clorazepate dipotassium 1 1 mg/2ml tabs 7.5 mg midazolam hcl (pf) soln 5 1 DIASTAT ACUDIAL GEL mg/ml 10 MG [diazepam 1 midazolam hcl soln 10 1 (anticonvulsant)] mg/2ml DIASTAT ACUDIAL GEL midazolam hcl soln 2 1 20 MG [diazepam 1 mg/2ml (anticonvulsant)] midazolam hcl syrp 2 1 DIASTAT PEDIATRIC mg/ml GEL 2.5 MG [diazepam 1 [Pentobarbital Sodium] (anticonvulsant)] NEMBUTAL SOLN 50 1 [Diazepam] DIAZEPAM MG/ML INTENSOL CONC 5 1 oxazepam caps 10 mg 1 QL - 30 day(s) MG/ML oxazepam caps 15 mg 1 QL - 30 day(s) diazepam soln 5 mg/5ml 1 oxazepam caps 30 mg 1 QL - 30 day(s) diazepam soln 5 mg/ml 1 PHENOBARBITAL ELIX diazepam tabs 10 mg 1 20 MG/5ML 1 diazepam tabs 2 mg 1 [phenobarbital] diazepam tabs 5 mg 1 PHENOBARBITAL droperidol soln 2.5 SODIUM SOLN 130 1 1 mg/ml MG/ML [phenobarbital hydroxyzine hcl soln 25 1 sodium] mg/ml PHENOBARBITAL hydroxyzine hcl soln 50 1 SODIUM SOLN 65 MG/ML 1 mg/ml [phenobarbital sodium] hydroxyzine hcl syrp 10 PHENOBARBITAL TABS 1 1 mg/5ml 100 MG [phenobarbital] hydroxyzine hcl tabs 10 PHENOBARBITAL TABS 1 1 mg 15 MG [phenobarbital] hydroxyzine hcl tabs 25 PHENOBARBITAL TABS 1 1 mg 16.2 MG [phenobarbital] hydroxyzine hcl tabs 50 PHENOBARBITAL TABS 1 1 mg 30 MG [phenobarbital] hydroxyzine pamoate PHENOBARBITAL TABS 1 1 caps 100 mg 32.4 MG [phenobarbital] hydroxyzine pamoate PHENOBARBITAL TABS 1 1 caps 25 mg 60 MG [phenobarbital] hydroxyzine pamoate PHENOBARBITAL TABS 1 1 caps 50 mg 64.8 MG [phenobarbital] [Lorazepam] PHENOBARBITAL TABS 1 LORAZEPAM INTENSOL 1 QL - 30 day(s) 97.2 MG [phenobarbital] CONC 2 MG/ML PRECEDEX SOLN 200 lorazepam soln 2 mg/ml 1 MCG/2ML 1 lorazepam soln 4 mg/ml 1 [dexmedetomidine hcl]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 45 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits SILENOR TABS 3 MG propofol emul 200 1 1 [doxepin hcl (sleep)] mg/20ml SILENOR TABS 6 MG 1 MULTIPLE SCLEROSIS AGENTS [doxepin hcl (sleep)] AVONEX KIT 30MCG 1 QL - 30 day(s) temazepam caps 15 mg 1 QL - 30 day(s) [interferon beta-1a] temazepam caps 30 mg 1 QL - 30 day(s) EXTAVIA KIT 0.3 MG 1 QL - 30 day(s) zolpidem tartrate tabs 5 [interferon beta-1b] 1 QL - 30 day(s) mg [Glatiramer Acetate] CENTRAL NERVOUS SYSTEM AGENTS, GLATOPA SOSY 20 1 QL - 30 day(s) MISCELLANEOUS MG/ML acamprosate calcium OPIATE ANTAGONISTS 1 tbec 333 mg naloxone hcl soct 0.4 1 flumazenil soln 0.5 1 mg/ml mg/5ml naloxone hcl soln 0.4 1 guanfacine hcl er tb24 1 1 mg/ml mg naloxone hcl sosy 2 1 guanfacine hcl er tb24 2 1 mg/2ml mg NALTREXONE HCL guanfacine hcl er tb24 3 1 POWD [naltrexone hcl 1 mg (bulk)] guanfacine hcl er tb24 4 naltrexone hcl tabs 50 1 1 mg mg memantine hcl tabs 10 NARCAN LIQD 4 1 1 mg MG/0.1ML [naloxone hcl] memantine hcl tabs 5 mg 1 PSYCHOTHERAPEUTIC AGENTS NAMENDA SOL amitriptyline hcl tabs 10 1 10MG/5ML [memantine 1 mg hcl] amitriptyline hcl tabs 100 1 NAMENDA TITRATION mg PAK TABS 28 x 5 MG & amitriptyline hcl tabs 150 1 1 21 X 10 MG [memantine mg hcl] amitriptyline hcl tabs 25 1 riluzole tabs 50 mg 1 mg selegiline hcl caps 5 mg 1 amitriptyline hcl tabs 50 1 GENERAL ANESTHETICS mg amitriptyline hcl tabs 75 BREVITAL SODIUM 1 SOLR 500 MG 1 mg [methohexital sodium] amoxapine tabs 100 mg 1 etomidate soln 2 mg/ml 1 amoxapine tabs 150 mg 1 FORANE SOLN amoxapine tabs 25 mg 1 1 [isoflurane] amoxapine tabs 50 mg 1 ketamine hcl soln 10 1 aripiprazole tabs 10 mg 1 mg/ml aripiprazole tabs 15 mg 1 ketamine hcl soln 100 1 aripiprazole tabs 2 mg 1 mg/ml aripiprazole tabs 20 mg 1 ketamine hcl soln 50 1 1 mg/ml aripiprazole tabs 30 mg propofol emul 1000 aripiprazole tabs 5 mg 1 1 mg/100ml

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 46 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits ARISTADA PRSY 1064 clomipramine hcl caps 1 MG/3.9ML [aripiprazole 1 25 mg lauroxil] clomipramine hcl caps 1 ARISTADA PRSY 441 50 mg MG/1.6ML [aripiprazole 1 clomipramine hcl caps 1 lauroxil] 75 mg ARISTADA PRSY 662 clozapine tabs 100 mg 1 MG/2.4ML [aripiprazole 1 clozapine tabs 200 mg 1 lauroxil] clozapine tabs 25 mg 1 ARISTADA PRSY 882 clozapine tabs 50 mg 1 MG/3.2ML 1 [aripiprazole [Prochlorperazine] 1 lauroxil] COMPRO SUPP 25 MG bupropion hcl er (sr) 1 desipramine hcl tabs 10 tb12 100 mg 1 mg bupropion hcl er (sr) 1 desipramine hcl tabs 100 tb12 150 mg 1 mg bupropion hcl er (sr) 1 desipramine hcl tabs 150 tb12 200 mg 1 mg bupropion hcl er (xl) 1 desipramine hcl tabs 25 tb24 150 mg 1 mg bupropion hcl er (xl) 1 desipramine hcl tabs 50 tb24 300 mg 1 mg bupropion hcl tabs 100 1 desipramine hcl tabs 75 mg 1 mg bupropion hcl tabs 75 1 doxepin hcl caps 10 mg 1 mg 1 chlorpromazine hcl soln doxepin hcl caps 100 mg 1 25 mg/ml doxepin hcl caps 150 mg 1 chlorpromazine hcl tabs doxepin hcl caps 25 mg 1 1 10 mg doxepin hcl caps 50 mg 1 chlorpromazine hcl tabs doxepin hcl caps 75 mg 1 1 100 mg doxepin hcl conc 10 1 chlorpromazine hcl tabs mg/ml 1 200 mg duloxetine hcl cpep 20 1 chlorpromazine hcl tabs mg 1 25 mg duloxetine hcl cpep 30 1 chlorpromazine hcl tabs mg 1 50 mg duloxetine hcl cpep 60 1 citalopram mg hydrobromide soln 10 1 escitalopram oxalate 1 mg/5ml soln 5 mg/5ml citalopram escitalopram oxalate 1 hydrobromide tabs 10 1 tabs 10 mg mg escitalopram oxalate 1 citalopram tabs 20 mg hydrobromide tabs 20 1 escitalopram oxalate 1 mg tabs 5 mg citalopram fluoxetine hcl caps 10 1 hydrobromide tabs 40 1 mg mg

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 47 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits fluoxetine hcl caps 20 INVEGA SUSTENNA 1 mg SUSY 234 MG/1.5ML 1 fluoxetine hcl caps 40 [paliperidone palmitate] 1 mg INVEGA SUSTENNA fluoxetine hcl soln 20 SUSY 39 MG/0.25ML 1 1 mg/5ml [paliperidone palmitate] fluphenazine decanoate INVEGA SUSTENNA 1 soln 25 mg/ml SUSY 78 MG/0.5ML 1 fluphenazine hcl conc 5 [paliperidone palmitate] 1 loxapine succinate caps mg/ml 1 fluphenazine hcl tabs 1 10 mg 1 loxapine succinate caps mg 1 fluphenazine hcl tabs 10 25 mg 1 loxapine succinate caps mg 1 fluphenazine hcl tabs 2.5 5 mg 1 loxapine succinate caps mg 1 fluphenazine hcl tabs 5 50 mg 1 maprotiline hcl tabs 25 mg 1 fluvoxamine maleate mg 1 maprotiline hcl tabs 50 tabs 100 mg 1 fluvoxamine maleate mg 1 maprotiline hcl tabs 75 tabs 25 mg 1 fluvoxamine maleate mg 1 tabs 50 mg mirtazapine tabs 15 mg 1 haloperidol decanoate 1 mirtazapine tabs 30 mg 1 soln 100 mg/ml mirtazapine tabs 45 mg 1 haloperidol decanoate nefazodone hcl tabs 100 1 1 soln 50 mg/ml mg haloperidol lactate conc nefazodone hcl tabs 150 1 1 2 mg/ml mg haloperidol lactate soln nefazodone hcl tabs 200 1 1 5 mg/ml mg haloperidol tabs 0.5 mg 1 nefazodone hcl tabs 250 1 haloperidol tabs 1 mg 1 mg haloperidol tabs 10 mg 1 nefazodone hcl tabs 50 1 haloperidol tabs 2 mg 1 mg nortriptyline hcl caps 10 haloperidol tabs 20 mg 1 1 haloperidol tabs 5 mg 1 mg imipramine hcl tabs 10 nortriptyline hcl caps 25 1 1 mg mg imipramine hcl tabs 25 nortriptyline hcl caps 50 1 1 mg mg imipramine hcl tabs 50 nortriptyline hcl caps 75 1 1 mg mg nortriptyline hcl soln 10 INVEGA SUSTENNA 1 SUSY 117 MG/0.75ML 1 mg/5ml [paliperidone palmitate] olanzapine solr 10 mg 1 INVEGA SUSTENNA olanzapine tabs 10 mg 1 SUSY 156 MG/ML 1 olanzapine tabs 15 mg 1 [paliperidone palmitate] olanzapine tabs 2.5 mg 1

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 48 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits 1 quetiapine fumarate tabs olanzapine tabs 20 mg 1 olanzapine tabs 5 mg 1 200 mg quetiapine fumarate tabs olanzapine tabs 7.5 mg 1 1 ORAP TABS 1 MG 25 mg 1 quetiapine fumarate tabs [pimozide] 1 ORAP TABS 2 MG 300 mg 1 quetiapine fumarate tabs [pimozide] 1 paroxetine hcl tabs 10 400 mg 1 quetiapine fumarate tabs mg 1 paroxetine hcl tabs 20 50 mg 1 mg RISPERDAL CONSTA paroxetine hcl tabs 30 SRER 12.5 MG 1 1 mg [risperidone paroxetine hcl tabs 40 microspheres] 1 mg RISPERDAL CONSTA SRER 25 MG perphenazine tabs 16 mg 1 1 [risperidone perphenazine tabs 2 mg 1 microspheres] perphenazine tabs 4 mg 1 RISPERDAL CONSTA perphenazine tabs 8 mg 1 SRER 37.5 MG 1 perphenazine- [risperidone amitriptyline tabs 2-10 1 microspheres] mg RISPERDAL CONSTA perphenazine- SRER 50 MG 1 amitriptyline tabs 2-25 1 [risperidone mg microspheres] perphenazine- RISPERIDONE SOLN 1 1 amitriptyline tabs 4-10 1 MG/ML [risperidone] mg RISPERIDONE TABS 1 perphenazine- 0.25 MG [risperidone] amitriptyline tabs 4-25 1 RISPERIDONE TABS 0.5 1 mg MG [risperidone] perphenazine- risperidone tabs 1 mg 1 amitriptyline tabs 4-50 1 RISPERIDONE TABS 2 1 mg MG [risperidone] phenelzine sulfate tabs RISPERIDONE TABS 3 1 1 15 mg MG [risperidone] pimozide tabs 2 mg 1 RISPERIDONE TABS 4 prochlorperazine 1 1 MG [risperidone] edisylate soln 10 mg/2ml sertraline hcl tabs 100 prochlorperazine 1 1 mg maleate tabs 10 mg sertraline hcl tabs 25 mg 1 prochlorperazine 1 sertraline hcl tabs 50 mg 1 maleate tabs 5 mg thioridazine hcl tabs 10 protriptyline hcl tabs 10 1 1 mg mg thioridazine hcl tabs 100 protriptyline hcl tabs 5 1 1 mg mg thioridazine hcl tabs 25 quetiapine fumarate tabs 1 1 mg 100 mg

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 49 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits thioridazine hcl tabs 50 ziprasidone hcl caps 80 1 1 mg mg thiothixene caps 1 mg 1 CONTRACEPTIVES (FOAMS, DEVICES) thiothixene caps 10 mg 1 CONTRACEPTIVES (FOAMS, DEVICES) thiothixene caps 2 mg 1 WIDE-SEAL DIAPHRAGM thiothixene caps 5 mg 1 60 DPRH 2 % [diaphragm 1 tranylcypromine sulfate wide seal] 1 tabs 10 mg WIDE-SEAL DIAPHRAGM trazodone hcl tabs 100 65 DPRH 2 % [diaphragm 1 1 mg wide seal] trazodone hcl tabs 150 WIDE-SEAL DIAPHRAGM 1 mg 70 DPRH 2 % [diaphragm 1 trazodone hcl tabs 50 wide seal] 1 mg WIDE-SEAL DIAPHRAGM trifluoperazine hcl tabs 1 75 DPRH 2 % [diaphragm 1 1 mg wide seal] trifluoperazine hcl tabs WIDE-SEAL DIAPHRAGM 1 10 mg 80 DPRH 2 % [diaphragm 1 trifluoperazine hcl tabs 2 wide seal] 1 mg WIDE-SEAL DIAPHRAGM trifluoperazine hcl tabs 5 85 DPRH 2 % [diaphragm 1 1 mg wide seal] trimipramine maleate WIDE-SEAL DIAPHRAGM 1 caps 100 mg 90 DPRH 2 % [diaphragm 1 trimipramine maleate wide seal] 1 caps 25 mg WIDE-SEAL DIAPHRAGM trimipramine maleate 95 DPRH 2 % [diaphragm 1 1 caps 50 mg wide seal] venlafaxine hcl er cp24 DEVICES 1 150 mg DEVICES venlafaxine hcl er cp24 1 AEROCHAMBER PLUS 37.5 mg FLO-VU SMALL MISC 1 venlafaxine hcl er cp24 1 [spacer/aerosol-holding 75 mg chambers] venlafaxine hcl tabs 100 1 AEROCHAMBER Z-STAT mg PLUS MISC 1 venlafaxine hcl tabs 25 1 [spacer/aerosol-holding mg chambers] venlafaxine hcl tabs 37.5 AEROCHAMBER Z-STAT 1 mg PLUS/LARGE MISC 1 venlafaxine hcl tabs 50 [spacer/aerosol-holding 1 mg chambers] venlafaxine hcl tabs 75 AEROCHAMBER Z-STAT 1 mg PLUS/MEDIUM MISC 1 ziprasidone hcl caps 20 [spacer/aerosol-holding 1 mg chambers] ziprasidone hcl caps 40 AEROTRACH PLUS MISC 1 mg [respiratory therapy 1 ziprasidone hcl caps 60 supplies] 1 mg

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 50 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits BD INSULIN SYRINGE U- CORTROSYN SOLR 0.25 1 500 MISC 31G X 6MM 0.5 MG [cosyntropin] 1 ML [insulin CYSTO-CONRAY II SOLN syringe/needle u-500] 17.2 % [iothalamate 1 BD VEO INSULIN SYR meglumine] U/F 1/2UNIT MISC 31G X CYSTOGRAFIN SOLN 30 1 15/64" 0.3 ML [insulin % [diatrizoate 1 syringe/needle u-100] meglumine] MONOJECT INSULIN CYSTOGRAFIN-DILUTE SYRINGE MISC 27G X SOLN 18 % 1 1 [diatrizoate 1/2" 1 ML [insulin meglumine] syringe/needle u-100] D-XYLOSE POWD [d- 1 MONOJECT INSULIN xylose] SYRINGE MISC 29G X E-Z-CAT DRY PACK 2 % 1 1 1/2" 0.3 ML [insulin [barium sulfate] syringe/needle u-100] EOVIST SOLN 0.25 MONOJECT INSULIN MOL/L [gadoxetate 1 SYRINGE MISC 29G X 1 disodium] 1/2" 1 ML [insulin GADAVIST SOLN 1 1 syringe/needle u-100] MMOL/ML [gadobutrol] OMNITROPE PEN 5 INJ GASTROGRAFIN SOLN DEVICE MISC [injection 1 66-10 % [diatrizoate 1 device] meglumine & sodium] TRUZONE PEAK FLOW indigotindisulfonate 1 METER DEVI [peak flow 1 sodium soln meter] LEXISCAN SOLN 0.4 1 DIAGNOSTIC AGENTS MG/5ML [regadenoson] DIAGNOSTIC AGENTS LUMASON SUSR 60.7-25 MG [sulfur hexafluoride adenosine soln 3 mg/ml 1 1 AK-FLUOR SOLN 10 % lipid-type a [fluorescein sodium 1 microspheres] injection] MAGNEVIST SOLN 469.01 MG/ML ALTAFLUOR BENOX 1 SOLN 0.25-0.4 % [gadopentetate 1 [fluorescein w/ dimeglumine] benoxinate] MD-76 R SOLN 66-10 % BIO GLO STRP 1 MG [diatrizoate meglumine & 1 [fluorescein sodium 1 sodium] METOPIRONE CAPS 250 topical] 1 CANDIN SOLN [candida MG [metyrapone] albicans skin test 1 MULTIHANCE SOLN 529 antigen] MG/ML [gadobenate 1 CHIRHOSTIM SOLR 16 dimeglumine] OMNIPAQUE INJ MCG [secretin acetate 1 1 (human)] 300MG/ML [iohexol] CONRAY 43 INJ 43% OMNIPAQUE INJ 1 1 [iothalamate meglumine] 350MG/ML [iohexol] CONRAY SOLN 60 % OMNIPAQUE SOLN 180 1 1 [iothalamate meglumine] MG/ML [iohexol] OMNIPAQUE SOLN 240 1 MG/ML [iohexol]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 51 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits OMNIPAQUE SOLN 300 SODIUM BICARBONATE 1 MG/ML [iohexol] SOLN 4.2 % [sodium 1 OMNIPAQUE SOLN 350 bicarbonate] 1 MG/ML [iohexol] SODIUM BICARBONATE READI-CAT 2 SUSP 2 % SOLN 7.5 % [sodium 1 1 [barium sulfate] bicarbonate] READI-CAT 2 SUSP 2.1 SODIUM BICARBONATE 1 % [barium sulfate] SOLN 8.4 % [sodium 1 THYROGEN SOLR 1.1 bicarbonate] 1 MG [thyrotropin alfa] THAM SOLN 30 TISSUEBLUE SOSY MEQ/100ML 1 1 0.025 % [brilliant blue g] [tromethamine] TUBERSOL SOLN 5 TRICITRATES SOLN 550- UNIT/0.1ML [tuberculin 1 500-334 MG/5ML [pot & 1 ppd] sod citrates w/citric ac] VOLUMEN SUSP 0.1 % AMMONIA DETOXICANTS 1 [barium sulfate] BUPHENYL TABS 500 ELECTROLYTIC, CALORIC, AND WATER MG [sodium 1 QL - 30 day(s) BALANCE phenylbutyrate] ALKALINIZING AGENTS lactulose CYTRA K CRYSTALS (encephalopathy) soln 1 PACK 3300-1002 MG 10 gm/15ml 1 lactulose soln 10 [potassium citrate-citric 1 acid] gm/15ml CYTRA-K SOLN 1100-334 LITHOSTAT TABS 250 MG/5ML [potassium 1 MG [acetohydroxamic 1 citrate-citric acid] acid] NEUT SOLN 4 % [sodium sodium phenylbutyrate 1 1 QL - 30 day(s) bicarbonate] powd 3 gm/tsp POTASSIUM CITRATE CALORIC AGENTS ER TBCR 10 MEQ (1080 AMINOSYN II SOLN 10 % 1 1 MG) [potassium citrate [amino acid infusion] (alkalinizer)] AMINOSYN POTASSIUM CITRATE II/ELECTROLYTES SOLN 1 ER TBCR 5 MEQ (540 8.5 % [amino acid 1 MG) [potassium citrate electrolyte infusion] (alkalinizer)] CLINIMIX E/DEXTROSE POTASSIUM CITRATE- (2.75/10) SOLN 2.75 % CITRIC ACID SOLN 1100- [amino acid electrolyte 1 1 334 MG/5ML [potassium w/ calcium infusion in citrate-citric acid] d10w] SOD CITRATE-CITRIC CLINIMIX E/DEXTROSE ACID SOLN 500-334 (2.75/5) SOLN 2.75 % 1 MG/5ML [sodium citrate [amino acid electrolyte 1 & citric acid] w/ calcium infusion in SODIUM ACETATE SOLN d5w] 2 MEQ/ML [sodium 1 CLINIMIX E/DEXTROSE acetate] (4.25/10) SOLN 4.25 % 1 [amino acid electrolyte

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 52 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits w/ calcium infusion in CLINIMIX/DEXTROSE d10w] (5/20) SOLN 5 % [amino 1 CLINIMIX E/DEXTROSE acid infusion in d20w] (4.25/25) SOLN 4.25 % CLINIMIX/DEXTROSE [amino acid electrolyte 1 (5/25) SOLN 5 % [amino 1 w/ calcium infusion in acid infusion in d25w] d25w] [Amino Acid Infusion] 1 CLINIMIX E/DEXTROSE CLINISOL SF SOLN 15 % (4.25/5) SOLN 4.25 % DEXTROSE SOLN 10 % 1 [amino acid electrolyte 1 [dextrose] w/ calcium infusion in DEXTROSE SOLN 20 % 1 d5w] [dextrose] CLINIMIX E/DEXTROSE DEXTROSE SOLN 40 % 1 (5/15) SOLN 5 % [amino [dextrose] acid electrolyte w/ 1 DEXTROSE SOLN 5 % 1 calcium infusion in [dextrose] d15w] DEXTROSE SOLN 50 % 1 CLINIMIX E/DEXTROSE [dextrose] (5/20) SOLN 5 % [amino DEXTROSE SOLN 70 % 1 acid electrolyte w/ 1 [dextrose] calcium infusion in INTRALIPID EMUL 20 % d20w] [fat emulsion plant 1 CLINIMIX E/DEXTROSE based] (5/25) SOLN 5 % [amino INTRALIPID EMUL 30 % acid electrolyte w/ 1 [fat emulsion plant 1 calcium infusion in based] d25w] PROCALAMINE SOLN 3 CLINIMIX/DEXTROSE % [amino acid 1 (2.75/5) SOLN 2.75 % 1 electrolyte infusion] [amino acid infusion in PROSOL SOLN 20 % 1 d5w] [amino acid infusion] CLINIMIX/DEXTROSE TRAVASOL SOLN 10 % (4.25/10) SOLN 4.25 % 1 1 [amino acid infusion] [amino acid infusion in TROPHAMINE SOLN 10 1 d10w] % [amino acid infusion] CLINIMIX/DEXTROSE TROPHAMINE SOLN 6 % (4.25/20) SOLN 4.25 % 1 1 [amino acid infusion] [amino acid infusion in DIURETICS d20w] amiloride- CLINIMIX/DEXTROSE hydrochlorothiazide tabs 1 (4.25/25) SOLN 4.25 % 1 5-50 mg [amino acid infusion in bumetanide soln 0.25 d25w] 1 mg/ml CLINIMIX/DEXTROSE bumetanide tabs 0.5 mg 1 (4.25/5) SOLN 4.25 % 1 [amino acid infusion in bumetanide tabs 1 mg 1 d5w] bumetanide tabs 2 mg 1 chlorthalidone tabs 25 CLINIMIX/DEXTROSE 1 (5/15) SOLN 5 % [amino 1 mg chlorthalidone tabs 50 acid infusion in d15w] 1 mg

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 53 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits DYRENIUM CAPS 100 [Sodium Polystyrene 1 MG [triamterene] Sulfonate] KIONEX SUSP 1 DYRENIUM CAPS 50 MG 15 GM/60ML 1 [triamterene] RENVELA PACK 2.4 GM 1 EDECRIN TABS 25 MG [sevelamer carbonate] 1 [ethacrynic acid] RENVELA TABS 800 MG 1 ethacrynic acid tabs 25 [sevelamer carbonate] 1 mg sevelamer carbonate 1 furosemide soln 10 pack 2.4 gm 1 mg/ml sevelamer carbonate 1 furosemide soln 8 mg/ml 1 tabs 800 mg FUROSEMIDE TABS 20 sodium polystyrene 1 1 MG [furosemide] sulfonate powd FUROSEMIDE TABS 40 sodium polystyrene 1 MG [furosemide] sulfonate susp 15 1 furosemide tabs 80 mg 1 gm/60ml hydrochlorothiazide tabs sodium polystyrene 1 12.5 mg sulfonate susp 30 1 hydrochlorothiazide tabs gm/120ml 1 25 mg [Sodium Polystyrene hydrochlorothiazide tabs Sulfonate] SPS SUSP 15 1 1 50 mg GM/60ML indapamide tabs 1.25 mg 1 IRRIGATING SOLUTIONS ACETIC ACID SOLN 0.25 indapamide tabs 2.5 mg 1 1 MANNITOL SOLN 25 % % [acetic acid] 1 [mannitol] DIANEAL LOW metolazone tabs 10 mg 1 CALCIUM/4.25% DEX SOLN 483 MOSM/L 1 metolazone tabs 2.5 mg 1 [peritoneal dialysis 1 metolazone tabs 5 mg solutions] OSMITROL SOLN 20 % 1 DIANEAL PD-2/1.5% [mannitol] DEXTROSE SOLN 346 1 SODIUM EDECRIN SOLR MOSM/L [peritoneal 50 MG [ethacrynate 1 dialysis solutions] sodium] DIANEAL PD-2/2.5% torsemide tabs 10 mg 1 DEXTROSE SOLN 396 1 torsemide tabs 100 mg 1 MOSM/L [peritoneal torsemide tabs 20 mg 1 dialysis solutions] torsemide tabs 5 mg 1 DIANEAL PD-2/4.25% triamterene-hctz caps DEXTROSE SOLN 485 1 1 37.5-25 mg MOSM/L [peritoneal TRIAMTERENE-HCTZ dialysis solutions] TABS 37.5-25 MG LACTATED RINGERS 1 [triamterene & SOLN [lactated ringer's 1 hydrochlorothiazide] (irrigation)] TRIAMTERENE-HCTZ RINGERS IRRIGATION TABS 75-50 MG SOLN [ringer's 1 1 [triamterene & irrigation] hydrochlorothiazide] SODIUM CHLORIDE ION-REMOVING AGENTS SOLN 0.9 % [sodium 1 chloride (gu irrigant)]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 54 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits STERILE WATER FOR DEXTROSE-NACL SOLN IRRIGATION SOLN 5-0.33 % [dextrose w/ 1 1 [water for irrigation, sodium chloride] sterile] DEXTROSE-NACL SOLN ULTRABAG/DIANEAL/1.5 5-0.45 % [dextrose w/ 1 % DEXTROSE SOLN 344 sodium chloride] 1 MOSM/L [peritoneal DEXTROSE-NACL SOLN dialysis solutions] 5-0.9 % [dextrose w/ 1 ULTRABAG/DIANEAL/2.5 sodium chloride] % DEXTROSE SOLN 395 EFFER-K TBEF 25 MEQ 1 1 MOSM/L [peritoneal [potassium bicarbonate] dialysis solutions] [Calcium Acetate REPLACEMENT PREPARATIONS (phosphate Binder)] 1 calcium acetate (phos ELIPHOS TABS 667 MG 1 hetastarch-nacl soln 6- binder) caps 667 mg 1 CALCIUM CHLORIDE 0.9 % SOLN 10 % [calcium 1 HEXTEND SOLN 6 % chloride (dihydrate)] [hetastarch in lactated 1 CALCIUM GLUCONATE electrolyte] HYPERLYTE-CR CONC SOLN 10 % [calcium 1 1 gluconate] [parenteral electrolytes] CHROMIC CHLORIDE K-EFFERVESCENT TBEF SOLN 40 MCG/10ML 1 25 MEQ [potassium 1 [chromic chloride] bicarbonate] CUPRIC CHLORIDE K-PHOS TABS 500 MG SOLN 0.4 MG/ML [cupric 1 [potassium phosphate 1 chloride] monobasic] K-TAB TBCR 10 MEQ DEXTROSE 1 5%/ELECTROLYTE #48 [potassium chloride] 1 SOLN [electrolyte-48 in KCL IN DEXTROSE- dextrose] NACL SOLN 10-5-0.45 DEXTROSE IN MEQ/L-%-% [potassium 1 LACTATED RINGERS chloride in dextrose & 1 SOLN 5 % [dextrose in sodium chloride] lactated ringers] KCL IN DEXTROSE- dextrose in ringers soln NACL SOLN 20-5-0.2 1 5 % MEQ/L-%-% [potassium 1 DEXTROSE-NACL SOLN chloride in dextrose & 10-0.45 % [dextrose w/ 1 sodium chloride] sodium chloride] KCL IN DEXTROSE- DEXTROSE-NACL SOLN NACL SOLN 20-5-0.45 2.5-0.45 % [dextrose w/ 1 MEQ/L-%-% [potassium 1 sodium chloride] chloride in dextrose & DEXTROSE-NACL SOLN sodium chloride] 5-0.2 % [dextrose w/ 1 KCL IN DEXTROSE- sodium chloride] NACL SOLN 20-5-0.9 DEXTROSE-NACL SOLN MEQ/L-%-% [potassium 1 5-0.225 % [dextrose w/ 1 chloride in dextrose & sodium chloride] sodium chloride] KCL IN DEXTROSE- 1 NACL SOLN 30-5-0.45

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 55 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits MEQ/L-%-% [potassium PLASMA-LYTE A SOLN 1 chloride in dextrose & [electrolyte-a] sodium chloride] POTASSIUM ACETATE KCL IN DEXTROSE- SOLN 2 MEQ/ML 1 NACL SOLN 40-5-0.45 [potassium acetate] MEQ/L-%-% [potassium 1 potassium chloride chloride in dextrose & 0.075%/d5w/nacl 0.225% 1 sodium chloride] inj .075/.2% KCL IN DEXTROSE- potassium chloride crys 1 NACL SOLN 40-5-0.9 er tbcr 10 meq MEQ/L-%-% [potassium 1 potassium chloride crys 1 chloride in dextrose & er tbcr 20 meq sodium chloride] potassium chloride er 1 KCL-LACTATED cpcr 10 meq RINGERS-D5W SOLN 20 potassium chloride er 1 MEQ/L [potassium 1 cpcr 8 meq chloride in d5w lactated POTASSIUM CHLORIDE ringers] IN DEXTROSE SOLN 20- KLOR-CON TBCR 8 MEQ 1 1 5 MEQ/L-% [potassium [potassium chloride] chloride in dextrose] LACTATED RINGERS 1 POTASSIUM CHLORIDE SOLN [lactated ringer's] IN DEXTROSE SOLN 40- [Dextran 40 In D5w] LMD 1 1 5 MEQ/L-% [potassium IN D5W SOLN 10-5 % chloride in dextrose] [Dextran 40 In Saline] POTASSIUM CHLORIDE LMD IN NACL SOLN 10- 1 IN NACL SOLN 20-0.45 1 0.9 % MEQ/L-% [potassium M.T.E.-5 CONCENTRATE chloride in nacl] INJ CONC [trace 1 POTASSIUM CHLORIDE minerals (cr-cu-mn-se- IN NACL SOLN 20-0.9 1 zn)] MEQ/L-% [potassium MAGNESIUM SULFATE chloride in nacl] IN D5W SOLN 1-5 POTASSIUM CHLORIDE GM/100ML-% 1 IN NACL SOLN 40-0.9 1 [magnesium sulfate in MEQ/L-% [potassium dextrose] chloride in nacl] MANGANESE CHLORIDE POTASSIUM CHLORIDE SOLN 0.1 MG/ML 1 PACK 20 MEQ 1 [manganese chloride] [potassium chloride] MULTITRACE-4 potassium chloride sol 1 CONCENTRATE SOLN 10% sf 0.01-1-0.5-5 MG/ML 1 POTASSIUM CHLORIDE [trace minerals (cr-cu- SOLN 10 MEQ/100ML 1 mn-zn)] [potassium chloride] NORMAL SALINE FLUSH POTASSIUM CHLORIDE SOLN 0.9 % [sodium 1 SOLN 10 MEQ/50ML 1 chloride flush] [potassium chloride] PHOSLYRA SOLN 667 potassium chloride soln 1 MG/5ML [calcium acetate 1 2 meq/ml (phosphate binder)]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 56 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits POTASSIUM CHLORIDE TRACE ELEMENTS SOLN 20 MEQ/100ML 1 4/PEDIATRIC SOLN 1- [potassium chloride] 100-30-500 MCG/ML 1 POTASSIUM CHLORIDE [trace minerals (cr-cu- SOLN 20 MEQ/50ML 1 mn-zn)] [potassium chloride] ZINC CHLORIDE SOLN 1 1 POTASSIUM CHLORIDE MG/ML [zinc chloride] SOLN 40 MEQ/100ML 1 ZINC SULFATE SOLN 1 1 [potassium chloride] MG/ML [zinc sulfate] POTASSIUM CHLORIDE URICOSURIC AGENTS SOLN 40 MEQ/15ML colchicine-probenecid 1 1 (20%) [potassium tabs 0.5-500 mg chloride] probenecid tabs 500 mg 1 potassium phosphate inj 1 ENZYMES 3mm/ml ENZYMES POTASSIUM PHOSPHATES SOLN 45 ALDURAZYME SOLN 2.9 1 1 MMOLE/15ML MG/5ML [laronidase] [potassium phosphates] ARALAST NP SOLR 1000 RINGERS SOLN MG [alpha1-proteinase 1 QL - 30 day(s) 1 [ringer's] inhibitor (human)] SELENIUM SOLN 40 CEREZYME SOLR 400 1 1 MCG/ML [selenious acid] UNIT [imiglucerase] ELAPRASE SOLN 6 SODIUM CHLORIDE (PF) 1 QL - 30 day(s) SOLN 0.9 % [sodium 1 MG/3ML [idursulfase] ELITEK SOLR 1.5 MG chloride] 1 SODIUM CHLORIDE [rasburicase] BACTERIOSTATIC SOLN ELITEK SOLR 7.5 MG 1 1 0.9 % [bacteriostatic [rasburicase] FABRAZYME SOLR 35 sodium chloride] 1 QL - 30 day(s) SODIUM CHLORIDE MG [agalsidase beta] FABRAZYME SOLR 5 MG SOLN 0.45 % [sodium 1 1 QL - 30 day(s) chloride] [agalsidase beta] SODIUM CHLORIDE HYLENEX SOLN 150 SOLN 0.9 % [sodium 1 UNIT/ML [hyaluronidase 1 chloride] human] LUMIZYME SOLR 50 MG SODIUM CHLORIDE 1 QL - 30 day(s) SOLN 3 % [sodium 1 [alglucosidase alfa] NAGLAZYME SOLN 1 chloride] 1 QL - 30 day(s) SODIUM CHLORIDE MG/ML [galsulfase] PULMOZYME SOLN 1 SOLN 4 MEQ/ML [sodium 1 1 QL - 30 day(s) chloride] MG/ML [dornase alfa] SODIUM CHLORIDE STRENSIQ SOLN 18 SOLN 5 % [sodium 1 MG/0.45ML [asfotase 1 QL - 30 day(s) chloride] alfa] STRENSIQ SOLN 28 SODIUM PHOSPHATES 1 QL - 30 day(s) SOLN 45 MMOLE/15ML MG/0.7ML [asfotase alfa] STRENSIQ SOLN 40 [sodium phosphates 1 1 QL - 30 day(s) (sodium phosphate MG/ML [asfotase alfa] STRENSIQ SOLN 80 dibasic & monobasic)] 1 QL - 30 day(s) MG/0.8ML [asfotase alfa]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 57 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits VIMIZIM SOLN 5 MG/5ML ZYMAXID SOLN 0.5 % 1 QL - 30 day(s) 1 [elosulfase alfa] [gatifloxacin (ophth)] VORAXAZE SOLR 1000 1 QL - 30 day(s) ANTI-INFLAMMATORY AGENTS UNIT [glucarpidase] [Sulfacetamide Sod- VPRIV SOLR 400 UNIT prednisolone] 1 1 [velaglucerase alfa] BLEPHAMIDE S.O.P. EYE, EAR, NOSE, AND THROAT (EENT) OINT 10-0.2 % PREPARATIONS BLEPHAMIDE SUSP 10- ANTI-INFECTIVES 0.2 % [sulfacetamide 1 bacitracin oint 500 sod-prednisolone] 1 CEQUA SOLN 0.09 % unit/gm 1 bacitracin-polymyxin b [cyclosporine (ophth)] 1 oint 500-10000 unit/gm ciprofloxacin- chlorhexidine gluconate dexamethasone susp 1 1 soln 0.12 % 0.3-0.1 % ciprofloxacin hcl soln 0.3 COLY-MYCIN S SUSP 1 3.3-3-10-0.5 MG/ML % 1 erythromycin oint 5 [neomycin-colistin-hc- 1 mg/gm thonzonium] dexamethasone sodium gatifloxacin soln 0.5 % 1 1 [Gentamicin Sulfate phosphate soln 0.1 % diclofenac sodium soln (ophth)] GENTAK OINT 1 1 0.3 % 0.1 % gentamicin sulfate soln flunisolide soln 25 1 1 0.3 % mcg/act (0.025%) MITOSOL KIT 0.2 MG fluorometholone susp 1 1 [mitomycin (ophthalmic)] 0.1 % moxifloxacin hcl soln 0.5 flurbiprofen sodium soln 1 1 % 0.03 % NATACYN SUSP 5 % fluticasone propionate 1 1 [natamycin] susp 50 mcg/act neomycin-bacitracin zn- FML FORTE SUSP 0.25 polymyx oint 5-400- 1 % [fluorometholone 1 10000 (ophth)] neomycin-polymyxin- FML OINT 0.1 % gramicidin soln 1.75- 1 [fluorometholone 1 10000-.025 (ophth)] ketorolac tromethamine [Neomycin-polymyxin- 1 gramicidin] NEOSPORIN 1 soln 0.4 % ketorolac tromethamine SOLN 1.75-10000-.025 1 ofloxacin soln 0.3 % 1 soln 0.5 % polymyxin b- neomycin-polymyxin- 1 trimethoprim soln 10000- 1 dexameth oint 3.5-10000- 0.1 unit/ml-% 0.1 sulfacetamide sodium neomycin-polymyxin- 1 1 soln 10 % dexameth susp 3.5- 10000-0.1 tobramycin soln 0.3 % 1 neomycin-polymyxin-hc TOBREX OINT 0.3 % 1 1 soln 1 % [tobramycin (ophth)] trifluridine soln 1 % 1

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 58 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits neomycin-polymyxin-hc methazolamide tabs 50 1 1 susp 3.5-10000-1 mg OZURDEX IMPL 0.7 MG MIOCHOL-E SOLR 20 MG 1 1 [dexamethasone (ophth)] [acetylcholine chloride] PRED MILD SUSP 0.12 % MIOSTAT SOLN 0.01 % 1 [prednisolone acetate 1 [carbachol (ophth)] (ophth)] PHOSPHOLINE IODIDE prednisolone acetate SOLR 0.125 % 1 1 susp 1 % [echothiophate iodide] prednisolone sodium 1 1 pilocarpine hcl soln 1 % phosphate soln 1 % pilocarpine hcl soln 2 % 1 RETISERT IMPL 0.59 MG pilocarpine hcl soln 4 % 1 [fluocinolone acetonide 1 timolol maleate soln 0.25 1 (ophth)] % sulfacetamide- timolol maleate soln 0.5 1 prednisolone soln 10- 1 % 0.23 % EENT DRUGS, MISCELLANEOUS TOBRADEX OINT 0.3-0.1 ACETIC ACID SOLN 2 % % [tobramycin- 1 1 [acetic acid (otic)] dexamethasone] acetic acid-aluminum 1 ANTIALLERGIC AGENTS acetate soln 2 % ALOCRIL SOLN 2 % apraclonidine hcl soln 1 [nedocromil sodium 1 0.5 % (ophth)] BSS PLUS SOLN azelastine hcl soln 0.1 % 1 [ophthalmic irrigation 1 cromolyn sodium soln 4 1 solution - intraocular] % BSS SOLN [ophthalmic olopatadine hcl soln 0.1 1 irrigation solution - 1 % intraocular] ANTIGLAUCOMA AGENTS EYLEA SOLN 2 1 acetazolamide er cp12 MG/0.05ML 1 [aflibercept] 500 mg EYLEA SOSY 2 1 acetazolamide sodium 1 MG/0.05ML [aflibercept] solr 500 mg HEALON5 INJ 23MG/ML 1 acetazolamide tabs 125 1 [sodium hyaluronate] mg IOPIDINE SOLN 1 % 1 acetazolamide tabs 250 1 [apraclonidine hcl] mg JETREA SOLN 0.5 1 betaxolol hcl soln 0.5 % 1 MG/0.2ML [ocriplasmin] 1 LACRISERT INST 5 MG bimatoprost soln 0.03 % 1 brimonidine tartrate soln [artificial tear insert] 1 0.2 % LUCENTIS SOLN 0.3 dorzolamide hcl soln 2 % 1 MG/0.05ML 1 QL - 30 day(s) dorzolamide hcl-timolol [ranibizumab] 1 mal soln 22.3-6.8 mg/ml LUCENTIS SOLN 0.5 latanoprost soln 0.005 % 1 MG/0.05ML 1 QL - 30 day(s) levobunolol hcl soln 0.5 [ranibizumab] 1 % LUCENTIS SOSY 0.3 methazolamide tabs 25 MG/0.05ML 1 QL - 30 day(s) 1 mg [ranibizumab]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 59 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits LUCENTIS SOSY 0.5 tropicamide soln 1 % 1 MG/0.05ML 1 QL - 30 day(s) VASOCONSTRICTORS [ranibizumab] naphazoline hcl soln 1 MACUGEN SOLN 0.3 MG 1 PHENYLEPHRINE HCL [pegaptanib sodium] SOLN 10 % 1 PHOTREXA-PHOTREXA [phenylephrine hcl VISCOUS KIT SOSY (mydriatic)] 0.146 &0.146-20 % 1 PHENYLEPHRINE HCL [riboflavin5-phos sod & SOLN 2.5 % 1 riboflavin 5-phosphate [phenylephrine hcl sodium-dextran] (mydriatic)] VISUDYNE SOLR 15 MG 1 GASTROINTESTINAL DRUGS [verteporfin] ANTI-INFLAMMATORY AGENTS LOCAL ANESTHETICS balsalazide disodium AKTEN GEL 3.5 % 1 1 caps 750 mg [lidocaine hcl (ophth)] LIALDA TBEC 1.2 GM [Proparacaine Hcl] 1 1 [mesalamine] ALCAINE SOLN 0.5 % mesalamine enem 4 gm 1 C-TOPICAL SOLN 4 % 1 mesalamine supp 1000 [cocaine hcl] 1 lidocaine viscous hcl mg 1 soln 2 % mesalamine tbec 1.2 gm 1 proparacaine hcl soln PENTASA CPCR 250 MG 1 1 0.5 % [mesalamine] PENTASA CPCR 500 MG TETRACAINE HCL SOLN 1 0.5 % [tetracaine hcl 1 [mesalamine] (ophth)] ANTIDIARRHEA AGENTS TETRAVISC SOLN 0.5 % diphenoxylate-atropine 1 1 [tetracaine hcl (ophth)] liqd 2.5-0.025 mg/5ml diphenoxylate-atropine MYDRIATICS 1 ATROPINE SULFATE tabs 2.5-0.025 mg PAREGORIC TINC 2 OINT 1 % [atropine 1 1 sulfate (ophthalmic)] MG/5ML [paregoric] ATROPINE SULFATE ANTIEMETICS SOLN 1 % [atropine 1 AKYNZEO CAPS 300-0.5 sulfate (ophthalmic)] MG [netupitant- 1 QL - 30 day(s) [Cyclopentolate Hcl] palonosetron] 1 CYCLOGYL SOLN 0.5 % dronabinol caps 10 mg 1 [Cyclopentolate W/ dronabinol caps 2.5 mg 1 Phenylephrine] 1 dronabinol caps 5 mg 1 CYCLOMYDRIL SOLN EMEND CAPS 125 MG 1 QL - 30 day(s) 0.2-1 % [aprepitant] cyclopentolate hcl soln 1 EMEND CAPS 40 MG 1 1 QL - 30 day(s) % [aprepitant] cyclopentolate hcl soln 2 EMEND CAPS 80 MG 1 1 QL - 30 day(s) % [aprepitant] HOMATROPINE HBR EMEND TRI-PACK CAPS 1 QL - 30 day(s) SOLN 5 % [homatropine 1 80 & 125 MG [aprepitant] hbr] tropicamide soln 0.5 % 1

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 60 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits fosaprepitant sucralfate tabs 1 gm 1 dimeglumine solr 150 1 CATHARTICS AND LAXATIVES mg AMITIZA CAPS 24 MCG 1 meclizine hcl tabs 25 mg 1 [lubiprostone] ondansetron hcl soln 4 AMITIZA CAPS 8 MCG 1 1 mg/2ml [lubiprostone] ondansetron hcl soln 4 1 CASCARA SAGRADA mg/5ml EXTR 1 GM/ML [cascara 1 ondansetron hcl soln 40 1 sagrada] mg/20ml [Peg 3350-kcl-sod Bicarb- ondansetron hcl tabs 4 sod Chloride-sod Sulfate] 1 1 mg GAVILYTE-G SOLR 236 ondansetron hcl tabs 8 1 GM mg GOLYTELY SOLR 236 ondansetron tbdp 4 mg 1 GM [peg 3350-kcl-sod 1 ondansetron tbdp 8 mg 1 bicarb-sod chloride-sod scopolamine pt72 1 sulfate] 1 peg 3350-kcl-na bicarb- mg/3days 1 TRANSDERM-SCOP (1.5 nacl solr 420 gm peg 3350/electrolytes MG) PT72 1 MG/3DAYS 1 1 [scopolamine] solr 240 gm ANTIULCER AGENTS AND ACID CHOLELITHOLYTIC AGENTS SUPPRESSANTS URSO FORTE TABS 500 1 CARAFATE SUSP 1 MG 1 [ursodiol] GM/10ML [sucralfate] ursodiol tabs 250 mg 1 cimetidine hcl soln 300 1 DIGESTANTS mg/5ml CREON CPEP 12000- famotidine premixed 38000 UNIT 1 1 soln 20-0.9 mg/50ml-% [pancrelipase (lipase- famotidine soln 20 1 protease-amylase)] mg/2ml CREON CPEP 24000- famotidine soln 40 76000 UNIT 1 1 mg/4ml [pancrelipase (lipase- famotidine susr 40 1 protease-amylase)] mg/5ml CREON CPEP 3000-9500 famotidine tabs 20 mg 1 UNIT [pancrelipase 1 famotidine tabs 40 mg 1 (lipase-protease- misoprostol tabs 100 amylase)] 1 mcg CREON CPEP 36000- misoprostol tabs 200 114000 UNIT 1 1 mcg [pancrelipase (lipase- omeprazole cpdr 10 mg 1 protease-amylase)] omeprazole cpdr 20 mg 1 CREON CPEP 6000- 19000 UNIT omeprazole cpdr 40 mg 1 1 pantoprazole sodium [pancrelipase (lipase- 1 tbec 20 mg protease-amylase)] pantoprazole sodium ZENPEP CPEP 10000- 1 32000 UNIT tbec 40 mg 1 PROTONIX SOLR 40 MG [pancrelipase (lipase- 1 [pantoprazole sodium] protease-amylase)]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 61 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits ZENPEP CPEP 15000- EXJADE TBSO 125 MG 1 QL - 30 day(s) 47000 UNIT [deferasirox] 1 [pancrelipase (lipase- EXJADE TBSO 250 MG 1 QL - 30 day(s) protease-amylase)] [deferasirox] ZENPEP CPEP 20000- EXJADE TBSO 500 MG 1 QL - 30 day(s) 63000 UNIT 1 [deferasirox] [pancrelipase (lipase- JADENU SPRINKLE protease-amylase)] PACK 180 MG 1 QL - 30 day(s) ZENPEP CPEP 25000- [deferasirox] 79000 UNIT 1 JADENU SPRINKLE [pancrelipase (lipase- PACK 360 MG 1 QL - 30 day(s) protease-amylase)] [deferasirox] ZENPEP CPEP 3000- JADENU SPRINKLE 10000 UNIT 1 PACK 90 MG 1 QL - 30 day(s) [pancrelipase (lipase- [deferasirox] protease-amylase)] JADENU TABS 180 MG 1 QL - 30 day(s) ZENPEP CPEP 40000- [deferasirox] 126000 UNIT JADENU TABS 360 MG 1 1 QL - 30 day(s) [pancrelipase (lipase- [deferasirox] protease-amylase)] JADENU TABS 90 MG 1 QL - 30 day(s) ZENPEP CPEP 5000- [deferasirox] 24000 UNIT penicillamine caps 250 1 1 [pancrelipase (lipase- mg protease-amylase)] HORMONES AND SYNTHETIC SUBSTITUTES PROKINETIC AGENTS ADRENALS metoclopramide hcl soln 1 ASMANEX (120 10 mg/10ml METERED DOSES) AEPB metoclopramide hcl soln 1 220 MCG/INH 1 5 mg/ml [mometasone furoate metoclopramide hcl tabs 1 (inhalation)] 10 mg ASMANEX (30 METERED metoclopramide hcl tabs DOSES) AEPB 110 1 1 5 mg MCG/INH [mometasone GOLD COMPOUNDS furoate (inhalation)] GOLD COMPOUNDS ASMANEX (60 METERED RIDAURA CAPS 3 MG DOSES) AEPB 220 1 1 [auranofin] MCG/INH [mometasone HEAVY METAL ANTAGONISTS furoate (inhalation)] HEAVY METAL ANTAGONISTS ASMANEX HFA AERO 100 MCG/ACT BAL IN OIL SOLN 100 1 1 [mometasone furoate MG/ML [dimercaprol] (inhalation)] CHEMET CAPS 100 MG 1 ASMANEX HFA AERO [succimer] 200 MCG/ACT deferasirox tabs 360 mg 1 QL - 30 day(s) 1 [mometasone furoate deferasirox tabs 90 mg 1 QL - 30 day(s) (inhalation)] deferoxamine mesylate 1 betamethasone sod solr 2 gm phos & acet susp 6 (3-3) 1 deferoxamine mesylate 1 mg/ml solr 500 mg budesonide cpep 3 mg 1

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 62 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits budesonide susp 0.25 MEDROL TABS 2 MG 1 1 mg/2ml [methylprednisolone] budesonide susp 0.5 methylprednisolone 1 1 mg/2ml acetate susp 40 mg/ml cortisone acetate tabs 25 methylprednisolone 1 1 mg acetate susp 80 mg/ml dexamethasone elix 0.5 methylprednisolone 1 mg/5ml sodium succ solr 1000 1 [Dexamethasone] mg DEXAMETHASONE methylprednisolone 1 1 INTENSOL CONC 1 sodium succ solr 125 mg MG/ML methylprednisolone 1 dexamethasone sodium sodium succ solr 40 mg phosphate soln 10 1 methylprednisolone tabs 1 mg/ml 16 mg dexamethasone sodium methylprednisolone tabs 1 phosphate soln 20 1 32 mg mg/5ml methylprednisolone tabs 1 dexamethasone soln 0.5 1 4 mg mg/5ml methylprednisolone tabs 1 dexamethasone tabs 0.5 1 8 mg mg methylprednisolone tbpk 1 dexamethasone tabs 1 4 mg 0.75 mg [Prednisolone] MILLIPRED 1 dexamethasone tabs 1 TABS 5 MG 1 mg prednisolone sodium dexamethasone tabs 1.5 1 1 phosphate soln 15 mg mg/5ml dexamethasone tabs 2 1 prednisolone sodium mg phosphate soln 6.7 (5 1 dexamethasone tabs 4 base) mg/5ml 1 mg prednisolone soln 15 1 dexamethasone tabs 6 mg/5ml 1 mg [Prednisone] FLOVENT HFA AERO 44 PREDNISONE INTENSOL 1 MCG/ACT [fluticasone 1 CONC 5 MG/ML propionate hfa] prednisone soln 5 1 fludrocortisone acetate mg/5ml 1 tabs 0.1 mg prednisone tabs 1 mg 1 hydrocortisone tabs 10 1 prednisone tabs 10 mg 1 mg prednisone tabs 2.5 mg 1 hydrocortisone tabs 20 1 prednisone tabs 20 mg 1 mg prednisone tabs 5 mg 1 hydrocortisone tabs 5 1 prednisone tabs 50 mg 1 mg prednisone tbpk 10 mg KENALOG SUSP 10 1 MG/ML [triamcinolone 1 (21) prednisone tbpk 5 mg acetonide] 1 KENALOG SUSP 40 (21) PULMICORT MG/ML [triamcinolone 1 1 acetonide] FLEXHALER AEPB 180

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 63 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits MCG/ACT [budesonide methyltestosterone tabs 1 (inhalation)] 10 mg SOLU-CORTEF SOLR oxandrolone tabs 10 mg 1 100 MG [hydrocortisone 1 oxandrolone tabs 2.5 mg 1 sod succinate] testosterone cypionate 1 SOLU-CORTEF SOLR soln 200 mg/ml 1000 MG testosterone enanthate 1 1 [hydrocortisone sod soln 200 mg/ml succinate] testosterone gel 12.5 1 SOLU-CORTEF SOLR mg/act (1%) 250 MG [hydrocortisone 1 testosterone gel 20.25 1 sod succinate] mg/act (1.62%) SOLU-CORTEF SOLR testosterone gel 25 1 500 MG [hydrocortisone 1 mg/2.5gm (1%) sod succinate] testosterone gel 50 1 SOLU-MEDROL SOLR mg/5gm (1%) 125 MG 1 ANTIDIABETIC AGENTS [methylprednisolone sod acarbose tabs 100 mg 1 succ] SOLU-MEDROL SOLR acarbose tabs 25 mg 1 500 MG acarbose tabs 50 mg 1 1 BYDUREON BCISE AUIJ [methylprednisolone sod 1 succ] 2 MG/0.85ML [exenatide] SYMBICORT AERO 160- glimepiride tabs 1 mg 1 4.5 MCG/ACT glimepiride tabs 2 mg 1 1 [budesonide-formoterol glimepiride tabs 4 mg 1 fumarate dihydrate] glipizide tabs 10 mg 1 SYMBICORT AERO 80- glipizide tabs 5 mg 1 4.5 MCG/ACT 1 glipizide tb24 10 mg 1 [budesonide-formoterol glipizide tb24 2.5 mg 1 fumarate dihydrate] glipizide tb24 5 mg 1 ANDROGENS glipizide-metformin hcl ANDRODERM PT24 2 1 1 tabs 2.5-250 mg MG/24HR [testosterone] glipizide-metformin hcl ANDRODERM PT24 4 1 1 tabs 2.5-500 mg MG/24HR [testosterone] glipizide-metformin hcl [Methyltestosterone] 1 1 tabs 5-500 mg ANDROID CAPS 10 MG 1 [Fluoxymesterone] glyburide tabs 1.25 mg 1 ANDROXY TABS 10 MG glyburide tabs 2.5 mg 1 danazol caps 100 mg 1 glyburide tabs 5 mg 1 danazol caps 200 mg 1 HUMALOG MIX 50/50 KWIKPEN SUPN (50-50) danazol caps 50 mg 1 100 UNIT/ML [insulin 1 [Testosterone Cypionate] lispro protamine & DEPO-TESTOSTERONE 1 lispro] SOLN 100 MG/ML HUMALOG MIX 50/50 [Testosterone Cypionate] SUSP (50-50) 100 DEPO-TESTOSTERONE 1 1 UNIT/ML [insulin lispro SOLN 200 MG/ML protamine & lispro]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 64 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits HUMALOG SOLN 100 glucagon emergency kit 1 1 UNIT/ML [insulin lispro] 1 mg HUMULIN R U-500 CONTRACEPTIVES (CONCENTRATED) 1 [Norethindrone-eth SOLN 500 UNIT/ML Estradiol (triphasic)] 1 [insulin regular (human)] ARANELLE TABS HUMULIN R U-500 0.5/1/0.5-35 MG-MCG KWIKPEN SOPN 500 1 [Norgestrel & Ethinyl UNIT/ML [insulin regular Estradiol] CRYSELLE-28 1 (human)] TABS 0.3-30 MG-MCG JARDIANCE TABS 10 MG drospirenone-ethinyl 1 1 [empagliflozin] estradiol tabs 3-0.02 mg JARDIANCE TABS 25 MG drospirenone-ethinyl 1 1 [empagliflozin] estradiol tabs 3-0.03 mg LANTUS SOLN 100 ELLA TABS 30 MG 1 UNIT/ML [insulin 1 [ulipristal acetate] glargine] [Etonogestrel-ethinyl metformin hcl er tb24 Estradiol] ELURYNG 1 1 500 mg RING 0.12-0.015 metformin hcl er tb24 1 MG/24HR 750 mg JOLIVETTE TABS 0.35 metformin hcl tabs 1000 1 MG [norethindrone 1 mg (contraceptive)] metformin hcl tabs 500 1 [Norethin Acet & Estrad-fe] mg JUNEL FE 1.5/30 TABS 1 metformin hcl tabs 850 1 1.5-30 MG-MCG mg [Norethin Acet & Estrad-fe] pioglitazone hcl tabs 15 1 JUNEL FE 1/20 TABS 1- 1 mg 20 MG-MCG pioglitazone hcl tabs 30 1 [Ethynodiol Diacet & Eth mg Estrad] KELNOR 1/50 1 pioglitazone hcl tabs 45 TABS 1-50 MG-MCG 1 mg [Norethindrone Acet & Eth SYMLINPEN 120 SOPN Estra] LOESTRIN 1/20 1 2700 MCG/2.7ML 1 (21) TABS 1-20 MG-MCG [pramlintide acetate] [Levonorgestrel & Eth tolbutamide tabs 500 mg 1 Estradiol] LUTERA TABS 1 TRADJENTA TABS 5 MG 0.1-20 MG-MCG 1 [linagliptin] MIRENA (52 MG) IUD 20 VICTOZA SOPN 18 MCG/24HR 1 1 MG/3ML [liraglutide] [levonorgestrel (iud)] ANTIHYPOGLYCEMIC AGENTS [Norethindrone & Eth Estradiol] NECON 0.5/35 BAQSIMI TWO PACK 1 POWD 3 MG/DOSE 1 (28) TABS 0.5-35 MG- [glucagon] MCG GLUCAGEN HYPOKIT [Norethindrone-eth Estradiol (biphasic)] SOLR 1 MG [glucagon 1 1 hcl (rdna)] NECON 10/11-28 TAB GLUCAGEN INJ 1MG 10/11-28 1 NEXPLANON IMPL 68 [glucagon hcl (rdna)] 1 MG [etonogestrel]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 65 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits [Norethindrone & Eth CLIMARA PTWK 0.06 1 Estradiol] NORTREL 1/35 1 MG/24HR [estradiol] (28) TABS 1-35 MG-MCG CLIMARA PTWK 0.075 1 [Norethindrone-eth MG/24HR [estradiol] Estradiol (triphasic)] CLIMARA PTWK 0.1 1 1 NORTREL 7/7/7 TABS MG/24HR [estradiol] 0.5/0.75/1-35 MG-MCG clomiphene citrate tabs 1 [Norgestrel & Ethinyl 50 mg Estradiol] OGESTREL 1 DELESTROGEN OIL 20 TABS 0.5-50 MG-MCG MG/ML [estradiol 1 [Levonorgestrel & Eth valerate] Estradiol] PORTIA-28 1 DELESTROGEN OIL 40 TABS 0.15-30 MG-MCG MG/ML [estradiol 1 [Desogestrel & Ethinyl valerate] Estradiol] RECLIPSEN 1 [Estradiol Cypionate] TABS 0.15-30 MG-MCG DEPO-ESTRADIOL OIL 5 1 [Norgestimate-ethinyl MG/ML Estradiol] SPRINTEC 28 1 EEMT HS TABS 0.625- TABS 0.25-35 MG-MCG 1.25 MG [esterified 1 [Norgestimate-ethinyl estrogens & Estradiol (triphasic)] TRI- methyltestosterone] LO-SPRINTEC TABS 1 EEMT TABS 1.25-2.5 MG 0.18/0.215/0.25 MG-25 [esterified estrogens & 1 MCG methyltestosterone] [Norgestimate-ethinyl [Estradiol Vaginal] Estradiol (triphasic)] TRI- ESTRACE CREA 0.1 1 SPRINTEC TABS 1 MG/GM 0.18/0.215/0.25 MG-35 estradiol pttw 0.025 1 MCG mg/24hr [Levonorgestrel-eth estradiol pttw 0.0375 Estradiol (triphasic)] 1 1 mg/24hr TRIVORA (28) TABS 50- estradiol pttw 0.05 1 30/75-40/ 125-30 MCG mg/24hr [Norelgestromin-ethinyl estradiol pttw 0.075 1 Estradiol] XULANE PTWK 1 mg/24hr 150-35 MCG/24HR estradiol pttw 0.1 1 [Norelgestromin-ethinyl mg/24hr Estradiol] ZAFEMY PTWK 1 estradiol ptwk 0.05 1 150-35 MCG/24HR mg/24hr [Ethynodiol Diacet & Eth estradiol ptwk 0.075 1 Estrad] ZOVIA 1/35E (28) 1 mg/24hr TABS 1-35 MG-MCG estradiol ptwk 0.1 1 ESTROGENS AND ESTROGEN AGONISTS- mg/24hr ANTAGONISTS estradiol tabs 0.5 mg 1 CLIMARA PTWK 0.025 1 estradiol tabs 1 mg 1 MG/24HR [estradiol] estradiol tabs 2 mg 1 CLIMARA PTWK 0.0375 1 estradiol valerate inj MG/24HR [estradiol] 1 10mg/ml CLIMARA PTWK 0.05 1 estradiol valerate oil 20 MG/24HR [estradiol] 1 mg/ml

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 66 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits estradiol valerate oil 40 [desmopressin acetate 1 mg/ml refrigerated] ESTRING RING 2 MG desmopressin ace spray 1 1 [estradiol vaginal] refrig soln 0.01 % PREMARIN SOLR 25 MG desmopressin acetate 1 1 [estrogens, conjugated] soln 4 mcg/ml desmopressin acetate raloxifene hcl tabs 60 mg 1 1 VAGIFEM TABS 10 MCG spray soln 0.01 % 1 desmopressin acetate [estradiol vaginal] 1 GONADOTROPINS tabs 0.1 mg desmopressin acetate GONAL-F RFF REDIJECT 1 SOLN 300 UNIT/0.5ML 1 tabs 0.2 mg [follitropin alfa] STIMATE SOLN 1.5 GONAL-F RFF REDIJECT MG/ML [desmopressin 1 SOLN 450 UNT/0.75ML 1 acetate] [follitropin alfa] PROGESTINS GONAL-F RFF REDIJECT DEPO-PROVERA SUSP 400 MG/ML SOLN 900 UNIT/1.5ML 1 1 [follitropin alfa] [medroxyprogesterone GONAL-F RFF SOLR 75 acetate (antineoplastic)] 1 UNIT [follitropin alfa] ENDOMETRIN INST 100 GONAL-F SOLR 1050 MG [progesterone 1 1 UNIT [follitropin alfa] (vaginal)] GONAL-F SOLR 450 hydroxyprogesterone 1 UNIT [follitropin alfa] caproate soln 1.25 1 QL - 30 day(s) MENOPUR SOLR 75 gm/5ml 1 UNIT [menotropins] MAKENA OIL 250 MG/ML NOVAREL SOLR 10000 [hydroxyprogesterone 1 QL - 30 day(s) UNIT [chorionic 1 caproate] medroxyprogesterone gonadotropin] 1 OVIDREL INJ 250 acetate susp 150 mg/ml MCG/0.5ML medroxyprogesterone 1 1 [choriogonadotropin acetate susy 150 mg/ml medroxyprogesterone alfa] 1 SYNAREL SOLN 2 acetate tabs 10 mg medroxyprogesterone MG/ML [nafarelin 1 1 acetate] acetate tabs 2.5 mg medroxyprogesterone PARATHYROID 1 calcitonin (salmon) soln acetate tabs 5 mg 1 norethindrone acetate 200 unit/act 1 FORTEO SOPN 620 tabs 5 mg MCG/2.48ML progesterone caps 100 1 QL - 30 day(s) 1 [teriparatide mg progesterone caps 200 (recombinant)] 1 PITUITARY mg ACTHAR GEL 80 PROGESTERONE OIL 50 1 LD 1 UNIT/ML [corticotropin] MG/ML [progesterone] DDAVP RHINAL TUBE SOMATROPIN AGONISTS-ANTAGONISTS 1 SOLN 0.01 %

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 67 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits NORDITROPIN FLEXPRO liothyronine sodium tabs 1 SOPN 15 MG/1.5ML 1 QL - 30 day(s) 25 mcg [somatropin] liothyronine sodium tabs 1 OMNITROPE SOCT 10 5 mcg 1 QL - 30 day(s) MG/1.5ML [somatropin] liothyronine sodium tabs 1 OMNITROPE SOCT 5 50 mcg 1 QL - 30 day(s) MG/1.5ML [somatropin] methimazole tabs 10 mg 1 OMNITROPE SOLR 5.8 1 methimazole tabs 5 mg 1 MG [somatropin] propylthiouracil tabs 50 1 SEROSTIM SOLR 4 MG mg [somatropin (non- 1 QL - 30 day(s) SSKI SOLN 1 GM/ML refrigerated)] [potassium iodide 1 SEROSTIM SOLR 5 MG (expectorant)] [somatropin (non- 1 QL - 30 day(s) IMMUNOLOGICAL AGENTS refrigerated)] ANTIRHEUMATIC AGENTS SEROSTIM SOLR 6 MG ENBREL SOLR 25 MG [somatropin (non- 1 QL - 30 day(s) 1 QL - 30 day(s) [etanercept] refrigerated)] ENBREL SOSY 25 THYROID AND ANTITHYROID AGENTS 1 QL - 30 day(s) MG/0.5ML [etanercept] LEVOTHYROXINE ENBREL SOSY 50 SODIUM SOLR 200 MCG 1 1 QL - 30 day(s) MG/ML [etanercept]

[levothyroxine sodium] ENBREL SURECLICK LEVOTHYROXINE SOAJ 50 MG/ML 1 QL - 30 day(s) SODIUM SOLR 500 MCG 1 [etanercept]

[levothyroxine sodium] HUMIRA PEN PNKT 40 levothyroxine sodium 1 QL - 30 day(s) 1 MG/0.8ML [adalimumab] tabs 100 mcg HUMIRA PSKT 10 levothyroxine sodium 1 QL - 30 day(s) 1 MG/0.2ML [adalimumab] tabs 112 mcg HUMIRA PSKT 20 levothyroxine sodium 1 QL - 30 day(s) 1 MG/0.4ML [adalimumab] tabs 125 mcg HUMIRA PSKT 40 levothyroxine sodium 1 QL - 30 day(s) 1 MG/0.8ML [adalimumab] tabs 150 mcg KINERET INJ QL - 30 levothyroxine sodium 1 1 [anakinra] day(s),LD tabs 175 mcg leflunomide tabs 10 mg 1 levothyroxine sodium 1 1 tabs 200 mcg leflunomide tabs 20 mg levothyroxine sodium ORENCIA CLICKJECT 1 tabs 25 mcg SOAJ 125 MG/ML 1 QL - 30 day(s) levothyroxine sodium [abatacept] 1 ORENCIA SOLR 250 MG tabs 300 mcg 1 QL - 30 day(s) levothyroxine sodium [abatacept] 1 ORENCIA SOSY 125 tabs 50 mcg 1 MG/ML levothyroxine sodium [abatacept] 1 ORENCIA SOSY 50 tabs 75 mcg 1 QL - 30 day(s) MG/0.4ML levothyroxine sodium [abatacept] 1 ORENCIA SOSY 87.5 tabs 88 mcg 1 QL - 30 day(s) LEVOXYL TABS 137 MG/0.7ML [abatacept] OTEZLA TAB 10/20/30 MCG [levothyroxine 1 1 QL - 30 day(s) sodium] [apremilast]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 68 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits OTEZLA TABS 30 MG PROGRAF SOLN 5 1 QL - 30 day(s) 1 [apremilast] MG/ML [tacrolimus] OTEZLA TBPK 10 & 20 & RAPAMUNE SOLN 1 1 QL - 30 day(s) 1 30 MG [apremilast] MG/ML [sirolimus] RASUVO SOAJ 10 SANDIMMUNE CAPS 100 1 MG/0.2ML [methotrexate 1 MG [cyclosporine] (antirheumatic)] SANDIMMUNE CAPS 25 1 RASUVO SOAJ 12.5 MG [cyclosporine] MG/0.25ML SANDIMMUNE SOLN 100 1 1 [methotrexate MG/ML [cyclosporine] (antirheumatic)] SANDIMMUNE SOLN 50 1 RASUVO SOAJ 15 MG/ML [cyclosporine] MG/0.3ML [methotrexate 1 sirolimus tabs 0.5 mg 1 (antirheumatic)] sirolimus tabs 1 mg 1 RASUVO SOAJ 17.5 sirolimus tabs 2 mg 1 MG/0.35ML 1 tacrolimus caps 0.5 mg 1 [methotrexate tacrolimus caps 1 mg 1 (antirheumatic)] RASUVO SOAJ 20 tacrolimus caps 5 mg 1 MG/0.4ML [methotrexate 1 LOCAL ANESTHETICS (antirheumatic)] LOCAL ANESTHETICS RASUVO SOAJ 22.5 BUPIVACAINE MG/0.45ML FISIOPHARMA SOLN 2.5 1 1 [methotrexate MG/ML [bupivacaine hcl] (antirheumatic)] bupivacaine hcl (pf) soln 1 RASUVO SOAJ 25 0.25 % MG/0.5ML [methotrexate 1 bupivacaine hcl (pf) soln 1 (antirheumatic)] 0.5 % RASUVO SOAJ 30 bupivacaine hcl (pf) soln 1 MG/0.6ML [methotrexate 1 0.75 % (antirheumatic)] bupivacaine hcl inj 1 RASUVO SOAJ 7.5 0.75% MG/0.15ML bupivacaine hcl soln 1 1 [methotrexate 0.25 % (antirheumatic)] bupivacaine hcl soln 0.5 REMICADE SOLR 100 1 1 % MG [infliximab] bupivacaine in dextrose 1 IMMUNE SUPPRESSANTS soln 0.75-8.25 % ATGAM INJ 50 MG/ML bupivacaine-epinephrine 1 [lymphocyte immune (pf) soln 0.25% -1:200000 1 globulin,anti-thymocyte bupivacaine-epinephrine 1 globulin (equine)] (pf) soln 0.5% -1:200000 1 bupivacaine-epinephrine azathioprine tabs 50 mg 1 mycophenolate mofetil soln 0.25% -1:200000 1 bupivacaine-epinephrine caps 250 mg 1 mycophenolate mofetil soln 0.5% -1:200000 1 chloroprocaine hcl (pf) susr 200 mg/ml 1 NEORAL SOLN 100 soln 2 % MG/ML [cyclosporine chloroprocaine hcl inj 1 1 modified (for 3% microemulsion)]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 69 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits LIDOCAINE HCL SENSORCAINE- (CARDIAC) PF SOLN 100 MPF/EPINEPHRINE 1 MG/5ML [lidocaine hcl SOLN 0.75-1:200000 % 1 (cardiac)] [bupivacaine w/ lidocaine hcl (pf) soln 0.5 epinephrine] 1 % TETRACAINE HCL SOLN 1 lidocaine hcl (pf) soln 1 1 % [tetracaine hcl] 1 % XYLOCAINE- lidocaine hcl (pf) soln 2 MPF/EPINEPHRINE 1 % SOLN 1 %-1:200000 1 lidocaine hcl (pf) soln 4 [lidocaine w/ 1 % epinephrine] lidocaine hcl soln 0.5 % 1 MISCELLANEOUS THERAPEUTIC AGENTS lidocaine hcl soln 1 % 1 MISCELLANEOUS THERAPEUTIC AGENTS lidocaine hcl soln 2 % 1 acetylcysteine soln 10 % 1 lidocaine-epinephrine 1 acetylcysteine soln 20 % 1 soln 0.5 %-1:200000 ACETYLCYSTEINE SOLN lidocaine-epinephrine 200 MG/ML 1 1 soln 1 %-1:100000 [acetylcysteine lidocaine-epinephrine 1 (antidote)] soln 1.5 %-1:200000 ACTIMMUNE SOLN lidocaine-epinephrine 1 2000000 UNIT/0.5ML 1 QL - 30 day(s) soln 2 %-1:100000 [interferon gamma-1b] lidocaine-epinephrine alendronate sodium tabs 1 1 soln 2 %-1:200000 10 mg NAROPIN SOLN 10 alendronate sodium tabs 1 1 MG/ML [ropivacaine hcl] 35 mg NAROPIN SOLN 2 MG/ML alendronate sodium tabs 1 1 [ropivacaine hcl] 40 mg NAROPIN SOLN 5 MG/ML alendronate sodium tabs 1 1 [ropivacaine hcl] 70 mg NAROPIN SOLN 7.5 1 allopurinol tabs 100 mg 1 MG/ML [ropivacaine hcl] allopurinol tabs 300 mg 1 NESACAINE SOLN 1 % [Disulfiram] ANTABUSE 1 1 [chloroprocaine hcl] TABS 250 MG NESACAINE SOLN 2 % 1 AVONEX PEN AJKT 30 [chloroprocaine hcl] MCG/0.5ML [interferon 1 QL - 30 day(s) [Mepivacaine Hcl] 1 beta-1a] POLOCAINE SOLN 1 % BOTOX COSMETIC [Mepivacaine Hcl] SOLR 100 UNIT 1 1 POLOCAINE SOLN 2 % [onabotulinumtoxina [Mepivacaine Hcl] (cosmetic)] POLOCAINE-MPF SOLN 1 BOTOX SOLR 100 UNIT 1 1 % [onabotulinumtoxina] [Mepivacaine Hcl] BOTOX SOLR 200 UNIT 1 POLOCAINE-MPF SOLN 1 [onabotulinumtoxina] 1.5 % BRIDION SOLN 200 [Mepivacaine Hcl] MG/2ML [sugammadex 1 POLOCAINE-MPF SOLN 1 sodium] 2 %

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 70 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits CERDELGA CAPS 84 MG [Cyclosporine Modified (for 1 QL - 30 day(s) [eliglustat tartrate] Microemulsion)] 1 cinacalcet hcl tabs 30 GENGRAF CAPS 100 MG 1 mg [Cyclosporine Modified (for cinacalcet hcl tabs 60 Microemulsion)] 1 1 mg GENGRAF CAPS 25 MG cinacalcet hcl tabs 90 [Glatiramer Acetate] 1 mg GLATOPA SOSY 40 1 CINRYZE SOLR 500 UNIT MG/ML [c1 esterase inhibitor 1 QL - 30 day(s) GRASTEK SUBL 2800 (human)] BAU [timothy grass 1 colchicine tabs 0.6 mg 1 pollen allergen extract] CYSTADANE POWD HAEGARDA SOLR 2000 1 QL - 30 day(s) [betaine] UNIT [c1 esterase 1 QL - 30 day(s) CYSTAGON CAPS 150 inhibitor (human)] QL - 30 MG [cysteamine 1 HAEGARDA SOLR 3000 day(s),LD bitartrate] UNIT [c1 esterase 1 QL - 30 day(s) CYSTAGON CAPS 50 MG QL - 30 inhibitor (human)] 1 [cysteamine bitartrate] day(s),LD HUMIRA PEDIATRIC dexrazoxane hcl solr 250 CROHNS START PSKT 1 1 QL - 30 day(s) mg 80 MG/0.8ML dexrazoxane hcl solr 500 [adalimumab] 1 mg HUMIRA PEDIATRIC dimethyl fumarate cpdr CROHNS START PSKT 1 120 mg 80 MG/0.8ML & 1 QL - 30 day(s) dimethyl fumarate cpdr 40MG/0.4ML 1 240 mg [adalimumab] HUMIRA PEN PNKT 40 dimethyl fumarate 1 QL - 30 day(s) starter pack misc 120 & 1 MG/0.4ML [adalimumab] 240 mg HUMIRA PEN-CD/UC/HS disulfiram tabs 250 mg 1 STARTER PNKT 80 1 QL - 30 day(s) MG/0.8ML disulfiram tabs 500 mg 1 [adalimumab] HUMIRA PEN- ELMIRON CAPS 100 MG PSOR/UVEIT STARTER [pentosan polysulfate 1 PNKT 80 MG/0.8ML & 1 QL - 30 day(s) sodium] 40MG/0.4ML etidronate disodium tabs 1 [adalimumab] 200 mg HUMIRA PSKT 10 etidronate disodium tabs 1 QL - 30 day(s) 1 MG/0.1ML [adalimumab] 400 mg HUMIRA PSKT 20 finasteride tabs 5 mg 1 1 QL - 30 day(s) MG/0.2ML [adalimumab] FIRAZYR SOLN 30 HUMIRA PSKT 40 MG/3ML 1 QL - 30 day(s) 1 QL - 30 day(s) [icatibant MG/0.4ML [adalimumab] acetate] icatibant acetate soln 30 FLUORITAB CHEW 2.2 (1 1 QL - 30 day(s) 1 mg/3ml F) MG [sodium fluoride] INFLECTRA SOLR 100 FLURA-DROPS SOLN 1 MG [infliximab-dyyb] 0.55 (0.25 F) MG/DROP 1 KALYDECO PACK 50 MG [sodium fluoride] 1 QL - 30 day(s) [ivacaftor] FUSILEV SOLR 50 MG 1 KALYDECO PACK 75 MG [levoleucovorin calcium] 1 QL - 30 day(s) [ivacaftor]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 71 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits KALYDECO TABS 150 pamidronate disodium 1 QL - 30 day(s) 1 MG [ivacaftor] soln 30 mg/10ml leucovorin calcium solr pamidronate disodium 1 1 100 mg soln 6 mg/ml leucovorin calcium solr pamidronate disodium 1 1 350 mg soln 90 mg/10ml leucovorin calcium solr pamidronate disodium 1 1 50 mg solr 30 mg leucovorin calcium tabs pamidronate disodium 1 1 25 mg solr 90 mg leucovorin calcium tabs PREVIDENT 5000 PLUS 1 5 mg CREA 1.1 % [sodium 1 levocarnitine inj fluoride (dental)] 1 200mg/ml PREVIDENT GEL 1.1 % LEVOCARNITINE SOLN 1 [sodium fluoride 1 GM/10ML [levocarnitine 1 (dental)] (metabolic modifiers)] PREVIDENT SOLN 0.2 % LEVOCARNITINE TABS [sodium fluoride 1 330 MG [levocarnitine 1 (dental)] (metabolic modifiers)] RASUVO SOAJ 27.5 LUDENT CHEW 0.55 MG/0.55ML 1 (0.25 F) MG [sodium 1 [methotrexate fluoride] (antirheumatic)] MESNA SOLN 100 RIMSO-50 SOLN 50 % 1 1 MG/ML [mesna] [dimethyl sulfoxide] MESNEX TABS 400 MG SANDOSTATIN LAR 1 QL - 30 day(s) [mesna] DEPOT KIT 10 MG 1 QL - 30 day(s) METHYLENE BLUE [octreotide acetate] SOLN 1 % [methylene 1 SANDOSTATIN LAR blue (antidote)] DEPOT KIT 20 MG 1 QL - 30 day(s) mycophenolate mofetil [octreotide acetate] 1 tabs 500 mg SANDOSTATIN LAR MYOBLOC SOLN 10000 DEPOT KIT 30 MG 1 QL - 30 day(s) UNIT/2ML 1 [octreotide acetate] [rimabotulinumtoxinb] SF 5000 PLUS CREA 1.1 MYOBLOC SOLN 2500 % [sodium fluoride 1 UNIT/0.5ML 1 (dental)] [rimabotulinumtoxinb] sirolimus soln 1 mg/ml 1 MYOBLOC SOLN 5000 SODIUM FLUORIDE UNIT/ML 1 CHEW 1.1 (0.5 F) MG 1 [rimabotulinumtoxinb] [sodium fluoride] octreotide acetate soln SODIUM FLUORIDE 1 100 mcg/ml SOLN 1.1 (0.5 F) MG/ML 1 octreotide acetate soln [sodium fluoride] 1 1000 mcg/ml SOLIRIS SOLN 300 1 octreotide acetate soln MG/30ML [eculizumab] 1 200 mcg/ml sterile water for injection 1 octreotide acetate soln soln 1 50 mcg/ml TAKHZYRO SOLN 300 octreotide acetate soln MG/2ML [lanadelumab- 1 QL - 30 day(s) 1 500 mcg/ml flyo]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 72 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits THALOMID CAPS 100 OXYTOCIN SOLN 10 1 QL - 30 day(s) 1 MG [thalidomide] UNIT/ML [oxytocin] THALOMID CAPS 150 PREPIDIL GEL 0.5 1 QL - 30 day(s) 1 MG [thalidomide] MG/3GM [dinoprostone] THALOMID CAPS 200 PROSTIN E2 SUPP 20 1 QL - 30 day(s) 1 MG [thalidomide] MG [dinoprostone] THALOMID CAPS 50 MG 1 QL - 30 day(s) PHARMACEUTICAL AIDS [thalidomide] PHARMACEUTICAL AIDS THIOLA TABS 100 MG ALOE VERA POWD [aloe 1 LD 1 [tiopronin] vera (bulk)] TRI-CHLOR LIQD 80 % ALPROSTADIL POWD 1 1 [trichloroacetic acid] [alprostadil (bulk)] TYSABRI CONC 300 QL - 30 1 ATROPINE SULFATE MG/15ML [natalizumab] day(s),LD MONOHYDRATE POW 1 ULTOMIRIS SOLN 1100 MONOHYDT [atropine MG/11ML [ravulizumab- 1 sulfate monohydrate] cwvz] BACLOFEN POWD 1 ULTOMIRIS SOLN 300 [baclofen] MG/30ML [ravulizumab- 1 BACTERIOSTATIC cwvz] WATER(BENZ ALC) ULTOMIRIS SOLN 300 SOLN [water for inject, 1 MG/3ML [ravulizumab- 1 bacteriostatic benzyl cwvz] alcohol] XELJANZ TABS 10 MG CANTHARIDIN POW 1 1 [tofacitinib citrate] [cantharidin] XELJANZ TABS 5 MG CARBAMAZEPINE POWD 1 QL - 30 day(s) 1 [tofacitinib citrate] [carbamazepine] XELJANZ XR TB24 11 CHLOROFORM SOL 1 QL - 30 day(s) 1 MG [tofacitinib citrate] [chloroform] ZINECARD SOLR 250 MG 1 CHLORPROMAZINE HCL [dexrazoxane hcl] POW HCL 1 ZINECARD SOLR 500 MG 1 [chlorpromazine hcl] [dexrazoxane hcl] CLINDAMYCIN HCL zoledronic acid conc 4 1 POWD [clindamycin hcl 1 mg/5ml (bulk)] zoledronic acid soln 5 1 CLOBETASOL mg/100ml PROPIONATE POW 1 OXYTOCICS PROPIONA [clobetasol OXYTOCICS propionate] CERVIDIL INST 10 MG CLONIDINE HCL POWD 1 1 [dinoprostone] [clonidine hcl] CLOTRIMAZOLE CRYS HEMABATE SOLN 250 1 MCG/ML [carboprost 1 [clotrimazole (topical)] CLOTRIMAZOLE POWD tromethamine] 1 methylergonovine [clotrimazole (topical)] 1 maleate soln 0.2 mg/ml COAL TAR EXTRACT methylergonovine SOLN 20 % [coal tar 1 1 maleate tabs 0.2 mg (crude)] MIFEPREX TABS 200 MG 1 [mifepristone]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 73 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits CYSTEAMINE HCL METRONIDAZOLE POWD [cysteamine hcl 1 POWD [metronidazole 1 (bulk)] (bulk)] DEXAMETHASONE MORPHINE SULFATE POWD [dexamethasone 1 POWD [morphine 1 (bulk)] sulfate] DILTIAZEM HCL POWD NEOMYCIN SULFATE 1 [diltiazem hcl (bulk)] POWD [neomycin 1 ESTRADIOL POW sulfate (topical)] 1 [estradiol] PAPAVERINE HCL 1 GABAPENTIN POWD POWD [papaverine hcl] 1 [gabapentin (bulk)] PHENOBARBITAL POWD 1 GLYCERIN LIQD [phenobarbital] 1 [glycerin (bulk)] PHENTOLAMINE GLYCOPYRROLATE MESYLATE POWD 1 POWD [glycopyrrolate 1 [phentolamine mesylate (bulk)] (bulk)] HALOPERIDOL POWD PLURONIC F127 GEL 20 1 1 [haloperidol (bulk)] % [pluronic f127 base] HYDROCORTISONE PODOPHYLLUM RESIN POWD [hydrocortisone 1 POWD [podophyllum 1 (topical)] resin] HYDROXOCOBALAMIN POLYETHYLENE POW GLYCOL 8000 POWD 1 1 [hydroxocobalamin [polyethylene glycol (bulk)] 8000] HYDROXYPROGESTER PROGESTERONE ONE CAPROATE POWD MICRONIZED POWD 1 1 [hydroxyprogesterone [progesterone caproate (bulk)] micronized (bulk)] INDOMETHACIN POWD PROGESTERONE 1 [indomethacin] WETTABLE POWD 1 ISOSORBIDE POWD [progesterone (bulk)] 1 QUINACRINE HCL POWD [isosorbide (bulk)] 1 KETAMINE HCL POWD [quinacrine hcl] 1 SALICYLIC ACID POWD [ketamine hcl (bulk)] 1 KETOPROFEN POWD [salicylic acid (bulk)] 1 [ketoprofen (bulk)] SODIUM BENZOATE L-PROLINE POWD POWD [sodium 1 1 [proline] benzoate] SORBITOL SOLN 70 % LACTOSE 1 MONOHYDRATE POWD 1 [sorbitol] [lactose monohydrate] SQUARIC ACID LIDOCAINE HCL POWD DIBUTYLESTER POW 1 1 [lidocaine hcl (bulk)] DIBUTYLS [squaric acid METHADONE HCL dibutylester] 1 POWD [methadone hcl] STERILE WATER FOR METOCLOPRAMIDE HCL INJECTION SOLN [water 1 MONOHYDRATE POWD for injection, sterile] 1 TESTOSTERONE [metoclopramide hcl 1 monohydrate] PROPIONATE POWD

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 74 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits [testosterone propionate hydrocodone- (bulk)] homatropine syrp 5-1.5 1 TRANEXAMIC ACID mg/5ml POWD [tranexamic acid 1 promethazine-codeine 1 (bulk)] soln 6.25-10 mg/5ml TRIAMCINOLONE promethazine-dm soln 1 ACETONIDE POWD 1 6.25-15 mg/5ml [triamcinolone acetonide promethazine-dm syrp 1 (topical)] 6.25-15 mg/5ml VERAPAMIL HCL POWD 1 [Hydrocodone W/ [verapamil hcl] Homatropine] TUSSIGON 1 ZINC SULFATE GRAN TABS 5-1.5 MG 1 [zinc sulfate] MUCOLYTIC AGENTS RESPIRATORY TRACT AGENTS SODIUM CHLORIDE ANTI-INFLAMMATORY AGENTS NEBU 0.9 % [sodium 1 ADVAIR HFA AERO 115- chloride (inhalant)] 21 MCG/ACT 1 SODIUM CHLORIDE [fluticasone-salmeterol] NEBU 10 % [sodium 1 ADVAIR HFA AERO 230- chloride (inhalant)] 21 MCG/ACT 1 SODIUM CHLORIDE [fluticasone-salmeterol] NEBU 3 % [sodium 1 ADVAIR HFA AERO 45-21 chloride (inhalant)] MCG/ACT [fluticasone- 1 SODIUM CHLORIDE salmeterol] NEBU 7 % [sodium 1 AEROSPAN AERS 80 chloride (inhalant)] MCG/ACT [flunisolide 1 PULMONARY SURFACTANTS hfa] CUROSURF SUSP 120 ALVESCO AERS 160 MG/1.5ML [poractant 1 1 MCG/ACT [ciclesonide] alfa] ALVESCO AERS 80 CUROSURF SUSP 240 1 1 MCG/ACT [ciclesonide] MG/3ML [poractant alfa] COMBIVENT RESPIMAT SURVANTA SUSP 25-0.9 AERS 20-100 MCG/ACT 1 MG/ML-% [beractant in 1 [ipratropium-albuterol] nacl] cromolyn sodium conc 1 RESPIRATORY AGENTS, MISCELLANEOUS 100 mg/5ml ARALAST NP SOLR 500 cromolyn sodium nebu 1 MG [alpha1-proteinase 1 QL - 30 day(s) 20 mg/2ml inhibitor (human)] montelukast sodium DALIRESP TABS 500 1 1 chew 4 mg MCG [roflumilast] montelukast sodium KALYDECO PACK 25 MG 1 1 QL - 30 day(s) chew 5 mg [ivacaftor] montelukast sodium OFEV CAPS 100 MG 1 1 pack 4 mg [nintedanib esylate] montelukast sodium OFEV CAPS 150 MG 1 1 tabs 10 mg [nintedanib esylate] ANTITUSSIVES ORKAMBI PACK 100-125 benzonatate caps 100 MG [lumacaftor- 1 QL - 30 day(s) 1 mg ivacaftor]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 75 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits ORKAMBI PACK 150-188 CROFAB SOLR MG [lumacaftor- 1 QL - 30 day(s) [crotalidae polyvalent 1 ivacaftor] immune fab (ovine)] ORKAMBI TABS 100-125 CYTOGAM INJ 50 MG/ML MG [lumacaftor- 1 QL - 30 day(s) [cytomegalovirus 1 ivacaftor] immune globulin ORKAMBI TABS 200-125 (human)] MG [lumacaftor- 1 DIGIFAB SOLR 40 MG 1 ivacaftor] [digoxin immune fab] SYMDEKO TBPK 100-150 FLEBOGAMMA DIF SOLN & 150 MG [tezacaftor- 1 QL - 30 day(s) 0.5 GM/10ML [immune 1 ivacaftor] globulin (human) iv] SYMDEKO TBPK 50-75 & FLEBOGAMMA DIF SOLN 75 MG [tezacaftor- 1 2.5 GM/50ML [immune 1 ivacaftor] globulin (human) iv] TRIKAFTA TBPK 100-50- FLEBOGAMMA DIF SOLN 75 & 150 MG 20 GM/400ML [immune 1 1 QL - 30 day(s) [elexacaftor-tezacaftor- globulin (human) iv] ivacaftor] FLEBOGAMMA DIF SOLN TRIKAFTA TBPK 50-25- 5 GM/50ML [immune 1 37.5 & 75 MG globulin (human) iv] 1 QL - 30 day(s) [elexacaftor-tezacaftor- GAMASTAN INJ ivacaftor] [immune globulin 1 XOLAIR SOLR 150 MG QL - 30 (human) im] 1 [omalizumab] day(s),LD GAMMAGARD S/D LESS XOLAIR SOSY 150 IGA SOLR 10 GM 1 QL - 30 day(s) 1 MG/ML [omalizumab] [immune globulin XOLAIR SOSY 75 (human) iv] 1 QL - 30 day(s) MG/0.5ML [omalizumab] GAMMAGARD S/D LESS VASODILATING IGA SOLR 5 GM [immune 1 TRACLEER TBSO 32 MG globulin (human) iv] 1 QL - 30 day(s) [bosentan] GAMMAGARD SOLN 1 GM/10ML [immune SERUMS, TOXOIDS, AND VACCINES 1 globulin (human) iv or SERUMS subcutaneous] ANAVIP SOLR GAMMAGARD SOLN 30 [crotalidae immune 1 GM/300ML [immune f(ab')2 (equine)] 1 globulin (human) iv or ANTIVENIN subcutaneous] LATRODECTUS GAMMAKED SOLN 1 MACTANS KIT 1 GM/10ML [immune [antivenin latrodectus 1 globulin (human) iv or mactans] subcutaneous] CARIMUNE NF SOLR 12 GAMMAKED SOLN 10 GM [immune globulin 1 GM/100ML [immune (human) iv] 1 globulin (human) iv or CARIMUNE NF SOLR 6 subcutaneous] GM 1 [immune globulin GAMMAKED SOLN 2.5 (human) iv] GM/25ML [immune 1 globulin (human) iv or subcutaneous]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 76 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits GAMMAKED SOLN 20 globulin (human) GM/200ML [immune subcutaneous] 1 globulin (human) iv or HYPERRAB S/D SOLN subcutaneous] 300 UNIT/2ML [rabies 1 GAMMAKED SOLN 5 immune globulin GM/50ML [immune (human)] 1 globulin (human) iv or HYPERRAB SOLN 300 subcutaneous] UNIT/ML [rabies immune 1 GAMMAPLEX SOLN 10 globulin (human)] GM/200ML [immune 1 HYPERTET S/D INJ 250 globulin (human) iv] UNIT/ML [tetanus 1 GAMMAPLEX SOLN 20 immune globulin GM/400ML [immune 1 (human)] globulin (human) iv] HYQVIA KIT 10 GAMMAPLEX SOLN 5 GM/100ML [immune GM/100ML [immune 1 globulin (human)- 1 QL - 30 day(s) globulin (human) iv] hyaluronidase (human GAMUNEX-C SOLN 1 recombinant)] GM/10ML [immune HYQVIA KIT 2.5 GM/25ML 1 [immune globulin globulin (human) iv or 1 QL - 30 day(s) subcutaneous] (human)-hyaluronidase GAMUNEX-C SOLN 10 (human recombinant)] GM/100ML [immune HYQVIA KIT 20 1 globulin (human) iv or GM/200ML [immune subcutaneous] globulin (human)- 1 QL - 30 day(s) GAMUNEX-C SOLN 2.5 hyaluronidase (human GM/25ML [immune recombinant)] 1 globulin (human) iv or HYQVIA KIT 30 subcutaneous] GM/300ML [immune GAMUNEX-C SOLN 20 globulin (human)- 1 QL - 30 day(s) GM/200ML [immune hyaluronidase (human 1 globulin (human) iv or recombinant)] subcutaneous] HYQVIA KIT 5 GM/50ML [immune globulin GAMUNEX-C SOLN 5 1 QL - 30 day(s) GM/50ML [immune (human)-hyaluronidase 1 globulin (human) iv or (human recombinant)] subcutaneous] IMOGAM RABIES-HT SOLN 300 UNIT/2ML HIZENTRA SOLN 1 1 GM/5ML [immune [rabies immune globulin 1 QL - 30 day(s) globulin (human) (human)] subcutaneous] MICRHOGAM ULTRA- FILTERED PLUS SOSY HIZENTRA SOLN 10 1 GM/50ML [immune 250 UNIT [rho d immune 1 QL - 30 day(s) globulin (human) globulin (human)] subcutaneous] NABI-HB SOLN HIZENTRA SOLN 2 [hepatitis b immune 1 GM/10ML [immune globulin (human)] 1 QL - 30 day(s) globulin (human) OCTAGAM SOLN 1 subcutaneous] GM/20ML [immune 1 HIZENTRA SOLN 4 globulin (human) iv] 1 QL - 30 day(s) GM/20ML [immune

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 77 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits OCTAGAM SOLN 2.5 BEXSERO SUSY GM/50ML [immune 1 [meningococcal vac 1 globulin (human) iv] group b (recombant omv OCTAGAM SOLN 25 adjuvanted)] GM/500ML [immune 1 ENGERIX-B SUSP 10 globulin (human) iv] MCG/0.5ML [hepatitis b 1 ODACTRA SUBL 12 SQ- vaccine (recomb)] HDM [dust mite mixed 1 ENGERIX-B SUSP 20 allergen extract] MCG/ML [hepatitis b 1 PRIVIGEN SOLN 10 vaccine (recomb)] GM/100ML [immune 1 FLUAD SUSY 0.5 ML globulin (human) iv] [influenza virus vaccine 1 PRIVIGEN SOLN 20 types a & b surface GM/200ML [immune 1 antigen adjuvant] globulin (human) iv] FLUZONE HIGH-DOSE PRIVIGEN SOLN 5 SUSY 0.5 ML [influenza 1 GM/50ML [immune 1 virus vaccine split high- globulin (human) iv] dose preservative free] RHOGAM ULTRA- FLUZONE SUSP FILTERED PLUS SOSY [influenza virus vaccine 1 1500 UNIT [rho d 1 split] immune globulin GARDASIL 9 SUSP (human)] [human papillomavirus 1 RHOPHYLAC SOSY 1500 (hpv) 9-valent UNIT/2ML [rho d immune 1 recombinant vaccine] globulin (human)] GARDASIL 9 SUSY [human papillomavirus TOXOIDS 1 ADACEL SUSP 5-2-15.5 (hpv) 9-valent LF-MCG/0.5 [tetanus recombinant vaccine] toxoid-diphtheria- 1 GARDASIL INJ [human papillomavirus acellular pertussis 1 adsorb (tdap)] (hpv) quadrivalent DIPHTHERIA-TETANUS recombinant vaccine] TOXOIDS DT SUSP 25-5 GARDASIL SUSP 1 [human papillomavirus LFU/0.5ML [diphtheria- 1 tetanus toxoids (dt)] (hpv) quadrivalent INFANRIX SUSP 25-58-10 recombinant vaccine] [diphtheria, acellular HAVRIX SUSP 1440 EL 1 pertussis & tetanus U/ML [hepatitis a 1 toxoids] vaccine] TDVAX SUSP 2-2 HAVRIX SUSP 720 EL LF/0.5ML [tetanus- 1 U/0.5ML [hepatitis a 1 diphtheria toxoids (td)] vaccine] VACCINES HIBERIX SOLR 10 MCG ACTHIB SOLR [haemophilus b polysac 1 [haemophilus b polysac 1 conj vac] conj vac] IMOVAX RABIES INJ 2.5 AFLURIA SUSP UNIT/ML [rabies virus 1 [influenza virus vaccine 1 vaccine, hdc] IPOL INJ [poliovirus split] 1 vaccine, ipv]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 78 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits IXIARO SUSP [japanese TICE BCG SUSR 50 MG 1 encephalitis vaccine 1 [bcg live intravesical] inactivated adsorbed] TWINRIX SUSY 720-20 KINRIX SUSP [diph- ELU-MCG/ML [hepatitis a 1 tetanus tox ad-acell (inactivated)-hepatitis b 1 pertussis & polio virus, (recombinant) vaccines] ipv vac] TYPHIM VI SOLN 25 M-M-R II SOLR MCG/0.5ML [typhoid vi 1 [measles, mumps & 1 polysaccharide vaccine] rubella virus vaccines] VAQTA SUSP 25 MENVEO SOLR UNIT/0.5ML [hepatitis a 1 [meningococcal vaccine] (a,c,y&w-135) 1 VAQTA SUSP 50 oligosaccharide UNIT/ML [hepatitis a 1 conjugate vac] vaccine] PEDIARIX SUSP [diph- VARIVAX INJ 1350 tetanus tox-acell pert- PFU/0.5ML 1 1 [varicella hepatitis b recomb-polio virus vaccine live] ipv vac] VAXCHORA SUSR PNEUMOVAX 23 INJ 25 [cholera vaccine live 1 MCG/0.5ML 1 attenuated] [pneumococcal vac VIVOTIF CPDR [typhoid 1 polyvalent] vaccine] PREVNAR 13 SUSP YF-VAX INJ [yellow 1 [pneumococcal 13-valent 1 fever vaccine] conjugate vaccine] SKIN AND MUCOUS MEMBRANE AGENTS PROQUAD SUSR ANTI-INFECTIVES [measles-mumps- 1 AKTIPAK PACK 5-3 % rubella-varicella virus [benzoyl peroxide- 1 vaccines] erythromycin] RABAVERT SUSR 1 benzoyl peroxide- 1 [rabies vaccine, pcec] erythromycin gel 5-3 % RECOMBIVAX HB SUSP clindamycin phos- 10 MCG/ML 1 1 [hepatitis b benzoyl perox gel 1-5 % vaccine (recomb)] clindamycin phos- RECOMBIVAX HB SUSP benzoyl perox gel 1.2-5 1 40 MCG/ML 1 [hepatitis b % vaccine (recomb)] clindamycin phosphate RECOMBIVAX HB SUSP 1 crea 2 % 5 MCG/0.5ML [hepatitis b 1 clindamycin phosphate vaccine (recomb)] 1 gel 1 % ROTARIX SUSR clindamycin phosphate [rotavirus vaccine, live 1 1 lotn 1 % oral] clindamycin phosphate ROTATEQ SOLN 1 soln 1 % [rotavirus vaccine, live 1 clotrimazole troc 10 mg 1 oral pentavalent] SHINGRIX SUSR 50 erythromycin soln 2 % 1 MCG/0.5ML [zoster gentamicin sulfate crea 1 1 vaccine recombinant 0.1 % adjuvanted]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 79 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits gentamicin sulfate oint BETAMETHASONE 1 0.1 % DIPROPIONATE CREA 1 HYDROCORTISONE- 0.05 % [betamethasone IODOQUINOL CREA 1-1 1 dipropionate (topical)] % [iodoquinol-hc] BETAMETHASONE VALERATE CREA 0.1 % ketoconazole sham 2 % 1 1 malathion lotn 0.5 % 1 [betamethasone metronidazole crea 0.75 valerate] 1 betamethasone valerate % 1 metronidazole gel 0.75 % 1 foam 0.12 % metronidazole lotn 0.75 BETAMETHASONE 1 VALERATE LOTN 0.1 % % 1 mupirocin oint 2 % 1 [betamethasone valerate] neomycin-polymyxin b 1 BETAMETHASONE gu soln 40-200000 VALERATE OINT 0.1 % nystatin crea 100000 1 1 [betamethasone unit/gm valerate] [Nystatin (topical)] clobetasol propionate NYSTOP POWD 100000 1 1 crea 0.05 % UNIT/GM clobetasol propionate permethrin crea 5 % 1 1 foam 0.05 % selenium sulfide lotn 2.5 clobetasol propionate 1 1 % gel 0.05 % SILVER SULFADIAZINE clobetasol propionate CREA 1 % 1 1 [silver lotn 0.05 % sulfadiazine] clobetasol propionate SULFAMYLON CREA 85 1 oint 0.05 % MG/GM [mafenide 1 clobetasol propionate acetate] 1 soln 0.05 % ANTI-INFLAMMATORY AGENTS CLOBEX LOTN 0.05 % alclometasone 1 1 [clobetasol propionate] dipropionate crea 0.05 % CLOBEX SPRAY LIQD alclometasone 1 0.05 % [clobetasol 1 dipropionate oint 0.05 % propionate] ANUCORT-HC SUPP 25 CORDRAN TAPE 4 MG [hydrocortisone 1 MCG/SQCM 1 acetate (rectal)] [flurandrenolide] betamethasone CORTISPORIN CREA dipropionate aug crea 1 3.5-10000-0.5 [neomycin- 1 0.05 % polymyxin-hc] betamethasone CORTISPORIN OINT 1 % dipropionate aug gel 1 [bacitracin-polymyxin- 1 0.05 % neomycin hc] betamethasone desonide oint 0.05 % 1 dipropionate aug lotn 1 [Desonide] DESOWEN 1 0.05 % LOTN 0.05 % betamethasone desoximetasone crea 1 1 dipropionate aug oint 0.25 % 0.05 % fluocinolone acetonide 1 body oil 0.01 %

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 80 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits fluocinolone acetonide PRAMOSONE OINT 1-1 1 1 scalp oil 0.01 % % [pramoxine-hc] fluocinolone acetonide PRAMOSONE OINT 1-2.5 1 1 soln 0.01 % % [pramoxine-hc] fluocinonide crea 0.05 % 1 [Hydrocortisone (rectal)] fluocinonide gel 0.05 % 1 PROCTOSOL HC CREA 1 fluocinonide oint 0.05 % 1 2.5 % triamcinolone acetonide fluocinonide soln 0.05 % 1 1 fluticasone propionate crea 0.025 % 1 triamcinolone acetonide crea 0.05 % 1 fluticasone propionate crea 0.1 % 1 triamcinolone acetonide oint 0.005 % 1 halobetasol propionate crea 0.5 % 1 triamcinolone acetonide crea 0.05 % 1 halobetasol propionate lotn 0.1 % 1 triamcinolone acetonide oint 0.05 % 1 HYDROCORTISONE oint 0.025 % triamcinolone acetonide ACE-PRAMOXINE CREA 1 1 2.5-1 % [pramoxine-hc] oint 0.1 % triamcinolone acetonide hydrocortisone crea 1 % 1 1 oint 0.5 % hydrocortisone crea 2.5 1 triamcinolone acetonide % 1 pste 0.1 % hydrocortisone enem 1 100 mg/60ml ANTIPRURITICS AND LOCAL ANESTHETICS hydrocortisone lotn 2.5 [Hydrocortisone Acetate 1 W/ Pramoxine] % 1 hydrocortisone oint 2.5 ANALPRAM-HC CREA 1- 1 % 1 % mometasone furoate [Hydrocortisone Acetate 1 W/ Pramoxine] crea 0.1 % 1 ANALPRAM-HC LOTN mometasone furoate oint 1 2.5-1 % 0.1 % HYDROCORT- mometasone furoate 1 PRAMOXINE (PERIANAL) soln 0.1 % CREA 2.5-1 % 1 nystatin-triamcinolone [hydrocortisone acetate crea 100000-0.1 unit/gm- 1

% w/ pramoxine] hydrocortisone ace- nystatin-triamcinolone 1 pramoxine crea 1-1 % oint 100000-0.1 unit/gm- 1 % lidocaine hcl soln 4 % 1 lidocaine hcl [Pramoxine-hc] 1 PRAMOSONE CREA 1-1 1 urethral/mucosal gel 2 % % lidocaine hcl [Pramoxine-hc] urethral/mucosal prsy 2 1 PRAMOSONE LOTN 1-1 1 % % lidocaine oint 5 % 1 lidocaine-prilocaine crea [Pramoxine-hc] 1 PRAMOSONE LOTN 1- 1 2.5-2.5 % lidocaine-prilocaine kit 2.5 % 1 2.5-2.5 %

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 81 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits [Hydrocortisone Acetate SULFACETAMIDE W/ Pramoxine] SODIUM-SULFUR SUSP 1 1 PROCTOFOAM HC 8-4 % [sulfacetamide FOAM 1-1 % sodium w/ sulfur] ASTRINGENTS SKIN AND MUCOUS MEMBRANE AGENTS, DRYSOL SOLN 20 % MISCELLANEOUS 1 [aluminum chloride] acitretin caps 10 mg 1 QL - 30 day(s) CELL STIMULANTS AND PROLIFERANTS acitretin caps 25 mg 1 QL - 30 day(s) AVITA CREA 0.025 % adapalene gel 0.1 % 1 1 [tretinoin] adapalene gel 0.3 % 1 KEPIVANCE SOLR 6.25 adapalene-benzoyl 1 QL - 30 day(s) 1 MG [palifermin] peroxide gel 0.1-2.5 % RETIN-A CREA 0.025 % calcipotriene crea 0.005 1 1 [tretinoin] % RETIN-A CREA 0.05 % calcipotriene soln 0.005 1 1 [tretinoin] % RETIN-A CREA 0.1 % [Isotretinoin] CLARAVIS 1 1 QL - 30 day(s) [tretinoin] CAPS 10 MG RETIN-A GEL 0.01 % [Isotretinoin] CLARAVIS 1 1 QL - 30 day(s) [tretinoin] CAPS 20 MG RETIN-A GEL 0.025 % [Isotretinoin] CLARAVIS 1 1 QL - 30 day(s) [tretinoin] CAPS 30 MG RETIN-A MICRO GEL [Isotretinoin] CLARAVIS 1 QL - 30 day(s) 0.04 % [tretinoin 1 CAPS 40 MG microsphere] CONDYLOX GEL 0.5 % 1 RETIN-A MICRO GEL 0.1 [podofilox] % [tretinoin 1 COSENTYX (300 MG microsphere] DOSE) SOSY 150 MG/ML 1 QL - 30 day(s) DEPIGMENTING AND PIGMENTING AGENTS [secukinumab] methoxsalen rapid caps COSENTYX 1 SENSOREADY (300 MG) 10 mg 1 QL - 30 day(s) OXSORALEN ULTRA SOAJ 150 MG/ML CAPS 10 MG 1 [secukinumab] [methoxsalen rapid] COSENTYX SENSOREADY PEN KERATOLYTIC AGENTS 1 QL - 30 day(s) KERALYT GEL 6 % SOAJ 150 MG/ML 1 [salicylic acid] [secukinumab] COSENTYX SOSY 150 SULFACETAMIDE 1 QL - 30 day(s) SODIUM-SULFUR EMUL MG/ML [secukinumab] 1 diclofenac sodium gel 1 10-5 % [sulfacetamide 1 sodium w/ sulfur] % diclofenac sodium soln SULFACETAMIDE 1 SODIUM-SULFUR LOTN 1.5 % 1 DIFFERIN CREA 0.1 % 10-5 % [sulfacetamide 1 sodium w/ sulfur] [adapalene] DIFFERIN GEL 0.3 % SULFACETAMIDE 1 SODIUM-SULFUR SUSP [adapalene] 1 DRITHO-CREME HP 10-5 % [sulfacetamide 1 sodium w/ sulfur] CREA 1 % [anthralin]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 82 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits EPIDUO FORTE GEL 0.3- MYRBETRIQ TB24 25 MG 1 2.5 % [adapalene- 1 [mirabegron] benzoyl peroxide] MYRBETRIQ TB24 50 MG 1 FLUOROPLEX CREA 1 % [mirabegron] 1 [fluorouracil (topical)] oxybutynin chloride er 1 fluorouracil crea 5 % 1 tb24 10 mg oxybutynin chloride er fluorouracil soln 2 % 1 1 fluorouracil soln 5 % 1 tb24 15 mg oxybutynin chloride er imiquimod crea 5 % 1 1 LEVULAN KERASTICK tb24 5 mg oxybutynin chloride syrp SOLR 20 % 1 1 [aminolevulinic acid hcl] 5 mg/5ml oxybutynin chloride tabs pimecrolimus crea 1 % 1 1 5 mg PODOCON SOLN 25 % 1 solifenacin succinate [podophyllum resin] 1 tabs 10 mg podofilox soln 0.5 % 1 solifenacin succinate SANTYL OINT 250 1 1 tabs 5 mg UNIT/GM [collagenase] trospium chloride er SKYRIZI (150 MG DOSE) 1 cp24 60 mg PSKT 75 MG/0.83ML 1 trospium chloride tabs [risankizumab-rzaa] 1 20 mg STELARA SOLN 45 1 MG/0.5ML [ustekinumab] RESPIRATORY SMOOTH MUSCLE RELAXANTS STELARA SOSY 45 aminophylline soln 25 1 1 MG/0.5ML [ustekinumab] mg/ml STELARA SOSY 90 theophylline er tb12 100 1 1 MG/ML [ustekinumab] mg TACROLIMUS OINT 0.03 theophylline er tb12 200 1 1 % [tacrolimus (topical)] mg TACROLIMUS OINT 0.1 theophylline er tb12 300 1 1 % [tacrolimus (topical)] mg TARGRETIN GEL 1 % theophylline er tb12 450 1 1 [bexarotene (topical)] mg theophylline er tb24 400 tazarotene crea 0.1 % 1 1 mg TAZORAC CREA 0.05 % 1 THEOPHYLLINE IN D5W [tazarotene] SOLN 0.8-5 MG/ML-% TAZORAC GEL 0.05 % 1 1 [theophylline in [tazarotene] dextrose] TAZORAC GEL 0.1 % 1 [tazarotene] VITAMINS TREMFYA SOPN 100 MULTIVITAMIN PREPARATIONS 1 INFUVITE ADULT INJ MG/ML [guselkumab] 1 TREMFYA SOSY 100 [multiple vitamin] 1 MG/ML [guselkumab] INFUVITE PEDIATRIC VECTICAL OINT 3 SOLN [pediatric multiple 1 MCG/GM [calcitriol 1 vitamins] pediatric multivitamins (topical)] 1 SMOOTH MUSCLE RELAXANTS w/fl chew pediatric multivitamins GENITOURINARY SMOOTH MUSCLE 1 RELAXANTS w/fl chew

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 83 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits MULTI-VIT/FLUORIDE TRI-VIT/FLUORIDE SOLN SOLN 0.5 MG/ML 0.5 MG/ML [pediatric 1 1 [pediatric multivitamins vitamins acd w/ fluoride] w/fl] VITAMINS ACD- MULTI- FLUORIDE SOLN 0.25 1 VIT/FLUORIDE/IRON MG/ML [pediatric SOLN 0.25-10 MG/ML 1 vitamins acd w/ fluoride] [ped multivitamins w/fl & VITAMIN A iron] AQUASOL A SOLN 15 1 MULTI- MG/ML [vitamin a] VIT/IRON/FLUORIDE VITAMIN B COMPLEX SOLN 0.25-10 MG/ML 1 cyanocobalamin soln 1 [ped multivitamins w/fl & 1000 mcg/ml iron] folic acid soln 5 mg/ml 1 MULTIVITAMIN/FLUORID POTABA CAPS 500 MG E CHEW 0.25 MG 1 [potassium 1 [pediatric multivitamins aminobenzoate] w/fl] pyridoxine hcl soln 100 MULTIVITAMIN/FLUORID 1 mg/ml E CHEW 0.5 MG 1 thiamine hcl soln 100 [pediatric multivitamins 1 mg/ml w/fl] MULTIVITAMIN/FLUORID VITAMIN C E CHEW 1 MG [pediatric 1 ASCORBIC ACID SOLN multivitamins w/fl] 500 MG/ML [ascorbic 1 MULTIVITAMIN/FLUORID acid] E SOLN 0.25 MG/ML VITAMIN D 1 [pediatric multivitamins calcitriol caps 0.25 mcg 1 w/fl] calcitriol caps 0.5 mcg 1 MVC-FLUORIDE CHEW vitamin d (ergocalciferol) 1 0.25 MG [pediatric 1 caps 1.25 mg (50000 ut) multivitamins w/fl] VITAMIN K ACTIVITY MVC-FLUORIDE CHEW MEPHYTON TABS 5 MG 1 0.5 MG [pediatric 1 [phytonadione] multivitamins w/fl] phytonadione soln 1 1 MVC-FLUORIDE CHEW 1 mg/0.5ml MG [pediatric 1 vitamin k1 soln 1 1 multivitamins w/fl] mg/0.5ml RENAL CAPS 1 MG [b- vitamin k1 soln 10 mg/ml 1 complex w/ c & folic 1 acid]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 84 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits NICORETTE GUM 2 MG ANTI-INFECTIVE AGENTS 1 OTC ANTHELMINTICS [nicotine polacrilex] NICORETTE LOZG 2 MG REESES PINWORM 1 OTC MEDICINE SUSP 144 (50 [nicotine polacrilex] 1 OTC NICORETTE LOZG 4 MG Base) MG/ML [pyrantel 1 OTC pamoate] [nicotine polacrilex] ANTIHISTAMINE DRUGS NICORETTE MINI LOZG FIRST GENERATION ANTIHISTAMINES 2 MG [nicotine 1 OTC polacrilex] loratadine syrp 5 mg/5ml 1 OTC nicotine polacrilex gum CHLORPHENIRAMINE 1 OTC 2 mg MALEATE TABS 4 MG 1 OTC nicotine polacrilex gum [chlorpheniramine 1 OTC 4 mg maleate] nicotine polacrilex lozg 2 DIMAPHEN CHILDRENS 1 OTC mg ELIX 1-2.5 MG/5ML 1 OTC nicotine pt24 14 mg/24hr 1 OTC [brompheniramine & phenyleph] nicotine pt24 21 mg/24hr 1 OTC DIPHENHIST LIQD 12.5 nicotine pt24 7 mg/24hr 1 OTC MG/5ML 1 OTC SYMPATHOMIMETIC (ADRENERGIC) AGENTS [diphenhydramine hcl] KP PSEUDOEPHEDRINE DIPHENHYDRAMINE HCL TABS 60 MG 1 OTC HCL CAPS 25 MG 1 OTC [pseudoephedrine hcl] [diphenhydramine hcl] PSEUDOEPHEDRINE DIPHENHYDRAMINE HCL TABS 30 MG 1 OTC HCL CAPS 50 MG 1 OTC [pseudoephedrine hcl] [diphenhydramine hcl] S2 (RACEPINEPHRINE) ED CHLORPED JR SYRP NEBU 2.25 % 1 OTC 2 MG/5ML [racepinephrine hcl] 1 OTC [chlorpheniramine BLOOD FORMATION, COAGULATION, AND maleate] THROMBOSIS HISTEX-PE SYRP 2.5-10 ANTIANEMIA DRUGS MG/5ML [triprolidine- 1 OTC FERREX 150 CAPS 150 phenylephrine] MG [polysaccharide iron 1 OTC J-TAN PD LIQD 1 MG/ML complex] [brompheniramine 1 OTC FERROUS SULFATE maleate] SOLN 75 (15 Fe) MG/ML 1 OTC loratadine tabs 10 mg 1 OTC [ferrous sulfate] LORTUSS LQ LIQD 6.25- FERROUS SULFATE 30 MG/5ML [doxylamine- 1 OTC TABS 325 (65 Fe) MG 1 OTC pseudoephedrine] [ferrous sulfate] POLY HIST FORTE TABS PROFERRIN ES TABS 12 7.5-10 MG [doxylamine- 1 OTC MG [iron heme 1 OTC phenylephrine] polypeptide] AUTONOMIC DRUGS CENTRAL NERVOUS SYSTEM AGENTS AUTONOMIC DRUGS, MISCELLANEOUS ANALGESICS AND ANTIPYRETICS nicotine polacrilex lozg 4 1 OTC BAYER ADVANCED mg ASPIRIN EX ST TABS 1 OTC 500 MG [aspirin]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 85 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits GOODSENSE PAIN ML [insulin RELIEF EXTRA ST TABS 1 OTC syringe/needle u-100] 500 MG [acetaminophen] BD INSULIN SYRINGE acetaminophen tbcr 650 U/F MISC 30G X 1/2" 1 1 OTC 1 OTC mg ML [insulin PAIN & FEVER syringe/needle u-100] CHILDRENS SOLN 160 BD INSULIN SYRINGE 1 OTC MG/5ML U/F MISC 31G X 5/16" 0.3 1 OTC [acetaminophen] ML [insulin PAIN RELIEVER TABS syringe/needle u-100] 1 OTC 325 MG [acetaminophen] BD INSULIN SYRINGE U/F MISC 31G X 5/16" 0.5 TRI-BUFFERED ASPIRIN 1 OTC TABS 325 MG [aspirin ML [insulin 1 OTC buffered (cal carb-mag syringe/needle u-100] carb-mag oxide)] BD INSULIN SYRINGE U/F MISC 31G X 5/16" 1 DEVICES 1 OTC DEVICES ML [insulin BD 3ML LUER-LOK syringe/needle u-100] SYRINGE/22G X 1-1/4" [Insulin Syringe/needle U- 100] BD INSULIN MIS 22GX1.25 1 OTC 1 OTC SYRINGE ULTRAFINE [syringe/needle (disp) 3 MISC 31G X 5/16" 0.5 ML ml] BD INSULIN SYRINGE [Insulin Syringe/needle U- MICROFINE MISC 27G X 100] BD INTEGRA 1 OTC INSULIN SYRINGE/U- 1 OTC 5/8" 1 ML [insulin 100/1ML/29G X 1/2" MIS syringe/needle u-100] 1ML/29G [Insulin Syringe/needle U- 100] BD INSULIN BD INTEGRA SYRINGE 1 OTC MISC 25G X 5/8" 3 ML SYRINGE MICROFINE 1 OTC MISC 28G X 1/2" 0.3 ML [syringe/needle (disp) 3

BD INSULIN SYRINGE ml] BD LANCET DEVICE MIS MISC 25G X 1" 1 ML 1 OTC DEVICE 1 OTC [insulin syringe/needle [lancet u-100] devices] BD LANCET ULTRAFINE BD INSULIN SYRINGE 1 OTC 33G MISC MISC 27G X 1/2" 1 ML [lancets] 1 OTC [insulin syringe/needle BD PEN NEEDLE MINI u-100] U/F MISC 31G X 5 MM 1 OTC BD INSULIN SYRINGE [insulin pen needle] U/F 1/2UNIT MISC 31G X BD PEN NEEDLE NANO 1 OTC 5/16" 0.3 ML [insulin U/F MISC 32G X 4 MM 1 OTC syringe/needle u-100] [insulin pen needle] BD INSULIN SYRINGE BD PEN NEEDLE U/F MISC 30G X 1/2" 0.3 ORIGINAL U/F MISC 29G 1 OTC 1 OTC ML [insulin X 12.7MM [insulin pen syringe/needle u-100] needle] BD INSULIN SYRINGE BD PEN NEEDLE SHORT 1 OTC U/F MISC 30G X 1/2" 0.5 U/F MISC 31G X 8 MM 1 OTC [insulin pen needle]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 86 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits BD SAFETYGLIDE glucose monitoring INSULIN SYRINGE MISC supplies] 29G X 1/2" 0.3 ML 1 OTC ONETOUCH ULTRASOFT [insulin syringe/needle LANCETS MISC 1 OTC u-100] [lancets] BD SAFETYGLIDE ONETOUCH VERIO SYRINGE/NEEDLE MISC SOLN HIGH [blood 1 OTC 27G X 5/8" 1 ML 1 OTC glucose calibration] [syringe/needle (disp) 1 PEDIATRIC SMALL 1 OTC ml] MASK MISC [masks] BD VEO INSULIN SYR PENLET II BLOOD U/F 1/2UNIT MISC 31G X SAMPLER KIT 1 OTC 1 OTC [lancets 15/64" 0.3 ML [insulin misc.] syringe/needle u-100] PRODIGY CONTROL BD VEO INSULIN SOLUTION SOLN LOW 1 OTC SYRINGE U/F MISC 31G 1 OTC [blood glucose X 15/64" 0.3 ML [insulin calibration] syringe/needle u-100] SURE COMFORT BD VEO INSULIN INSULIN SYRINGE MISC SYRINGE U/F MISC 31G 28G X 1/2" 0.5 ML 1 OTC 1 OTC X 15/64" 0.5 ML [insulin [insulin syringe/needle syringe/needle u-100] u-100] BD VEO INSULIN SURE COMFORT SYRINGE U/F MISC 31G INSULIN SYRINGE MISC 1 OTC 1 OTC X 15/64" 1 ML [insulin 28G X 1/2" 1 ML [insulin syringe/needle u-100] syringe/needle u-100] CLICKFINE PEN SURE COMFORT NEEDLES MISC 31G X 6 1 OTC INSULIN SYRINGE MISC MM [insulin pen needle] 29G X 1/2" 0.3 ML 1 OTC CONTOUR NEXT [insulin syringe/needle CONTROL SOLN u-100] 1 OTC NORMAL [blood glucose SURE COMFORT calibration] INSULIN SYRINGE MISC DISPOSABLE POWER 29G X 1/2" 0.5 ML 1 OTC 1 OTC KIT [misc. devices] [insulin syringe/needle ONETOUCH DELICA u-100] LANCETS 33G MISC 1 OTC SURE COMFORT [lancets] INSULIN SYRINGE MISC ONETOUCH FINEPOINT 30G X 1/2" 0.3 ML 1 OTC LANCETS MISC 1 OTC [insulin syringe/needle [lancets] u-100] ONETOUCH SURESOFT SURE COMFORT LANCING DEV MISC 1 OTC INSULIN SYRINGE MISC [lancets misc.] 30G X 1/2" 0.5 ML 1 OTC ONETOUCH ULTRA [insulin syringe/needle CONTROL SOLN [blood 1 OTC u-100] SURE COMFORT glucose calibration] 1 OTC ONETOUCH ULTRA MINI INSULIN SYRINGE MISC 1 OTC KIT W/DEVICE [blood

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 87 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits 30G X 1/2" 1 ML [insulin PHENEX-1 POWD syringe/needle u-100] [nutritional 1 OTC SURE COMFORT supplements] INSULIN SYRINGE MISC PHLEXY-10 PACK 1 OTC 30G X 5/16" 1 ML [insulin [nutritional 1 OTC syringe/needle u-100] supplements] SURE COMFORT EYE, EAR, NOSE, AND THROAT (EENT) INSULIN SYRINGE MISC PREPARATIONS 31G X 5/16" 0.3 ML 1 OTC ANTI-INFLAMMATORY AGENTS [insulin syringe/needle FLONASE SENSIMIST u-100] SUSP 27.5 MCG/SPRAY 1 OTC SURE COMFORT [fluticasone furoate] INSULIN SYRINGE MISC 1 OTC fluticasone propionate 31G X 5/16" 1 ML 1 OTC [insulin susp 50 mcg/act syringe/needle u-100] EENT DRUGS, MISCELLANEOUS [Insulin Syringe/needle U- 100] TERUMO INSULIN NASAL DECONGESTANT PE MAX ST TABS 10 MG SYRINGE/U- 1 OTC 1 OTC 100/0.5ML/27G X 1/2" MIS [phenylephrine hcl 0.5/27G (oral)] ULTRA THIN LANCETS GASTROINTESTINAL DRUGS 1 OTC 30G MISC [lancets] ANTACIDS AND ADSORBENTS ULTRA-COMFORT ANTACID SUSP 200-200- INSULIN SYRINGE MISC 20 MG/5ML [alum & mag 1 OTC 31G X 5/16" 0.3 ML 1 OTC hydrox-simethicone] [insulin syringe/needle BISMATROL MAXIMUM STRENGTH SUSP 525 u-100] 1 OTC DIAGNOSTIC AGENTS MG/15ML [bismuth DIAGNOSTIC AGENTS subsalicylate] BISMATROL SUSP 262 ACETEST TAB TABLETS 1 OTC MG/15ML 1 OTC [acetone (urine) test] [bismuth subsalicylate] ALBUSTIX STRP 1 OTC BISMUTH [albumin (urine) test] SUBSALICYLATE CHEW CHEMSTRIP 9 STRP 1 OTC 1 OTC 262 MG [bismuth [multiple urine tests] subsalicylate] DIASTIX STRP [glucose CALCIUM CARBONATE urine test-(glucose 1 OTC TABS 1250 (500 Ca) MG 1 OTC oxidase)] [calcium carbonate] KETO-DIASTIX STRP CALCIUM GLUCONATE [urine glucose-ketones 1 OTC TABS 500 MG [calcium 1 OTC test] gluconate] KETOSTIX STRP 1 OTC GELUSIL CHEW 200-200- [acetone (urine) test] 25 MG [alum & mag 1 OTC ONETOUCH ULTRA 1 OTC hydrox-simethicone] STRP [glucose blood] MAG-AL LIQD 200-200 ELECTROLYTIC, CALORIC, AND WATER MG/5ML [aluminum & 1 OTC BALANCE magnesium hydroxide] CALORIC AGENTS

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 88 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits MAGNEBIND 300 TABS HUMULIN N SUSP 100 250-300 MG [calcium UNIT/ML [insulin nph 1 OTC 1 OTC carbonate-magnesium (human) (isophane)] carbonate] HUMULIN R SOLN 100 MI-ACID MAXIMUM UNIT/ML [insulin regular 1 OTC STRENGTH SUSP 400- (human)] 400-40 MG/5ML [alum & 1 OTC CONTRACEPTIVES mag hydrox- [Levonorgestrel simethicone] (emergency Oc)] 1 OTC SM FOAMING ANTACID ECONTRA EZ TABS 1.5 CHEW 80-20 MG 1 OTC MG [aluminum hydroxide- PHARMACEUTICAL AIDS mag trisil] PHARMACEUTICAL AIDS SM STOMACH RELIEF BIOTIN-D POWD [biotin TABS 262 MG [bismuth 1 OTC 1 OTC (bulk)] subsalicylate] BORIC ACID POWD ANTIDIARRHEA AGENTS 1 OTC [boric acid (bulk)] PEPTIC RELIEF CHEW CHOLESTEROL POWD 262 MG 1 OTC 1 OTC [bismuth [cholesterol] subsalicylate] COLLODION FLEXIBLE 1 OTC ANTIEMETICS LIQD [collodion flexible] MECLIZINE HCL TABS GLYCERIN LIQD 1 OTC 1 OTC 12.5 MG [meclizine hcl] [glycerin (bulk)] MECLIZINE HCL TABS 25 HYDROPHILIC OINT 1 OTC 1 OTC MG [meclizine hcl] [hydrophilic ointment] TRAVEL SICKNESS L-ARGININE POWD 1 OTC CHEW 25 MG [meclizine 1 OTC [arginine] hcl] L-CITRULLINE POWD 1 OTC CATHARTICS AND LAXATIVES [citrulline (bulk)] DOCUSATE SODIUM L-ISOLEUCINE POWD 1 OTC CAPS 100 MG [docusate 1 OTC [isoleucine] sodium] L-VALINE POWD [valine] 1 OTC SORBITOL SOLN 70 % LACTIC ACID SOLN 1 OTC 1 OTC [sorbitol (laxative)] [lactic acid (bulk)] HORMONES AND SYNTHETIC SUBSTITUTES LACTOSE POWD 1 OTC ANTIDIABETIC AGENTS [lactose] HUMULIN 70/30 POLYETHYLENE KWIKPEN SUPN (70-30) GLYCOL 400 LIQD 1 OTC 1 OTC 100 UNIT/ML [insulin nph [polyethylene glycol 400] isophane & reg (human)] PROPYLENE GLYCOL HUMULIN 70/30 SUSP LIQD [propylene glycol 1 OTC (70-30) 100 UNIT/ML (bulk)] 1 OTC SULFUR PRECIPITATED [insulin nph isophane & 1 OTC reg (human)] POWD [sulfur (bulk)] HUMULIN N KWIKPEN THYMOL CRYS [thymol] 1 OTC SUPN 100 UNIT/ML UREA POWD [urea 1 OTC 1 OTC [insulin nph (human) (bulk)] (isophane)]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 89 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits ZINC SULFATE TOLNAFTATE SOLN 1 % 1 OTC HEPTAHYDRATE POWD 1 OTC [tolnaftate] [zinc sulfate] [Miconazole Nitrate ZINC SULFATE Vaginal] VAGISTAT-3 KIT 1 OTC MONOHYDRATE POWD 1 OTC 200 & 2 MG-% (9GM) [zinc sulfate] ANTI-INFLAMMATORY AGENTS RESPIRATORY TRACT AGENTS AQUANIL HC LOTN 1 % ANTITUSSIVES [hydrocortisone 1 OTC CHERATUSSIN AC SYRP (topical)] 100-10 MG/5ML 1 OTC GNP [guaifenesin-codeine] HYDROCORTISONE PHENYLHISTINE DH LIQ CREA 0.5 % 1 OTC DH [pseudoeph- 1 OTC [hydrocortisone chlorphen w/ cod] (topical)] phenylephrine- HYDROCORTISONE 1 OTC CREA 0.5 % chlorphen-dm liqd 1 OTC VIRTUSSIN DAC SOLN [hydrocortisone 30-10-100 MG/5ML (topical)] 1 OTC [pseudoephedrine w/ HYDROCORTISONE OINT 0.5 % codeine-gg] 1 OTC SKIN AND MUCOUS MEMBRANE AGENTS [hydrocortisone (topical)] ANTI-INFECTIVES HYDROCORTISONE 1 OTC clotrimazole crea 1 % OINT 1 % 1 OTC DAKINS (1/4 STRENGTH) [hydrocortisone SOLN 0.125 % [sodium 1 OTC (topical)] hypochlorite] KP HYDROCORTISONE DAKINS (FULL CREA 1 % 1 OTC STRENGTH) SOLN 0.5 % 1 OTC [hydrocortisone [sodium hypochlorite] (topical)] DOUBLE ANTIBIOTIC ANTIPRURITICS AND LOCAL ANESTHETICS OINT 500-10000 UNIT/GM 1 OTC PHENOL LIQD [phenol] 1 OTC [bacitracin-polymyxin b] SARNA LOTN 0.5-0.5 % EQ MICONAZOLE 7 1 OTC

CREA 2 % [miconazole 1 OTC [camphor & menthol] nitrate vaginal] ASTRINGENTS GENTIAN VIOLET SOLN XERAC AC SOLN 6.25 % 1 OTC 1 % [gentian violet] [aluminum chloride in 1 OTC HYSEPT SOLN 0.25 % alcohol] 1 OTC [sodium hypochlorite] EMOLLIENTS, DEMULCENTS, AND ISAGEL GEL 60 % PROTECTANTS CALAMINE LOTN 8-8 % [antiseptic products, 1 OTC 1 OTC misc.] [calamine-zinc oxide] permethrin lotn 1 % 1 OTC KERATOPLASTIC AGENTS miconazole nitrate ELTA TAR CREA 2 % 1 OTC 1 OTC vaginal supp 100 mg [coal tar extract] TOLNAFTATE CREA 1 % SKIN AND MUCOUS MEMBRANE AGENTS, 1 OTC [tolnaftate] MISCELLANEOUS

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 90 of 145 Drug Requirement Drug Requirement Name of drug Name of drug Tier / Limits Tier / Limits AQUAPHOR OINT TRI-VI-SOL A/C/D SOLN 1 OTC [emollient] 250-50-10 [pediatric 1 OTC BENZOIN COMPOUND vitamins adc] TINC [benzoin 1 OTC VITAMIN B COMPLEX compound] FOLIC ACID TABS 400 BENZOIN TINC 1 OTC 1 OTC MCG [folic acid] [benzoin] NIACIN ER CPCR 250 DESITIN PSTE 40 % [zinc 1 OTC 1 OTC MG [niacin] oxide (topical)] NIACIN ER CPCR 500 DIFFERIN GEL 0.1 % 1 OTC 1 OTC MG [niacin] [adapalene] NIACIN ER TBCR 250 MG 1 OTC KP BENZOYL PEROXIDE [niacin] GEL 10 % [benzoyl 1 OTC NIACIN TABS 100 MG 1 OTC peroxide] [niacin] KP BENZOYL PEROXIDE NIACIN TABS 250 MG 1 OTC GEL 5 % [benzoyl 1 OTC [niacin] peroxide] NIACIN TABS 50 MG 1 OTC SODIUM CHLORIDE [niacin] TABS 1 GM [sodium 1 OTC NIACIN TABS 500 MG 1 OTC chloride] [niacin] VITAMINS PYRIDOXINE HCL TABS 1 OTC MULTIVITAMIN PREPARATIONS 25 MG [pyridoxine hcl] SLO-NIACIN TBCR 500 KP PRENATAL 1 OTC MULTIVITAMINS TABS MG [niacin] SLO-NIACIN TBCR 750 28-0.8 MG [prenatal vit 1 OTC 1 OTC w/ ferrous fumarate-folic MG [niacin] VITAMIN B-6 TABS 100 acid] 1 OTC POLY-VI-SOL SOLN MG [pyridoxine hcl] 1 OTC VITAMIN B-6 TABS 50 [pediatric multiple 1 OTC vitamins] MG [pyridoxine hcl] POLY-VI-SOL/IRON VITAMIN D SOLN 11 MG/ML 1 OTC ERGOCALCIFEROL [pediatric multiple SOLN 200 MCG/ML 1 OTC vitamins w/ iron] [ergocalciferol]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 91 of 145 Index abacavir sulfate tabs 300 mg ...... 4 ADACEL SUSP 5-2-15.5 LF-MCG/0.5 [tetanus abacavir sulfate-lamivudine tabs 600-300 mg 4 toxoid-diphtheria-acellular pertussis abacavir-lamivudine-zidovudine tabs 300-150- adsorb (tdap)] ...... 78 300 mg ...... 4 ADAKVEO SOLN 100 MG/10ML ABELCET SUSP 5 MG/ML [amphotericin b [crizanlizumab-tmca] ...... 30 lipid] ...... 10 adapalene gel 0.1 % ...... 82 abiraterone acetate tabs 250 mg ...... 14 adapalene gel 0.3 % ...... 82 ABRAXANE SUSR 100 MG [paclitaxel protein- adapalene-benzoyl peroxide gel 0.1-2.5 % ... 82 bound particles] ...... 14 ADCETRIS SOLR 50 MG [brentuximab acamprosate calcium tbec 333 mg ...... 46 vedotin] ...... 14 acarbose tabs 100 mg ...... 64 adefovir dipivoxil tabs 10 mg ...... 12 acarbose tabs 25 mg ...... 64 adenosine inj 6mg/2ml ...... 33 acarbose tabs 50 mg ...... 64 adenosine soln 12 mg/4ml ...... 33 ACD-A NOCLOT-50 SOLN 0.73-2.45-2.2 adenosine soln 3 mg/ml ...... 51 GM/100ML [anticoagulant citrate dextrose adenosine soln 6 mg/2ml ...... 33 solution a] ...... 28 ADVAIR HFA AERO 115-21 MCG/ACT acetaminophen tbcr 650 mg ...... 86 [fluticasone-salmeterol] ...... 75 acetaminophen-codeine #2 tabs 300-15 mg 36 ADVAIR HFA AERO 230-21 MCG/ACT acetaminophen-codeine #3 tabs 300-30 mg 36 [fluticasone-salmeterol] ...... 75 acetaminophen-codeine #4 tabs 300-60 mg 36 ADVAIR HFA AERO 45-21 MCG/ACT acetaminophen-codeine soln 120-12 mg/5ml [fluticasone-salmeterol] ...... 75 ...... 36 ADVATE SOLR 1000 UNIT [antihemophilic acetazolamide er cp12 500 mg ...... 59 factor (rcmb) plasma/albumin free (rahf- acetazolamide sodium solr 500 mg ...... 59 pfm)] ...... 25 acetazolamide tabs 125 mg ...... 59 ADVATE SOLR 1500 UNIT [antihemophilic acetazolamide tabs 250 mg ...... 59 factor (rcmb) plasma/albumin free (rahf- ACETEST TAB TABLETS [acetone (urine) pfm)] ...... 25 test] ...... 88 ADVATE SOLR 2000 UNIT [antihemophilic ACETIC ACID SOLN 0.25 % [acetic acid] ...... 54 factor (rcmb) plasma/albumin free (rahf- ACETIC ACID SOLN 2 % [acetic acid (otic)] . 59 pfm)] ...... 25 acetic acid-aluminum acetate soln 2 % ...... 59 ADVATE SOLR 250 UNIT [antihemophilic acetylcysteine soln 10 % ...... 70 factor (rcmb) plasma/albumin free (rahf- acetylcysteine soln 20 % ...... 70 pfm)] ...... 25 ACETYLCYSTEINE SOLN 200 MG/ML ADVATE SOLR 3000 UNIT [antihemophilic [acetylcysteine (antidote)] ...... 70 factor (rcmb) plasma/albumin free (rahf- acitretin caps 10 mg ...... 82 pfm)] ...... 25 acitretin caps 25 mg ...... 82 ADVATE SOLR 4000 UNIT [antihemophilic ACTHAR GEL 80 UNIT/ML [corticotropin] .... 67 factor (rcmb) plasma/albumin free (rahf- ACTHIB SOLR [haemophilus b polysac conj pfm)] ...... 25 vac] ...... 78 ADVATE SOLR 500 UNIT [antihemophilic ACTIMMUNE SOLN 2000000 UNIT/0.5ML factor (rcmb) plasma/albumin free (rahf- [interferon gamma-1b] ...... 70 pfm)] ...... 25 ACTIVASE SOLR 100 MG [alteplase] ...... 28 AEROCHAMBER PLUS FLO-VU SMALL MISC ACTIVASE SOLR 50 MG [alteplase] ...... 28 [spacer/aerosol-holding chambers] ...... 50 acyclovir caps 200 mg ...... 12 AEROCHAMBER Z-STAT PLUS MISC acyclovir sodium inj 1000mg ...... 12 [spacer/aerosol-holding chambers] ...... 50 acyclovir sodium soln 50 mg/ml ...... 12 AEROCHAMBER Z-STAT PLUS/LARGE MISC acyclovir susp 200 mg/5ml ...... 12 [spacer/aerosol-holding chambers] ...... 50 acyclovir tabs 400 mg ...... 12 AEROCHAMBER Z-STAT PLUS/MEDIUM MISC acyclovir tabs 800 mg ...... 12 [spacer/aerosol-holding chambers] ...... 50

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 92 of 145 AEROSPAN AERS 80 MCG/ACT [flunisolide alendronate sodium tabs 35 mg ...... 70 hfa] ...... 75 alendronate sodium tabs 40 mg ...... 70 AEROTRACH PLUS MISC [respiratory alendronate sodium tabs 70 mg ...... 70 therapy supplies] ...... 50 alfentanil hcl soln 1000 mcg/2ml ...... 36 AFINITOR TABS 10 MG [everolimus] ...... 14 ALIMTA SOLR 500 MG [pemetrexed disodium] AFLURIA SUSP [influenza virus vaccine split] ...... 14 ...... 78 ALINIA SUSR 100 MG/5ML [nitazoxanide] .... 12 AFSTYLA KIT 1000 UNIT [antihemophilic ALINIA TABS 500 MG [nitazoxanide] ...... 12 factor (recombinant) single chain] ...... 25 ALKERAN TABS 2 MG [melphalan] ...... 15 AFSTYLA KIT 1500 UNIT [antihemophilic allopurinol tabs 100 mg ...... 70 factor (recombinant) single chain] ...... 25 allopurinol tabs 300 mg ...... 70 AFSTYLA KIT 2000 UNIT [antihemophilic ALOCRIL SOLN 2 % [nedocromil sodium factor (recombinant) single chain] ...... 25 (ophth)] ...... 59 AFSTYLA KIT 250 UNIT [antihemophilic factor ALOE VERA POWD [aloe vera (bulk)] ...... 73 (recombinant) single chain] ...... 25 ALPHANATE/VWF COMPLEX/HUMAN SOLR AFSTYLA KIT 2500 UNIT [antihemophilic 1000 UNIT [antihemophilic factor/von factor (recombinant) single chain] ...... 25 willebrand factor complex (human)] ...... 25 AFSTYLA KIT 3000 UNIT [antihemophilic ALPHANATE/VWF COMPLEX/HUMAN SOLR factor (recombinant) single chain] ...... 25 1500 UNIT [antihemophilic factor/von AFSTYLA KIT 500 UNIT [antihemophilic factor willebrand factor complex (human)] ...... 25 (recombinant) single chain] ...... 25 ALPHANINE SD SOLR 1000 UNIT [coagulation AGGRENOX CP12 25-200 MG [aspirin- factor ix] ...... 25 dipyridamole] ...... 28 ALPHANINE SD SOLR 1500 UNIT [coagulation AK-FLUOR SOLN 10 % [fluorescein sodium factor ix] ...... 25 injection] ...... 51 ALPHANINE SD SOLR 500 UNIT [coagulation AKTEN GEL 3.5 % [lidocaine hcl (ophth)] .... 60 factor ix] ...... 25 AKTIPAK PACK 5-3 % [benzoyl peroxide- alprazolam tabs 0.25 mg ...... 44 erythromycin] ...... 79 alprazolam tabs 0.5 mg ...... 44 AKYNZEO CAPS 300-0.5 MG [netupitant- alprazolam tabs 1 mg ...... 44 palonosetron] ...... 60 alprazolam tabs 2 mg ...... 44 ALBENZA TABS 200 MG [albendazole]...... 4 ALPROSTADIL POWD [alprostadil (bulk)] ... 73 ALBUMIN HUMAN SOLN 25 % [albumin, alprostadil soln 500 mcg/ml ...... 35 human] ...... 24 ALTAFLUOR BENOX SOLN 0.25-0.4 % ALBURX SOLN 5 % [albumin, human] ...... 24 [fluorescein w/ benoxinate] ...... 51 ALBUSTIX STRP [albumin (urine) test] ...... 88 ALUNBRIG TABS 180 MG [brigatinib] ...... 15 ALBUTEIN SOLN 25 % [albumin, human] ..... 24 ALUNBRIG TABS 30 MG [brigatinib] ...... 15 albuterol sulfate hfa aers 108 (90 base) ALUNBRIG TABS 90 MG [brigatinib] ...... 15 mcg/act ...... 23 ALUNBRIG TBPK 90 & 180 MG [brigatinib] ... 15 albuterol sulfate nebu (2.5 mg/3ml) 0.083% . 23 ALVESCO AERS 160 MCG/ACT [ciclesonide] albuterol sulfate nebu (5 mg/ml) 0.5% ...... 23 ...... 75 albuterol sulfate nebu 0.63 mg/3ml ...... 23 ALVESCO AERS 80 MCG/ACT [ciclesonide] 75 albuterol sulfate nebu 1.25 mg/3ml ...... 23 amantadine hcl caps 100 mg...... 43 albuterol sulfate nebu 2.5 mg/0.5ml ...... 23 amantadine hcl syrp 50 mg/5ml ...... 43 albuterol sulfate syrp 2 mg/5ml ...... 23 AMBISOME SUSR 50 MG [amphotericin b albuterol sulfate tabs 2 mg ...... 23 liposome] ...... 11 albuterol sulfate tabs 4 mg ...... 23 ambrisentan tabs 10 mg ...... 35 alclometasone dipropionate crea 0.05 % ..... 80 ambrisentan tabs 5 mg ...... 35 alclometasone dipropionate oint 0.05 % ...... 80 amikacin sulfate soln 500 mg/2ml ...... 5 ALDURAZYME SOLN 2.9 MG/5ML [laronidase] amiloride-hydrochlorothiazide tabs 5-50 mg ...... 57 ...... 53 ALECENSA CAPS 150 MG [alectinib hcl] ..... 14 aminocaproic acid soln 250 mg/ml ...... 25 alendronate sodium tabs 10 mg ...... 70 aminophylline soln 25 mg/ml ...... 83

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 93 of 145 AMINOSYN II SOLN 10 % [amino acid amphetamine-dextroamphetamine tabs 12.5 infusion] ...... 52 mg ...... 39 AMINOSYN II/ELECTROLYTES SOLN 8.5 % amphetamine-dextroamphetamine tabs 15 mg [amino acid electrolyte infusion] ...... 52 ...... 39 amiodarone hcl soln 150 mg/3ml ...... 33 amphetamine-dextroamphetamine tabs 20 mg amiodarone hcl soln 900 mg/18ml ...... 33 ...... 39 amiodarone hcl tabs 200 mg...... 33 amphetamine-dextroamphetamine tabs 30 mg AMITIZA CAPS 24 MCG [lubiprostone] ...... 61 ...... 39 AMITIZA CAPS 8 MCG [lubiprostone] ...... 61 amphetamine-dextroamphetamine tabs 5 mg amitriptyline hcl tabs 10 mg...... 46 ...... 39 amitriptyline hcl tabs 100 mg ...... 46 amphetamine-dextroamphetamine tabs 7.5 amitriptyline hcl tabs 150 mg ...... 46 mg ...... 39 amitriptyline hcl tabs 25 mg...... 46 amphotericin b solr 50 mg ...... 11 amitriptyline hcl tabs 50 mg...... 46 ampicillin cap 250mg ...... 5 amitriptyline hcl tabs 75 mg...... 46 ampicillin caps 500 mg ...... 5 amlodipine besylate tabs 10 mg ...... 32 ampicillin sodium solr 1 gm ...... 5 amlodipine besylate tabs 2.5 mg ...... 32 ampicillin sodium solr 10 gm ...... 6 amlodipine besylate tabs 5 mg ...... 32 ampicillin sodium solr 125 mg ...... 6 amoxapine tabs 100 mg ...... 46 ampicillin sodium solr 2 gm ...... 6 amoxapine tabs 150 mg ...... 46 ampicillin sodium solr 250 mg ...... 6 amoxapine tabs 25 mg ...... 46 ampicillin sodium solr 500 mg ...... 6 amoxapine tabs 50 mg ...... 46 ampicillin sus 125/5ml ...... 6 amoxicillin caps 250 mg ...... 5 ampicillin sus 250/5ml ...... 6 amoxicillin caps 500 mg ...... 5 ampicillin-sulbactam sodium solr 1.5 (1-0.5) amoxicillin chew 125 mg ...... 5 gm ...... 6 amoxicillin chew 250 mg ...... 5 ampicillin-sulbactam sodium solr 15 (10-5) amoxicillin susr 125 mg/5ml ...... 5 gm ...... 6 amoxicillin susr 200 mg/5ml ...... 5 ampicillin-sulbactam sodium solr 3 (2-1) gm . 6 amoxicillin susr 250 mg/5ml ...... 5 amp-sulbacta inj 1.5gm ...... 5 amoxicillin susr 400 mg/5ml ...... 5 anagrelide hcl caps 0.5 mg ...... 28 amoxicillin-pot clavulanate chew 200-28.5 mg anagrelide hcl caps 1 mg ...... 28 ...... 5 anastrozole tabs 1 mg ...... 15 amoxicillin-pot clavulanate chew 400-57 mg . 5 ANAVIP SOLR [crotalidae immune f(ab')2 amoxicillin-pot clavulanate susr 200-28.5 (equine)] ...... 76 mg/5ml ...... 5 ANDRODERM PT24 2 MG/24HR [testosterone] amoxicillin-pot clavulanate susr 250-62.5 ...... 64 mg/5ml ...... 5 ANDRODERM PT24 4 MG/24HR [testosterone] amoxicillin-pot clavulanate susr 400-57 ...... 64 mg/5ml ...... 5 ANGIOMAX SOLR 250 MG [bivalirudin amoxicillin-pot clavulanate susr 600-42.9 trifluoroacetate] ...... 28 mg/5ml ...... 5 ANTACID SUSP 200-200-20 MG/5ML [alum & amoxicillin-pot clavulanate tabs 250-125 mg 5 mag hydrox-simethicone] ...... 88 amoxicillin-pot clavulanate tabs 500-125 mg 5 ANTIVENIN LATRODECTUS MACTANS KIT amoxicillin-pot clavulanate tabs 875-125 mg 5 [antivenin latrodectus mactans]...... 76 amphetamine-dextroamphet er cp24 10 mg 39 ANUCORT-HC SUPP 25 MG [hydrocortisone amphetamine-dextroamphet er cp24 15 mg 39 acetate (rectal)] ...... 80 amphetamine-dextroamphet er cp24 20 mg 39 APOKYN SOCT 30 MG/3ML [apomorphine amphetamine-dextroamphet er cp24 25 mg 39 hydrochloride] ...... 43 amphetamine-dextroamphet er cp24 30 mg 39 apraclonidine hcl soln 0.5 % ...... 59 amphetamine-dextroamphet er cp24 5 mg .. 39 APTENSIO XR CP24 10 MG [methylphenidate amphetamine-dextroamphetamine tabs 10 mg hcl] ...... 39 ...... 39 APTENSIO XR CP24 15 MG [methylphenidate

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 94 of 145 hcl] ...... 39 [mometasone furoate (inhalation)] ...... 62 APTENSIO XR CP24 20 MG [methylphenidate ASMANEX HFA AERO 200 MCG/ACT hcl] ...... 40 [mometasone furoate (inhalation)] ...... 62 APTENSIO XR CP24 30 MG [methylphenidate aspirin-dipyridamole er cp12 25-200 mg ...... 28 hcl] ...... 40 atazanavir sulfate caps 150 mg ...... 12 APTENSIO XR CP24 40 MG [methylphenidate atazanavir sulfate caps 200 mg ...... 12 hcl] ...... 40 atazanavir sulfate caps 300 mg ...... 12 APTENSIO XR CP24 50 MG [methylphenidate atenolol tabs 100 mg ...... 31 hcl] ...... 40 atenolol tabs 25 mg...... 31 APTENSIO XR CP24 60 MG [methylphenidate atenolol tabs 50 mg...... 31 hcl] ...... 40 atenolol-chlorthalidone tabs 100-25 mg ...... 31 APTIVUS CAPS 250 MG [tipranavir] ...... 4 atenolol-chlorthalidone tabs 50-25 mg ...... 31 AQUANIL HC LOTN 1 % [hydrocortisone ATGAM INJ 50 MG/ML [lymphocyte immune (topical)] ...... 90 globulin,anti-thymocyte globulin (equine)] AQUAPHOR OINT [emollient] ...... 90 ...... 69 AQUASOL A SOLN 15 MG/ML [vitamin a] ..... 84 atorvastatin calcium tabs 10 mg ...... 30 ARALAST NP SOLR 1000 MG [alpha1- atorvastatin calcium tabs 20 mg ...... 30 proteinase inhibitor (human)] ...... 57 atorvastatin calcium tabs 40 mg ...... 30 ARALAST NP SOLR 500 MG [alpha1- atorvastatin calcium tabs 80 mg ...... 30 proteinase inhibitor (human)] ...... 75 atovaquone susp 750 mg/5ml ...... 12 ARGATROBAN IN SODIUM CHLORIDE SOLN atovaquone-proguanil hcl tabs 250-100 mg . 12 125-0.9 MG/125ML-% [argatroban in sodium atovaquone-proguanil hcl tabs 62.5-25 mg .. 12 chloride] ...... 28 atracurium besylate soln 100 mg/10ml...... 22 ARGATROBAN SOLN 250 MG/2.5ML atracurium besylate soln 50 mg/5ml ...... 22 [argatroban] ...... 28 atropine sulfate inj 1mg/ml ...... 21 aripiprazole tabs 10 mg ...... 46 ATROPINE SULFATE MONOHYDRATE POW aripiprazole tabs 15 mg ...... 46 MONOHYDT [atropine sulfate aripiprazole tabs 2 mg ...... 46 monohydrate] ...... 73 aripiprazole tabs 20 mg ...... 46 ATROPINE SULFATE OINT 1 % [atropine aripiprazole tabs 30 mg ...... 46 sulfate (ophthalmic)] ...... 60 aripiprazole tabs 5 mg ...... 46 ATROPINE SULFATE SOLN 0.4 MG/ML ARISTADA PRSY 1064 MG/3.9ML [aripiprazole [atropine sulfate] ...... 21 lauroxil] ...... 47 ATROPINE SULFATE SOLN 1 % [atropine ARISTADA PRSY 441 MG/1.6ML [aripiprazole sulfate (ophthalmic)] ...... 60 lauroxil] ...... 47 ATROPINE SULFATE SOLN 8 MG/20ML ARISTADA PRSY 662 MG/2.4ML [aripiprazole [atropine sulfate] ...... 21 lauroxil] ...... 47 ATROPINE SULFATE SOSY 0.5 MG/5ML ARISTADA PRSY 882 MG/3.2ML [aripiprazole [atropine sulfate] ...... 21 lauroxil] ...... 47 ATROVENT HFA AERS 17 MCG/ACT ARRANON SOLN 5 MG/ML [nelarabine] ...... 15 [ipratropium bromide hfa] ...... 21 ASCORBIC ACID SOLN 500 MG/ML [ascorbic AUGMENTIN SUSR 125-31.25 MG/5ML acid] ...... 84 [amoxicillin & pot clavulanate] ...... 6 ASMANEX (120 METERED DOSES) AEPB 220 AVASTIN SOLN 100 MG/4ML [bevacizumab] 15 MCG/INH [mometasone furoate (inhalation)] AVASTIN SOLN 400 MG/16ML [bevacizumab] ...... 62 ...... 15 ASMANEX (30 METERED DOSES) AEPB 110 AVELOX SOLN 400 MG/250ML [moxifloxacin MCG/INH [mometasone furoate (inhalation)] hcl in sodium chloride] ...... 6 ...... 62 AVITA CREA 0.025 % [tretinoin] ...... 82 ASMANEX (60 METERED DOSES) AEPB 220 AVONEX KIT 30MCG [interferon beta-1a] .. 46 MCG/INH [mometasone furoate (inhalation)] AVONEX PEN AJKT 30 MCG/0.5ML [interferon ...... 62 beta-1a] ...... 70 ASMANEX HFA AERO 100 MCG/ACT azacitidine susr 100 mg ...... 15

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 95 of 145 AZACTAM IN DEXTROSE SOLN 1 GM/50ML BD PEN NEEDLE NANO U/F MISC 32G X 4 MM [aztreonam-dextrose] ...... 6 [insulin pen needle] ...... 86 AZACTAM IN DEXTROSE SOLN 2 GM/50ML BD PEN NEEDLE ORIGINAL U/F MISC 29G X [aztreonam-dextrose] ...... 6 12.7MM [insulin pen needle] ...... 86 azathioprine tabs 50 mg ...... 69 BD PEN NEEDLE SHORT U/F MISC 31G X 8 azelastine hcl soln 0.1 % ...... 59 MM [insulin pen needle] ...... 86 azithromycin solr 500 mg ...... 6 BD SAFETYGLIDE INSULIN SYRINGE MISC azithromycin susr 100 mg/5ml ...... 6 29G X 1/2 ...... 87 azithromycin susr 200 mg/5ml ...... 6 BD SAFETYGLIDE SYRINGE/NEEDLE MISC azithromycin tabs 250 mg ...... 6 27G X 5/8 ...... 87 azithromycin tabs 500 mg ...... 6 BD VEO INSULIN SYR U/F 1/2UNIT MISC 31G azithromycin tabs 600 mg ...... 6 X 15/64 ...... 51, 87 aztreonam solr 1 gm ...... 6 BD VEO INSULIN SYRINGE U/F MISC 31G X aztreonam solr 2 gm ...... 6 15/64 ...... 87 bacitracin oint 500 unit/gm ...... 58 BELLADONNA ALKALOIDS-OPIUM SUPP 16.2- bacitracin solr 50000 unit ...... 6 30 MG [belladonna alkaloids & opium] ..... 21 bacitracin-polymyxin b oint 500-10000 BELLADONNA ALKALOIDS-OPIUM SUPP 16.2- unit/gm ...... 58 60 MG [belladonna alkaloids & opium] ..... 21 BACLOFEN POWD [baclofen] ...... 73 benazepril hcl tabs 10 mg ...... 34 baclofen tabs 10 mg ...... 23 benazepril hcl tabs 20 mg ...... 34 baclofen tabs 20 mg ...... 23 benazepril hcl tabs 40 mg ...... 34 BACTERIOSTATIC WATER(BENZ ALC) SOLN benazepril hcl tabs 5 mg ...... 34 [water for inject, bacteriostatic benzyl BENDEKA SOLN 100 MG/4ML [bendamustine alcohol] ...... 73 hcl] ...... 15 BAL IN OIL SOLN 100 MG/ML [dimercaprol] 62 BENEFIX KIT 1000 UNIT [coagulation factor ix balsalazide disodium caps 750 mg ...... 60 (recombinant)] ...... 25 BANZEL SUSP 40 MG/ML [rufinamide] ...... 41 BENEFIX KIT 2000 UNIT [coagulation factor ix BANZEL TABS 200 MG [rufinamide] ...... 41 (recombinant)] ...... 25 BANZEL TABS 400 MG [rufinamide] ...... 41 BENEFIX KIT 250 UNIT [coagulation factor ix BAQSIMI TWO PACK POWD 3 MG/DOSE (recombinant)] ...... 25 [glucagon] ...... 65 BENEFIX KIT 3000 UNIT [coagulation factor ix BARACLUDE SOLN 0.05 MG/ML [entecavir] 12 (recombinant)] ...... 25 BAYER ADVANCED ASPIRIN EX ST TABS 500 BENEFIX KIT 500 UNIT [coagulation factor ix MG [aspirin] ...... 85 (recombinant)] ...... 26 BD 3ML LUER-LOK SYRINGE/22G X 1-1/4 .... 86 BENTYL SOLN 10 MG/ML [dicyclomine hcl] . 21 BD INSULIN SYRINGE MICROFINE MISC 27G BENZOIN COMPOUND TINC [benzoin X 5/8 ...... 86 compound] ...... 91 BD INSULIN SYRINGE MISC 25G X 1 ...... 86 BENZOIN TINC [benzoin] ...... 91 BD INSULIN SYRINGE MISC 27G X 1/2...... 86 benzonatate caps 100 mg ...... 75 BD INSULIN SYRINGE U/F 1/2UNIT MISC 31G benzoyl peroxide-erythromycin gel 5-3 % .... 79 X 5/16 ...... 86 benztropine mesylate soln 1 mg/ml ...... 43 BD INSULIN SYRINGE U/F MISC 30G X 1/2 .. 86 benztropine mesylate tabs 0.5 mg ...... 43 BD INSULIN SYRINGE U/F MISC 31G X 5/16 86 benztropine mesylate tabs 1 mg ...... 43 BD INSULIN SYRINGE U-500 MISC 31G X 6MM benztropine mesylate tabs 2 mg ...... 43 0.5 ML [insulin syringe/needle u-500] ...... 51 betamethasone dipropionate aug crea 0.05 % BD INTEGRA SYRINGE MISC 25G X 5/8 ...... 86 ...... 80 BD LANCET DEVICE MIS DEVICE [lancet betamethasone dipropionate aug gel 0.05 % devices] ...... 86 ...... 80 BD LANCET ULTRAFINE 33G MISC [lancets] betamethasone dipropionate aug lotn 0.05 % ...... 86 ...... 80 BD PEN NEEDLE MINI U/F MISC 31G X 5 MM betamethasone dipropionate aug oint 0.05 % [insulin pen needle] ...... 86 ...... 80

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 96 of 145 BETAMETHASONE DIPROPIONATE CREA sod-prednisolone] ...... 58 0.05 % [betamethasone dipropionate BLINCYTO SOLR 35 MCG [blinatumomab] .. 15 (topical)] ...... 80 BORIC ACID POWD [boric acid (bulk)] ...... 89 betamethasone sod phos & acet susp 6 (3-3) BOTOX COSMETIC SOLR 100 UNIT mg/ml ...... 62 [onabotulinumtoxina (cosmetic)] ...... 70 BETAMETHASONE VALERATE CREA 0.1 % BOTOX SOLR 100 UNIT [onabotulinumtoxina] [betamethasone valerate] ...... 80 ...... 70 betamethasone valerate foam 0.12 % ...... 80 BOTOX SOLR 200 UNIT [onabotulinumtoxina] BETAMETHASONE VALERATE LOTN 0.1 % ...... 70 [betamethasone valerate] ...... 80 BREVIBLOC IN NACL SOLN 2000 MG/100ML BETAMETHASONE VALERATE OINT 0.1 % [esmolol hcl-sodium chloride] ...... 31 [betamethasone valerate] ...... 80 BREVIBLOC IN NACL SOLN 2500 MG/250ML betaxolol hcl soln 0.5 % ...... 59 [esmolol hcl-sodium chloride] ...... 31 bethanechol chloride tabs 10 mg ...... 22 BREVITAL SODIUM SOLR 500 MG bethanechol chloride tabs 25 mg ...... 22 [methohexital sodium] ...... 46 bethanechol chloride tabs 5 mg ...... 22 BRIDION SOLN 200 MG/2ML [sugammadex bethanechol chloride tabs 50 mg ...... 22 sodium] ...... 70 BEXSERO SUSY [meningococcal vac group BRILINTA TABS 90 MG [ticagrelor] ...... 28 b (recombant omv adjuvanted)] ...... 78 brimonidine tartrate soln 0.2 % ...... 59 bicalutamide tabs 50 mg ...... 15 BRIVIACT TABS 10 MG [brivaracetam] ...... 41 BICILLIN L-A SUSP 1200000 UNIT/2ML BRIVIACT TABS 100 MG [brivaracetam] ...... 41 [penicillin g benzathine] ...... 6 BRIVIACT TABS 25 MG [brivaracetam] ...... 41 BICILLIN L-A SUSP 2400000 UNIT/4ML BRIVIACT TABS 50 MG [brivaracetam] ...... 41 [penicillin g benzathine] ...... 6 BRIVIACT TABS 75 MG [brivaracetam] ...... 41 BICILLIN L-A SUSP 600000 UNIT/ML [penicillin bromocriptine mesylate caps 5 mg ...... 43 g benzathine] ...... 6 bromocriptine mesylate tabs 2.5 mg ...... 43 BICNU SOLR 100 MG [carmustine] ...... 15 BRUKINSA CAPS 80 MG [zanubrutinib] ...... 15 BIKTARVY TABS 50-200-25 MG [bictegravir- BSS PLUS SOLN [ophthalmic irrigation emtricitabine-tenofovir alafenamide solution - intraocular] ...... 59 fumarate] ...... 4 BSS SOLN [ophthalmic irrigation solution - BILTRICIDE TABS 600 MG [praziquantel] ...... 4 intraocular] ...... 59 bimatoprost soln 0.03 % ...... 59 budesonide cpep 3 mg ...... 62 BIO GLO STRP 1 MG [fluorescein sodium budesonide susp 0.25 mg/2ml ...... 63 topical] ...... 51 budesonide susp 0.5 mg/2ml ...... 63 BIOTIN-D POWD [biotin (bulk)] ...... 89 bumetanide soln 0.25 mg/ml ...... 53 BISMATROL MAXIMUM STRENGTH SUSP 525 bumetanide tabs 0.5 mg ...... 53 MG/15ML [bismuth subsalicylate] ...... 88 bumetanide tabs 1 mg ...... 53 BISMATROL SUSP 262 MG/15ML [bismuth bumetanide tabs 2 mg ...... 53 subsalicylate] ...... 88 BUMINATE SOLN 5 % [albumin, human] ...... 24 BISMUTH SUBSALICYLATE CHEW 262 MG BUPHENYL TABS 500 MG [sodium [bismuth subsalicylate] ...... 88 phenylbutyrate] ...... 52 bisoprolol fumarate tabs 10 mg ...... 31 BUPIVACAINE FISIOPHARMA SOLN 2.5 bisoprolol fumarate tabs 5 mg ...... 31 MG/ML [bupivacaine hcl] ...... 69 bisoprolol-hydrochlorothiazide tabs 10-6.25 bupivacaine hcl (pf) soln 0.25 % ...... 69 mg ...... 31 bupivacaine hcl (pf) soln 0.5 % ...... 69 bisoprolol-hydrochlorothiazide tabs 2.5-6.25 bupivacaine hcl (pf) soln 0.75 % ...... 69 mg ...... 31 bupivacaine hcl inj 0.75% ...... 69 bisoprolol-hydrochlorothiazide tabs 5-6.25 bupivacaine hcl soln 0.25 % ...... 69 mg ...... 31 bupivacaine hcl soln 0.5 % ...... 69 bleomycin sulfate solr 15 unit ...... 15 bupivacaine in dextrose soln 0.75-8.25 % .... 69 bleomycin sulfate solr 30 unit ...... 15 bupivacaine-epinephrine (pf) soln 0.25% -1 BLEPHAMIDE SUSP 10-0.2 % [sulfacetamide 200000 ...... 69

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 97 of 145 bupivacaine-epinephrine (pf) soln 0.5% -1 CAMPTOSAR SOLN 100 MG/5ML [irinotecan 200000 ...... 69 hcl] ...... 15 bupivacaine-epinephrine soln 0.25% -1 CAMPTOSAR SOLN 40 MG/2ML [irinotecan 200000 ...... 69 hcl] ...... 15 bupivacaine-epinephrine soln 0.5% -1 CANCIDAS SOLR 50 MG [caspofungin 200000 ...... 69 acetate] ...... 11 buprenorphine hcl soln 0.3 mg/ml ...... 36 CANCIDAS SOLR 70 MG [caspofungin buprenorphine hcl-naloxone hcl subl 2-0.5 acetate] ...... 11 mg ...... 36 CANDIN SOLN [candida albicans skin test buprenorphine hcl-naloxone hcl subl 8-2 mg antigen] ...... 51 ...... 36 CANTHARIDIN POW [cantharidin] ...... 73 bupropion hcl er (sr) tb12 100 mg ...... 47 CAPASTAT SULFATE SOLR 1 GM bupropion hcl er (sr) tb12 150 mg ...... 47 [capreomycin sulfate] ...... 11 bupropion hcl er (sr) tb12 200 mg ...... 47 capecitabine tabs 150 mg ...... 15 bupropion hcl er (xl) tb24 150 mg ...... 47 capecitabine tabs 500 mg ...... 15 bupropion hcl er (xl) tb24 300 mg ...... 47 CAPRELSA TABS 100 MG [vandetanib] ...... 15 bupropion hcl tabs 100 mg ...... 47 CAPRELSA TABS 300 MG [vandetanib] ...... 15 bupropion hcl tabs 75 mg ...... 47 captopril tabs 100 mg ...... 34 buspirone hcl tabs 10 mg ...... 44 captopril tabs 12.5 mg ...... 34 buspirone hcl tabs 15 mg ...... 44 captopril tabs 25 mg ...... 34 buspirone hcl tabs 30 mg ...... 44 captopril tabs 50 mg ...... 34 buspirone hcl tabs 5 mg ...... 44 CARAFATE SUSP 1 GM/10ML [sucralfate] ... 61 buspirone hcl tabs 7.5 mg ...... 44 carbamazepine chew 100 mg ...... 41 butorphanol tartrate soln 1 mg/ml ...... 36 carbamazepine er cp12 100 mg ...... 41 butorphanol tartrate soln 2 mg/ml ...... 36 carbamazepine er cp12 200 mg ...... 41 BYDUREON BCISE AUIJ 2 MG/0.85ML carbamazepine er cp12 300 mg ...... 41 [exenatide] ...... 64 carbamazepine er tb12 100 mg ...... 41 cabergoline tabs 0.5 mg ...... 43 carbamazepine er tb12 200 mg ...... 41 CABOMETYX TABS 20 MG [cabozantinib s- carbamazepine er tb12 400 mg ...... 41 malate] ...... 15 CARBAMAZEPINE POWD [carbamazepine] 73 CABOMETYX TABS 40 MG [cabozantinib s- carbamazepine susp 100 mg/5ml ...... 41 malate] ...... 15 carbamazepine tabs 200 mg...... 41 CABOMETYX TABS 60 MG [cabozantinib s- carbidopa tabs 25 mg ...... 43 malate] ...... 15 carbidopa-levodopa er tbcr 25-100 mg ...... 43 caffeine citrate soln 60 mg/3ml ...... 40 carbidopa-levodopa er tbcr 50-200 mg ...... 43 CALAMINE LOTN 8-8 % [calamine-zinc oxide] carbidopa-levodopa tabs 10-100 mg ...... 43 ...... 90 carbidopa-levodopa tabs 25-100 mg ...... 43 calcipotriene crea 0.005 % ...... 82 carbidopa-levodopa tabs 25-250 mg ...... 43 calcipotriene soln 0.005 % ...... 82 carbidopa-levodopa-entacapone tabs 12.5-50- calcitonin (salmon) soln 200 unit/act ...... 67 200 mg ...... 43 calcitriol caps 0.25 mcg ...... 84 carbidopa-levodopa-entacapone tabs 18.75- calcitriol caps 0.5 mcg ...... 84 75-200 mg ...... 43 calcium acetate (phos binder) caps 667 mg 55 carbidopa-levodopa-entacapone tabs 25-100- CALCIUM CARBONATE TABS 1250 (500 Ca) 200 mg ...... 43 MG [calcium carbonate] ...... 88 carbidopa-levodopa-entacapone tabs 31.25- CALCIUM CHLORIDE SOLN 10 % [calcium 125-200 mg ...... 43 chloride (dihydrate)] ...... 55 carbidopa-levodopa-entacapone tabs 37.5- CALCIUM GLUCONATE SOLN 10 % [calcium 150-200 mg ...... 44 gluconate] ...... 55 carbidopa-levodopa-entacapone tabs 50-200- CALCIUM GLUCONATE TABS 500 MG 200 mg ...... 44 [calcium gluconate] ...... 88 CARDENE IV SOLN 20-0.86 MG/200ML-% CALQUENCE CAPS 100 MG [acalabrutinib] 15 [nicardipine hcl in sodium chloride] ...... 32

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 98 of 145 CARDENE IV SOLN 20-4.8 MG/200ML-% dextrose] ...... 7 [nicardipine hcl in dextrose] ...... 32 CEFOTETAN DISODIUM-DEXTROSE SOLR 2- CARDENE IV SOLN 40-0.83 MG/200ML-% 2.08 GM-%(50ML) [cefotetan disodium and [nicardipine hcl in sodium chloride] ...... 32 dextrose] ...... 7 CARDENE IV SOLN 40-5 MG/200ML-% cefoxitin sodium solr 1 gm ...... 7 [nicardipine hcl in dextrose] ...... 32 cefoxitin sodium solr 10 gm ...... 7 CARIMUNE NF SOLR 12 GM [immune cefoxitin sodium solr 2 gm ...... 7 globulin (human) iv] ...... 76 CEFOXITIN SODIUM-DEXTROSE SOLR 1-4 CARIMUNE NF SOLR 6 GM [immune globulin GM-%(50ML) [cefoxitin sodium and (human) iv] ...... 76 dextrose] ...... 7 carmustine solr 100 mg ...... 15 CEFOXITIN SODIUM-DEXTROSE SOLR 2-2.2 carvedilol tabs 12.5 mg ...... 31 GM-%(50ML) [cefoxitin sodium and carvedilol tabs 25 mg ...... 31 dextrose] ...... 7 carvedilol tabs 3.125 mg ...... 31 cefpodoxime proxetil susr 100 mg/5ml ...... 7 carvedilol tabs 6.25 mg ...... 31 cefpodoxime proxetil susr 50 mg/5ml ...... 7 CASCARA SAGRADA EXTR 1 GM/ML [cascara cefpodoxime proxetil tabs 100 mg ...... 7 sagrada] ...... 61 cefpodoxime proxetil tabs 200 mg ...... 7 CATHFLO ACTIVASE SOLR 2 MG [alteplase] ceftazidime solr 6 gm ...... 7 ...... 28 CEFTIN SUSR 125 MG/5ML [cefuroxime CAVERJECT SOLR 20 MCG [alprostadil axetil] ...... 7 (vasodilator)] ...... 35 ceftriaxone sodium in dextrose soln 20 mg/ml CAVERJECT SOLR 40 MCG [alprostadil ...... 7 (vasodilator)] ...... 35 ceftriaxone sodium in dextrose soln 40 mg/ml CAYSTON SOLR 75 MG [aztreonam lysine] ... 6 ...... 7 cefaclor caps 250 mg ...... 6 ceftriaxone sodium solr 1 gm ...... 7 cefaclor caps 500 mg ...... 6 ceftriaxone sodium solr 10 gm ...... 7 cefadroxil caps 500 mg ...... 6 ceftriaxone sodium solr 2 gm ...... 7 cefazolin sodium solr 1 gm ...... 6 ceftriaxone sodium solr 250 mg ...... 7 cefazolin sodium solr 10 gm ...... 6 ceftriaxone sodium solr 500 mg ...... 7 cefazolin sodium solr 20 gm ...... 6 CEFTRIAXONE SODIUM-DEXTROSE SOLR 1- cefazolin sodium solr 500 mg ...... 6 3.74 GM-%(50ML) [ceftriaxone sodium and CEFAZOLIN SODIUM-DEXTROSE SOLN 1-4 dextrose] ...... 7 GM/50ML-% [cefazolin sodium-dextrose] .. 6 CEFTRIAXONE SODIUM-DEXTROSE SOLR 2- CEFAZOLIN SODIUM-DEXTROSE SOLR 1-4 2.22 GM-%(50ML) [ceftriaxone sodium and GM-%(50ML) [cefazolin sodium-dextrose] . 6 dextrose] ...... 7 cefdinir susr 125 mg/5ml ...... 6 cefuroxime axetil tabs 250 mg ...... 7 cefdinir susr 250 mg/5ml ...... 6 cefuroxime axetil tabs 500 mg ...... 7 cefepime hcl solr 1 gm ...... 6 cefuroxime sodium solr 1.5 gm ...... 7 cefepime hcl solr 2 gm ...... 6 cefuroxime sodium solr 7.5 gm ...... 7 CEFEPIME-DEXTROSE SOLR 1-5 GM- cefuroxime sodium solr 750 mg ...... 7 %(50ML) [cefepime hcl-dextrose] ...... 6 CELONTIN CAPS 300 MG [methsuximide] ... 41 CEFEPIME-DEXTROSE SOLR 2-5 GM- cephalexin caps 250 mg ...... 7 %(50ML) [cefepime hcl-dextrose] ...... 6 cephalexin caps 500 mg ...... 7 cefixime caps 400 mg ...... 6 cephalexin susr 125 mg/5ml...... 7 cefotaxime sodium inj 10gm ...... 6 cephalexin susr 250 mg/5ml...... 7 cefotaxime sodium solr 1 gm ...... 6 cephalexin tabs 500 mg ...... 7 cefotaxime sodium solr 2 gm ...... 6 CEQUA SOLN 0.09 % [cyclosporine (ophth)] cefotaxime sodium solr 500 mg ...... 6 ...... 58 cefotetan disodium solr 1 gm ...... 7 CERDELGA CAPS 84 MG [eliglustat tartrate] cefotetan disodium solr 2 gm ...... 7 ...... 71 CEFOTETAN DISODIUM-DEXTROSE SOLR 1- CEREZYME SOLR 400 UNIT [imiglucerase] . 57 3.58 GM-%(50ML) [cefotetan disodium and CERVIDIL INST 10 MG [dinoprostone] ...... 73

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 99 of 145 CHANTIX CONTINUING MONTH PAK TABS 1 cinacalcet hcl tabs 30 mg ...... 71 MG [varenicline tartrate] ...... 22 cinacalcet hcl tabs 60 mg ...... 71 CHANTIX STARTING MONTH PAK TABS 0.5 cinacalcet hcl tabs 90 mg ...... 71 MG X 11 & 1 MG X 42 [varenicline tartrate] CINRYZE SOLR 500 UNIT [c1 esterase ...... 22 inhibitor (human)] ...... 71 CHANTIX TABS 0.5 MG [varenicline tartrate] CIPRO SUSR 250 MG/5ML (5%) ...... 22 [ciprofloxacin]...... 7 CHANTIX TABS 1 MG [varenicline tartrate] .. 22 CIPRO SUSR 500 MG/5ML (10%) CHEMET CAPS 100 MG [succimer] ...... 62 [ciprofloxacin]...... 7 CHEMSTRIP 9 STRP [multiple urine tests] . 88 ciprofloxacin hcl soln 0.3 % ...... 58 CHERATUSSIN AC SYRP 100-10 MG/5ML ciprofloxacin hcl tabs 250 mg ...... 7 [guaifenesin-codeine] ...... 90 ciprofloxacin hcl tabs 500 mg ...... 7 CHIRHOSTIM SOLR 16 MCG [secretin acetate ciprofloxacin hcl tabs 750 mg ...... 7 (human)] ...... 51 ciprofloxacin in d5w soln 200 mg/100ml ...... 7 chloramphenicol sod succinate solr 1 gm .... 7 ciprofloxacin in d5w soln 400 mg/200ml ...... 7 chlordiazepoxide hcl caps 10 mg ...... 44 ciprofloxacin-dexamethasone susp 0.3-0.1 % chlordiazepoxide hcl caps 25 mg ...... 44 ...... 58 chlordiazepoxide hcl caps 5 mg ...... 45 cisatracurium besylate (pf) soln 10 mg/5ml . 23 CHLORDIAZEPOXIDE-CLIDINIUM CAPS 5-2.5 cisatracurium besylate (pf) soln 200 mg/20ml MG [chlordiazepoxide hcl-clidinium ...... 23 bromide] ...... 21 cisatracurium besylate soln 20 mg/10ml ...... 23 chlorhexidine gluconate soln 0.12 % ...... 58 cisplatin soln 100 mg/100ml ...... 15 CHLOROFORM SOL [chloroform] ...... 73 cisplatin soln 50 mg/50ml ...... 15 chloroprocaine hcl (pf) soln 2 % ...... 69 citalopram hydrobromide soln 10 mg/5ml ... 47 chloroprocaine hcl inj 3% ...... 69 citalopram hydrobromide tabs 10 mg ...... 47 chloroquine phosphate tabs 250 mg...... 12 citalopram hydrobromide tabs 20 mg ...... 47 chloroquine phosphate tabs 500 mg...... 12 citalopram hydrobromide tabs 40 mg ...... 47 CHLORPHENIRAMINE MALEATE TABS 4 MG cladribine soln 10 mg/10ml ...... 15 [chlorpheniramine maleate] ...... 85 clarithromycin susr 125 mg/5ml ...... 7 CHLORPROMAZINE HCL POW HCL clarithromycin susr 250 mg/5ml ...... 7 [chlorpromazine hcl] ...... 73 clarithromycin tabs 250 mg ...... 8 chlorpromazine hcl soln 25 mg/ml ...... 47 clarithromycin tabs 500 mg ...... 8 chlorpromazine hcl tabs 10 mg ...... 47 CLEOCIN IN D5W SOLN 300 MG/50ML chlorpromazine hcl tabs 100 mg ...... 47 [clindamycin phosphate in d5w] ...... 8 chlorpromazine hcl tabs 200 mg ...... 47 CLEOCIN IN D5W SOLN 600 MG/50ML chlorpromazine hcl tabs 25 mg ...... 47 [clindamycin phosphate in d5w] ...... 8 chlorpromazine hcl tabs 50 mg ...... 47 CLEOCIN IN D5W SOLN 900 MG/50ML chlorthalidone tabs 25 mg ...... 53 [clindamycin phosphate in d5w] ...... 8 chlorthalidone tabs 50 mg ...... 53 CLEVIPREX EMUL 25 MG/50ML [clevidipine] CHOLESTEROL POWD [cholesterol]...... 89 ...... 32 cholestyramine light pack 4 gm ...... 30 CLEVIPREX EMUL 50 MG/100ML [clevidipine] cholestyramine light powd 4 gm/dose ...... 30 ...... 32 cholestyramine pack 4 gm ...... 30 CLICKFINE PEN NEEDLES MISC 31G X 6 MM cholestyramine powd 4 gm/dose ...... 31 [insulin pen needle] ...... 87 CHOLINE-MAG TRISALICYLATE LIQD 500 CLIMARA PTWK 0.025 MG/24HR [estradiol] . 66 MG/5ML [choline & mag salicylate] ...... 36 CLIMARA PTWK 0.0375 MG/24HR [estradiol] CHROMIC CHLORIDE SOLN 40 MCG/10ML ...... 66 [chromic chloride] ...... 55 CLIMARA PTWK 0.05 MG/24HR [estradiol] ... 66 cidofovir soln 75 mg/ml ...... 12 CLIMARA PTWK 0.06 MG/24HR [estradiol] ... 66 CIMDUO TABS 300-300 MG [lamivudine- CLIMARA PTWK 0.075 MG/24HR [estradiol] . 66 tenofovir disoproxil fumarate] ...... 4 CLIMARA PTWK 0.1 MG/24HR [estradiol] ..... 66 cimetidine hcl soln 300 mg/5ml ...... 61 clindamycin hcl caps 150 mg ...... 8

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 100 of 145 clindamycin hcl caps 300 mg ...... 8 acid infusion in d20w] ...... 53 CLINDAMYCIN HCL POWD [clindamycin hcl CLINIMIX/DEXTROSE (5/25) SOLN 5 % [amino (bulk)] ...... 73 acid infusion in d25w] ...... 53 clindamycin palmitate hcl solr 75 mg/5ml ..... 8 clobetasol propionate crea 0.05 % ...... 80 clindamycin phos-benzoyl perox gel 1.2-5 % clobetasol propionate foam 0.05 % ...... 80 ...... 79 clobetasol propionate gel 0.05 % ...... 80 clindamycin phos-benzoyl perox gel 1-5 % . 79 clobetasol propionate lotn 0.05 % ...... 80 clindamycin phosphate crea 2 % ...... 79 clobetasol propionate oint 0.05 % ...... 80 clindamycin phosphate gel 1 % ...... 79 CLOBETASOL PROPIONATE POW PROPIONA clindamycin phosphate lotn 1 % ...... 79 [clobetasol propionate] ...... 73 clindamycin phosphate soln 1 % ...... 79 clobetasol propionate soln 0.05 % ...... 80 clindamycin phosphate soln 300 mg/2ml ...... 8 CLOBEX LOTN 0.05 % [clobetasol propionate] CLINDAMYCIN PHOSPHATE SOLN 600 ...... 80 MG/4ML [clindamycin phosphate] ...... 8 CLOBEX SPRAY LIQD 0.05 % [clobetasol clindamycin phosphate soln 9000 mg/60ml .. 8 propionate] ...... 80 CLINIMIX E/DEXTROSE (2.75/10) SOLN 2.75 % clomiphene citrate tabs 50 mg ...... 66 [amino acid electrolyte w/ calcium infusion clomipramine hcl caps 25 mg ...... 47 in d10w] ...... 52 clomipramine hcl caps 50 mg ...... 47 CLINIMIX E/DEXTROSE (2.75/5) SOLN 2.75 % clomipramine hcl caps 75 mg ...... 47 [amino acid electrolyte w/ calcium infusion clonazepam tabs 0.5 mg ...... 41 in d5w] ...... 52 clonazepam tabs 1 mg ...... 41 CLINIMIX E/DEXTROSE (4.25/10) SOLN 4.25 % clonazepam tabs 2 mg ...... 41 [amino acid electrolyte w/ calcium infusion CLONIDINE HCL POWD [clonidine hcl] ...... 73 in d10w] ...... 52 clonidine hcl tabs 0.1 mg ...... 34 CLINIMIX E/DEXTROSE (4.25/25) SOLN 4.25 % clonidine hcl tabs 0.2 mg ...... 34 [amino acid electrolyte w/ calcium infusion clonidine hcl tabs 0.3 mg ...... 34 in d25w] ...... 52 clonidine ptwk 0.1 mg/24hr ...... 34 CLINIMIX E/DEXTROSE (4.25/5) SOLN 4.25 % clonidine ptwk 0.2 mg/24hr ...... 34 [amino acid electrolyte w/ calcium infusion clonidine ptwk 0.3 mg/24hr ...... 34 in d5w] ...... 53 clopidogrel bisulfate tabs 75 mg ...... 28 CLINIMIX E/DEXTROSE (5/15) SOLN 5 % clorazepate dipotassium tabs 15 mg ...... 45 [amino acid electrolyte w/ calcium infusion clorazepate dipotassium tabs 3.75 mg ...... 45 in d15w] ...... 53 clorazepate dipotassium tabs 7.5 mg ...... 45 CLINIMIX E/DEXTROSE (5/20) SOLN 5 % clotrimazole crea 1 % ...... 90 [amino acid electrolyte w/ calcium infusion CLOTRIMAZOLE CRYS [clotrimazole in d20w] ...... 53 (topical)] ...... 73 CLINIMIX E/DEXTROSE (5/25) SOLN 5 % CLOTRIMAZOLE POWD [clotrimazole [amino acid electrolyte w/ calcium infusion (topical)] ...... 73 in d25w] ...... 53 clotrimazole troc 10 mg ...... 79 CLINIMIX/DEXTROSE (2.75/5) SOLN 2.75 % clozapine tabs 100 mg ...... 47 [amino acid infusion in d5w] ...... 53 clozapine tabs 200 mg ...... 47 CLINIMIX/DEXTROSE (4.25/10) SOLN 4.25 % clozapine tabs 25 mg ...... 47 [amino acid infusion in d10w] ...... 53 clozapine tabs 50 mg ...... 47 CLINIMIX/DEXTROSE (4.25/20) SOLN 4.25 % COAL TAR EXTRACT SOLN 20 % [coal tar [amino acid infusion in d20w] ...... 53 (crude)] ...... 73 CLINIMIX/DEXTROSE (4.25/25) SOLN 4.25 % COARTEM TABS 20-120 MG [artemether- [amino acid infusion in d25w] ...... 53 lumefantrine] ...... 12 CLINIMIX/DEXTROSE (4.25/5) SOLN 4.25 % CODEINE SULFATE TABS 15 MG [codeine [amino acid infusion in d5w] ...... 53 sulfate] ...... 36 CLINIMIX/DEXTROSE (5/15) SOLN 5 % [amino CODEINE SULFATE TABS 30 MG [codeine acid infusion in d15w] ...... 53 sulfate] ...... 36 CLINIMIX/DEXTROSE (5/20) SOLN 5 % [amino CODEINE SULFATE TABS 60 MG [codeine

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 101 of 145 sulfate] ...... 36 [pancrelipase (lipase-protease-amylase)] 61 colchicine tabs 0.6 mg ...... 71 CREON CPEP 3000-9500 UNIT [pancrelipase colchicine-probenecid tabs 0.5-500 mg ...... 57 (lipase-protease-amylase)] ...... 61 colestipol hcl gran 5 gm ...... 31 CREON CPEP 36000-114000 UNIT colestipol hcl pack 5 gm ...... 31 [pancrelipase (lipase-protease-amylase)] 61 colestipol hcl tabs 1 gm ...... 31 CREON CPEP 6000-19000 UNIT [pancrelipase COLLODION FLEXIBLE LIQD [collodion (lipase-protease-amylase)] ...... 61 flexible] ...... 89 CRIXIVAN CAPS 200 MG [indinavir sulfate] ... 4 COLY-MYCIN S SUSP 3.3-3-10-0.5 MG/ML CRIXIVAN CAPS 400 MG [indinavir sulfate] ... 4 [neomycin-colistin-hc-thonzonium] ...... 58 CROFAB SOLR [crotalidae polyvalent COMBIVENT RESPIMAT AERS 20-100 immune fab (ovine)] ...... 76 MCG/ACT [ipratropium-albuterol] ...... 75 cromolyn sodium conc 100 mg/5ml ...... 75 COMETRIQ (100 MG DAILY DOSE) KIT 80 & 20 cromolyn sodium nebu 20 mg/2ml ...... 75 MG [cabozantinib s-malate] ...... 15 cromolyn sodium soln 4 % ...... 59 COMETRIQ (140 MG DAILY DOSE) KIT 3 x 20 C-TOPICAL SOLN 4 % [cocaine hcl] ...... 60 MG & 80 MG [cabozantinib s-malate] ...... 15 CUBICIN SOLR 500 MG [daptomycin]...... 8 COMETRIQ (60 MG DAILY DOSE) KIT 20 MG CUPRIC CHLORIDE SOLN 0.4 MG/ML [cupric [cabozantinib s-malate] ...... 15 chloride] ...... 55 COMPLERA TABS 200-25-300 MG CUROSURF SUSP 120 MG/1.5ML [poractant [emtricitabine-rilpivirine-tenofovir alfa] ...... 75 disoproxil fumarate] ...... 4 CUROSURF SUSP 240 MG/3ML [poractant CONDYLOX GEL 0.5 % [podofilox] ...... 82 alfa] ...... 75 CONRAY 43 INJ 43% [iothalamate CUVPOSA SOLN 1 MG/5ML [glycopyrrolate]21 meglumine] ...... 51 cyanocobalamin soln 1000 mcg/ml ...... 84 CONRAY SOLN 60 % [iothalamate cyclobenzaprine hcl tabs 10 mg ...... 23 meglumine] ...... 51 cyclobenzaprine hcl tabs 5 mg ...... 23 CONTOUR NEXT CONTROL SOLN NORMAL cyclopentolate hcl soln 1 % ...... 60 [blood glucose calibration] ...... 87 cyclopentolate hcl soln 2 % ...... 60 COPIKTRA CAPS 15 MG [duvelisib] ...... 15 CYCLOPHOSPHAMIDE CAPS 25 MG COPIKTRA CAPS 25 MG [duvelisib] ...... 15 [cyclophosphamide] ...... 15 CORDRAN TAPE 4 MCG/SQCM CYCLOPHOSPHAMIDE CAPS 50 MG [flurandrenolide] ...... 80 [cyclophosphamide] ...... 15 cortisone acetate tabs 25 mg...... 63 cyclophosphamide solr 1 gm ...... 15 CORTISPORIN CREA 3.5-10000-0.5 cyclophosphamide solr 2 gm ...... 15 [neomycin-polymyxin-hc] ...... 80 cyclophosphamide solr 500 mg ...... 15 CORTISPORIN OINT 1 % [bacitracin- cycloserine caps 250 mg ...... 12 polymyxin-neomycin hc] ...... 80 cyproheptadine hcl syrp 2 mg/5ml ...... 14 CORTROSYN SOLR 0.25 MG [cosyntropin] . 51 cyproheptadine hcl tabs 4 mg ...... 14 COSENTYX (300 MG DOSE) SOSY 150 MG/ML CYRAMZA SOLN 100 MG/10ML [ramucirumab] [secukinumab]...... 82 ...... 15 COSENTYX SENSOREADY (300 MG) SOAJ CYRAMZA SOLN 500 MG/50ML [ramucirumab] 150 MG/ML [secukinumab] ...... 82 ...... 15 COSENTYX SENSOREADY PEN SOAJ 150 CYSTADANE POWD [betaine] ...... 71 MG/ML [secukinumab] ...... 82 CYSTAGON CAPS 150 MG [cysteamine COSENTYX SOSY 150 MG/ML [secukinumab] bitartrate] ...... 71 ...... 82 CYSTAGON CAPS 50 MG [cysteamine COSMEGEN SOLR 0.5 MG [dactinomycin] .. 15 bitartrate] ...... 71 COTELLIC TABS 20 MG [cobimetinib CYSTEAMINE HCL POWD [cysteamine hcl fumarate] ...... 15 (bulk)] ...... 74 CREON CPEP 12000-38000 UNIT CYSTO-CONRAY II SOLN 17.2 % [iothalamate [pancrelipase (lipase-protease-amylase)] 61 meglumine] ...... 51 CREON CPEP 24000-76000 UNIT CYSTOGRAFIN SOLN 30 % [diatrizoate

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 102 of 145 meglumine] ...... 51 (antineoplastic)] ...... 67 CYSTOGRAFIN-DILUTE SOLN 18 % DESCOVY TABS 200-25 MG [emtricitabine- [diatrizoate meglumine] ...... 51 tenofovir alafenamide fumarate] ...... 13 cytarabine (pf) soln 100 mg/ml ...... 15 desipramine hcl tabs 10 mg ...... 47 cytarabine (pf) soln 20 mg/ml ...... 16 desipramine hcl tabs 100 mg ...... 47 cytarabine soln 20 mg/ml ...... 16 desipramine hcl tabs 150 mg ...... 47 CYTOGAM INJ 50 MG/ML [cytomegalovirus desipramine hcl tabs 25 mg ...... 47 immune globulin (human)] ...... 76 desipramine hcl tabs 50 mg ...... 47 CYTRA K CRYSTALS PACK 3300-1002 MG desipramine hcl tabs 75 mg ...... 47 [potassium citrate-citric acid] ...... 52 DESITIN PSTE 40 % [zinc oxide (topical)] .... 91 CYTRA-K SOLN 1100-334 MG/5ML [potassium desmopressin ace spray refrig soln 0.01 % . 67 citrate-citric acid] ...... 52 desmopressin acetate soln 4 mcg/ml ...... 67 dacarbazine solr 100 mg ...... 16 desmopressin acetate spray soln 0.01 % ..... 67 dacarbazine solr 200 mg ...... 16 desmopressin acetate tabs 0.1 mg ...... 67 DACOGEN SOLR 50 MG [decitabine] ...... 16 desmopressin acetate tabs 0.2 mg ...... 67 DAKINS (1/4 STRENGTH) SOLN 0.125 % desonide oint 0.05 % ...... 80 [sodium hypochlorite] ...... 90 desoximetasone crea 0.25 %...... 80 DAKINS (FULL STRENGTH) SOLN 0.5 % dexamethasone elix 0.5 mg/5ml ...... 63 [sodium hypochlorite] ...... 90 DEXAMETHASONE POWD [dexamethasone DAKLINZA TABS 30 MG [daclatasvir (bulk)] ...... 74 dihydrochloride] ...... 13 dexamethasone sodium phosphate soln 0.1 DAKLINZA TABS 60 MG [daclatasvir % ...... 58 dihydrochloride] ...... 13 dexamethasone sodium phosphate soln 10 DALIRESP TABS 500 MCG [roflumilast] ...... 75 mg/ml...... 63 danazol caps 100 mg ...... 64 dexamethasone sodium phosphate soln 20 danazol caps 200 mg ...... 64 mg/5ml...... 63 danazol caps 50 mg ...... 64 dexamethasone soln 0.5 mg/5ml ...... 63 dantrolene sodium caps 100 mg ...... 23 dexamethasone tabs 0.5 mg ...... 63 dantrolene sodium caps 25 mg ...... 23 dexamethasone tabs 0.75 mg ...... 63 dantrolene sodium caps 50 mg ...... 23 dexamethasone tabs 1 mg ...... 63 dapsone tabs 100 mg ...... 12 dexamethasone tabs 1.5 mg ...... 63 dapsone tabs 25 mg ...... 12 dexamethasone tabs 2 mg ...... 63 DARAPRIM TABS 25 MG [pyrimethamine] ... 12 dexamethasone tabs 4 mg ...... 63 DARZALEX SOLN 100 MG/5ML dexamethasone tabs 6 mg ...... 63 [daratumumab] ...... 16 dexmethylphenidate hcl er cp24 10 mg ...... 40 DARZALEX SOLN 400 MG/20ML dexmethylphenidate hcl er cp24 15 mg ...... 40 [daratumumab] ...... 16 dexmethylphenidate hcl er cp24 20 mg ...... 40 daunorubicin hcl soln 20 mg/4ml ...... 16 dexmethylphenidate hcl er cp24 25 mg ...... 40 DDAVP RHINAL TUBE SOLN 0.01 % dexmethylphenidate hcl er cp24 30 mg ...... 40 [desmopressin acetate refrigerated] ...... 67 dexmethylphenidate hcl er cp24 35 mg ...... 40 deferasirox tabs 360 mg ...... 62 dexmethylphenidate hcl er cp24 40 mg ...... 40 deferasirox tabs 90 mg ...... 62 dexmethylphenidate hcl er cp24 5 mg...... 40 deferoxamine mesylate solr 2 gm ...... 62 dexmethylphenidate hcl tabs 10 mg ...... 40 deferoxamine mesylate solr 500 mg ...... 62 dexmethylphenidate hcl tabs 2.5 mg ...... 40 DELESTROGEN OIL 20 MG/ML [estradiol dexmethylphenidate hcl tabs 5 mg ...... 40 valerate] ...... 66 dexrazoxane hcl solr 250 mg ...... 71 DELESTROGEN OIL 40 MG/ML [estradiol dexrazoxane hcl solr 500 mg ...... 71 valerate] ...... 66 dextroamphetamine sulfate er cp24 10 mg .. 40 demeclocycline hcl tabs 150 mg ...... 8 dextroamphetamine sulfate er cp24 15 mg .. 40 demeclocycline hcl tabs 300 mg ...... 8 dextroamphetamine sulfate er cp24 5 mg .... 40 DEPO-PROVERA SUSP 400 MG/ML dextroamphetamine sulfate tabs 10 mg ...... 40 [medroxyprogesterone acetate dextroamphetamine sulfate tabs 5 mg ...... 40

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 103 of 145 DEXTROSE 5%/ELECTROLYTE #48 SOLN dicyclomine hcl caps 10 mg ...... 21 [electrolyte-48 in dextrose] ...... 55 dicyclomine hcl soln 10 mg/5ml ...... 21 DEXTROSE IN LACTATED RINGERS SOLN 5 dicyclomine hcl tabs 20 mg ...... 21 % [dextrose in lactated ringers] ...... 55 didanosine cap 125mg ...... 4 dextrose in ringers soln 5 % ...... 55 didanosine cpdr 200 mg ...... 13 DEXTROSE SOLN 10 % [dextrose] ...... 53 didanosine cpdr 250 mg ...... 13 DEXTROSE SOLN 20 % [dextrose] ...... 53 didanosine cpdr 400 mg ...... 13 DEXTROSE SOLN 40 % [dextrose] ...... 53 DIFFERIN CREA 0.1 % [adapalene] ...... 82 DEXTROSE SOLN 5 % [dextrose] ...... 53 DIFFERIN GEL 0.1 % [adapalene] ...... 91 DEXTROSE SOLN 50 % [dextrose] ...... 53 DIFFERIN GEL 0.3 % [adapalene] ...... 82 DEXTROSE SOLN 70 % [dextrose] ...... 53 DIGIFAB SOLR 40 MG [digoxin immune fab]76 DEXTROSE-NACL SOLN 10-0.45 % [dextrose DIGOXIN SOLN 0.05 MG/ML [digoxin]...... 33 w/ sodium chloride] ...... 55 digoxin soln 0.25 mg/ml ...... 33 DEXTROSE-NACL SOLN 2.5-0.45 % [dextrose digoxin tabs 125 mcg ...... 33 w/ sodium chloride] ...... 55 digoxin tabs 250 mcg ...... 33 DEXTROSE-NACL SOLN 5-0.2 % [dextrose w/ dihydroergotamine mesylate soln 1 mg/ml .. 23 sodium chloride] ...... 55 diltiazem hcl er coated beads cp24 180 mg . 32 DEXTROSE-NACL SOLN 5-0.225 % [dextrose diltiazem hcl er cp12 120 mg ...... 32 w/ sodium chloride] ...... 55 diltiazem hcl er cp12 60 mg ...... 32 DEXTROSE-NACL SOLN 5-0.33 % [dextrose diltiazem hcl er cp12 90 mg ...... 32 w/ sodium chloride] ...... 55 diltiazem hcl er cp24 120 mg ...... 32 DEXTROSE-NACL SOLN 5-0.45 % [dextrose diltiazem hcl er cp24 180 mg ...... 32 w/ sodium chloride] ...... 55 diltiazem hcl er cp24 240 mg ...... 32 DEXTROSE-NACL SOLN 5-0.9 % [dextrose w/ DILTIAZEM HCL POWD [diltiazem hcl (bulk)] sodium chloride] ...... 55 ...... 74 DIANEAL LOW CALCIUM/4.25% DEX SOLN diltiazem hcl soln 125 mg/25ml ...... 32 483 MOSM/L [peritoneal dialysis solutions] diltiazem hcl soln 25 mg/5ml ...... 32 ...... 54 diltiazem hcl soln 50 mg/10ml ...... 32 DIANEAL PD-2/1.5% DEXTROSE SOLN 346 diltiazem hcl tabs 120 mg ...... 32 MOSM/L [peritoneal dialysis solutions] ... 54 diltiazem hcl tabs 30 mg ...... 32 DIANEAL PD-2/2.5% DEXTROSE SOLN 396 diltiazem hcl tabs 60 mg ...... 32 MOSM/L [peritoneal dialysis solutions] ... 54 diltiazem hcl tabs 90 mg ...... 32 DIANEAL PD-2/4.25% DEXTROSE SOLN 485 DIMAPHEN CHILDRENS ELIX 1-2.5 MG/5ML MOSM/L [peritoneal dialysis solutions] ... 54 [brompheniramine & phenyleph] ...... 85 DIASTAT ACUDIAL GEL 10 MG [diazepam dimethyl fumarate cpdr 120 mg ...... 71 (anticonvulsant)] ...... 45 dimethyl fumarate cpdr 240 mg ...... 71 DIASTAT ACUDIAL GEL 20 MG [diazepam dimethyl fumarate starter pack misc 120 & (anticonvulsant)] ...... 45 240 mg ...... 71 DIASTAT PEDIATRIC GEL 2.5 MG [diazepam DIPHENHIST LIQD 12.5 MG/5ML (anticonvulsant)] ...... 45 [diphenhydramine hcl] ...... 85 DIASTIX STRP [glucose urine test-(glucose DIPHENHYDRAMINE HCL CAPS 25 MG oxidase)] ...... 88 [diphenhydramine hcl] ...... 85 diazepam soln 5 mg/5ml ...... 45 DIPHENHYDRAMINE HCL CAPS 50 MG diazepam soln 5 mg/ml ...... 45 [diphenhydramine hcl] ...... 85 diazepam tabs 10 mg ...... 45 diphenhydramine hcl soln 50 mg/ml ...... 14 diazepam tabs 2 mg...... 45 diphenoxylate-atropine liqd 2.5-0.025 mg/5ml diazepam tabs 5 mg...... 45 ...... 60 diclofenac sodium gel 1 % ...... 82 diphenoxylate-atropine tabs 2.5-0.025 mg ... 60 diclofenac sodium soln 0.1 % ...... 58 DIPHTHERIA-TETANUS TOXOIDS DT SUSP diclofenac sodium soln 1.5 % ...... 82 25-5 LFU/0.5ML [diphtheria-tetanus toxoids dicloxacillin sodium caps 250 mg ...... 8 (dt)] ...... 78 dicloxacillin sodium caps 500 mg ...... 8 dipyridamole soln 5 mg/ml ...... 35

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 104 of 145 dipyridamole tabs 25 mg ...... 35 DOUBLE ANTIBIOTIC OINT 500-10000 dipyridamole tabs 50 mg ...... 35 UNIT/GM [bacitracin-polymyxin b] ...... 90 dipyridamole tabs 75 mg ...... 35 DOVATO TABS 50-300 MG [dolutegravir disopyramide phosphate caps 100 mg ...... 33 sodium-lamivudine] ...... 4 disopyramide phosphate caps 150 mg ...... 33 doxazosin mesylate tabs 1 mg ...... 30 DISPOSABLE POWER KIT [misc. devices] . 87 doxazosin mesylate tabs 2 mg ...... 30 disulfiram tabs 250 mg ...... 71 doxazosin mesylate tabs 4 mg ...... 30 disulfiram tabs 500 mg ...... 71 doxazosin mesylate tabs 8 mg ...... 30 divalproex sodium csdr 125 mg ...... 41 doxepin hcl caps 10 mg ...... 47 divalproex sodium er tb24 250 mg ...... 41 doxepin hcl caps 100 mg ...... 47 divalproex sodium er tb24 500 mg ...... 41 doxepin hcl caps 150 mg ...... 47 divalproex sodium tbec 125 mg ...... 41 doxepin hcl caps 25 mg ...... 47 divalproex sodium tbec 250 mg ...... 41 doxepin hcl caps 50 mg ...... 47 divalproex sodium tbec 500 mg ...... 41 doxepin hcl caps 75 mg ...... 47 dobutamine hcl soln 250 mg/20ml ...... 23 doxepin hcl conc 10 mg/ml ...... 47 DOBUTAMINE IN D5W SOLN 1-5 MG/ML-% DOXIL INJ 2 MG/ML [doxorubicin hcl [dobutamine in d5w] ...... 23 liposomal] ...... 16 DOBUTAMINE IN D5W SOLN 2 MG/ML doxorubicin hcl liposomal inj 2 mg/ml ...... 16 [dobutamine in d5w] ...... 23 doxorubicin hcl soln 2 mg/ml ...... 16 DOCETAXEL (NON-ALCOHOL) SOLN 160 doxorubicin hcl solr 10 mg ...... 16 MG/8ML [docetaxel] ...... 16 doxorubicin hcl solr 50 mg ...... 16 DOCETAXEL (NON-ALCOHOL) SOLN 20 doxycycline hyclate caps 100 mg ...... 8 MG/ML [docetaxel] ...... 16 doxycycline hyclate caps 50 mg ...... 8 docetaxel conc 80 mg/4ml ...... 16 doxycycline hyclate tabs 100 mg ...... 8 DOCUSATE SODIUM CAPS 100 MG [docusate doxycycline hyclate tabs 20 mg ...... 8 sodium] ...... 89 doxycycline monohydrate susr 25 mg/5ml .... 8 dofetilide caps 125 mcg ...... 33 doxycycline monohydrate tabs 100 mg ...... 8 dofetilide caps 250 mcg ...... 33 doxycycline monohydrate tabs 50 mg ...... 8 dofetilide caps 500 mcg ...... 33 DRITHO-CREME HP CREA 1 % [anthralin] ... 82 donepezil hcl tabs 10 mg ...... 22 dronabinol caps 10 mg ...... 60 DONEPEZIL HCL TABS 5 MG [donepezil dronabinol caps 2.5 mg ...... 60 hydrochloride] ...... 22 dronabinol caps 5 mg ...... 60 donepezil hcl tbdp 10 mg ...... 22 droperidol soln 2.5 mg/ml ...... 45 donepezil hcl tbdp 5 mg ...... 22 drospirenone-ethinyl estradiol tabs 3-0.02 mg DONNATAL ELIX 16.2 MG/5ML [phenobarbital- ...... 65 hyoscyamine-atropine-scopolamine] ...... 21 drospirenone-ethinyl estradiol tabs 3-0.03 mg DONNATAL TABS 16.2 MG [phenobarbital- ...... 65 hyoscyamine-atropine-scopolamine] ...... 21 DRYSOL SOLN 20 % [aluminum chloride] ... 82 dopamine hcl inj 80mg/ml ...... 23 duloxetine hcl cpep 20 mg ...... 47 dopamine hcl soln 160 mg/ml ...... 24 duloxetine hcl cpep 30 mg ...... 47 DOPAMINE HCL SOLN 40 MG/ML [dopamine duloxetine hcl cpep 60 mg ...... 47 hcl] ...... 24 DUOPA SUSP 4.63-20 MG/ML [carbidopa- dopamine hcl soln 80 mg/ml ...... 24 levodopa] ...... 44 DOPAMINE IN D5W SOLN 0.8-5 MG/ML-% DURAMORPH SOLN 0.5 MG/ML [morphine [dopamine in d5w] ...... 24 sulfate] ...... 36 DOPAMINE IN D5W SOLN 1.6-5 MG/ML-% DURAMORPH SOLN 1 MG/ML [morphine [dopamine in d5w] ...... 24 sulfate] ...... 37 DOPAMINE IN D5W SOLN 3.2-5 MG/ML-% D-XYLOSE POWD [d-xylose] ...... 51 [dopamine in d5w] ...... 24 DYRENIUM CAPS 100 MG [triamterene] ...... 53 dorzolamide hcl soln 2 % ...... 59 DYRENIUM CAPS 50 MG [triamterene] ...... 54 dorzolamide hcl-timolol mal soln 22.3-6.8 ED CHLORPED JR SYRP 2 MG/5ML mg/ml ...... 59 [chlorpheniramine maleate] ...... 85

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 105 of 145 EDECRIN TABS 25 MG [ethacrynic acid] ..... 54 ...... 26 EDEX KIT 10 MCG [alprostadil (vasodilator)] ELOCTATE SOLR 6000 UNIT [antihemophilic ...... 35 factor (rcmb) fc fusion protein(bdd-rfviiifc)] EDEX KIT 20 MCG [alprostadil (vasodilator)] ...... 26 ...... 35 ELOCTATE SOLR 750 UNIT [antihemophilic EDEX KIT 40 MCG [alprostadil (vasodilator)] factor (rcmb) fc fusion protein(bdd-rfviiifc)] ...... 35 ...... 26 EDURANT TABS 25 MG [rilpivirine hcl] ...... 4 ELTA TAR CREA 2 % [coal tar extract] ...... 90 EEMT HS TABS 0.625-1.25 MG [esterified EMCYT CAPS 140 MG [estramustine estrogens & methyltestosterone] ...... 66 phosphate sodium] ...... 16 EEMT TABS 1.25-2.5 MG [esterified estrogens EMEND CAPS 125 MG [aprepitant] ...... 60 & methyltestosterone] ...... 66 EMEND CAPS 40 MG [aprepitant] ...... 60 efavirenz caps 200 mg ...... 13 EMEND CAPS 80 MG [aprepitant] ...... 60 efavirenz caps 50 mg ...... 13 EMEND TRI-PACK CAPS 80 & 125 MG efavirenz tabs 600 mg ...... 13 [aprepitant] ...... 60 efavirenz-emtricitab-tenofovir tabs 600-200- emtricitabine caps 200 mg ...... 13 300 mg ...... 13 emtricitabine-tenofovir df tabs 100-150 mg . 13 EFFER-K TBEF 25 MEQ [potassium emtricitabine-tenofovir df tabs 133-200 mg . 13 bicarbonate] ...... 55 emtricitabine-tenofovir df tabs 167-250 mg . 13 EFFIENT TABS 10 MG [prasugrel hcl] ...... 28 emtricitabine-tenofovir df tabs 200-300 mg . 13 EFFIENT TABS 5 MG [prasugrel hcl] ...... 28 EMTRIVA SOLN 10 MG/ML [emtricitabine] ..... 4 ELAPRASE SOLN 6 MG/3ML [idursulfase] ... 57 enalaprilat inj 1.25 mg/ml ...... 34 eletriptan hydrobromide tabs 20 mg ...... 43 ENBREL SOLR 25 MG [etanercept] ...... 68 eletriptan hydrobromide tabs 40 mg ...... 43 ENBREL SOSY 25 MG/0.5ML [etanercept] .... 68 ELITEK SOLR 1.5 MG [rasburicase] ...... 57 ENBREL SOSY 50 MG/ML [etanercept] ...... 68 ELITEK SOLR 7.5 MG [rasburicase] ...... 57 ENBREL SURECLICK SOAJ 50 MG/ML ELLA TABS 30 MG [ulipristal acetate] ...... 65 [etanercept] ...... 68 ELMIRON CAPS 100 MG [pentosan ENDOMETRIN INST 100 MG [progesterone polysulfate sodium] ...... 71 (vaginal)] ...... 67 ELOCTATE SOLR 1000 UNIT [antihemophilic ENGERIX-B SUSP 10 MCG/0.5ML [hepatitis b factor (rcmb) fc fusion protein(bdd-rfviiifc)] vaccine (recomb)] ...... 78 ...... 26 ENGERIX-B SUSP 20 MCG/ML [hepatitis b ELOCTATE SOLR 1500 UNIT [antihemophilic vaccine (recomb)] ...... 78 factor (rcmb) fc fusion protein(bdd-rfviiifc)] ENTACAPONE TABS 200 MG [entacapone] . 44 ...... 26 entecavir tabs 0.5 mg ...... 13 ELOCTATE SOLR 2000 UNIT [antihemophilic entecavir tabs 1 mg...... 13 factor (rcmb) fc fusion protein(bdd-rfviiifc)] ENTRESTO TABS 24-26 MG [sacubitril- ...... 26 valsartan] ...... 34 ELOCTATE SOLR 250 UNIT [antihemophilic ENTRESTO TABS 49-51 MG [sacubitril- factor (rcmb) fc fusion protein(bdd-rfviiifc)] valsartan] ...... 34 ...... 26 ENTRESTO TABS 97-103 MG [sacubitril- ELOCTATE SOLR 3000 UNIT [antihemophilic valsartan] ...... 34 factor (rcmb) fc fusion protein(bdd-rfviiifc)] EOVIST SOLN 0.25 MOL/L [gadoxetate ...... 26 disodium] ...... 51 ELOCTATE SOLR 4000 UNIT [antihemophilic EPCLUSA TABS 200-50 MG [sofosbuvir- factor (rcmb) fc fusion protein(bdd-rfviiifc)] velpatasvir] ...... 13 ...... 26 EPCLUSA TABS 400-100 MG [sofosbuvir- ELOCTATE SOLR 500 UNIT [antihemophilic velpatasvir] ...... 13 factor (rcmb) fc fusion protein(bdd-rfviiifc)] EPHEDRINE SULFATE SOLN 50 MG/ML ...... 26 [ephedrine sulfate (pressors)] ...... 24 ELOCTATE SOLR 5000 UNIT [antihemophilic EPIDUO FORTE GEL 0.3-2.5 % [adapalene- factor (rcmb) fc fusion protein(bdd-rfviiifc)] benzoyl peroxide] ...... 83

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 106 of 145 epinephrine hcl inj 1mg/ml ...... 24 estradiol tabs 1 mg ...... 66 EPINEPHRINE PF SOLN 1 MG/ML estradiol tabs 2 mg ...... 66 [epinephrine] ...... 24 estradiol valerate inj 10mg/ml ...... 66 epinephrine soaj 0.15 mg/0.15ml ...... 24 estradiol valerate oil 20 mg/ml ...... 66 EPINEPHRINE SOLN 30 MG/30ML estradiol valerate oil 40 mg/ml ...... 67 [epinephrine] ...... 24 ESTRING RING 2 MG [estradiol vaginal] ...... 67 EPINEPHRINE SOSY 1 MG/10ML ethacrynic acid tabs 25 mg ...... 54 [epinephrine] ...... 24 ethambutol hcl tabs 100 mg ...... 12 EPIPEN 2-PAK SOAJ 0.3 MG/0.3ML ethambutol hcl tabs 400 mg ...... 12 [epinephrine (anaphylaxis)] ...... 24 ETHAMOLIN SOLN 5 % [ethanolamine oleate] EPIPEN JR 2-PAK SOAJ 0.15 MG/0.3ML ...... 35 [epinephrine (anaphylaxis)] ...... 24 ethosuximide caps 250 mg ...... 41 EPIVIR HBV SOLN 5 MG/ML [lamivudine ethosuximide soln 250 mg/5ml ...... 41 (hbv)] ...... 13 etidronate disodium tabs 200 mg ...... 71 EPIVIR HBV TABS 100 MG [lamivudine (hbv)] etidronate disodium tabs 400 mg ...... 71 ...... 13 etodolac caps 200 mg ...... 37 EQ MICONAZOLE 7 CREA 2 % [miconazole etodolac caps 300 mg ...... 37 nitrate vaginal] ...... 90 etodolac tabs 400 mg ...... 37 EQUETRO CP12 200 MG [carbamazepine etodolac tabs 500 mg ...... 37 (antipsychotic)] ...... 41 etomidate soln 2 mg/ml ...... 46 ERBITUX SOLN 100 MG/50ML [cetuximab] .. 16 etoposide caps 50 mg ...... 16 ERBITUX SOLN 200 MG/100ML [cetuximab] 16 everolimus tabs 2.5 mg ...... 16 ERGOCALCIFEROL SOLN 200 MCG/ML everolimus tabs 5 mg ...... 16 [ergocalciferol] ...... 91 everolimus tabs 7.5 mg ...... 16 ergoloid mesylates tabs 1 mg ...... 43 EVOTAZ TABS 300-150 MG [atazanavir ergotamine-caffeine tabs 1-100 mg ...... 43 sulfate-cobicistat] ...... 13 ERIVEDGE CAPS 150 MG [vismodegib] ...... 16 exemestane tabs 25 mg ...... 16 erlotinib hcl tabs 100 mg ...... 16 EXJADE TBSO 125 MG [deferasirox] ...... 62 erlotinib hcl tabs 150 mg ...... 16 EXJADE TBSO 250 MG [deferasirox] ...... 62 erlotinib hcl tabs 25 mg ...... 16 EXJADE TBSO 500 MG [deferasirox] ...... 62 ERWINAZE SOLR 10000 UNIT [asparaginase EXTAVIA KIT 0.3 MG [interferon beta-1b] ..... 46 erwinia chrysanthemi] ...... 16 EYLEA SOLN 2 MG/0.05ML [aflibercept] ...... 59 ERYTHROCIN LACTOBIONATE SOLR 500 MG EYLEA SOSY 2 MG/0.05ML [aflibercept] ...... 59 [erythromycin lactobionate] ...... 8 E-Z-CAT DRY PACK 2 % [barium sulfate] ..... 51 erythromycin oint 5 mg/gm ...... 58 ezetimibe tabs 10 mg ...... 31 erythromycin soln 2 % ...... 79 FABRAZYME SOLR 35 MG [agalsidase beta] escitalopram oxalate soln 5 mg/5ml ...... 47 ...... 57 escitalopram oxalate tabs 10 mg ...... 47 FABRAZYME SOLR 5 MG [agalsidase beta] . 57 escitalopram oxalate tabs 20 mg ...... 47 famciclovir tabs 500 mg ...... 13 escitalopram oxalate tabs 5 mg ...... 47 famotidine premixed soln 20-0.9 mg/50ml-% ESMOLOL HCL SOLN 100 MG/10ML [esmolol ...... 61 hcl] ...... 31 famotidine soln 20 mg/2ml ...... 61 ESTRADIOL POW [estradiol] ...... 74 famotidine soln 40 mg/4ml ...... 61 estradiol pttw 0.025 mg/24hr...... 66 famotidine susr 40 mg/5ml ...... 61 estradiol pttw 0.0375 mg/24hr ...... 66 famotidine tabs 20 mg ...... 61 estradiol pttw 0.05 mg/24hr ...... 66 famotidine tabs 40 mg ...... 61 estradiol pttw 0.075 mg/24hr...... 66 felbamate susp 600 mg/5ml...... 41 estradiol pttw 0.1 mg/24hr ...... 66 felbamate tabs 400 mg ...... 41 estradiol ptwk 0.05 mg/24hr ...... 66 felbamate tabs 600 mg ...... 41 estradiol ptwk 0.075 mg/24hr ...... 66 fenofibrate tabs 160 mg ...... 31 estradiol ptwk 0.1 mg/24hr ...... 66 fenofibrate tabs 54 mg ...... 31 estradiol tabs 0.5 mg ...... 66 fentanyl citrate (pf) soct 100 mcg/2ml ...... 37

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 107 of 145 FENTANYL CITRATE (PF) SOLN 100 MCG/2ML fluconazole tabs 50 mg ...... 11 [fentanyl citrate] ...... 37 flucytosine caps 250 mg ...... 11 FENTANYL CITRATE (PF) SOLN 500 flucytosine caps 500 mg ...... 11 MCG/10ML [fentanyl citrate] ...... 37 fludarabine phosphate solr 50 mg ...... 16 fentanyl pt72 100 mcg/hr ...... 37 fludrocortisone acetate tabs 0.1 mg ...... 63 fentanyl pt72 12 mcg/hr ...... 37 flumazenil soln 0.5 mg/5ml ...... 46 fentanyl pt72 25 mcg/hr ...... 37 flunisolide soln 25 mcg/act (0.025%) ...... 58 fentanyl pt72 50 mcg/hr ...... 37 fluocinolone acetonide body oil 0.01 % ...... 80 fentanyl pt72 75 mcg/hr ...... 37 fluocinolone acetonide scalp oil 0.01 % ...... 81 FERREX 150 CAPS 150 MG [polysaccharide fluocinolone acetonide soln 0.01 % ...... 81 iron complex] ...... 85 fluocinonide crea 0.05 % ...... 81 FERROUS SULFATE SOLN 75 (15 Fe) MG/ML fluocinonide gel 0.05 % ...... 81 [ferrous sulfate]...... 85 fluocinonide oint 0.05 % ...... 81 FERROUS SULFATE TABS 325 (65 Fe) MG fluocinonide soln 0.05 % ...... 81 [ferrous sulfate]...... 85 FLUORITAB CHEW 2.2 (1 F) MG [sodium finasteride tabs 5 mg ...... 71 fluoride] ...... 71 FIRAZYR SOLN 30 MG/3ML [icatibant acetate] fluorometholone susp 0.1 % ...... 58 ...... 71 FLUOROPLEX CREA 1 % [fluorouracil FIRVANQ SOLR 25 MG/ML [vancomycin hcl] 8 (topical)] ...... 83 FIRVANQ SOLR 50 MG/ML [vancomycin hcl] 8 fluorouracil crea 5 % ...... 83 FLEBOGAMMA DIF SOLN 0.5 GM/10ML fluorouracil soln 1 gm/20ml...... 16 [immune globulin (human) iv] ...... 76 fluorouracil soln 2 % ...... 83 FLEBOGAMMA DIF SOLN 2.5 GM/50ML fluorouracil soln 2.5 gm/50ml ...... 16 [immune globulin (human) iv] ...... 76 fluorouracil soln 5 % ...... 83 FLEBOGAMMA DIF SOLN 20 GM/400ML fluorouracil soln 5 gm/100ml ...... 16 [immune globulin (human) iv] ...... 76 fluorouracil soln 500 mg/10ml ...... 16 FLEBOGAMMA DIF SOLN 5 GM/50ML fluoxetine hcl caps 10 mg ...... 47 [immune globulin (human) iv] ...... 76 fluoxetine hcl caps 20 mg ...... 48 flecainide acetate tabs 100 mg ...... 33 fluoxetine hcl caps 40 mg ...... 48 flecainide acetate tabs 150 mg ...... 33 fluoxetine hcl soln 20 mg/5ml ...... 48 flecainide acetate tabs 50 mg ...... 33 fluphenazine decanoate soln 25 mg/ml ...... 48 FLONASE SENSIMIST SUSP 27.5 fluphenazine hcl conc 5 mg/ml ...... 48 MCG/SPRAY [fluticasone furoate] ...... 88 fluphenazine hcl tabs 1 mg ...... 48 FLOVENT HFA AERO 44 MCG/ACT fluphenazine hcl tabs 10 mg ...... 48 [fluticasone propionate hfa] ...... 63 fluphenazine hcl tabs 2.5 mg ...... 48 FLUAD SUSY 0.5 ML [influenza virus vaccine fluphenazine hcl tabs 5 mg ...... 48 types a & b surface antigen adjuvant] ...... 78 FLURA-DROPS SOLN 0.55 (0.25 F) MG/DROP fluconazole in dextrose inj dex 200 ...... 11 [sodium fluoride] ...... 71 fluconazole in dextrose soln 400 mg/200ml 11 flurbiprofen sodium soln 0.03 % ...... 58 fluconazole in nacl inj nacl 200 ...... 11 flutamide caps 125 mg ...... 16 fluconazole in nacl inj nacl 400 ...... 11 fluticasone propionate crea 0.05 % ...... 81 fluconazole in sodium chloride soln 100-0.9 fluticasone propionate oint 0.005 % ...... 81 mg/50ml-% ...... 8 fluticasone propionate susp 50 mcg/act 58, 88 fluconazole in sodium chloride soln 200-0.9 fluvoxamine maleate tabs 100 mg ...... 48 mg/100ml-% ...... 11 fluvoxamine maleate tabs 25 mg ...... 48 fluconazole in sodium chloride soln 400-0.9 fluvoxamine maleate tabs 50 mg ...... 48 mg/200ml-% ...... 11 FLUZONE HIGH-DOSE SUSY 0.5 ML fluconazole susr 10 mg/ml ...... 11 [influenza virus vaccine split high-dose fluconazole susr 40 mg/ml ...... 11 preservative free] ...... 78 fluconazole tabs 100 mg ...... 11 FLUZONE SUSP [influenza virus vaccine fluconazole tabs 150 mg ...... 11 split] ...... 78 fluconazole tabs 200 mg ...... 11 FML FORTE SUSP 0.25 % [fluorometholone

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 108 of 145 (ophth)] ...... 58 galantamine hydrobromide tabs 12 mg ...... 22 FML OINT 0.1 % [fluorometholone (ophth)] . 58 galantamine hydrobromide tabs 4 mg ...... 22 folic acid soln 5 mg/ml ...... 84 galantamine hydrobromide tabs 8 mg ...... 22 FOLIC ACID TABS 400 MCG [folic acid] ...... 91 GAMASTAN INJ [immune globulin (human) FORANE SOLN [isoflurane]...... 46 im] ...... 76 FORTAZ IN D5W SOLN 1-5 GM/50ML-% GAMMAGARD S/D LESS IGA SOLR 10 GM [ceftazidime sodium in d5w] ...... 8 [immune globulin (human) iv] ...... 76 FORTAZ IN D5W SOLN 2-5 GM/50ML-% GAMMAGARD S/D LESS IGA SOLR 5 GM [ceftazidime sodium in d5w] ...... 8 [immune globulin (human) iv] ...... 76 FORTAZ SOLR 500 MG [ceftazidime] ...... 8 GAMMAGARD SOLN 1 GM/10ML [immune FORTEO SOPN 620 MCG/2.48ML [teriparatide globulin (human) iv or subcutaneous] ..... 76 (recombinant)] ...... 67 GAMMAGARD SOLN 30 GM/300ML [immune fosamprenavir calcium tabs 700 mg ...... 13 globulin (human) iv or subcutaneous] ..... 76 fosaprepitant dimeglumine solr 150 mg ...... 61 GAMMAKED SOLN 1 GM/10ML [immune FOSCAVIR SOLN 6000 MG/250ML [foscarnet globulin (human) iv or subcutaneous] ..... 76 sodium] ...... 13 GAMMAKED SOLN 10 GM/100ML [immune fosphenytoin sodium soln 100 mg pe/2ml ... 41 globulin (human) iv or subcutaneous] ..... 76 fosphenytoin sodium soln 500 mg pe/10ml . 41 GAMMAKED SOLN 2.5 GM/25ML [immune fulvestrant soln 250 mg/5ml...... 16 globulin (human) iv or subcutaneous] ..... 76 furosemide soln 10 mg/ml ...... 54 GAMMAKED SOLN 20 GM/200ML [immune furosemide soln 8 mg/ml ...... 54 globulin (human) iv or subcutaneous] ..... 77 FUROSEMIDE TABS 20 MG [furosemide] .... 54 GAMMAKED SOLN 5 GM/50ML [immune FUROSEMIDE TABS 40 MG [furosemide] .... 54 globulin (human) iv or subcutaneous] ..... 77 furosemide tabs 80 mg ...... 54 GAMMAPLEX SOLN 10 GM/200ML [immune FUSILEV SOLR 50 MG [levoleucovorin globulin (human) iv] ...... 77 calcium] ...... 71 GAMMAPLEX SOLN 20 GM/400ML [immune FUZEON SOLR 90 MG [enfuvirtide] ...... 4 globulin (human) iv] ...... 77 gabapentin caps 100 mg ...... 41 GAMMAPLEX SOLN 5 GM/100ML [immune gabapentin caps 300 mg ...... 41 globulin (human) iv] ...... 77 gabapentin caps 400 mg ...... 41 GAMUNEX-C SOLN 1 GM/10ML [immune GABAPENTIN POWD [gabapentin (bulk)] ... 74 globulin (human) iv or subcutaneous] ..... 77 gabapentin soln 250 mg/5ml ...... 41 GAMUNEX-C SOLN 10 GM/100ML [immune gabapentin tabs 600 mg ...... 41 globulin (human) iv or subcutaneous] ..... 77 gabapentin tabs 800 mg ...... 41 GAMUNEX-C SOLN 2.5 GM/25ML [immune GABLOFEN SOLN 10000 MCG/20ML globulin (human) iv or subcutaneous] ..... 77 [baclofen] ...... 23 GAMUNEX-C SOLN 20 GM/200ML [immune GABLOFEN SOLN 20000 MCG/20ML globulin (human) iv or subcutaneous] ..... 77 [baclofen] ...... 23 GAMUNEX-C SOLN 5 GM/50ML [immune GABLOFEN SOLN 40000 MCG/20ML globulin (human) iv or subcutaneous] ..... 77 [baclofen] ...... 23 ganciclovir sodium solr 500 mg ...... 13 GABLOFEN SOSY 10000 MCG/20ML GARDASIL 9 SUSP [human papillomavirus [baclofen] ...... 23 (hpv) 9-valent recombinant vaccine] ...... 78 GABLOFEN SOSY 20000 MCG/20ML GARDASIL 9 SUSY [human papillomavirus [baclofen] ...... 23 (hpv) 9-valent recombinant vaccine] ...... 78 GABLOFEN SOSY 40000 MCG/20ML GARDASIL INJ [human papillomavirus [baclofen] ...... 23 (hpv) quadrivalent recombinant vaccine] . 78 GABLOFEN SOSY 50 MCG/ML [baclofen] .... 23 GARDASIL SUSP [human papillomavirus GADAVIST SOLN 1 MMOL/ML [gadobutrol] . 51 (hpv) quadrivalent recombinant vaccine] . 78 galantamine hydrobromide er cp24 16 mg .. 22 GASTROGRAFIN SOLN 66-10 % [diatrizoate galantamine hydrobromide er cp24 24 mg .. 22 meglumine & sodium] ...... 51 GALANTAMINE HYDROBROMIDE ER CP24 8 gatifloxacin soln 0.5 % ...... 58 MG [galantamine hydrobromide] ...... 22 GAZYVA SOLN 1000 MG/40ML

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 109 of 145 [obinutuzumab] ...... 16 GLYCERIN LIQD [glycerin (bulk)] ...... 74, 89 GELFILM FILM [gelatin adsorbable (ophth)] 26 GLYCOPYRROLATE POWD [glycopyrrolate GELFOAM SPONGE MISC 12-7 MM [gelatin (bulk)] ...... 74 absorbable] ...... 26 glycopyrrolate soln 0.2 mg/ml ...... 21 GELFOAM SPONGE SIZE 100 MISC [gelatin glycopyrrolate soln 0.4 mg/2ml ...... 21 absorbable] ...... 26 glycopyrrolate soln 1 mg/5ml...... 21 GELFOAM SPONGE SIZE 50 MISC [gelatin glycopyrrolate soln 4 mg/20ml ...... 21 absorbable] ...... 26 glycopyrrolate tabs 1 mg ...... 21 GELUSIL CHEW 200-200-25 MG [alum & mag glycopyrrolate tabs 2 mg ...... 21 hydrox-simethicone] ...... 88 GNP HYDROCORTISONE CREA 0.5 % gemcitabine hcl solr 200 mg ...... 16 [hydrocortisone (topical)] ...... 90 gemfibrozil tabs 600 mg ...... 31 GOLYTELY SOLR 236 GM [peg 3350-kcl-sod GEMZAR SOLR 1 GM [gemcitabine hcl] ...... 16 bicarb-sod chloride-sod sulfate] ...... 61 gentamicin in saline soln 0.8-0.9 mg/ml-% .... 8 GONAL-F RFF REDIJECT SOLN 300 gentamicin in saline soln 0.9-0.9 mg/ml-% .... 8 UNIT/0.5ML [follitropin alfa] ...... 67 gentamicin in saline soln 1.2-0.9 mg/ml-% .... 8 GONAL-F RFF REDIJECT SOLN 450 gentamicin in saline soln 1.4-0.9 mg/ml-% .... 8 UNT/0.75ML [follitropin alfa] ...... 67 gentamicin in saline soln 1.6-0.9 mg/ml-% .... 8 GONAL-F RFF REDIJECT SOLN 900 gentamicin in saline soln 1-0.9 mg/ml-% ...... 8 UNIT/1.5ML [follitropin alfa] ...... 67 gentamicin in saline soln 2-0.9 mg/ml-% ...... 8 GONAL-F RFF SOLR 75 UNIT [follitropin alfa] gentamicin sulfate crea 0.1 % ...... 79 ...... 67 gentamicin sulfate oint 0.1 %...... 80 GONAL-F SOLR 1050 UNIT [follitropin alfa] . 67 gentamicin sulfate soln 0.3 % ...... 58 GONAL-F SOLR 450 UNIT [follitropin alfa] ... 67 gentamicin sulfate soln 10 mg/ml ...... 9 GOODSENSE PAIN RELIEF EXTRA ST TABS gentamicin sulfate soln 40 mg/ml ...... 9 500 MG [acetaminophen] ...... 86 GENTIAN VIOLET SOLN 1 % [gentian violet]90 GRASTEK SUBL 2800 BAU [timothy grass GENVOYA TABS 150-150-200-10 MG pollen allergen extract] ...... 71 [elvitegravir-cobicistat-emtricitabine- griseofulvin microsize susp 125 mg/5ml ...... 11 tenofovir alafenamide] ...... 13 griseofulvin microsize tabs 500 mg ...... 11 GLEOSTINE CAPS 10 MG [lomustine] ...... 16 griseofulvin ultramicrosize tabs 125 mg ...... 11 GLEOSTINE CAPS 100 MG [lomustine] ...... 16 griseofulvin ultramicrosize tabs 250 mg ...... 11 GLEOSTINE CAPS 40 MG [lomustine] ...... 16 guanfacine hcl er tb24 1 mg ...... 46 GLEOSTINE CAPS 5 MG [lomustine] ...... 16 guanfacine hcl er tb24 2 mg ...... 46 glimepiride tabs 1 mg ...... 64 guanfacine hcl er tb24 3 mg ...... 46 glimepiride tabs 2 mg ...... 64 guanfacine hcl er tb24 4 mg ...... 46 glimepiride tabs 4 mg ...... 64 guanfacine hcl tabs 1 mg ...... 23 glipizide tabs 10 mg...... 64 guanfacine hcl tabs 2 mg ...... 23 glipizide tabs 5 mg...... 64 GUANIDINE HCL TABS 125 MG [guanidine glipizide tb24 10 mg...... 64 hcl] ...... 22 glipizide tb24 2.5 mg ...... 64 HAEGARDA SOLR 2000 UNIT [c1 esterase glipizide tb24 5 mg...... 64 inhibitor (human)] ...... 71 glipizide-metformin hcl tabs 2.5-250 mg ...... 64 HAEGARDA SOLR 3000 UNIT [c1 esterase glipizide-metformin hcl tabs 2.5-500 mg ...... 64 inhibitor (human)] ...... 71 glipizide-metformin hcl tabs 5-500 mg ...... 64 HALAVEN SOLN 1 MG/2ML [eribulin mesylate] GLUCAGEN HYPOKIT SOLR 1 MG [glucagon ...... 16 hcl (rdna)] ...... 65 halobetasol propionate crea 0.05 % ...... 81 GLUCAGEN INJ 1MG [glucagon hcl (rdna)] halobetasol propionate oint 0.05 % ...... 81 ...... 65 haloperidol decanoate soln 100 mg/ml ...... 48 glucagon emergency kit 1 mg ...... 65 haloperidol decanoate soln 50 mg/ml ...... 48 glyburide tabs 1.25 mg ...... 64 haloperidol lactate conc 2 mg/ml ...... 48 glyburide tabs 2.5 mg ...... 64 haloperidol lactate soln 5 mg/ml ...... 48 glyburide tabs 5 mg ...... 64 HALOPERIDOL POWD [haloperidol (bulk)] . 74

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 110 of 145 haloperidol tabs 0.5 mg ...... 48 25000-5 UT/500ML-% [heparin sod (porcine) haloperidol tabs 1 mg ...... 48 in d5w] ...... 29 haloperidol tabs 10 mg ...... 48 HEPARIN SOD (PORCINE) IN D5W SOLN 40-5 haloperidol tabs 2 mg ...... 48 UNIT/ML-% [heparin sod (porcine) in d5w] haloperidol tabs 20 mg ...... 48 ...... 29 haloperidol tabs 5 mg ...... 48 heparin sodium (porcine) lock flush soln .... 28 HARVONI TABS 45-200 MG [ledipasvir- HEPARIN SODIUM (PORCINE) PF SOLN 5000 sofosbuvir] ...... 11 UNIT/0.5ML [heparin sodium (porcine)] .... 29 HARVONI TABS 90-400 MG [ledipasvir- HEPARIN SODIUM (PORCINE) SOLN 1000 sofosbuvir] ...... 11 UNIT/ML [heparin sodium (porcine)] ...... 29 HAVRIX SUSP 1440 EL U/ML [hepatitis a HEPARIN SODIUM (PORCINE) SOLN 10000 vaccine] ...... 78 UNIT/ML [heparin sodium (porcine)] ...... 29 HAVRIX SUSP 720 EL U/0.5ML [hepatitis a HEPARIN SODIUM (PORCINE) SOLN 20000 vaccine] ...... 78 UNIT/ML [heparin sodium (porcine)] ...... 29 HEALON5 INJ 23MG/ML [sodium HEPARIN SODIUM (PORCINE) SOLN 5000 hyaluronate] ...... 59 UNIT/ML [heparin sodium (porcine)] ...... 29 HELIXATE FS KIT 250 UNIT [antihemophilic HEPARIN SODIUM LOCK FLUSH SOLN 100 factor (recombinant) (rfviii)] ...... 26 UNIT/ML [heparin sodium (porcine) lock HEMABATE SOLN 250 MCG/ML [carboprost flush] ...... 29 tromethamine] ...... 73 HERCEPTIN SOLR 150 MG [trastuzumab] ... 16 HEMLIBRA SOLN 105 MG/0.7ML [emicizumab- hetastarch-nacl soln 6-0.9 % ...... 55 kxwh] ...... 26 HEXALEN CAPS 50 MG [altretamine]...... 16 HEMLIBRA SOLN 150 MG/ML [emicizumab- HEXTEND SOLN 6 % [hetastarch in lactated kxwh] ...... 26 electrolyte] ...... 55 HEMLIBRA SOLN 30 MG/ML [emicizumab- HIBERIX SOLR 10 MCG [haemophilus b kxwh] ...... 26 polysac conj vac] ...... 78 HEMLIBRA SOLN 60 MG/0.4ML [emicizumab- HISTEX-PE SYRP 2.5-10 MG/5ML [triprolidine- kxwh] ...... 26 phenylephrine]...... 85 HEMOFIL M INJ 220-400 [antihemophilic HIZENTRA SOLN 1 GM/5ML [immune globulin factor (human)]...... 26 (human) subcutaneous] ...... 77 HEMOFIL M SOLR 1000 UNIT [antihemophilic HIZENTRA SOLN 10 GM/50ML [immune factor (human)]...... 26 globulin (human) subcutaneous] ...... 77 HEMOFIL M SOLR 1700 UNIT [antihemophilic HIZENTRA SOLN 2 GM/10ML [immune factor (human)]...... 26 globulin (human) subcutaneous] ...... 77 HEMOFIL M SOLR 500 UNIT [antihemophilic HIZENTRA SOLN 4 GM/20ML [immune factor (human)]...... 26 globulin (human) subcutaneous] ...... 77 HEPARIN (PORCINE) IN NACL SOLN 1000-0.9 HOMATROPINE HBR SOLN 5 % [homatropine UT/500ML-% [heparin (porcine) in sodium hbr] ...... 60 chloride] ...... 28 HUMALOG MIX 50/50 KWIKPEN SUPN (50-50) HEPARIN (PORCINE) IN NACL SOLN 2000-0.9 100 UNIT/ML [insulin lispro protamine & UNIT/L-% [heparin (porcine) in sodium lispro] ...... 64 chloride] ...... 28 HUMALOG MIX 50/50 SUSP (50-50) 100 HEPARIN (PORCINE) IN NACL SOLN 25000- UNIT/ML [insulin lispro protamine & lispro] 0.45 UT/250ML-% [heparin (porcine) in ...... 64 sodium chloride] ...... 28 HUMALOG SOLN 100 UNIT/ML [insulin lispro] HEPARIN LOCK FLUSH SOLN 1 UNIT/ML ...... 65 [heparin sodium (porcine) lock flush] ...... 29 HUMATE-P SOLR 1000-2400 UNIT HEPARIN LOCK FLUSH SOLN 10 UNIT/ML [antihemophilic factor/von willebrand factor [heparin sodium (porcine) lock flush] ...... 29 complex (human)] ...... 26 HEPARIN SOD (PORCINE) IN D5W SOLN 100 HUMATE-P SOLR 250-600 UNIT UNIT/ML [heparin sod (porcine) in d5w] ... 29 [antihemophilic factor/von willebrand factor HEPARIN SOD (PORCINE) IN D5W SOLN complex (human)] ...... 26

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 111 of 145 HUMATE-P SOLR 500-1200 UNIT hydrocodone-acetaminophen tabs 5-325 mg [antihemophilic factor/von willebrand factor ...... 37 complex (human)] ...... 26 hydrocodone-acetaminophen tabs 7.5-325 mg HUMIRA PEDIATRIC CROHNS START PSKT ...... 37 80 MG/0.8ML & 40MG/0.4ML [adalimumab] hydrocodone-homatropine syrp 5-1.5 mg/5ml ...... 71 ...... 75 HUMIRA PEDIATRIC CROHNS START PSKT hydrocortisone ace-pramoxine crea 1-1 % .. 81 80 MG/0.8ML [adalimumab] ...... 71 HYDROCORTISONE ACE-PRAMOXINE CREA HUMIRA PEN PNKT 40 MG/0.4ML 2.5-1 % [pramoxine-hc] ...... 81 [adalimumab] ...... 71 HYDROCORTISONE CREA 0.5 % HUMIRA PEN PNKT 40 MG/0.8ML [hydrocortisone (topical)] ...... 90 [adalimumab] ...... 68 hydrocortisone crea 1 % ...... 81 HUMIRA PEN-CD/UC/HS STARTER PNKT 80 hydrocortisone crea 2.5 % ...... 81 MG/0.8ML [adalimumab] ...... 71 hydrocortisone enem 100 mg/60ml ...... 81 HUMIRA PEN-PSOR/UVEIT STARTER PNKT hydrocortisone lotn 2.5 % ...... 81 80 MG/0.8ML & 40MG/0.4ML [adalimumab] HYDROCORTISONE OINT 0.5 % ...... 71 [hydrocortisone (topical)] ...... 90 HUMIRA PSKT 10 MG/0.1ML [adalimumab] . 71 HYDROCORTISONE OINT 1 % HUMIRA PSKT 10 MG/0.2ML [adalimumab] . 68 [hydrocortisone (topical)] ...... 90 HUMIRA PSKT 20 MG/0.2ML [adalimumab] . 71 hydrocortisone oint 2.5 % ...... 81 HUMIRA PSKT 20 MG/0.4ML [adalimumab] . 68 HYDROCORTISONE POWD [hydrocortisone HUMIRA PSKT 40 MG/0.4ML [adalimumab] . 71 (topical)] ...... 74 HUMIRA PSKT 40 MG/0.8ML [adalimumab] . 68 hydrocortisone tabs 10 mg ...... 63 HUMULIN 70/30 KWIKPEN SUPN (70-30) 100 hydrocortisone tabs 20 mg ...... 63 UNIT/ML [insulin nph isophane & reg hydrocortisone tabs 5 mg ...... 63 (human)] ...... 89 HYDROCORTISONE-IODOQUINOL CREA 1-1 HUMULIN 70/30 SUSP (70-30) 100 UNIT/ML % [iodoquinol-hc] ...... 80 [insulin nph isophane & reg (human)] ...... 89 HYDROCORT-PRAMOXINE (PERIANAL) CREA HUMULIN N KWIKPEN SUPN 100 UNIT/ML 2.5-1 % [hydrocortisone acetate w/ [insulin nph (human) (isophane)] ...... 89 pramoxine] ...... 81 HUMULIN N SUSP 100 UNIT/ML [insulin nph hydromorphone hcl liqd 1 mg/ml ...... 37 (human) (isophane)] ...... 89 hydromorphone hcl pf soln 500 mg/50ml .... 37 HUMULIN R SOLN 100 UNIT/ML [insulin HYDROMORPHONE HCL SOLN 1 MG/ML regular (human)] ...... 89 [hydromorphone hcl] ...... 37 HUMULIN R U-500 (CONCENTRATED) SOLN HYDROMORPHONE HCL SOLN 2 MG/ML 500 UNIT/ML [insulin regular (human)] ..... 65 [hydromorphone hcl] ...... 37 HUMULIN R U-500 KWIKPEN SOPN 500 HYDROMORPHONE HCL SOLN 4 MG/ML UNIT/ML [insulin regular (human)] ...... 65 [hydromorphone hcl] ...... 37 HYCAMTIN CAPS 0.25 MG [topotecan hcl] .. 16 HYDROMORPHONE HCL SUPP 3 MG HYCAMTIN CAPS 1 MG [topotecan hcl] ...... 16 [hydromorphone hcl] ...... 37 hydralazine hcl soln 20 mg/ml ...... 34 hydromorphone hcl tabs 2 mg ...... 37 hydralazine hcl tabs 10 mg ...... 34 hydromorphone hcl tabs 4 mg ...... 37 hydralazine hcl tabs 100 mg ...... 34 hydromorphone hcl tabs 8 mg ...... 37 hydralazine hcl tabs 25 mg ...... 34 HYDROPHILIC OINT [hydrophilic ointment] 89 hydralazine hcl tabs 50 mg ...... 34 HYDROXOCOBALAMIN POW hydrochlorothiazide tabs 12.5 mg ...... 54 [hydroxocobalamin (bulk)] ...... 74 hydrochlorothiazide tabs 25 mg ...... 54 hydroxychloroquine sulfate tabs 200 mg ..... 12 hydrochlorothiazide tabs 50 mg ...... 54 HYDROXYPROGESTERONE CAPROATE hydrocodone-acetaminophen soln 7.5-325 POWD [hydroxyprogesterone caproate mg/15ml ...... 37 (bulk)] ...... 74 hydrocodone-acetaminophen tabs 10-325 mg hydroxyprogesterone caproate soln 1.25 ...... 37 gm/5ml...... 67

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 112 of 145 hydroxyurea caps 500 mg ...... 16 IBRANCE TABS 100 MG [palbociclib] ...... 17 hydroxyzine hcl soln 25 mg/ml ...... 45 IBRANCE TABS 125 MG [palbociclib] ...... 17 hydroxyzine hcl soln 50 mg/ml ...... 45 IBRANCE TABS 75 MG [palbociclib] ...... 17 hydroxyzine hcl syrp 10 mg/5ml ...... 45 ibuprofen susp 100 mg/5ml ...... 37 hydroxyzine hcl tabs 10 mg ...... 45 ibutilide fumarate soln 1 mg/10ml ...... 33 hydroxyzine hcl tabs 25 mg ...... 45 icatibant acetate soln 30 mg/3ml ...... 71 hydroxyzine hcl tabs 50 mg ...... 45 IDAMYCIN PFS SOLN 10 MG/10ML [idarubicin hydroxyzine pamoate caps 100 mg ...... 45 hcl] ...... 17 hydroxyzine pamoate caps 25 mg ...... 45 IDAMYCIN PFS SOLN 20 MG/20ML [idarubicin hydroxyzine pamoate caps 50 mg ...... 45 hcl] ...... 17 HYLENEX SOLN 150 UNIT/ML [hyaluronidase idarubicin hcl soln 5 mg/5ml ...... 17 human] ...... 57 IDELVION SOLR 1000 UNIT [coagulation HYOSCYAMINE SULFATE ER TB12 0.375 MG factor ix recomb albumin fusion protein [hyoscyamine sulfate] ...... 21 (rix-fp)] ...... 26 HYOSCYAMINE SULFATE SUBL 0.125 MG IDELVION SOLR 2000 UNIT [coagulation [hyoscyamine sulfate] ...... 21 factor ix recomb albumin fusion protein HYOSCYAMINE SULFATE TABS 0.125 MG (rix-fp)] ...... 26 [hyoscyamine sulfate] ...... 21 IDELVION SOLR 250 UNIT [coagulation factor HYOSCYAMINE SULFATE TBDP 0.125 MG ix recomb albumin fusion protein (rix-fp)] 27 [hyoscyamine sulfate] ...... 21 IDELVION SOLR 500 UNIT [coagulation factor HYOSYNE ELIX 0.125 MG/5ML [hyoscyamine ix recomb albumin fusion protein (rix-fp)] 27 sulfate] ...... 21 IFOSFAMIDE SOLR 1 GM [ifosfamide] ...... 17 HYOSYNE SOLN 0.125 MG/ML [hyoscyamine imatinib mesylate tabs 100 mg ...... 17 sulfate] ...... 22 imatinib mesylate tabs 400 mg ...... 17 HYPERLYTE-CR CONC [parenteral IMBRUVICA CAPS 140 MG [ibrutinib] ...... 17 electrolytes] ...... 55 IMBRUVICA CAPS 70 MG [ibrutinib] ...... 17 HYPERRAB S/D SOLN 300 UNIT/2ML [rabies IMBRUVICA TABS 140 MG [ibrutinib]...... 17 immune globulin (human)] ...... 77 IMBRUVICA TABS 280 MG [ibrutinib]...... 17 HYPERRAB SOLN 300 UNIT/ML [rabies IMBRUVICA TABS 420 MG [ibrutinib]...... 17 immune globulin (human)] ...... 77 IMBRUVICA TABS 560 MG [ibrutinib]...... 17 HYPERTET S/D INJ 250 UNIT/ML [tetanus imipramine hcl tabs 10 mg ...... 48 immune globulin (human)] ...... 77 imipramine hcl tabs 25 mg ...... 48 HYQVIA KIT 10 GM/100ML [immune globulin imipramine hcl tabs 50 mg ...... 48 (human)-hyaluronidase (human imiquimod crea 5 % ...... 83 recombinant)] ...... 77 IMOGAM RABIES-HT SOLN 300 UNIT/2ML HYQVIA KIT 2.5 GM/25ML [immune globulin [rabies immune globulin (human)] ...... 77 (human)-hyaluronidase (human IMOVAX RABIES INJ 2.5 UNIT/ML [rabies virus recombinant)] ...... 77 vaccine, hdc] ...... 78 HYQVIA KIT 20 GM/200ML [immune globulin indapamide tabs 1.25 mg ...... 54 (human)-hyaluronidase (human indapamide tabs 2.5 mg ...... 54 recombinant)] ...... 77 indigotindisulfonate sodium soln ...... 51 HYQVIA KIT 30 GM/300ML [immune globulin indomethacin caps 25 mg ...... 37 (human)-hyaluronidase (human indomethacin caps 50 mg ...... 37 recombinant)] ...... 77 indomethacin er cpcr 75 mg...... 37 HYQVIA KIT 5 GM/50ML [immune globulin INDOMETHACIN POWD [indomethacin] ...... 74 (human)-hyaluronidase (human INDOMETHACIN SODIUM SOLR 1 MG recombinant)] ...... 77 [indomethacin sodium] ...... 37 HYSEPT SOLN 0.25 % [sodium hypochlorite] INFANRIX SUSP 25-58-10 [diphtheria, ...... 90 acellular pertussis & tetanus toxoids] ...... 78 IBRANCE CAPS 100 MG [palbociclib] ...... 16 INFED SOLN 50 MG/ML [iron dextran] ...... 24 IBRANCE CAPS 125 MG [palbociclib] ...... 16 INFLECTRA SOLR 100 MG [infliximab-dyyb]71 IBRANCE CAPS 75 MG [palbociclib] ...... 16 INFUMORPH 200 SOLN 200 MG/20ML (10

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 113 of 145 MG/ML) [morphine sulfate for continuous ISENTRESS CHEW 100 MG [raltegravir microinfusion] ...... 37 potassium] ...... 4 INFUMORPH 500 SOLN 500 MG/20ML (25 ISENTRESS CHEW 25 MG [raltegravir MG/ML) [morphine sulfate for continuous potassium] ...... 4 microinfusion] ...... 37 ISENTRESS HD TABS 600 MG [raltegravir INFUVITE ADULT INJ [multiple vitamin] ...... 83 potassium] ...... 4 INFUVITE PEDIATRIC SOLN [pediatric ISENTRESS TABS 400 MG [raltegravir multiple vitamins] ...... 83 potassium] ...... 4 INTEGRILIN SOLN 20 MG/10ML [eptifibatide] ISOMETHEPTENE-DICHLORAL-APAP CAPS ...... 29 65-100-325 MG [isometheptene- INTEGRILIN SOLN 75 MG/100ML [eptifibatide] dichloralphenazone-acetaminophen] ...... 43 ...... 29 isoniazid soln 100 mg/ml ...... 12 INTELENCE TABS 100 MG [etravirine] ...... 4 isoniazid syrp 50 mg/5ml ...... 12 INTELENCE TABS 200 MG [etravirine] ...... 4 isoniazid tabs 100 mg ...... 12 INTELENCE TABS 25 MG [etravirine] ...... 4 isoniazid tabs 300 mg ...... 12 INTRALIPID EMUL 20 % [fat emulsion plant isoproterenol hcl soln 0.2 mg/ml ...... 24 based] ...... 53 isosorbide dinitrate er tbcr 40 mg ...... 35 INTRALIPID EMUL 30 % [fat emulsion plant isosorbide dinitrate tabs 10 mg ...... 35 based] ...... 53 isosorbide dinitrate tabs 20 mg ...... 35 INTRON A SOLN 10000000 UNIT/ML isosorbide dinitrate tabs 30 mg ...... 35 [interferon alfa-2b] ...... 17 isosorbide dinitrate tabs 5 mg ...... 35 INTRON A SOLN 6000000 UNIT/ML [interferon isosorbide mononitrate er tb24 120 mg ...... 35 alfa-2b] ...... 17 isosorbide mononitrate er tb24 30 mg ...... 35 INTRON A SOLR 10000000 UNIT [interferon isosorbide mononitrate er tb24 60 mg ...... 35 alfa-2b] ...... 17 ISOSORBIDE POWD [isosorbide (bulk)] ...... 74 INTRON A SOLR 18000000 UNIT [interferon ISTODAX (OVERFILL) SOLR 10 MG alfa-2b] ...... 17 [romidepsin] ...... 17 INTRON A SOLR 50000000 UNIT [interferon itraconazole caps 100 mg ...... 11 alfa-2b] ...... 17 ivermectin tabs 3 mg ...... 4 INVANZ SOLR 1 GM [ertapenem sodium] ...... 9 IXEMPRA KIT SOLR 15 MG [ixabepilone] ..... 17 INVEGA SUSTENNA SUSY 117 MG/0.75ML IXEMPRA KIT SOLR 45 MG [ixabepilone] ..... 17 [paliperidone palmitate]...... 48 IXIARO SUSP [japanese encephalitis vaccine INVEGA SUSTENNA SUSY 156 MG/ML inactivated adsorbed] ...... 79 [paliperidone palmitate]...... 48 JADENU SPRINKLE PACK 180 MG INVEGA SUSTENNA SUSY 234 MG/1.5ML [deferasirox] ...... 62 [paliperidone palmitate]...... 48 JADENU SPRINKLE PACK 360 MG INVEGA SUSTENNA SUSY 39 MG/0.25ML [deferasirox] ...... 62 [paliperidone palmitate]...... 48 JADENU SPRINKLE PACK 90 MG INVEGA SUSTENNA SUSY 78 MG/0.5ML [deferasirox] ...... 62 [paliperidone palmitate]...... 48 JADENU TABS 180 MG [deferasirox] ...... 62 INVIRASE TABS 500 MG [saquinavir JADENU TABS 360 MG [deferasirox] ...... 62 mesylate] ...... 4 JADENU TABS 90 MG [deferasirox] ...... 62 IOPIDINE SOLN 1 % [apraclonidine hcl] ...... 59 JAKAFI TABS 10 MG [ruxolitinib phosphate]17 IPOL INJ [poliovirus vaccine, ipv] ...... 78 JAKAFI TABS 15 MG [ruxolitinib phosphate]17 ipratropium bromide soln 0.02 % ...... 22 JAKAFI TABS 20 MG [ruxolitinib phosphate]17 ipratropium bromide soln 0.03 % ...... 22 JAKAFI TABS 25 MG [ruxolitinib phosphate]17 ipratropium-albuterol soln 0.5-2.5 (3) mg/3ml JAKAFI TABS 5 MG [ruxolitinib phosphate] . 17 ...... 24 JARDIANCE TABS 10 MG [empagliflozin] ..... 65 IRESSA TABS 250 MG [gefitinib] ...... 17 JARDIANCE TABS 25 MG [empagliflozin] ..... 65 irinotecan hcl soln 500 mg/25ml ...... 17 JETREA SOLN 0.5 MG/0.2ML [ocriplasmin] .. 59 ISAGEL GEL 60 % [antiseptic products, misc.] JEVTANA SOLN 60 MG/1.5ML [cabazitaxel] . 17 ...... 90 JOLIVETTE TABS 0.35 MG [norethindrone

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 114 of 145 (contraceptive)] ...... 65 acetonide] ...... 63 J-TAN PD LIQD 1 MG/ML [brompheniramine KEPIVANCE SOLR 6.25 MG [palifermin] ...... 82 maleate] ...... 85 KERALYT GEL 6 % [salicylic acid] ...... 82 JULUCA TABS 50-25 MG [dolutegravir KETAMINE HCL POWD [ketamine hcl (bulk)] sodium-rilpivirine hcl] ...... 13 ...... 74 KADCYLA SOLR 100 MG [ado-trastuzumab ketamine hcl soln 10 mg/ml...... 46 emtansine] ...... 17 ketamine hcl soln 100 mg/ml ...... 46 KADCYLA SOLR 160 MG [ado-trastuzumab ketamine hcl soln 50 mg/ml...... 46 emtansine] ...... 17 ketoconazole sham 2 % ...... 80 KALETRA SOLN 400-100 MG/5ML [lopinavir- ketoconazole tabs 200 mg ...... 11 ritonavir] ...... 4 KETO-DIASTIX STRP [urine glucose-ketones KALETRA TABS 100-25 MG [lopinavir- test] ...... 88 ritonavir] ...... 4 KETOPROFEN POWD [ketoprofen (bulk)] ... 74 KALETRA TABS 200-50 MG [lopinavir- ketorolac tromethamine soln 0.4 % ...... 58 ritonavir] ...... 4 ketorolac tromethamine soln 0.5 % ...... 58 KALYDECO PACK 25 MG [ivacaftor]...... 75 ketorolac tromethamine soln 15 mg/ml ...... 37 KALYDECO PACK 50 MG [ivacaftor]...... 71 ketorolac tromethamine soln 30 mg/ml ...... 37 KALYDECO PACK 75 MG [ivacaftor]...... 71 ketorolac tromethamine soln 60 mg/2ml ...... 37 KALYDECO TABS 150 MG [ivacaftor] ...... 72 KETOSTIX STRP [acetone (urine) test] ...... 88 KANJINTI SOLR 420 MG [trastuzumab-anns] KEYTRUDA SOLN 100 MG/4ML ...... 17 [pembrolizumab] ...... 17 KCENTRA KIT 500 UNIT [prothrombin KINERET INJ [anakinra] ...... 68 complex concentrate human] ...... 27 KINRIX SUSP [diph-tetanus tox ad-acell KCL IN DEXTROSE-NACL SOLN 10-5-0.45 pertussis & polio virus, ipv vac]...... 79 MEQ/L-%-% [potassium chloride in KLOR-CON TBCR 8 MEQ [potassium chloride] dextrose & sodium chloride] ...... 55 ...... 56 KCL IN DEXTROSE-NACL SOLN 20-5-0.2 KOATE SOLR 1000 UNIT [antihemophilic MEQ/L-%-% [potassium chloride in factor (human)] ...... 27 dextrose & sodium chloride] ...... 55 KOATE-DVI SOLR 250 UNIT [antihemophilic KCL IN DEXTROSE-NACL SOLN 20-5-0.45 factor (human)] ...... 27 MEQ/L-%-% [potassium chloride in KOATE-DVI SOLR 500 UNIT [antihemophilic dextrose & sodium chloride] ...... 55 factor (human)] ...... 27 KCL IN DEXTROSE-NACL SOLN 20-5-0.9 KOGENATE FS KIT 1000 UNIT [antihemophilic MEQ/L-%-% [potassium chloride in factor (recombinant) (rfviii)] ...... 27 dextrose & sodium chloride] ...... 55 KOGENATE FS KIT 2000 UNIT [antihemophilic KCL IN DEXTROSE-NACL SOLN 30-5-0.45 factor (recombinant) (rfviii)] ...... 27 MEQ/L-%-% [potassium chloride in KOGENATE FS KIT 500 UNIT [antihemophilic dextrose & sodium chloride] ...... 55 factor (recombinant) (rfviii)] ...... 27 KCL IN DEXTROSE-NACL SOLN 40-5-0.45 KOVALTRY SOLR 1000 UNIT [antihemophilic MEQ/L-%-% [potassium chloride in factor (rcmb) plasma/albumin free (rahf- dextrose & sodium chloride] ...... 56 pfm)] ...... 27 KCL IN DEXTROSE-NACL SOLN 40-5-0.9 KOVALTRY SOLR 2000 UNIT [antihemophilic MEQ/L-%-% [potassium chloride in factor (rcmb) plasma/albumin free (rahf- dextrose & sodium chloride] ...... 56 pfm)] ...... 27 KCL-LACTATED RINGERS-D5W SOLN 20 KOVALTRY SOLR 250 UNIT [antihemophilic MEQ/L [potassium chloride in d5w lactated factor (rcmb) plasma/albumin free (rahf- ringers] ...... 56 pfm)] ...... 27 K-EFFERVESCENT TBEF 25 MEQ [potassium KOVALTRY SOLR 3000 UNIT [antihemophilic bicarbonate] ...... 55 factor (rcmb) plasma/albumin free (rahf- KENALOG SUSP 10 MG/ML [triamcinolone pfm)] ...... 27 acetonide] ...... 63 KOVALTRY SOLR 500 UNIT [antihemophilic KENALOG SUSP 40 MG/ML [triamcinolone factor (rcmb) plasma/albumin free (rahf-

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 115 of 145 pfm)] ...... 27 MG [lamotrigine] ...... 41 KP BENZOYL PEROXIDE GEL 10 % [benzoyl LAMICTAL STARTER KIT 84 x 25 MG & 14X100 peroxide] ...... 91 MG [lamotrigine] ...... 41 KP BENZOYL PEROXIDE GEL 5 % [benzoyl lamivudine soln 10 mg/ml ...... 4 peroxide] ...... 91 lamivudine tabs 100 mg ...... 13 KP HYDROCORTISONE CREA 1 % lamivudine tabs 150 mg ...... 4 [hydrocortisone (topical)] ...... 90 lamivudine tabs 300 mg ...... 4 KP PRENATAL MULTIVITAMINS TABS 28-0.8 lamivudine-zidovudine tabs 150-300 mg ...... 4 MG [prenatal vit w/ ferrous fumarate-folic lamotrigine chew 25 mg ...... 41 acid] ...... 91 lamotrigine chew 5 mg ...... 41 KP PSEUDOEPHEDRINE HCL TABS 60 MG lamotrigine tabs 100 mg ...... 41 [pseudoephedrine hcl] ...... 85 lamotrigine tabs 150 mg ...... 41 K-PHOS TABS 500 MG [potassium phosphate lamotrigine tabs 200 mg ...... 41 monobasic] ...... 55 lamotrigine tabs 25 mg ...... 41 KRINTAFEL TABS 150 MG [tafenoquine LANOXIN PEDIATRIC SOLN 0.1 MG/ML succinate] ...... 12 [digoxin] ...... 33 K-TAB TBCR 10 MEQ [potassium chloride] . 55 LANTUS SOLN 100 UNIT/ML [insulin glargine] KYNMOBI FILM 10 MG [apomorphine ...... 65 hydrochloride] ...... 44 L-ARGININE POWD [arginine] ...... 89 KYNMOBI FILM 15 MG [apomorphine latanoprost soln 0.005 % ...... 59 hydrochloride] ...... 44 L-CITRULLINE POWD [citrulline (bulk)] ...... 89 KYNMOBI FILM 20 MG [apomorphine leflunomide tabs 10 mg ...... 68 hydrochloride] ...... 44 leflunomide tabs 20 mg ...... 68 KYNMOBI FILM 25 MG [apomorphine LENVIMA (10 MG DAILY DOSE) CPPK 10 MG hydrochloride] ...... 44 [lenvatinib mesylate] ...... 17 KYNMOBI FILM 30 MG [apomorphine LENVIMA (12 MG DAILY DOSE) CPPK 3 x 4 hydrochloride] ...... 44 MG [lenvatinib mesylate] ...... 17 KYNMOBI TITRATION KIT KIT 10/15/20/25/30 LENVIMA (14 MG DAILY DOSE) CPPK 10 & 4 MG [apomorphine hydrochloride] ...... 44 MG [lenvatinib mesylate] ...... 17 KYPROLIS SOLR 10 MG [carfilzomib] ...... 17 LENVIMA (20 MG DAILY DOSE) CPPK 2 x 10 KYPROLIS SOLR 30 MG [carfilzomib] ...... 17 MG [lenvatinib mesylate] ...... 17 KYPROLIS SOLR 60 MG [carfilzomib] ...... 17 LENVIMA (24 MG DAILY DOSE) CPPK 2 x 10 labetalol hcl soln 5 mg/ml ...... 31 MG & 4 MG [lenvatinib mesylate] ...... 17 labetalol hcl tabs 100 mg ...... 31 LETAIRIS TABS 10 MG [ambrisentan] ...... 35 labetalol hcl tabs 200 mg ...... 31 LETAIRIS TABS 5 MG [ambrisentan] ...... 35 labetalol hcl tabs 300 mg ...... 31 letrozole tabs 2.5 mg ...... 18 LACRISERT INST 5 MG [artificial tear insert] leucovorin calcium solr 100 mg ...... 72 ...... 59 leucovorin calcium solr 350 mg ...... 72 LACTATED RINGERS SOLN [lactated ringer's leucovorin calcium solr 50 mg ...... 72 (irrigation)] ...... 54 leucovorin calcium tabs 25 mg ...... 72 LACTATED RINGERS SOLN [lactated leucovorin calcium tabs 5 mg ...... 72 ringer's] ...... 56 LEUKERAN TABS 2 MG [chlorambucil] ...... 18 LACTIC ACID SOLN [lactic acid (bulk)] ...... 89 LEUKINE SOLR 250 MCG [sargramostim] .... 30 LACTOSE MONOHYDRATE POWD [lactose leuprolide acetate kit 1 mg/0.2ml ...... 18 monohydrate] ...... 74 levetiracetam er tb24 500 mg ...... 41 LACTOSE POWD [lactose] ...... 89 levetiracetam er tb24 750 mg ...... 42 lactulose (encephalopathy) soln 10 gm/15ml LEVETIRACETAM IN NACL SOLN 1000 ...... 52 MG/100ML [levetiracetam in sodium lactulose soln 10 gm/15ml ...... 52 chloride] ...... 42 LAMICTAL STARTER KIT 35 x 25 MG LEVETIRACETAM IN NACL SOLN 1500 [lamotrigine] ...... 41 MG/100ML [levetiracetam in sodium LAMICTAL STARTER KIT 42 x 25 MG & 7 X 100 chloride] ...... 42

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 116 of 145 LEVETIRACETAM IN NACL SOLN 500 lidocaine hcl (pf) soln 0.5 % ...... 70 MG/100ML [levetiracetam in sodium lidocaine hcl (pf) soln 1 % ...... 70 chloride] ...... 42 lidocaine hcl (pf) soln 2 % ...... 70 levetiracetam soln 100 mg/ml ...... 42 lidocaine hcl (pf) soln 4 % ...... 70 levetiracetam soln 500 mg/5ml ...... 42 LIDOCAINE HCL POWD [lidocaine hcl (bulk)] levetiracetam tabs 1000 mg ...... 42 ...... 74 levetiracetam tabs 250 mg ...... 42 lidocaine hcl soln 0.5 % ...... 70 levetiracetam tabs 500 mg ...... 42 lidocaine hcl soln 1 % ...... 70 levetiracetam tabs 750 mg ...... 42 lidocaine hcl soln 2 % ...... 70 levobunolol hcl soln 0.5 % ...... 59 lidocaine hcl soln 4 % ...... 81 levocarnitine inj 200mg/ml ...... 72 lidocaine hcl urethral/mucosal gel 2 % ...... 81 LEVOCARNITINE SOLN 1 GM/10ML lidocaine hcl urethral/mucosal prsy 2 % ...... 81 [levocarnitine (metabolic modifiers)] ...... 72 LIDOCAINE IN D5W SOLN 4-5 MG/ML-% LEVOCARNITINE TABS 330 MG [levocarnitine [lidocaine in d5w] ...... 33 (metabolic modifiers)] ...... 72 LIDOCAINE IN D5W SOLN 8-5 MG/ML-% levofloxacin in d5w soln 250 mg/50ml ...... 9 [lidocaine in d5w] ...... 33 levofloxacin in d5w soln 500 mg/100ml ...... 9 lidocaine oint 5 % ...... 81 levofloxacin in d5w soln 750 mg/150ml ...... 9 lidocaine viscous hcl soln 2 % ...... 60 levofloxacin soln 25 mg/ml ...... 9 lidocaine-epinephrine soln 0.5 %-1 levofloxacin tabs 250 mg ...... 9 200000 ...... 70 levofloxacin tabs 500 mg ...... 9 lidocaine-epinephrine soln 1 %-1 levofloxacin tabs 750 mg ...... 9 100000 ...... 70 LEVOTHYROXINE SODIUM SOLR 200 MCG lidocaine-epinephrine soln 1.5 %-1 [levothyroxine sodium]...... 68 200000 ...... 70 LEVOTHYROXINE SODIUM SOLR 500 MCG lidocaine-epinephrine soln 2 %-1 [levothyroxine sodium]...... 68 100000 ...... 70 levothyroxine sodium tabs 100 mcg ...... 68 200000 ...... 70 levothyroxine sodium tabs 112 mcg ...... 68 lidocaine-prilocaine crea 2.5-2.5 % ...... 81 levothyroxine sodium tabs 125 mcg ...... 68 lidocaine-prilocaine kit 2.5-2.5 % ...... 81 levothyroxine sodium tabs 150 mcg ...... 68 linezolid soln 600 mg/300ml ...... 9 levothyroxine sodium tabs 175 mcg ...... 68 linezolid susr 100 mg/5ml ...... 9 levothyroxine sodium tabs 200 mcg ...... 68 liothyronine sodium tabs 25 mcg ...... 68 levothyroxine sodium tabs 25 mcg ...... 68 liothyronine sodium tabs 5 mcg ...... 68 levothyroxine sodium tabs 300 mcg ...... 68 liothyronine sodium tabs 50 mcg ...... 68 levothyroxine sodium tabs 50 mcg ...... 68 lisinopril tabs 10 mg ...... 34 levothyroxine sodium tabs 75 mcg ...... 68 lisinopril tabs 2.5 mg ...... 34 levothyroxine sodium tabs 88 mcg ...... 68 lisinopril tabs 20 mg ...... 34 LEVOXYL TABS 137 MCG [levothyroxine lisinopril tabs 30 mg ...... 34 sodium] ...... 68 lisinopril tabs 40 mg ...... 34 LEVSIN SOLN 0.5 MG/ML [hyoscyamine lisinopril tabs 5 mg ...... 34 sulfate] ...... 22 lisinopril-hydrochlorothiazide tabs 10-12.5 LEVULAN KERASTICK SOLR 20 % mg ...... 34 [aminolevulinic acid hcl] ...... 83 lisinopril-hydrochlorothiazide tabs 20-12.5 LEXISCAN SOLN 0.4 MG/5ML [regadenoson] mg ...... 34 ...... 51 lisinopril-hydrochlorothiazide tabs 20-25 mg LEXIVA TABS 700 MG [fosamprenavir ...... 34 calcium] ...... 4 L-ISOLEUCINE POWD [isoleucine] ...... 89 LIALDA TBEC 1.2 GM [mesalamine] ...... 60 lithium carbonate caps 150 mg ...... 42 LIDOCAINE HCL (CARDIAC) PF SOLN 100 LITHIUM CARBONATE CAPS 300 MG [lithium MG/5ML [lidocaine hcl (cardiac)] ...... 70 carbonate] ...... 42 lidocaine hcl (cardiac) pf sosy 100 mg/5ml . 33 lithium carbonate caps 600 mg ...... 42 lidocaine hcl (cardiac) sosy 50 mg/5ml ...... 33 lithium carbonate er tbcr 300 mg ...... 42

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 117 of 145 lithium carbonate er tbcr 450 mg ...... 42 LUCENTIS SOLN 0.3 MG/0.05ML LITHIUM CARBONATE TABS 300 MG [lithium [ranibizumab] ...... 59 carbonate] ...... 43 LUCENTIS SOLN 0.5 MG/0.05ML LITHIUM SOLN 8 MEQ/5ML [lithium]...... 43 [ranibizumab] ...... 59 LITHOSTAT TABS 250 MG [acetohydroxamic LUCENTIS SOSY 0.3 MG/0.05ML acid] ...... 52 [ranibizumab] ...... 59 LODOSYN TABS 25 MG [carbidopa] ...... 44 LUCENTIS SOSY 0.5 MG/0.05ML LONSURF TABS 15-6.14 MG [trifluridine- [ranibizumab] ...... 60 tipiracil] ...... 18 LUDENT CHEW 0.55 (0.25 F) MG [sodium LONSURF TABS 20-8.19 MG [trifluridine- fluoride] ...... 72 tipiracil] ...... 18 LUMASON SUSR 60.7-25 MG [sulfur loratadine syrp 5 mg/5ml ...... 85 hexafluoride lipid-type a microspheres] ... 51 loratadine tabs 10 mg ...... 85 LUMIZYME SOLR 50 MG [alglucosidase alfa] lorazepam soln 2 mg/ml ...... 45 ...... 57 lorazepam soln 4 mg/ml ...... 45 LUPRON DEPOT (1-MONTH) KIT 3.75 MG lorazepam tabs 0.5 mg ...... 45 [leuprolide acetate] ...... 18 lorazepam tabs 1 mg ...... 45 LUPRON DEPOT (1-MONTH) KIT 7.5 MG lorazepam tabs 2 mg ...... 45 [leuprolide acetate] ...... 18 LORBRENA TABS 100 MG [lorlatinib] ...... 18 LUPRON DEPOT (3-MONTH) KIT 11.25 MG LORBRENA TABS 25 MG [lorlatinib]...... 18 [leuprolide acetate (3 month)] ...... 18 LORTUSS LQ LIQD 6.25-30 MG/5ML LUPRON DEPOT (3-MONTH) KIT 22.5 MG [doxylamine-pseudoephedrine] ...... 85 [leuprolide acetate (3 month)] ...... 18 losartan potassium tabs 100 mg ...... 34 LUPRON DEPOT (4-MONTH) KIT 30 MG losartan potassium tabs 25 mg ...... 34 [leuprolide acetate (4 month)] ...... 18 losartan potassium tabs 50 mg ...... 34 LUPRON DEPOT (6-MONTH) KIT 45 MG losartan potassium-hctz tabs 100-12.5 mg .. 34 [leuprolide acetate (6 month)] ...... 18 losartan potassium-hctz tabs 100-25 mg ..... 34 LUPRON DEPOT-PED (1-MONTH) KIT 11.25 losartan potassium-hctz tabs 50-12.5 mg .... 34 MG [leuprolide acetate (cpp)] ...... 18 lovastatin tabs 10 mg ...... 31 LUPRON DEPOT-PED (1-MONTH) KIT 15 MG lovastatin tabs 20 mg ...... 31 [leuprolide acetate (cpp)] ...... 18 lovastatin tabs 40 mg ...... 31 LUPRON DEPOT-PED (1-MONTH) KIT 7.5 MG LOVENOX SOLN 100 MG/ML [enoxaparin [leuprolide acetate (cpp)] ...... 18 sodium] ...... 29 LUPRON DEPOT-PED (3-MONTH) KIT 11.25 LOVENOX SOLN 120 MG/0.8ML [enoxaparin MG (PED) [leuprolide acetate (cpp) (3 sodium] ...... 29 month)] ...... 18 LOVENOX SOLN 150 MG/ML [enoxaparin LUPRON DEPOT-PED (3-MONTH) KIT 30 MG sodium] ...... 29 (PED) [leuprolide acetate (cpp) (3 month)] LOVENOX SOLN 30 MG/0.3ML [enoxaparin ...... 18 sodium] ...... 29 L-VALINE POWD [valine] ...... 89 LOVENOX SOLN 300 MG/3ML [enoxaparin LYNPARZA TABS 100 MG [olaparib] ...... 18 sodium] ...... 29 LYNPARZA TABS 150 MG [olaparib] ...... 18 LOVENOX SOLN 40 MG/0.4ML [enoxaparin LYSODREN TABS 500 MG [mitotane] ...... 18 sodium] ...... 29 M.T.E.-5 CONCENTRATE INJ CONC [trace LOVENOX SOLN 60 MG/0.6ML [enoxaparin minerals (cr-cu-mn-se-zn)] ...... 56 sodium] ...... 29 MACRODANTIN CAPS 25 MG [nitrofurantoin LOVENOX SOLN 80 MG/0.8ML [enoxaparin macrocrystal] ...... 14 sodium] ...... 29 MACUGEN SOLN 0.3 MG [pegaptanib sodium] loxapine succinate caps 10 mg ...... 48 ...... 60 loxapine succinate caps 25 mg ...... 48 MAG-AL LIQD 200-200 MG/5ML [aluminum & loxapine succinate caps 5 mg ...... 48 magnesium hydroxide] ...... 88 loxapine succinate caps 50 mg ...... 48 MAGNEBIND 300 TABS 250-300 MG [calcium L-PROLINE POWD [proline] ...... 74 carbonate-magnesium carbonate] ...... 88

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 118 of 145 MAGNESIUM SULFATE IN D5W SOLN 1-5 sulfoxide] ...... 18 GM/100ML-% [magnesium sulfate in meloxicam tabs 15 mg ...... 38 dextrose] ...... 56 meloxicam tabs 7.5 mg ...... 38 MAGNESIUM SULFATE SOLN 20 GM/500ML melphalan hcl solr 50 mg ...... 18 [magnesium sulfate] ...... 42 memantine hcl tabs 10 mg ...... 46 MAGNESIUM SULFATE SOLN 4 GM/100ML memantine hcl tabs 5 mg ...... 46 [magnesium sulfate] ...... 42 MENOPUR SOLR 75 UNIT [menotropins] ..... 67 MAGNESIUM SULFATE SOLN 4 GM/50ML MENVEO SOLR [meningococcal (a,c,y&w- [magnesium sulfate] ...... 42 135) oligosaccharide conjugate vac] ...... 79 MAGNESIUM SULFATE SOLN 40 GM/1000ML meperidine hcl soln 100 mg/ml ...... 38 [magnesium sulfate] ...... 42 meperidine hcl soln 25 mg/ml ...... 38 magnesium sulfate soln 50 % ...... 42 meperidine hcl soln 50 mg/ml ...... 38 MAGNEVIST SOLN 469.01 MG/ML MEPHYTON TABS 5 MG [phytonadione] ...... 84 [gadopentetate dimeglumine] ...... 51 mercaptopurine tabs 50 mg ...... 18 MAKENA OIL 250 MG/ML meropenem solr 1 gm ...... 9 [hydroxyprogesterone caproate] ...... 67 meropenem solr 500 mg ...... 9 malathion lotn 0.5 % ...... 80 mesalamine enem 4 gm ...... 60 MANGANESE CHLORIDE SOLN 0.1 MG/ML mesalamine supp 1000 mg ...... 60 [manganese chloride] ...... 56 mesalamine tbec 1.2 gm ...... 60 MANNITOL SOLN 25 % [mannitol] ...... 54 MESNA SOLN 100 MG/ML [mesna] ...... 72 maprotiline hcl tabs 25 mg ...... 48 MESNEX TABS 400 MG [mesna] ...... 72 maprotiline hcl tabs 50 mg ...... 48 MESTINON SOLN 60 MG/5ML [pyridostigmine maprotiline hcl tabs 75 mg ...... 48 bromide] ...... 22 MARQIBO SUSP 5 MG/31ML [vincristine MESTINON TBCR 180 MG [pyridostigmine sulfate liposome] ...... 18 bromide] ...... 22 MATULANE CAPS 50 MG [procarbazine hcl] 18 metaproterenol sulfate syrp 10 mg/5ml ...... 24 MD-76 R SOLN 66-10 % [diatrizoate metaproterenol sulfate tabs 10 mg ...... 24 meglumine & sodium] ...... 51 metaproterenol sulfate tabs 20 mg ...... 24 MECLIZINE HCL TABS 12.5 MG [meclizine hcl] metformin hcl er tb24 500 mg ...... 65 ...... 89 metformin hcl er tb24 750 mg ...... 65 meclizine hcl tabs 25 mg ...... 61 metformin hcl tabs 1000 mg ...... 65 MECLIZINE HCL TABS 25 MG [meclizine hcl] metformin hcl tabs 500 mg ...... 65 ...... 89 metformin hcl tabs 850 mg ...... 65 meclofenamate sodium caps 100 mg...... 37 METHADONE HCL POWD [methadone hcl] 74 meclofenamate sodium caps 50 mg ...... 37 methadone hcl soln 10 mg/5ml ...... 38 MEDROL TABS 2 MG [methylprednisolone] 63 METHADONE HCL SOLN 10 MG/ML medroxyprogesterone acetate susp 150 [methadone hcl] ...... 38 mg/ml ...... 67 methadone hcl soln 5 mg/5ml ...... 38 medroxyprogesterone acetate susy 150 METHADONE HCL TABS 10 MG [methadone mg/ml ...... 67 hcl] ...... 38 medroxyprogesterone acetate tabs 10 mg .. 67 METHADONE HCL TABS 5 MG [methadone medroxyprogesterone acetate tabs 2.5 mg . 67 hcl] ...... 38 medroxyprogesterone acetate tabs 5 mg .... 67 methazolamide tabs 25 mg ...... 59 mefenamic acid caps 250 mg ...... 37 methazolamide tabs 50 mg ...... 59 mefloquine hcl tabs 250 mg ...... 12 methenamine hippurate tabs 1 gm ...... 14 megestrol acetate susp 40 mg/ml ...... 18 methimazole tabs 10 mg ...... 68 megestrol acetate susp 400 mg/10ml ...... 18 methimazole tabs 5 mg ...... 68 megestrol acetate tabs 20 mg ...... 18 methocarbamol tabs 500 mg ...... 23 megestrol acetate tabs 40 mg ...... 18 methocarbamol tabs 750 mg ...... 23 MEKINIST TABS 0.5 MG [trametinib dimethyl methotrexate sodium (pf) soln 50 mg/2ml ... 18 sulfoxide] ...... 18 METHOTREXATE SODIUM SOLN 50 MG/2ML MEKINIST TABS 2 MG [trametinib dimethyl [methotrexate sodium] ...... 18

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 119 of 145 methotrexate sodium solr 1 gm ...... 18 metoprolol succinate er tb24 25 mg ...... 31 methotrexate tabs 2.5 mg ...... 18 metoprolol succinate er tb24 50 mg ...... 31 methoxsalen rapid caps 10 mg ...... 82 metoprolol tartrate soln 5 mg/5ml ...... 31 methyldopa tabs 250 mg ...... 34 metoprolol tartrate tabs 100 mg ...... 31 methyldopa tabs 500 mg ...... 34 metoprolol tartrate tabs 25 mg ...... 31 methyldopate hcl soln 250 mg/5ml ...... 34 metoprolol tartrate tabs 50 mg ...... 31 METHYLENE BLUE SOLN 1 % [methylene metoprolol-hydrochlorothiazide tabs 100-50 blue (antidote)] ...... 72 mg ...... 31 methylergonovine maleate soln 0.2 mg/ml .. 73 metronidazole crea 0.75 % ...... 80 methylergonovine maleate tabs 0.2 mg ...... 73 metronidazole gel 0.75 % ...... 80 methylphenidate hcl er (cd) cpcr 10 mg ...... 40 METRONIDAZOLE IN NACL SOLN 5-0.79 methylphenidate hcl er (cd) cpcr 20 mg ...... 40 MG/ML-% [metronidazole in nacl] ...... 12 methylphenidate hcl er (cd) cpcr 30 mg ...... 40 METRONIDAZOLE IN NACL SOLN 500-0.74 methylphenidate hcl er (cd) cpcr 40 mg ...... 40 MG/100ML-% [metronidazole in nacl] ...... 12 methylphenidate hcl er (cd) cpcr 50 mg ...... 40 metronidazole lotn 0.75 % ...... 80 methylphenidate hcl er (cd) cpcr 60 mg ...... 40 METRONIDAZOLE POWD [metronidazole methylphenidate hcl er tbcr 10 mg ...... 40 (bulk)] ...... 74 methylphenidate hcl er tbcr 18 mg ...... 40 metronidazole tabs 250 mg ...... 12 methylphenidate hcl er tbcr 20 mg ...... 40 metronidazole tabs 500 mg ...... 12 methylphenidate hcl er tbcr 27 mg ...... 40 mexiletine hcl caps 150 mg ...... 33 methylphenidate hcl er tbcr 36 mg ...... 40 mexiletine hcl caps 200 mg ...... 33 methylphenidate hcl er tbcr 54 mg ...... 40 mexiletine hcl caps 250 mg ...... 33 methylphenidate hcl tabs 10 mg ...... 40 MI-ACID MAXIMUM STRENGTH SUSP 400- methylphenidate hcl tabs 20 mg ...... 40 400-40 MG/5ML [alum & mag hydrox- methylphenidate hcl tabs 5 mg ...... 40 simethicone] ...... 89 methylprednisolone acetate susp 40 mg/ml 63 miconazole nitrate vaginal supp 100 mg ...... 90 methylprednisolone acetate susp 80 mg/ml 63 MICRHOGAM ULTRA-FILTERED PLUS SOSY methylprednisolone sodium succ solr 1000 250 UNIT [rho d immune globulin (human)] mg ...... 63 ...... 77 methylprednisolone sodium succ solr 125 mg midazolam hcl (pf) soln 10 mg/2ml ...... 45 ...... 63 midazolam hcl (pf) soln 2 mg/2ml ...... 45 methylprednisolone sodium succ solr 40 mg midazolam hcl (pf) soln 5 mg/ml ...... 45 ...... 63 midazolam hcl soln 10 mg/2ml ...... 45 methylprednisolone tabs 16 mg ...... 63 midazolam hcl soln 2 mg/2ml...... 45 methylprednisolone tabs 32 mg ...... 63 midazolam hcl syrp 2 mg/ml ...... 45 methylprednisolone tabs 4 mg ...... 63 midodrine hcl tabs 10 mg ...... 24 methylprednisolone tabs 8 mg ...... 63 midodrine hcl tabs 2.5 mg ...... 24 methylprednisolone tbpk 4 mg ...... 63 midodrine hcl tabs 5 mg ...... 24 methyltestosterone tabs 10 mg ...... 64 MIFEPREX TABS 200 MG [mifepristone] ...... 73 METOCLOPRAMIDE HCL MONOHYDRATE MIGRANAL SOLN 4 MG/ML POWD [metoclopramide hcl monohydrate] [dihydroergotamine mesylate] ...... 23 ...... 74 milrinone lactate in dextrose soln 20-5 metoclopramide hcl soln 10 mg/10ml ...... 62 mg/100ml-% ...... 33 metoclopramide hcl soln 5 mg/ml ...... 62 milrinone lactate in dextrose soln 40-5 metoclopramide hcl tabs 10 mg ...... 62 mg/200ml-% ...... 33 metoclopramide hcl tabs 5 mg ...... 62 milrinone lactate inj 1mg/ml ...... 33 metolazone tabs 10 mg ...... 54 milrinone lactate soln 10 mg/10ml ...... 33 metolazone tabs 2.5 mg ...... 54 MINOCIN SOLR 100 MG [minocycline hcl] ..... 9 metolazone tabs 5 mg ...... 54 minocycline hcl caps 100 mg ...... 9 METOPIRONE CAPS 250 MG [metyrapone] . 51 minocycline hcl caps 50 mg ...... 9 metoprolol succinate er tb24 100 mg ...... 31 minocycline hcl caps 75 mg ...... 9 metoprolol succinate er tb24 200 mg ...... 31 minoxidil tabs 10 mg ...... 34

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 120 of 145 minoxidil tabs 2.5 mg ...... 34 [morphine sulfate] ...... 38 MIOCHOL-E SOLR 20 MG [acetylcholine MORPHINE SULFATE SOLN 10 MG/5ML chloride] ...... 59 [morphine sulfate] ...... 38 MIOSTAT SOLN 0.01 % [carbachol (ophth)] 59 MORPHINE SULFATE SOLN 10 MG/ML MIRENA (52 MG) IUD 20 MCG/24HR [morphine sulfate] ...... 38 [levonorgestrel (iud)] ...... 65 MORPHINE SULFATE SOLN 15 MG/ML mirtazapine tabs 15 mg ...... 48 [morphine sulfate] ...... 38 mirtazapine tabs 30 mg ...... 48 MORPHINE SULFATE SOLN 2 MG/ML mirtazapine tabs 45 mg ...... 48 [morphine sulfate] ...... 38 misoprostol tabs 100 mcg ...... 61 MORPHINE SULFATE SOLN 20 MG/5ML misoprostol tabs 200 mcg ...... 61 [morphine sulfate] ...... 38 mitomycin solr 20 mg ...... 18 MORPHINE SULFATE SOLN 25 MG/ML mitomycin solr 40 mg ...... 18 [morphine sulfate] ...... 38 mitomycin solr 5 mg ...... 18 MORPHINE SULFATE SOLN 4 MG/ML MITOSOL KIT 0.2 MG [mitomycin [morphine sulfate] ...... 38 (ophthalmic)] ...... 58 MORPHINE SULFATE SOLN 5 MG/ML mitoxantrone hcl conc 25 mg/12.5ml ...... 18 [morphine sulfate] ...... 38 M-M-R II SOLR [measles, mumps & rubella MORPHINE SULFATE SOLN 50 MG/ML virus vaccines] ...... 79 [morphine sulfate] ...... 38 modafinil tabs 100 mg ...... 40 MORPHINE SULFATE SOLN 8 MG/ML modafinil tabs 200 mg ...... 40 [morphine sulfate] ...... 38 mometasone furoate crea 0.1 % ...... 81 MORPHINE SULFATE SUPP 10 MG [morphine mometasone furoate oint 0.1 % ...... 81 sulfate] ...... 38 mometasone furoate soln 0.1 % ...... 81 MORPHINE SULFATE SUPP 20 MG [morphine MONOJECT INSULIN SYRINGE MISC 27G X sulfate] ...... 38 1/2 ...... 51 MORPHINE SULFATE SUPP 30 MG [morphine MONOJECT INSULIN SYRINGE MISC 29G X sulfate] ...... 38 1/2 ...... 51 MORPHINE SULFATE SUPP 5 MG [morphine MONONINE SOLR 1000 UNIT [coagulation sulfate] ...... 38 factor ix] ...... 27 MORPHINE SULFATE TABS 15 MG [morphine montelukast sodium chew 4 mg ...... 75 sulfate] ...... 38 montelukast sodium chew 5 mg ...... 75 MORPHINE SULFATE TABS 30 MG [morphine montelukast sodium pack 4 mg ...... 75 sulfate] ...... 38 montelukast sodium tabs 10 mg ...... 75 moxifloxacin hcl soln 0.5 %...... 58 morphine sulfate (concentrate) soln 100 moxifloxacin hcl tabs 400 mg ...... 9 mg/5ml ...... 38 MULTIHANCE SOLN 529 MG/ML [gadobenate morphine sulfate (pf) soln 0.5 mg/ml ...... 38 dimeglumine] ...... 51 morphine sulfate (pf) soln 1 mg/ml ...... 38 MULTITRACE-4 CONCENTRATE SOLN 0.01-1- MORPHINE SULFATE (PF) SOLN 10 MG/ML 0.5-5 MG/ML [trace minerals (cr-cu-mn-zn)] [morphine sulfate] ...... 38 ...... 56 MORPHINE SULFATE (PF) SOLN 2 MG/ML MULTI-VIT/FLUORIDE SOLN 0.5 MG/ML [morphine sulfate] ...... 38 [pediatric multivitamins w/fl] ...... 84 MORPHINE SULFATE (PF) SOLN 4 MG/ML MULTI-VIT/FLUORIDE/IRON SOLN 0.25-10 [morphine sulfate] ...... 38 MG/ML [ped multivitamins w/fl & iron] ...... 84 morphine sulfate er tbcr 100 mg ...... 38 MULTI-VIT/IRON/FLUORIDE SOLN 0.25-10 morphine sulfate er tbcr 15 mg ...... 38 MG/ML [ped multivitamins w/fl & iron] ...... 84 morphine sulfate er tbcr 200 mg ...... 38 MULTIVITAMIN/FLUORIDE CHEW 0.25 MG morphine sulfate er tbcr 30 mg ...... 38 [pediatric multivitamins w/fl] ...... 84 morphine sulfate er tbcr 60 mg ...... 38 MULTIVITAMIN/FLUORIDE CHEW 0.5 MG MORPHINE SULFATE POWD [morphine [pediatric multivitamins w/fl] ...... 84 sulfate] ...... 74 MULTIVITAMIN/FLUORIDE CHEW 1 MG MORPHINE SULFATE SOLN 1 MG/ML [pediatric multivitamins w/fl] ...... 84

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 121 of 145 MULTIVITAMIN/FLUORIDE SOLN 0.25 MG/ML naproxen sodium tabs 275 mg ...... 39 [pediatric multivitamins w/fl] ...... 84 naproxen sodium tabs 550 mg ...... 39 mupirocin oint 2 %...... 80 naproxen susp 125 mg/5ml ...... 39 MUSTARGEN SOLR 10 MG [mechlorethamine naproxen tabs 250 mg ...... 39 hcl] ...... 18 naproxen tabs 375 mg ...... 39 MVASI SOLN 100 MG/4ML [bevacizumab- naproxen tabs 500 mg ...... 39 awwb] ...... 19 naproxen tbec 375 mg ...... 39 MVC-FLUORIDE CHEW 0.25 MG [pediatric naratriptan hcl tabs 1 mg ...... 43 multivitamins w/fl] ...... 84 naratriptan hcl tabs 2.5 mg ...... 43 MVC-FLUORIDE CHEW 0.5 MG [pediatric NARCAN LIQD 4 MG/0.1ML [naloxone hcl] ... 46 multivitamins w/fl] ...... 84 NAROPIN SOLN 10 MG/ML [ropivacaine hcl] MVC-FLUORIDE CHEW 1 MG [pediatric ...... 70 multivitamins w/fl] ...... 84 NAROPIN SOLN 2 MG/ML [ropivacaine hcl] . 70 mycophenolate mofetil caps 250 mg ...... 69 NAROPIN SOLN 5 MG/ML [ropivacaine hcl] . 70 mycophenolate mofetil susr 200 mg/ml ...... 69 NAROPIN SOLN 7.5 MG/ML [ropivacaine hcl] mycophenolate mofetil tabs 500 mg ...... 72 ...... 70 MYLERAN TABS 2 MG [busulfan] ...... 19 NASAL DECONGESTANT PE MAX ST TABS 10 MYOBLOC SOLN 10000 UNIT/2ML MG [phenylephrine hcl (oral)] ...... 88 [rimabotulinumtoxinb] ...... 72 NATACYN SUSP 5 % [natamycin] ...... 58 MYOBLOC SOLN 2500 UNIT/0.5ML NEBUPENT SOLR 300 MG [pentamidine [rimabotulinumtoxinb] ...... 72 isethionate] ...... 12 MYOBLOC SOLN 5000 UNIT/ML nefazodone hcl tabs 100 mg ...... 48 [rimabotulinumtoxinb] ...... 72 nefazodone hcl tabs 150 mg ...... 48 MYRBETRIQ TB24 25 MG [mirabegron] ...... 83 nefazodone hcl tabs 200 mg ...... 48 MYRBETRIQ TB24 50 MG [mirabegron] ...... 83 nefazodone hcl tabs 250 mg ...... 48 NABI-HB SOLN [hepatitis b immune globulin nefazodone hcl tabs 50 mg ...... 48 (human)] ...... 77 NEOMYCIN SULFATE POWD [neomycin nabumetone tabs 500 mg ...... 38 sulfate (topical)] ...... 74 nabumetone tabs 750 mg ...... 39 neomycin sulfate tabs 500 mg ...... 9 nadolol tabs 20 mg ...... 31 neomycin-bacitracin zn-polymyx oint 5-400- nadolol tabs 40 mg ...... 31 10000 ...... 58 nadolol tabs 80 mg ...... 31 neomycin-polymyxin b gu soln 40-200000 ... 80 NAFCILLIN SODIUM IN DEXTROSE SOLN 1 neomycin-polymyxin-dexameth oint 3.5- GM/50ML [nafcillin sodium in dextrose] ..... 9 10000-0.1 ...... 58 NAFCILLIN SODIUM IN DEXTROSE SOLN 2 neomycin-polymyxin-dexameth susp 3.5- GM/100ML [nafcillin sodium in dextrose] ... 9 10000-0.1 ...... 58 nafcillin sodium solr 1 gm ...... 9 neomycin-polymyxin-gramicidin soln 1.75- nafcillin sodium solr 10 gm ...... 9 10000-.025 ...... 58 nafcillin sodium solr 2 gm ...... 9 neomycin-polymyxin-hc soln 1 % ...... 58 NAGLAZYME SOLN 1 MG/ML [galsulfase] ... 57 neomycin-polymyxin-hc susp 3.5-10000-1 ... 59 nalbuphine hcl soln 10 mg/ml ...... 39 NEOPROFEN SOLN 10 MG/ML [ibuprofen nalbuphine hcl soln 20 mg/ml ...... 39 lysine] ...... 39 naloxone hcl soct 0.4 mg/ml ...... 46 NEORAL SOLN 100 MG/ML [cyclosporine naloxone hcl soln 0.4 mg/ml ...... 46 modified (for microemulsion)] ...... 69 naloxone hcl sosy 2 mg/2ml ...... 46 neostigmine methylsulfate soln 0.5 mg/ml .. 22 NALTREXONE HCL POWD [naltrexone hcl NEOSTIGMINE METHYLSULFATE SOLN 10 (bulk)] ...... 46 MG/10ML [neostigmine methylsulfate] ..... 22 naltrexone hcl tabs 50 mg ...... 46 NESACAINE SOLN 1 % [chloroprocaine hcl]70 NAMENDA SOL 10MG/5ML [memantine hcl] 46 NESACAINE SOLN 2 % [chloroprocaine hcl]70 NAMENDA TITRATION PAK TABS 28 x 5 MG & NEUPOGEN SOSY 300 MCG/0.5ML 21 X 10 MG [memantine hcl] ...... 46 [filgrastim] ...... 30 naphazoline hcl soln ...... 60 NEUPOGEN SOSY 480 MCG/0.8ML

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 122 of 145 [filgrastim] ...... 30 nitrofurantoin susp 25 mg/5ml ...... 14 NEUT SOLN 4 % [sodium bicarbonate] ...... 52 NITROGLYCERIN ER CPCR 2.5 MG nevirapine er tb24 400 mg ...... 4 [nitroglycerin] ...... 35 nevirapine susp 50 mg/5ml ...... 4 NITROGLYCERIN ER CPCR 6.5 MG nevirapine tabs 200 mg ...... 4 [nitroglycerin] ...... 35 NEXAVAR TABS 200 MG [sorafenib tosylate] NITROGLYCERIN ER CPCR 9 MG ...... 19 [nitroglycerin] ...... 35 NEXPLANON IMPL 68 MG [etonogestrel] ..... 65 NITROGLYCERIN IN D5W SOLN 100-5 NIACIN ER CPCR 250 MG [niacin] ...... 91 MCG/ML-% [nitroglycerin in d5w] ...... 35 NIACIN ER CPCR 500 MG [niacin] ...... 91 NITROGLYCERIN IN D5W SOLN 200-5 NIACIN ER TBCR 250 MG [niacin] ...... 91 MCG/ML-% [nitroglycerin in d5w] ...... 36 NIACIN TABS 100 MG [niacin] ...... 91 NITROGLYCERIN IN D5W SOLN 400-5 NIACIN TABS 250 MG [niacin] ...... 91 MCG/ML-% [nitroglycerin in d5w] ...... 36 NIACIN TABS 50 MG [niacin] ...... 91 nitroglycerin pt24 0.4 mg/hr ...... 36 NIACIN TABS 500 MG [niacin] ...... 91 nitroglycerin soln 5 mg/ml ...... 36 nicardipine hcl soln 2.5 mg/ml ...... 32 nitroprusside sodium soln 25 mg/ml ...... 34 NICORETTE GUM 2 MG [nicotine polacrilex] NITROSTAT SUBL 0.3 MG [nitroglycerin] ..... 36 ...... 85 NITROSTAT SUBL 0.4 MG [nitroglycerin] ..... 36 NICORETTE LOZG 2 MG [nicotine polacrilex] NITROSTAT SUBL 0.6 MG [nitroglycerin] ..... 36 ...... 85 NIVESTYM SOLN 300 MCG/ML [filgrastim- NICORETTE LOZG 4 MG [nicotine polacrilex] aafi] ...... 30 ...... 85 NIVESTYM SOLN 480 MCG/1.6ML [filgrastim- NICORETTE MINI LOZG 2 MG [nicotine aafi] ...... 30 polacrilex] ...... 85 NIVESTYM SOSY 300 MCG/0.5ML [filgrastim- nicotine polacrilex gum 2 mg ...... 85 aafi] ...... 30 nicotine polacrilex gum 4 mg ...... 85 NIVESTYM SOSY 480 MCG/0.8ML [filgrastim- nicotine polacrilex lozg 2 mg ...... 85 aafi] ...... 30 nicotine polacrilex lozg 4 mg ...... 85 NORDITROPIN FLEXPRO SOPN 15 MG/1.5ML nicotine pt24 14 mg/24hr ...... 85 [somatropin] ...... 68 nicotine pt24 21 mg/24hr ...... 85 norepinephrine bitartrate soln 1 mg/ml ...... 24 nicotine pt24 7 mg/24hr ...... 85 norethindrone acetate tabs 5 mg ...... 67 nifedipine caps 10 mg ...... 32 NORMAL SALINE FLUSH SOLN 0.9 % [sodium nifedipine caps 20 mg ...... 32 chloride flush]...... 56 nifedipine er osmotic release tb24 30 mg .... 32 NORPACE CR CP12 100 MG [disopyramide nifedipine er osmotic release tb24 60 mg .... 32 phosphate] ...... 33 nifedipine er osmotic release tb24 90 mg .... 33 NORPACE CR CP12 150 MG [disopyramide nifedipine er tb24 30 mg ...... 33 phosphate] ...... 33 nifedipine er tb24 60 mg ...... 33 nortriptyline hcl caps 10 mg...... 48 nimodipine caps 30 mg ...... 33 nortriptyline hcl caps 25 mg...... 48 NINLARO CAPS 2.3 MG [ixazomib citrate] ... 19 nortriptyline hcl caps 50 mg...... 48 NINLARO CAPS 3 MG [ixazomib citrate] ...... 19 nortriptyline hcl caps 75 mg...... 48 NINLARO CAPS 4 MG [ixazomib citrate] ...... 19 nortriptyline hcl soln 10 mg/5ml ...... 48 NITRO-DUR PT24 0.3 MG/HR [nitroglycerin] 35 NORVIR SOLN 80 MG/ML [ritonavir] ...... 4 NITRO-DUR PT24 0.8 MG/HR [nitroglycerin] 35 NOVAREL SOLR 10000 UNIT [chorionic NITROFURANTOIN MACROCRYSTAL CAPS gonadotropin] ...... 67 100 MG [nitrofurantoin macrocrystal] ...... 14 NOVOSEVEN RT SOLR 1 MG [coagulation NITROFURANTOIN MACROCRYSTAL CAPS factor viia (recombinant)] ...... 27 25 MG [nitrofurantoin macrocrystal] ...... 14 NOVOSEVEN RT SOLR 2 MG [coagulation NITROFURANTOIN MACROCRYSTAL CAPS factor viia (recombinant)] ...... 27 50 MG [nitrofurantoin macrocrystal] ...... 14 NOVOSEVEN RT SOLR 5 MG [coagulation nitrofurantoin monohyd macro caps 100 mg factor viia (recombinant)] ...... 27 ...... 14 NOVOSEVEN RT SOLR 8 MG [coagulation

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 123 of 145 factor viia (recombinant)] ...... 27 OMNITROPE SOCT 5 MG/1.5ML [somatropin] nystatin crea 100000 unit/gm ...... 80 ...... 68 nystatin susp 100000 unit/ml ...... 11 OMNITROPE SOLR 5.8 MG [somatropin] ..... 68 nystatin tabs 500000 unit ...... 11 ONCASPAR SOLN 750 UNIT/ML nystatin-triamcinolone crea 100000-0.1 [pegaspargase] ...... 19 unit/gm-% ...... 81 ondansetron hcl soln 4 mg/2ml ...... 61 nystatin-triamcinolone oint 100000-0.1 ondansetron hcl soln 4 mg/5ml ...... 61 unit/gm-% ...... 81 ondansetron hcl soln 40 mg/20ml ...... 61 OCTAGAM SOLN 1 GM/20ML [immune ondansetron hcl tabs 4 mg ...... 61 globulin (human) iv] ...... 77 ondansetron hcl tabs 8 mg ...... 61 OCTAGAM SOLN 2.5 GM/50ML [immune ondansetron tbdp 4 mg ...... 61 globulin (human) iv] ...... 78 ondansetron tbdp 8 mg ...... 61 OCTAGAM SOLN 25 GM/500ML [immune ONETOUCH DELICA LANCETS 33G MISC globulin (human) iv] ...... 78 [lancets] ...... 87 octreotide acetate soln 100 mcg/ml ...... 72 ONETOUCH FINEPOINT LANCETS MISC octreotide acetate soln 1000 mcg/ml ...... 72 [lancets] ...... 87 octreotide acetate soln 200 mcg/ml ...... 72 ONETOUCH SURESOFT LANCING DEV MISC octreotide acetate soln 50 mcg/ml ...... 72 [lancets misc.] ...... 87 octreotide acetate soln 500 mcg/ml ...... 72 ONETOUCH ULTRA CONTROL SOLN [blood ODACTRA SUBL 12 SQ-HDM [dust mite mixed glucose calibration] ...... 87 allergen extract] ...... 78 ONETOUCH ULTRA MINI KIT W/DEVICE ODEFSEY TABS 200-25-25 MG [emtricitabine- [blood glucose monitoring supplies] ...... 87 rilpivirine-tenofovir alafenamide fumarate] ONETOUCH ULTRA STRP [glucose blood] . 88 ...... 13 ONETOUCH ULTRASOFT LANCETS MISC ODOMZO CAPS 200 MG [sonidegib [lancets] ...... 87 phosphate] ...... 19 ONETOUCH VERIO SOLN HIGH [blood OFEV CAPS 100 MG [nintedanib esylate] .... 75 glucose calibration] ...... 87 OFEV CAPS 150 MG [nintedanib esylate] .... 75 OPANA SOLN 1 MG/ML [oxymorphone hcl] . 39 OFIRMEV SOLN 10 MG/ML [acetaminophen] OPDIVO SOLN 100 MG/10ML [nivolumab] .... 19 ...... 39 OPDIVO SOLN 40 MG/4ML [nivolumab] ...... 19 ofloxacin soln 0.3 % ...... 58 ORAP TABS 1 MG [pimozide] ...... 49 olanzapine solr 10 mg ...... 48 ORAP TABS 2 MG [pimozide] ...... 49 olanzapine tabs 10 mg ...... 48 ORENCIA CLICKJECT SOAJ 125 MG/ML olanzapine tabs 15 mg ...... 48 [abatacept] ...... 68 olanzapine tabs 2.5 mg ...... 48 ORENCIA SOLR 250 MG [abatacept] ...... 68 olanzapine tabs 20 mg ...... 49 ORENCIA SOSY 125 MG/ML [abatacept] ...... 68 olanzapine tabs 5 mg ...... 49 ORENCIA SOSY 50 MG/0.4ML [abatacept] ... 68 olanzapine tabs 7.5 mg ...... 49 ORENCIA SOSY 87.5 MG/0.7ML [abatacept] 68 olopatadine hcl soln 0.1 % ...... 59 ORKAMBI PACK 100-125 MG [lumacaftor- omeprazole cpdr 10 mg ...... 61 ivacaftor] ...... 75 omeprazole cpdr 20 mg ...... 61 ORKAMBI PACK 150-188 MG [lumacaftor- omeprazole cpdr 40 mg ...... 61 ivacaftor] ...... 76 OMNIPAQUE INJ 300MG/ML [iohexol] ...... 51 ORKAMBI TABS 100-125 MG [lumacaftor- OMNIPAQUE INJ 350MG/ML [iohexol] ...... 51 ivacaftor] ...... 76 OMNIPAQUE SOLN 180 MG/ML [iohexol] ..... 51 ORKAMBI TABS 200-125 MG [lumacaftor- OMNIPAQUE SOLN 240 MG/ML [iohexol] ..... 51 ivacaftor] ...... 76 OMNIPAQUE SOLN 300 MG/ML [iohexol] ..... 52 oseltamivir phosphate caps 30 mg ...... 13 OMNIPAQUE SOLN 350 MG/ML [iohexol] ..... 52 oseltamivir phosphate caps 45 mg ...... 13 OMNITROPE PEN 5 INJ DEVICE MISC oseltamivir phosphate caps 75 mg ...... 13 [injection device] ...... 51 oseltamivir phosphate susr 6 mg/ml ...... 13 OMNITROPE SOCT 10 MG/1.5ML OSMITROL SOLN 20 % [mannitol] ...... 54 [somatropin] ...... 68 OTEZLA TAB 10/20/30 [apremilast] ...... 68

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 124 of 145 OTEZLA TABS 30 MG [apremilast] ...... 69 pantoprazole sodium tbec 20 mg ...... 61 OTEZLA TBPK 10 & 20 & 30 MG [apremilast]69 pantoprazole sodium tbec 40 mg ...... 61 OVIDREL INJ 250 MCG/0.5ML PAPAVERINE HCL POWD [papaverine hcl] . 74 [choriogonadotropin alfa] ...... 67 PAPAVERINE HCL SOLN 30 MG/ML OXACILLIN SODIUM IN DEXTROSE SOLN 1 [papaverine hcl] ...... 36 GM/50ML [oxacillin sodium in dextrose] .... 9 PAREGORIC TINC 2 MG/5ML [paregoric] ..... 60 OXACILLIN SODIUM IN DEXTROSE SOLN 2 paromomycin sulfate caps 250 mg ...... 12 GM/50ML [oxacillin sodium in dextrose] .... 9 paroxetine hcl tabs 10 mg ...... 49 oxacillin sodium solr 1 gm ...... 9 paroxetine hcl tabs 20 mg ...... 49 OXACILLIN SODIUM SOLR 2 GM [oxacillin paroxetine hcl tabs 30 mg ...... 49 sodium] ...... 9 paroxetine hcl tabs 40 mg ...... 49 oxaliplatin soln 100 mg/20ml ...... 19 PEDIARIX SUSP [diph-tetanus tox-acell pert- oxaliplatin soln 50 mg/10ml ...... 19 hepatitis b recomb-polio ipv vac] ...... 79 oxandrolone tabs 10 mg ...... 64 pediatric multivitamins w/fl chew ...... 83 oxandrolone tabs 2.5 mg ...... 64 PEDIATRIC SMALL MASK MISC [masks] ..... 87 oxazepam caps 10 mg ...... 45 peg 3350/electrolytes solr 240 gm ...... 61 oxazepam caps 15 mg ...... 45 peg 3350-kcl-na bicarb-nacl solr 420 gm ..... 61 oxazepam caps 30 mg ...... 45 PEGASYS PROCLICK SOLN 135 MCG/0.5ML oxcarbazepine susp 300 mg/5ml ...... 42 [peginterferon alfa-2a] ...... 11 oxcarbazepine tabs 150 mg ...... 42 PEGASYS PROCLICK SOLN 180 MCG/0.5ML oxcarbazepine tabs 300 mg ...... 42 [peginterferon alfa-2a] ...... 11 oxcarbazepine tabs 600 mg ...... 42 PEGASYS SOLN 180 MCG/0.5ML OXSORALEN ULTRA CAPS 10 MG [peginterferon alfa-2a] ...... 11 [methoxsalen rapid] ...... 82 PEGASYS SOLN 180 MCG/ML [peginterferon oxybutynin chloride er tb24 10 mg ...... 83 alfa-2a]...... 11 oxybutynin chloride er tb24 15 mg ...... 83 PEGINTRON KIT 50 MCG/0.5ML oxybutynin chloride er tb24 5 mg ...... 83 [peginterferon alfa-2b] ...... 11 oxybutynin chloride syrp 5 mg/5ml ...... 83 PEG-INTRON REDIPEN KIT 120 RP oxybutynin chloride tabs 5 mg ...... 83 [peginterferon alfa-2b] ...... 11 oxycodone hcl tabs 5 mg ...... 39 PEG-INTRON REDIPEN KIT 150 RP oxycodone-acetaminophen tabs 10-325 mg 39 [peginterferon alfa-2b] ...... 11 oxycodone-acetaminophen tabs 5-325 mg .. 39 penicillamine caps 250 mg ...... 62 oxycodone-acetaminophen tabs 7.5-325 mg PENICILLIN G POT IN DEXTROSE SOLN ...... 39 20000 UNIT/ML [penicillin g pot in dextrose] OXYTOCIN SOLN 10 UNIT/ML [oxytocin] ..... 73 ...... 9 OZURDEX IMPL 0.7 MG [dexamethasone PENICILLIN G POT IN DEXTROSE SOLN (ophth)] ...... 59 40000 UNIT/ML [penicillin g pot in dextrose] paclitaxel conc 300 mg/50ml ...... 19 ...... 9 PADCEV SOLR 20 MG [enfortumab vedotin- PENICILLIN G POT IN DEXTROSE SOLN ejfv] ...... 19 60000 UNIT/ML [penicillin g pot in dextrose] PADCEV SOLR 30 MG [enfortumab vedotin- ...... 9 ejfv] ...... 19 penicillin g potassium solr 20000000 unit ...... 9 PAIN & FEVER CHILDRENS SOLN 160 penicillin g potassium solr 5000000 unit ...... 9 MG/5ML [acetaminophen] ...... 86 penicillin g procaine susp 600000 unit/ml ...... 9 PAIN RELIEVER TABS 325 MG penicillin g sodium solr 5000000 unit ...... 9 [acetaminophen] ...... 86 penicillin v potassium solr 125 mg/5ml ...... 9 pamidronate disodium soln 30 mg/10ml ...... 72 penicillin v potassium solr 250 mg/5ml ...... 9 pamidronate disodium soln 6 mg/ml...... 72 penicillin v potassium tabs 250 mg ...... 9 pamidronate disodium soln 90 mg/10ml ...... 72 penicillin v potassium tabs 500 mg ...... 9 pamidronate disodium solr 30 mg ...... 72 PENLET II BLOOD SAMPLER KIT [lancets pamidronate disodium solr 90 mg ...... 72 misc.] ...... 87 pancuronium bromide soln 1 mg/ml ...... 23 PENTAM SOLR 300 MG [pentamidine

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 125 of 145 isethionate] ...... 12 phentolamine mesylate solr 5 mg ...... 23 PENTASA CPCR 250 MG [mesalamine] ...... 60 PHENYLEPHRINE HCL SOLN 10 % PENTASA CPCR 500 MG [mesalamine] ...... 60 [phenylephrine hcl (mydriatic)] ...... 60 pentazocine-naloxone hcl tabs 50-0.5 mg ... 39 PHENYLEPHRINE HCL SOLN 2.5 % pentostatin inj 10mg ...... 19 [phenylephrine hcl (mydriatic)] ...... 60 pentoxifylline er tbcr 400 mg ...... 30 phenylephrine-chlorphen-dm liqd ...... 90 PEPTIC RELIEF CHEW 262 MG [bismuth PHENYLHISTINE DH LIQ DH [pseudoeph- subsalicylate] ...... 89 chlorphen w/ cod] ...... 90 PERJETA SOLN 420 MG/14ML [pertuzumab] phenytoin sodium extended caps 100 mg ... 42 ...... 19 phenytoin sodium soln 50 mg/ml ...... 42 permethrin crea 5 % ...... 80 phenytoin susp 125 mg/5ml ...... 42 permethrin lotn 1 % ...... 90 PHLEXY-10 PACK [nutritional supplements] perphenazine tabs 16 mg ...... 49 ...... 88 perphenazine tabs 2 mg ...... 49 PHOSLYRA SOLN 667 MG/5ML [calcium perphenazine tabs 4 mg ...... 49 acetate (phosphate binder)] ...... 56 perphenazine tabs 8 mg ...... 49 PHOSPHOLINE IODIDE SOLR 0.125 % perphenazine-amitriptyline tabs 2-10 mg .... 49 [echothiophate iodide] ...... 59 perphenazine-amitriptyline tabs 2-25 mg .... 49 PHOTREXA-PHOTREXA VISCOUS KIT SOSY perphenazine-amitriptyline tabs 4-10 mg .... 49 0.146 &0.146-20 % [riboflavin5-phos sod & perphenazine-amitriptyline tabs 4-25 mg .... 49 riboflavin 5-phosphate sodium-dextran] .. 60 perphenazine-amitriptyline tabs 4-50 mg .... 49 PHYSOSTIGMINE SALICYLATE SOLN 1 phenelzine sulfate tabs 15 mg ...... 49 MG/ML [physostigmine salicylate] ...... 22 PHENEX-1 POWD [nutritional supplements] phytonadione soln 1 mg/0.5ml ...... 84 ...... 88 pilocarpine hcl soln 1 % ...... 59 PHENOBARBITAL ELIX 20 MG/5ML pilocarpine hcl soln 2 % ...... 59 [phenobarbital] ...... 45 pilocarpine hcl soln 4 % ...... 59 PHENOBARBITAL POWD [phenobarbital] ... 74 pilocarpine hcl tabs 5 mg ...... 22 PHENOBARBITAL SODIUM SOLN 130 MG/ML pimecrolimus crea 1 % ...... 83 [phenobarbital sodium] ...... 45 pimozide tabs 2 mg ...... 49 PHENOBARBITAL SODIUM SOLN 65 MG/ML pioglitazone hcl tabs 15 mg ...... 65 [phenobarbital sodium] ...... 45 pioglitazone hcl tabs 30 mg ...... 65 PHENOBARBITAL TABS 100 MG pioglitazone hcl tabs 45 mg ...... 65 [phenobarbital] ...... 45 piperacillin sod-tazobactam so solr 2.25 (2- PHENOBARBITAL TABS 15 MG 0.25) gm ...... 9 [phenobarbital] ...... 45 piperacillin sod-tazobactam so solr 3.375 (3- PHENOBARBITAL TABS 16.2 MG 0.375) gm ...... 9 [phenobarbital] ...... 45 piperacillin sod-tazobactam so solr 4.5 (4-0.5) PHENOBARBITAL TABS 30 MG gm ...... 10 [phenobarbital] ...... 45 piperacillin sod-tazobactam so solr 40.5 (36- PHENOBARBITAL TABS 32.4 MG 4.5) gm...... 10 [phenobarbital] ...... 45 PLASMA-LYTE A SOLN [electrolyte-a] ...... 56 PHENOBARBITAL TABS 60 MG PLASMANATE SOLN 5 % [plasma protein [phenobarbital] ...... 45 fraction] ...... 24 PHENOBARBITAL TABS 64.8 MG PLURONIC F127 GEL 20 % [pluronic f127 [phenobarbital] ...... 45 base] ...... 74 PHENOBARBITAL TABS 97.2 MG PNEUMOVAX 23 INJ 25 MCG/0.5ML [phenobarbital] ...... 45 [pneumococcal vac polyvalent] ...... 79 PHENOL LIQD [phenol] ...... 90 PODOCON SOLN 25 % [podophyllum resin] 83 PHENOL LIQD 89 % [phenol] ...... 27 podofilox soln 0.5 % ...... 83 phenoxybenzamine hcl caps 10 mg ...... 23 PODOPHYLLUM RESIN POWD [podophyllum PHENTOLAMINE MESYLATE POWD resin] ...... 74 [phentolamine mesylate (bulk)] ...... 74 POLY HIST FORTE TABS 7.5-10 MG

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 126 of 145 [doxylamine-phenylephrine] ...... 85 POTASSIUM CHLORIDE SOLN 40 MEQ/15ML POLYETHYLENE GLYCOL 400 LIQD (20%) [potassium chloride] ...... 57 [polyethylene glycol 400] ...... 89 POTASSIUM CITRATE ER TBCR 10 MEQ POLYETHYLENE GLYCOL 8000 POWD (1080 MG) [potassium citrate (alkalinizer)] [polyethylene glycol 8000] ...... 74 ...... 52 polymyxin b-trimethoprim soln 10000-0.1 POTASSIUM CITRATE ER TBCR 5 MEQ (540 unit/ml-% ...... 58 MG) [potassium citrate (alkalinizer)] ...... 52 POLY-VI-SOL SOLN [pediatric multiple POTASSIUM CITRATE-CITRIC ACID SOLN vitamins] ...... 91 1100-334 MG/5ML [potassium citrate-citric POLY-VI-SOL/IRON SOLN 11 MG/ML [pediatric acid] ...... 52 multiple vitamins w/ iron] ...... 91 potassium phosphate inj 3mm/ml ...... 57 POMALYST CAPS 1 MG [pomalidomide] ..... 19 POTASSIUM PHOSPHATES SOLN 45 POMALYST CAPS 2 MG [pomalidomide] ..... 19 MMOLE/15ML [potassium phosphates] .... 57 POMALYST CAPS 3 MG [pomalidomide] ..... 19 PRADAXA CAPS 110 MG [dabigatran etexilate POMALYST CAPS 4 MG [pomalidomide] ..... 19 mesylate] ...... 29 POTABA CAPS 500 MG [potassium PRADAXA CAPS 150 MG [dabigatran etexilate aminobenzoate]...... 84 mesylate] ...... 29 POTASSIUM ACETATE SOLN 2 MEQ/ML PRADAXA CAPS 75 MG [dabigatran etexilate [potassium acetate] ...... 56 mesylate] ...... 29 potassium chloride 0.075%/d5w/nacl 0.225% pramipexole dihydrochloride tabs 0.125 mg 44 inj .075/.2% ...... 56 pramipexole dihydrochloride tabs 0.25 mg . 44 potassium chloride crys er tbcr 10 meq ...... 56 pramipexole dihydrochloride tabs 0.5 mg ... 44 potassium chloride crys er tbcr 20 meq ...... 56 pramipexole dihydrochloride tabs 0.75 mg . 44 potassium chloride er cpcr 10 meq ...... 56 pramipexole dihydrochloride tabs 1 mg ...... 44 potassium chloride er cpcr 8 meq ...... 56 pramipexole dihydrochloride tabs 1.5 mg ... 44 POTASSIUM CHLORIDE IN DEXTROSE SOLN PRAMOSONE OINT 1-1 % [pramoxine-hc] ... 81 20-5 MEQ/L-% [potassium chloride in PRAMOSONE OINT 1-2.5 % [pramoxine-hc] 81 dextrose] ...... 56 pravastatin sodium tabs 10 mg ...... 31 POTASSIUM CHLORIDE IN DEXTROSE SOLN pravastatin sodium tabs 20 mg ...... 31 40-5 MEQ/L-% [potassium chloride in pravastatin sodium tabs 40 mg ...... 31 dextrose] ...... 56 pravastatin sodium tabs 80 mg ...... 31 POTASSIUM CHLORIDE IN NACL SOLN 20- PRAXBIND SOLN 2.5 GM/50ML 0.45 MEQ/L-% [potassium chloride in nacl] [idarucizumab] ...... 27 ...... 56 prazosin hcl caps 1 mg ...... 30 POTASSIUM CHLORIDE IN NACL SOLN 20-0.9 prazosin hcl caps 2 mg ...... 30 MEQ/L-% [potassium chloride in nacl] ..... 56 prazosin hcl caps 5 mg ...... 30 POTASSIUM CHLORIDE IN NACL SOLN 40-0.9 PRECEDEX SOLN 200 MCG/2ML MEQ/L-% [potassium chloride in nacl] ..... 56 [dexmedetomidine hcl] ...... 45 POTASSIUM CHLORIDE PACK 20 MEQ PRED MILD SUSP 0.12 % [prednisolone [potassium chloride] ...... 56 acetate (ophth)] ...... 59 potassium chloride sol 10% sf ...... 56 prednisolone acetate susp 1 % ...... 59 POTASSIUM CHLORIDE SOLN 10 MEQ/100ML prednisolone sodium phosphate soln 1 % .. 59 [potassium chloride] ...... 56 prednisolone sodium phosphate soln 15 POTASSIUM CHLORIDE SOLN 10 MEQ/50ML mg/5ml...... 63 [potassium chloride] ...... 56 prednisolone sodium phosphate soln 6.7 (5 potassium chloride soln 2 meq/ml ...... 56 base) mg/5ml ...... 63 POTASSIUM CHLORIDE SOLN 20 MEQ/100ML prednisolone soln 15 mg/5ml ...... 63 [potassium chloride] ...... 57 prednisone soln 5 mg/5ml ...... 63 POTASSIUM CHLORIDE SOLN 20 MEQ/50ML prednisone tabs 1 mg ...... 63 [potassium chloride] ...... 57 prednisone tabs 10 mg ...... 63 POTASSIUM CHLORIDE SOLN 40 MEQ/100ML prednisone tabs 2.5 mg ...... 63 [potassium chloride] ...... 57 prednisone tabs 20 mg ...... 63

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 127 of 145 prednisone tabs 5 mg ...... 63 PRIVIGEN SOLN 20 GM/200ML [immune prednisone tabs 50 mg ...... 63 globulin (human) iv] ...... 78 prednisone tbpk 10 mg (21) ...... 63 PRIVIGEN SOLN 5 GM/50ML [immune prednisone tbpk 5 mg (21) ...... 63 globulin (human) iv] ...... 78 pregabalin caps 100 mg ...... 42 probenecid tabs 500 mg ...... 57 pregabalin caps 150 mg ...... 42 procainamide hcl soln 100 mg/ml ...... 33 pregabalin caps 200 mg ...... 42 procainamide hcl soln 500 mg/ml ...... 33 pregabalin caps 225 mg ...... 42 PROCALAMINE SOLN 3 % [amino acid pregabalin caps 25 mg ...... 42 electrolyte infusion] ...... 53 pregabalin caps 300 mg ...... 42 prochlorperazine edisylate soln 10 mg/2ml . 49 pregabalin caps 50 mg ...... 42 prochlorperazine maleate tabs 10 mg ...... 49 pregabalin caps 75 mg ...... 42 prochlorperazine maleate tabs 5 mg ...... 49 pregabalin soln 20 mg/ml ...... 42 PROCRIT SOLN 10000 UNIT/ML [epoetin alfa] PREMARIN SOLR 25 MG [estrogens, ...... 30 conjugated] ...... 67 PROCRIT SOLN 2000 UNIT/ML [epoetin alfa] PREPIDIL GEL 0.5 MG/3GM [dinoprostone] . 73 ...... 30 PRETOMANID TABS 200 MG [pretomanid] .. 12 PROCRIT SOLN 20000 UNIT/ML [epoetin alfa] PREVIDENT 5000 PLUS CREA 1.1 % [sodium ...... 30 fluoride (dental)] ...... 72 PROCRIT SOLN 3000 UNIT/ML [epoetin alfa] PREVIDENT GEL 1.1 % [sodium fluoride ...... 30 (dental)] ...... 72 PROCRIT SOLN 4000 UNIT/ML [epoetin alfa] PREVIDENT SOLN 0.2 % [sodium fluoride ...... 30 (dental)] ...... 72 PROCRIT SOLN 40000 UNIT/ML [epoetin alfa] PREVNAR 13 SUSP [pneumococcal 13-valent ...... 30 conjugate vaccine] ...... 79 PRODIGY CONTROL SOLUTION SOLN LOW PREVYMIS SOLN 240 MG/12ML [letermovir] 13 [blood glucose calibration] ...... 87 PREVYMIS SOLN 480 MG/24ML [letermovir] 13 PROFERRIN ES TABS 12 MG [iron heme PREVYMIS TABS 240 MG [letermovir] ...... 13 polypeptide] ...... 85 PREVYMIS TABS 480 MG [letermovir] ...... 13 PROFERRIN-FORTE TABS 12-1 MG [iron PREZCOBIX TABS 800-150 MG [darunavir- heme polypeptide-folic acid] ...... 24 cobicistat] ...... 13 PROFILNINE SOLR 1000 UNIT [factor ix PREZISTA TABS 150 MG [darunavir complex] ...... 27 ethanolate] ...... 4 PROFILNINE SOLR 1500 UNIT [factor ix PREZISTA TABS 600 MG [darunavir complex] ...... 27 ethanolate] ...... 4 PROFILNINE SOLR 500 UNIT [factor ix PREZISTA TABS 75 MG [darunavir complex] ...... 27 ethanolate] ...... 4 progesterone caps 100 mg ...... 67 PREZISTA TABS 800 MG [darunavir progesterone caps 200 mg ...... 67 ethanolate] ...... 4 PROGESTERONE MICRONIZED POWD PRIFTIN TABS 150 MG [rifapentine] ...... 12 [progesterone micronized (bulk)] ...... 74 PRIMAQUINE PHOSPHATE TABS 26.3 (15 PROGESTERONE OIL 50 MG/ML Base) MG [primaquine phosphate] ...... 12 [progesterone] ...... 67 PRIMAXIN IV SOLR 250-250 MG [imipenem- PROGESTERONE WETTABLE POWD cilastatin] ...... 10 [progesterone (bulk)] ...... 74 PRIMAXIN IV SOLR 500-500 MG [imipenem- PROGLYCEM SUSP 50 MG/ML [diazoxide] .. 34 cilastatin] ...... 10 PROGRAF SOLN 5 MG/ML [tacrolimus] ...... 69 primidone tab 50mg...... 42 PROLEUKIN SOLR 22000000 UNIT primidone tabs 250 mg ...... 42 [aldesleukin] ...... 19 PRIMSOL SOLN 50 MG/5ML [trimethoprim PROMACTA PACK 25 MG [eltrombopag hcl] ...... 10 olamine] ...... 30 PRIVIGEN SOLN 10 GM/100ML [immune PROMACTA TABS 12.5 MG [eltrombopag globulin (human) iv] ...... 78 olamine] ...... 30

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 128 of 145 PROMACTA TABS 25 MG [eltrombopag pyridoxine hcl soln 100 mg/ml ...... 84 olamine] ...... 30 PYRIDOXINE HCL TABS 25 MG [pyridoxine PROMACTA TABS 50 MG [eltrombopag hcl] ...... 91 olamine] ...... 30 QUELICIN SOLN 20 MG/ML [succinylcholine PROMACTA TABS 75 MG [eltrombopag chloride] ...... 23 olamine] ...... 30 quetiapine fumarate tabs 100 mg ...... 49 promethazine hcl soln 25 mg/ml ...... 14 quetiapine fumarate tabs 200 mg ...... 49 promethazine hcl tabs 12.5 mg ...... 14 quetiapine fumarate tabs 25 mg ...... 49 promethazine hcl tabs 25 mg...... 14 quetiapine fumarate tabs 300 mg ...... 49 promethazine-codeine soln 6.25-10 mg/5ml 75 quetiapine fumarate tabs 400 mg ...... 49 promethazine-dm soln 6.25-15 mg/5ml ...... 75 quetiapine fumarate tabs 50 mg ...... 49 promethazine-dm syrp 6.25-15 mg/5ml ...... 75 QUINACRINE HCL POWD [quinacrine hcl] .. 74 propafenone hcl tabs 150 mg ...... 33 quinidine gluconate er tbcr 324 mg ...... 33 propafenone hcl tabs 225 mg ...... 33 QUINIDINE GLUCONATE SOLN 80 MG/ML propafenone hcl tabs 300 mg ...... 33 [quinidine gluconate] ...... 33 propantheline bromide tabs 15 mg ...... 22 quinidine sulfate tabs 200 mg ...... 34 proparacaine hcl soln 0.5 %...... 60 quinidine sulfate tabs 300 mg ...... 34 propofol emul 1000 mg/100ml ...... 46 RABAVERT SUSR [rabies vaccine, pcec] .... 79 propofol emul 200 mg/20ml ...... 46 raloxifene hcl tabs 60 mg ...... 67 propranolol hcl er cp24 120 mg ...... 31 ramipril caps 10 mg ...... 34 propranolol hcl er cp24 160 mg ...... 32 ramipril caps 2.5 mg ...... 34 propranolol hcl er cp24 60 mg ...... 32 ramipril caps 5 mg ...... 34 propranolol hcl er cp24 80 mg ...... 32 RAPAMUNE SOLN 1 MG/ML [sirolimus] ...... 69 propranolol hcl soln 1 mg/ml ...... 32 rasagiline mesylate tabs 0.5 mg ...... 44 propranolol hcl soln 20 mg/5ml ...... 32 rasagiline mesylate tabs 1 mg ...... 44 propranolol hcl tabs 10 mg ...... 32 RASUVO SOAJ 10 MG/0.2ML [methotrexate propranolol hcl tabs 20 mg ...... 32 (antirheumatic)] ...... 69 propranolol hcl tabs 40 mg ...... 32 RASUVO SOAJ 12.5 MG/0.25ML [methotrexate propranolol hcl tabs 60 mg ...... 32 (antirheumatic)] ...... 69 propranolol hcl tabs 80 mg ...... 32 RASUVO SOAJ 15 MG/0.3ML [methotrexate PROPYLENE GLYCOL LIQD [propylene (antirheumatic)] ...... 69 glycol (bulk)] ...... 89 RASUVO SOAJ 17.5 MG/0.35ML [methotrexate propylthiouracil tabs 50 mg ...... 68 (antirheumatic)] ...... 69 PROQUAD SUSR [measles-mumps-rubella- RASUVO SOAJ 20 MG/0.4ML [methotrexate varicella virus vaccines] ...... 79 (antirheumatic)] ...... 69 PROSOL SOLN 20 % [amino acid infusion] . 53 RASUVO SOAJ 22.5 MG/0.45ML [methotrexate PROSTIN E2 SUPP 20 MG [dinoprostone] ... 73 (antirheumatic)] ...... 69 protamine sulfate soln 10 mg/ml ...... 27 RASUVO SOAJ 25 MG/0.5ML [methotrexate PROTONIX SOLR 40 MG [pantoprazole (antirheumatic)] ...... 69 sodium] ...... 61 RASUVO SOAJ 27.5 MG/0.55ML [methotrexate protriptyline hcl tabs 10 mg ...... 49 (antirheumatic)] ...... 72 protriptyline hcl tabs 5 mg ...... 49 RASUVO SOAJ 30 MG/0.6ML [methotrexate PSEUDOEPHEDRINE HCL TABS 30 MG (antirheumatic)] ...... 69 [pseudoephedrine hcl] ...... 85 RASUVO SOAJ 7.5 MG/0.15ML [methotrexate PULMICORT FLEXHALER AEPB 180 MCG/ACT (antirheumatic)] ...... 69 [budesonide (inhalation)] ...... 63 READI-CAT 2 SUSP 2 % [barium sulfate] ..... 52 PULMOZYME SOLN 1 MG/ML [dornase alfa] 57 READI-CAT 2 SUSP 2.1 % [barium sulfate] .. 52 PURIXAN SUSP 2000 MG/100ML RECOMBINATE SOLR 1241-1800 UNIT [mercaptopurine] ...... 19 [antihemophilic factor (recombinant) (rfviii)] pyrazinamide tabs 500 mg ...... 12 ...... 27 pyridostigmine bromide er tbcr 180 mg ...... 22 RECOMBINATE SOLR 1801-2400 UNIT pyridostigmine bromide tabs 60 mg ...... 22 [antihemophilic factor (recombinant) (rfviii)]

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 129 of 145 ...... 27 RETIN-A MICRO GEL 0.04 % [tretinoin RECOMBINATE SOLR 220-400 UNIT microsphere] ...... 82 [antihemophilic factor (recombinant) (rfviii)] RETIN-A MICRO GEL 0.1 % [tretinoin ...... 27 microsphere] ...... 82 RECOMBINATE SOLR 401-800 UNIT RETISERT IMPL 0.59 MG [fluocinolone [antihemophilic factor (recombinant) (rfviii)] acetonide (ophth)] ...... 59 ...... 27 RETROVIR SOLN 10 MG/ML [zidovudine] .... 13 RECOMBINATE SOLR 801-1240 UNIT REVLIMID CAPS 10 MG [lenalidomide] ...... 19 [antihemophilic factor (recombinant) (rfviii)] REVLIMID CAPS 15 MG [lenalidomide] ...... 19 ...... 28 REVLIMID CAPS 2.5 MG [lenalidomide] ...... 19 RECOMBIVAX HB SUSP 10 MCG/ML [hepatitis REVLIMID CAPS 20 MG [lenalidomide] ...... 19 b vaccine (recomb)] ...... 79 REVLIMID CAPS 25 MG [lenalidomide] ...... 19 RECOMBIVAX HB SUSP 40 MCG/ML [hepatitis REVLIMID CAPS 5 MG [lenalidomide] ...... 19 b vaccine (recomb)] ...... 79 RHOGAM ULTRA-FILTERED PLUS SOSY 1500 RECOMBIVAX HB SUSP 5 MCG/0.5ML UNIT [rho d immune globulin (human)] .... 78 [hepatitis b vaccine (recomb)] ...... 79 RHOPHYLAC SOSY 1500 UNIT/2ML [rho d RECOTHROM SOLR 20000 UNIT [thrombin immune globulin (human)] ...... 78 (recombinant)] ...... 28 ribavirin caps 200 mg ...... 11 RECOTHROM SOLR 5000 UNIT [thrombin RIDAURA CAPS 3 MG [auranofin] ...... 62 (recombinant)] ...... 28 rifabutin caps 150 mg ...... 12 REESES PINWORM MEDICINE SUSP 144 (50 rifampin caps 150 mg ...... 12 Base) MG/ML [pyrantel pamoate] ...... 85 rifampin caps 300 mg ...... 12 REGONOL SOLN 10 MG/2ML [pyridostigmine rifampin solr 600 mg ...... 12 bromide] ...... 22 riluzole tabs 50 mg ...... 46 RELENZA DISKHALER AEPB 5 MG/BLISTER rimantadine hcl tabs 100 mg ...... 13 [zanamivir] ...... 13 RIMSO-50 SOLN 50 % [dimethyl sulfoxide] .. 72 REMICADE SOLR 100 MG [infliximab] ...... 69 RINGERS IRRIGATION SOLN [ringer's REMODULIN SOLN 100 MG/20ML [treprostinil] irrigation] ...... 54 ...... 36 RINGERS SOLN [ringer's] ...... 57 REMODULIN SOLN 20 MG/20ML [treprostinil] RISPERDAL CONSTA SRER 12.5 MG ...... 36 [risperidone microspheres] ...... 49 REMODULIN SOLN 200 MG/20ML [treprostinil] RISPERDAL CONSTA SRER 25 MG ...... 36 [risperidone microspheres] ...... 49 REMODULIN SOLN 50 MG/20ML [treprostinil] RISPERDAL CONSTA SRER 37.5 MG ...... 36 [risperidone microspheres] ...... 49 RENAL CAPS 1 MG [b-complex w/ c & folic RISPERDAL CONSTA SRER 50 MG acid] ...... 84 [risperidone microspheres] ...... 49 RENVELA PACK 2.4 GM [sevelamer RISPERIDONE SOLN 1 MG/ML [risperidone]49 carbonate] ...... 54 RISPERIDONE TABS 0.25 MG [risperidone] . 49 RENVELA TABS 800 MG [sevelamer RISPERIDONE TABS 0.5 MG [risperidone] ... 49 carbonate] ...... 54 risperidone tabs 1 mg ...... 49 RESCRIPTOR TABS 100 MG [delavirdine RISPERIDONE TABS 2 MG [risperidone] ...... 49 mesylate] ...... 4 RISPERIDONE TABS 3 MG [risperidone] ...... 49 RESCRIPTOR TABS 200 MG [delavirdine RISPERIDONE TABS 4 MG [risperidone] ...... 49 mesylate] ...... 5 ritonavir tabs 100 mg ...... 13 reserpine tab 0.1mg ...... 34 RITUXAN SOLN 100 MG/10ML [rituximab] .... 19 reserpine tab 0.25mg ...... 34 RITUXAN SOLN 500 MG/50ML [rituximab] .... 19 RETIN-A CREA 0.025 % [tretinoin] ...... 82 rizatriptan benzoate tabs 10 mg ...... 43 RETIN-A CREA 0.05 % [tretinoin] ...... 82 rizatriptan benzoate tabs 5 mg ...... 43 RETIN-A CREA 0.1 % [tretinoin] ...... 82 rizatriptan benzoate tbdp 10 mg ...... 43 RETIN-A GEL 0.01 % [tretinoin] ...... 82 rizatriptan benzoate tbdp 5 mg ...... 43 RETIN-A GEL 0.025 % [tretinoin] ...... 82 rocuronium bromide soln 100 mg/10ml ...... 23

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 130 of 145 rocuronium bromide soln 50 mg/5ml ...... 23 SARNA LOTN 0.5-0.5 % [camphor & menthol] romidepsin solr 10 mg ...... 19 ...... 90 ropinirole hcl er tb24 12 mg ...... 44 scopolamine pt72 1 mg/3days ...... 61 ropinirole hcl er tb24 2 mg ...... 44 selegiline hcl caps 5 mg ...... 46 ropinirole hcl er tb24 4 mg ...... 44 selegiline hcl tabs 5 mg ...... 44 ropinirole hcl er tb24 6 mg ...... 44 SELENIUM SOLN 40 MCG/ML [selenious acid] ropinirole hcl er tb24 8 mg ...... 44 ...... 57 ropinirole hcl tabs 0.25 mg ...... 44 selenium sulfide lotn 2.5 % ...... 80 ropinirole hcl tabs 0.5 mg ...... 44 SELZENTRY TABS 150 MG [maraviroc] ...... 5 ropinirole hcl tabs 1 mg ...... 44 SELZENTRY TABS 25 MG [maraviroc] ...... 5 ropinirole hcl tabs 2 mg ...... 44 SELZENTRY TABS 300 MG [maraviroc] ...... 5 ropinirole hcl tabs 3 mg ...... 44 SELZENTRY TABS 75 MG [maraviroc] ...... 5 ropinirole hcl tabs 4 mg ...... 44 SENSORCAINE-MPF/EPINEPHRINE SOLN ropinirole hcl tabs 5 mg ...... 44 0.75-1 rosuvastatin calcium tabs 10 mg ...... 31 200000 % [bupivacaine w/ epinephrine] ... 70 rosuvastatin calcium tabs 20 mg ...... 31 SEREVENT DISKUS AEPB 50 MCG/DOSE rosuvastatin calcium tabs 40 mg ...... 31 [salmeterol xinafoate] ...... 24 rosuvastatin calcium tabs 5 mg ...... 31 SEROSTIM SOLR 4 MG [somatropin (non- ROTARIX SUSR [rotavirus vaccine, live oral] refrigerated)] ...... 68 ...... 79 SEROSTIM SOLR 5 MG [somatropin (non- ROTATEQ SOLN [rotavirus vaccine, live oral refrigerated)] ...... 68 pentavalent] ...... 79 SEROSTIM SOLR 6 MG [somatropin (non- ROZLYTREK CAPS 100 MG [entrectinib] ..... 19 refrigerated)] ...... 68 ROZLYTREK CAPS 200 MG [entrectinib] ..... 19 sertraline hcl tabs 100 mg ...... 49 RYANODEX SUSR 250 MG [dantrolene sertraline hcl tabs 25 mg ...... 49 sodium] ...... 23 sertraline hcl tabs 50 mg ...... 49 RYDAPT CAPS 25 MG [midostaurin] ...... 19 sevelamer carbonate pack 2.4 gm ...... 54 S2 (RACEPINEPHRINE) NEBU 2.25 % sevelamer carbonate tabs 800 mg ...... 54 [racepinephrine hcl] ...... 85 SF 5000 PLUS CREA 1.1 % [sodium fluoride SABRIL PACK 500 MG [vigabatrin] ...... 42 (dental)] ...... 72 SALICYLIC ACID POWD [salicylic acid (bulk)] SHINGRIX SUSR 50 MCG/0.5ML [zoster ...... 74 vaccine recombinant adjuvanted] ...... 79 SALSALATE TABS 500 MG [salsalate] ...... 39 sildenafil citrate tabs 100 mg ...... 36 SALSALATE TABS 750 MG [salsalate] ...... 39 sildenafil citrate tabs 20 mg ...... 36 SANDIMMUNE CAPS 100 MG [cyclosporine] SILENOR TABS 3 MG [doxepin hcl (sleep)] .. 46 ...... 69 SILENOR TABS 6 MG [doxepin hcl (sleep)] .. 46 SANDIMMUNE CAPS 25 MG [cyclosporine] 69 SILVER SULFADIAZINE CREA 1 % [silver SANDIMMUNE SOLN 100 MG/ML sulfadiazine] ...... 80 [cyclosporine] ...... 69 simvastatin tabs 10 mg ...... 31 SANDIMMUNE SOLN 50 MG/ML simvastatin tabs 20 mg ...... 31 [cyclosporine] ...... 69 simvastatin tabs 40 mg ...... 31 SANDOSTATIN LAR DEPOT KIT 10 MG simvastatin tabs 5 mg ...... 31 [octreotide acetate] ...... 72 simvastatin tabs 80 mg ...... 31 SANDOSTATIN LAR DEPOT KIT 20 MG sirolimus soln 1 mg/ml ...... 72 [octreotide acetate] ...... 72 sirolimus tabs 0.5 mg ...... 69 SANDOSTATIN LAR DEPOT KIT 30 MG sirolimus tabs 1 mg ...... 69 [octreotide acetate] ...... 72 sirolimus tabs 2 mg ...... 69 SANTYL OINT 250 UNIT/GM [collagenase] .. 83 SKYRIZI (150 MG DOSE) PSKT 75 MG/0.83ML SARCLISA SOLN 100 MG/5ML [isatuximab- [risankizumab-rzaa] ...... 83 irfc] ...... 19 SLO-NIACIN TBCR 500 MG [niacin] ...... 91 SARCLISA SOLN 500 MG/25ML [isatuximab- SLO-NIACIN TBCR 750 MG [niacin] ...... 91 irfc] ...... 19 SM FOAMING ANTACID CHEW 80-20 MG

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 131 of 145 [aluminum hydroxide-mag trisil]...... 89 sodium polystyrene sulfonate susp 15 SM STOMACH RELIEF TABS 262 MG [bismuth gm/60ml ...... 54 subsalicylate] ...... 89 sodium polystyrene sulfonate susp 30 SOD CITRATE-CITRIC ACID SOLN 500-334 gm/120ml ...... 54 MG/5ML [sodium citrate & citric acid] ...... 52 solifenacin succinate tabs 10 mg ...... 83 SODIUM ACETATE SOLN 2 MEQ/ML [sodium solifenacin succinate tabs 5 mg ...... 83 acetate] ...... 52 SOLIRIS SOLN 300 MG/30ML [eculizumab] .. 72 SODIUM BENZOATE POWD [sodium SOLU-CORTEF SOLR 100 MG benzoate] ...... 74 [hydrocortisone sod succinate] ...... 64 SODIUM BICARBONATE SOLN 4.2 % [sodium SOLU-CORTEF SOLR 1000 MG bicarbonate] ...... 52 [hydrocortisone sod succinate] ...... 64 SODIUM BICARBONATE SOLN 7.5 % [sodium SOLU-CORTEF SOLR 250 MG bicarbonate] ...... 52 [hydrocortisone sod succinate] ...... 64 SODIUM BICARBONATE SOLN 8.4 % [sodium SOLU-CORTEF SOLR 500 MG bicarbonate] ...... 52 [hydrocortisone sod succinate] ...... 64 SODIUM CHLORIDE (PF) SOLN 0.9 % [sodium SOLU-MEDROL SOLR 125 MG chloride] ...... 57 [methylprednisolone sod succ]...... 64 SODIUM CHLORIDE BACTERIOSTATIC SOLN SOLU-MEDROL SOLR 500 MG 0.9 % [bacteriostatic sodium chloride] ..... 57 [methylprednisolone sod succ]...... 64 SODIUM CHLORIDE NEBU 0.9 % [sodium SORBITOL SOLN 70 % [sorbitol (laxative)] .. 89 chloride (inhalant)] ...... 75 SORBITOL SOLN 70 % [sorbitol] ...... 74 SODIUM CHLORIDE NEBU 10 % [sodium sotalol hcl (af) tabs 120 mg ...... 32 chloride (inhalant)] ...... 75 sotalol hcl (af) tabs 160 mg ...... 32 SODIUM CHLORIDE NEBU 3 % [sodium sotalol hcl (af) tabs 80 mg ...... 32 chloride (inhalant)] ...... 75 sotalol hcl tabs 120 mg ...... 32 SODIUM CHLORIDE NEBU 7 % [sodium sotalol hcl tabs 160 mg ...... 32 chloride (inhalant)] ...... 75 sotalol hcl tabs 240 mg ...... 32 SODIUM CHLORIDE SOLN 0.45 % [sodium sotalol hcl tabs 80 mg ...... 32 chloride] ...... 57 SOVALDI PACK 150 MG [sofosbuvir]...... 11 SODIUM CHLORIDE SOLN 0.9 % [sodium SOVALDI PACK 200 MG [sofosbuvir]...... 11 chloride (gu irrigant)] ...... 54 SOVALDI TABS 200 MG [sofosbuvir] ...... 11 SODIUM CHLORIDE SOLN 0.9 % [sodium SOVALDI TABS 400 MG [sofosbuvir] ...... 11 chloride] ...... 57 SPIRIVA RESPIMAT AERS 2.5 MCG/ACT SODIUM CHLORIDE SOLN 3 % [sodium [tiotropium bromide monohydrate] ...... 22 chloride] ...... 57 spironolactone tabs 100 mg ...... 34 SODIUM CHLORIDE SOLN 4 MEQ/ML [sodium spironolactone tabs 25 mg ...... 34 chloride] ...... 57 spironolactone tabs 50 mg ...... 34 SODIUM CHLORIDE SOLN 5 % [sodium spironolactone-hctz tabs 25-25 mg ...... 34 chloride] ...... 57 SPORANOX SOLN 10 MG/ML [itraconazole] 11 SODIUM CHLORIDE TABS 1 GM [sodium SPRYCEL TABS 100 MG [dasatinib] ...... 19 chloride] ...... 91 SPRYCEL TABS 140 MG [dasatinib] ...... 19 SODIUM EDECRIN SOLR 50 MG [ethacrynate SPRYCEL TABS 20 MG [dasatinib] ...... 19 sodium] ...... 54 SPRYCEL TABS 50 MG [dasatinib] ...... 19 SODIUM FLUORIDE CHEW 1.1 (0.5 F) MG SPRYCEL TABS 70 MG [dasatinib] ...... 19 [sodium fluoride] ...... 72 SPRYCEL TABS 80 MG [dasatinib] ...... 19 SODIUM FLUORIDE SOLN 1.1 (0.5 F) MG/ML SQUARIC ACID DIBUTYLESTER POW [sodium fluoride] ...... 72 DIBUTYLS [squaric acid dibutylester] ...... 74 sodium phenylbutyrate powd 3 gm/tsp ...... 52 SSKI SOLN 1 GM/ML [potassium iodide SODIUM PHOSPHATES SOLN 45 (expectorant)] ...... 68 MMOLE/15ML [sodium phosphates (sodium stavudine caps 15 mg ...... 5 phosphate dibasic & monobasic)] ...... 57 stavudine caps 20 mg ...... 5 sodium polystyrene sulfonate powd ...... 54 stavudine caps 30 mg ...... 5

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 132 of 145 stavudine caps 40 mg ...... 5 sulfasalazine tabs 500 mg ...... 10 STELARA SOLN 45 MG/0.5ML [ustekinumab] sulfasalazine tbec 500 mg ...... 10 ...... 83 SULFUR PRECIPITATED POWD [sulfur STELARA SOSY 45 MG/0.5ML [ustekinumab] (bulk)] ...... 89 ...... 83 sulindac tabs 150 mg ...... 39 STELARA SOSY 90 MG/ML [ustekinumab] .. 83 sulindac tabs 200 mg ...... 39 sterile water for injection soln ...... 72 sumatriptan soln 20 mg/act ...... 43 STERILE WATER FOR INJECTION SOLN sumatriptan succinate refill soct 6 mg/0.5ml [water for injection, sterile] ...... 74 ...... 43 STERILE WATER FOR IRRIGATION SOLN sumatriptan succinate soaj 6 mg/0.5ml ...... 43 [water for irrigation, sterile] ...... 55 sumatriptan succinate soln 6 mg/0.5ml ...... 43 STIMATE SOLN 1.5 MG/ML [desmopressin sumatriptan succinate sosy 6 mg/0.5ml ...... 43 acetate] ...... 67 sumatriptan succinate tabs 100 mg ...... 43 STIOLTO RESPIMAT AERS 2.5-2.5 MCG/ACT sumatriptan succinate tabs 25 mg ...... 43 [tiotropium bromide-olodaterol hcl] ...... 22 sumatriptan succinate tabs 50 mg ...... 43 STIVARGA TABS 40 MG [regorafenib] ...... 19 SURE COMFORT INSULIN SYRINGE MISC STRENSIQ SOLN 18 MG/0.45ML [asfotase 28G X 1/2 ...... 87 alfa] ...... 57 SURE COMFORT INSULIN SYRINGE MISC STRENSIQ SOLN 28 MG/0.7ML [asfotase alfa] 29G X 1/2 ...... 87 ...... 57 SURE COMFORT INSULIN SYRINGE MISC STRENSIQ SOLN 40 MG/ML [asfotase alfa] . 57 30G X 1/2 ...... 87 STRENSIQ SOLN 80 MG/0.8ML [asfotase alfa] SURE COMFORT INSULIN SYRINGE MISC ...... 57 30G X 5/16 ...... 88 streptomycin sulfate solr 1 gm ...... 10 SURE COMFORT INSULIN SYRINGE MISC STRIBILD TABS 150-150-200-300 MG 31G X 5/16 ...... 88 [elvitegravir-cobicistat-emtricitabine- SURVANTA SUSP 25-0.9 MG/ML-% [beractant tenofovir df] ...... 5 in nacl] ...... 75 STRIVERDI RESPIMAT AERS 2.5 MCG/ACT SUTENT CAPS 12.5 MG [sunitinib malate] ... 19 [olodaterol hcl] ...... 24 SUTENT CAPS 25 MG [sunitinib malate] ...... 19 sucralfate tabs 1 gm ...... 61 SUTENT CAPS 37.5 MG [sunitinib malate] ... 19 sufentanil citrate soln 50 mcg/ml ...... 39 SUTENT CAPS 50 MG [sunitinib malate] ...... 19 sulfacetamide sodium soln 10 % ...... 58 SYLVANT SOLR 100 MG [siltuximab] ...... 20 SULFACETAMIDE SODIUM-SULFUR EMUL 10- SYLVANT SOLR 400 MG [siltuximab] ...... 20 5 % [sulfacetamide sodium w/ sulfur] ...... 82 SYMBICORT AERO 160-4.5 MCG/ACT SULFACETAMIDE SODIUM-SULFUR LOTN 10- [budesonide-formoterol fumarate 5 % [sulfacetamide sodium w/ sulfur] ...... 82 dihydrate] ...... 64 SULFACETAMIDE SODIUM-SULFUR SUSP 10- SYMBICORT AERO 80-4.5 MCG/ACT 5 % [sulfacetamide sodium w/ sulfur] ...... 82 [budesonide-formoterol fumarate SULFACETAMIDE SODIUM-SULFUR SUSP 8-4 dihydrate] ...... 64 % [sulfacetamide sodium w/ sulfur] ...... 82 SYMDEKO TBPK 100-150 & 150 MG sulfacetamide-prednisolone soln 10-0.23 % 59 [tezacaftor-ivacaftor] ...... 76 sulfadiazine tabs 500 mg ...... 10 SYMDEKO TBPK 50-75 & 75 MG [tezacaftor- sulfamethoxazole-trimethoprim soln 400-80 ivacaftor] ...... 76 mg/5ml ...... 10 SYMFI LO TABS 400-300-300 MG [efavirenz- sulfamethoxazole-trimethoprim susp 200-40 lamivudine-tenofovir disoproxil fumarate] . 5 mg/5ml ...... 10 SYMFI TABS 600-300-300 MG [efavirenz- sulfamethoxazole-trimethoprim tabs 400-80 lamivudine-tenofovir disoproxil fumarate] . 5 mg ...... 10 SYMLINPEN 120 SOPN 2700 MCG/2.7ML sulfamethoxazole-trimethoprim tabs 800-160 [pramlintide acetate] ...... 65 mg ...... 10 SYMTUZA TABS 800-150-200-10 MG SULFAMYLON CREA 85 MG/GM [mafenide [darunavir-cobicistat-emtricitabine- acetate] ...... 80 tenofovir alafenamide] ...... 5

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 133 of 145 SYNAGIS SOLN 100 MG/ML [palivizumab] ... 13 [atezolizumab] ...... 20 SYNAGIS SOLN 50 MG/0.5ML [palivizumab] 13 temazepam caps 15 mg ...... 46 SYNAREL SOLN 2 MG/ML [nafarelin acetate] temazepam caps 30 mg ...... 46 ...... 67 temozolomide caps 100 mg ...... 20 SYNERCID SOLR 150-350 MG [quinupristin- temozolomide caps 140 mg ...... 20 dalfopristin] ...... 10 temozolomide caps 180 mg ...... 20 TABLOID TABS 40 MG [thioguanine] ...... 20 temozolomide caps 20 mg ...... 20 tacrolimus caps 0.5 mg ...... 69 temozolomide caps 250 mg ...... 20 tacrolimus caps 1 mg ...... 69 temozolomide caps 5 mg ...... 20 tacrolimus caps 5 mg ...... 69 TENIPOSIDE SOLN 10 MG/ML [teniposide] .. 20 TACROLIMUS OINT 0.03 % [tacrolimus tenofovir disoproxil fumarate tabs 300 mg .. 14 (topical)] ...... 83 terazosin hcl caps 1 mg ...... 30 TACROLIMUS OINT 0.1 % [tacrolimus terazosin hcl caps 10 mg ...... 30 (topical)] ...... 83 terazosin hcl caps 2 mg ...... 30 tadalafil (pah) tabs 20 mg ...... 36 terazosin hcl caps 5 mg ...... 30 tadalafil tabs 10 mg ...... 36 terbinafine hcl tabs 250 mg ...... 11 tadalafil tabs 2.5 mg ...... 36 terbutaline sulfate inj 1mg/ml...... 24 tadalafil tabs 20 mg ...... 36 terbutaline sulfate soln 1 mg/ml ...... 24 tadalafil tabs 5 mg ...... 36 terbutaline sulfate tabs 2.5 mg ...... 24 TAFINLAR CAPS 50 MG [dabrafenib mesylate] terbutaline sulfate tabs 5 mg...... 24 ...... 20 testosterone cypionate soln 200 mg/ml ...... 64 TAFINLAR CAPS 75 MG [dabrafenib mesylate] testosterone enanthate soln 200 mg/ml ...... 64 ...... 20 testosterone gel 12.5 mg/act (1%) ...... 64 TAGRISSO TABS 40 MG [osimertinib testosterone gel 20.25 mg/act (1.62%)...... 64 mesylate] ...... 20 testosterone gel 25 mg/2.5gm (1%) ...... 64 TAGRISSO TABS 80 MG [osimertinib testosterone gel 50 mg/5gm (1%) ...... 64 mesylate] ...... 20 TESTOSTERONE PROPIONATE POWD TAKHZYRO SOLN 300 MG/2ML [lanadelumab- [testosterone propionate (bulk)] ...... 74 flyo] ...... 72 TETRACAINE HCL SOLN 0.5 % [tetracaine hcl TAMIFLU CAPS 30 MG [oseltamivir (ophth)] ...... 60 phosphate] ...... 14 TETRACAINE HCL SOLN 1 % [tetracaine hcl] TAMIFLU CAPS 45 MG [oseltamivir ...... 70 phosphate] ...... 14 TETRACYCLINE HCL CAPS 250 MG TAMIFLU CAPS 75 MG [oseltamivir [tetracycline hcl] ...... 10 phosphate] ...... 14 TETRACYCLINE HCL CAPS 500 MG TAMIFLU SUSR 6 MG/ML [oseltamivir [tetracycline hcl] ...... 10 phosphate] ...... 14 TETRAVISC SOLN 0.5 % [tetracaine hcl tamoxifen citrate tabs 10 mg ...... 20 (ophth)] ...... 60 tamoxifen citrate tabs 20 mg ...... 20 THALOMID CAPS 100 MG [thalidomide] ...... 73 tamsulosin hcl caps 0.4 mg ...... 30 THALOMID CAPS 150 MG [thalidomide] ...... 73 TARGRETIN CAPS 75 MG [bexarotene] ...... 20 THALOMID CAPS 200 MG [thalidomide] ...... 73 TARGRETIN GEL 1 % [bexarotene (topical)] 83 THALOMID CAPS 50 MG [thalidomide] ...... 73 TASIGNA CAPS 150 MG [nilotinib hcl] ...... 20 THAM SOLN 30 MEQ/100ML [tromethamine]52 TASIGNA CAPS 200 MG [nilotinib hcl] ...... 20 theophylline er tb12 100 mg ...... 83 TAXOTERE INJ 80MG/2ML [docetaxel] ...... 20 theophylline er tb12 200 mg ...... 83 tazarotene crea 0.1 % ...... 83 theophylline er tb12 300 mg ...... 83 TAZORAC CREA 0.05 % [tazarotene] ...... 83 theophylline er tb12 450 mg ...... 83 TAZORAC GEL 0.05 % [tazarotene] ...... 83 theophylline er tb24 400 mg ...... 83 TAZORAC GEL 0.1 % [tazarotene] ...... 83 THEOPHYLLINE IN D5W SOLN 0.8-5 MG/ML-% TDVAX SUSP 2-2 LF/0.5ML [tetanus- [theophylline in dextrose] ...... 83 diphtheria toxoids (td)] ...... 78 thiamine hcl soln 100 mg/ml ...... 84 TECENTRIQ SOLN 1200 MG/20ML THIOLA TABS 100 MG [tiopronin] ...... 73

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 134 of 145 thioridazine hcl tabs 10 mg ...... 49 torsemide tabs 10 mg ...... 54 thioridazine hcl tabs 100 mg ...... 49 torsemide tabs 100 mg ...... 54 thioridazine hcl tabs 25 mg ...... 49 torsemide tabs 20 mg ...... 54 thioridazine hcl tabs 50 mg ...... 50 torsemide tabs 5 mg ...... 54 thiotepa solr 15 mg ...... 20 TRACE ELEMENTS 4/PEDIATRIC SOLN 1-100- thiothixene caps 1 mg ...... 50 30-500 MCG/ML [trace minerals (cr-cu-mn- thiothixene caps 10 mg ...... 50 zn)] ...... 57 thiothixene caps 2 mg ...... 50 TRACLEER TABS 125 MG [bosentan] ...... 36 thiothixene caps 5 mg ...... 50 TRACLEER TABS 62.5 MG [bosentan] ...... 36 THROMBATE III SOLR 500 UNIT [antithrombin TRACLEER TBSO 32 MG [bosentan] ...... 76 iii (human)] ...... 29 TRADJENTA TABS 5 MG [linagliptin] ...... 65 THROMBIN-JMI KIT 20000 UNIT [thrombin] . 28 tramadol hcl tabs 50 mg ...... 39 THROMBIN-JMI SOLR 20000 UNIT [thrombin] tramadol-acetaminophen tabs 37.5-325 mg . 39 ...... 28 TRANEXAMIC ACID POWD [tranexamic acid THROMBIN-JMI SOLR 5000 UNIT [thrombin]28 (bulk)] ...... 75 THYMOL CRYS [thymol] ...... 89 tranexamic acid soln 1000 mg/10ml ...... 28 THYROGEN SOLR 1.1 MG [thyrotropin alfa] 52 tranexamic acid tabs 650 mg ...... 28 TICE BCG SUSR 50 MG [bcg live intravesical] TRANSDERM-SCOP (1.5 MG) PT72 1 ...... 79 MG/3DAYS [scopolamine] ...... 61 timolol maleate soln 0.25 % ...... 59 tranylcypromine sulfate tabs 10 mg ...... 50 timolol maleate soln 0.5 % ...... 59 TRAVASOL SOLN 10 % [amino acid infusion] TISSUEBLUE SOSY 0.025 % [brilliant blue g] ...... 53 ...... 52 TRAVEL SICKNESS CHEW 25 MG [meclizine TIVICAY PD TBSO 5 MG [dolutegravir hcl] ...... 89 sodium] ...... 14 trazodone hcl tabs 100 mg ...... 50 TIVICAY TABS 10 MG [dolutegravir sodium] 14 trazodone hcl tabs 150 mg ...... 50 TIVICAY TABS 25 MG [dolutegravir sodium] 14 trazodone hcl tabs 50 mg ...... 50 TIVICAY TABS 50 MG [dolutegravir sodium] . 5 TREANDA SOLR 100 MG [bendamustine hcl] tizanidine hcl tabs 2 mg ...... 23 ...... 20 tizanidine hcl tabs 4 mg ...... 23 TRECATOR TABS 250 MG [ethionamide] ..... 12 TNKASE KIT 50 MG [tenecteplase] ...... 29 TREMFYA SOPN 100 MG/ML [guselkumab] . 83 TOBI PODHALER CAPS 28 MG [tobramycin] TREMFYA SOSY 100 MG/ML [guselkumab] . 83 ...... 10 treprostinil soln 100 mg/20ml...... 36 TOBRADEX OINT 0.3-0.1 % [tobramycin- treprostinil soln 20 mg/20ml...... 36 dexamethasone] ...... 59 treprostinil soln 200 mg/20ml...... 36 tobramycin nebu 300 mg/5ml ...... 10 treprostinil soln 50 mg/20ml...... 36 tobramycin soln 0.3 % ...... 58 tretinoin caps 10 mg ...... 20 tobramycin sulfate soln 10 mg/ml ...... 10 triamcinolone acetonide crea 0.025 %...... 81 tobramycin sulfate soln 80 mg/2ml ...... 10 triamcinolone acetonide crea 0.1 % ...... 81 tobramycin sulfate solr 1.2 gm ...... 10 triamcinolone acetonide crea 0.5 % ...... 81 TOBREX OINT 0.3 % [tobramycin (ophth)] .. 58 triamcinolone acetonide lotn 0.1 % ...... 81 tolbutamide tabs 500 mg ...... 65 triamcinolone acetonide oint 0.025 % ...... 81 TOLNAFTATE CREA 1 % [tolnaftate] ...... 90 triamcinolone acetonide oint 0.1 % ...... 81 TOLNAFTATE SOLN 1 % [tolnaftate] ...... 90 triamcinolone acetonide oint 0.5 % ...... 81 topiramate cpsp 15 mg ...... 42 TRIAMCINOLONE ACETONIDE POWD topiramate cpsp 25 mg ...... 42 [triamcinolone acetonide (topical)] ...... 75 topiramate tabs 100 mg ...... 42 triamcinolone acetonide pste 0.1 % ...... 81 topiramate tabs 200 mg ...... 42 triamterene-hctz caps 37.5-25 mg ...... 54 topiramate tabs 25 mg ...... 42 TRIAMTERENE-HCTZ TABS 37.5-25 MG topiramate tabs 50 mg ...... 42 [triamterene & hydrochlorothiazide] ...... 54 topotecan hcl solr 4 mg ...... 20 TRIAMTERENE-HCTZ TABS 75-50 MG TORISEL SOLN 25 MG/ML [temsirolimus] ... 20 [triamterene & hydrochlorothiazide] ...... 54

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 135 of 145 TRI-BUFFERED ASPIRIN TABS 325 MG TYPHIM VI SOLN 25 MCG/0.5ML [typhoid vi [aspirin buffered (cal carb-mag carb-mag polysaccharide vaccine] ...... 79 oxide)] ...... 86 TYSABRI CONC 300 MG/15ML [natalizumab] TRI-CHLOR LIQD 80 % [trichloroacetic acid] ...... 73 ...... 73 TYVASO SOLN 0.6 MG/ML [treprostinil] ...... 36 TRICITRATES SOLN 550-500-334 MG/5ML [pot ULTIVA SOLR 1 MG [remifentanil hcl] ...... 39 & sod citrates w/citric ac] ...... 52 ULTIVA SOLR 2 MG [remifentanil hcl] ...... 39 trifluoperazine hcl tabs 1 mg ...... 50 ULTIVA SOLR 5 MG [remifentanil hcl] ...... 39 trifluoperazine hcl tabs 10 mg ...... 50 ULTOMIRIS SOLN 1100 MG/11ML trifluoperazine hcl tabs 2 mg ...... 50 [ravulizumab-cwvz] ...... 73 trifluoperazine hcl tabs 5 mg ...... 50 ULTOMIRIS SOLN 300 MG/30ML trifluridine soln 1 % ...... 58 [ravulizumab-cwvz] ...... 73 trihexyphenidyl hcl soln 0.4 mg/ml ...... 44 ULTOMIRIS SOLN 300 MG/3ML [ravulizumab- trihexyphenidyl hcl tabs 2 mg ...... 44 cwvz] ...... 73 trihexyphenidyl hcl tabs 5 mg ...... 44 ULTRA THIN LANCETS 30G MISC [lancets] 88 TRIKAFTA TBPK 100-50-75 & 150 MG ULTRABAG/DIANEAL/1.5% DEXTROSE SOLN [elexacaftor-tezacaftor-ivacaftor]...... 76 344 MOSM/L [peritoneal dialysis solutions] TRIKAFTA TBPK 50-25-37.5 & 75 MG ...... 55 [elexacaftor-tezacaftor-ivacaftor]...... 76 ULTRABAG/DIANEAL/2.5% DEXTROSE SOLN trimethoprim tabs 100 mg ...... 14 395 MOSM/L [peritoneal dialysis solutions] trimipramine maleate caps 100 mg ...... 50 ...... 55 trimipramine maleate caps 25 mg ...... 50 ULTRA-COMFORT INSULIN SYRINGE MISC trimipramine maleate caps 50 mg ...... 50 31G X 5/16 ...... 88 TRISENOX SOLN 12 MG/6ML [arsenic UNITUXIN SOLN 17.5 MG/5ML [dinutuximab] trioxide] ...... 20 ...... 20 TRIUMEQ TABS 600-50-300 MG [abacavir- UREA POWD [urea (bulk)] ...... 89 dolutegravir-lamivudine] ...... 5 URSO FORTE TABS 500 MG [ursodiol] ...... 61 TRI-VI-SOL A/C/D SOLN 250-50-10 [pediatric ursodiol tabs 250 mg ...... 61 vitamins adc] ...... 91 VAGIFEM TABS 10 MCG [estradiol vaginal] . 67 TRI-VIT/FLUORIDE SOLN 0.5 MG/ML valacyclovir hcl tabs 1 gm ...... 14 [pediatric vitamins acd w/ fluoride] ...... 84 valacyclovir hcl tabs 500 mg ...... 14 TRIZIVIR TABS 300-150-300 MG [abacavir VALCYTE SOLR 50 MG/ML [valganciclovir sulfate-lamivudine-zidovudine]...... 14 hcl] ...... 14 TROPHAMINE SOLN 10 % [amino acid valganciclovir hcl tabs 450 mg ...... 14 infusion] ...... 53 valproate sodium soln 500 mg/5ml ...... 42 TROPHAMINE SOLN 6 % [amino acid valproic acid caps 250 mg ...... 42 infusion] ...... 53 valproic acid soln 250 mg/5ml ...... 42 tropicamide soln 0.5 % ...... 60 valsartan tabs 160 mg ...... 34 tropicamide soln 1 % ...... 60 valsartan tabs 320 mg ...... 34 trospium chloride er cp24 60 mg ...... 83 valsartan tabs 40 mg ...... 34 trospium chloride tabs 20 mg ...... 83 valsartan tabs 80 mg ...... 34 TRUZONE PEAK FLOW METER DEVI [peak valsartan-hydrochlorothiazide tabs 160-12.5 flow meter] ...... 51 mg ...... 35 TUBERSOL SOLN 5 UNIT/0.1ML [tuberculin valsartan-hydrochlorothiazide tabs 160-25 mg ppd] ...... 52 ...... 35 TUKYSA TABS 150 MG [tucatinib] ...... 20 valsartan-hydrochlorothiazide tabs 320-12.5 TUKYSA TABS 50 MG [tucatinib] ...... 20 mg ...... 35 TWINRIX SUSY 720-20 ELU-MCG/ML valsartan-hydrochlorothiazide tabs 320-25 mg [hepatitis a (inactivated)-hepatitis b ...... 35 (recombinant) vaccines] ...... 79 valsartan-hydrochlorothiazide tabs 80-12.5 TYKERB TABS 250 MG [lapatinib ditosylate] mg ...... 35 ...... 20 vancomycin hcl caps 125 mg ...... 10

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 136 of 145 vancomycin hcl caps 250 mg ...... 10 verapamil hcl tabs 80 mg ...... 33 VANCOMYCIN HCL IN DEXTROSE SOLN 1-5 VFEND IV SOLR 200 MG [voriconazole] ...... 11 GM/200ML-% [vancomycin hcl-dextrose] . 10 VICTOZA SOPN 18 MG/3ML [liraglutide] ...... 65 VANCOMYCIN HCL IN DEXTROSE SOLN 500- VIDEX SOLR 2 GM [didanosine] ...... 5 5 MG/100ML-% [vancomycin hcl-dextrose] VIDEX SOLR 4 GM [didanosine] ...... 5 ...... 10 VIMIZIM SOLN 5 MG/5ML [elosulfase alfa] ... 58 vancomycin hcl solr 1 gm ...... 10 vinblastine sulfate soln 1 mg/ml ...... 20 vancomycin hcl solr 10 gm ...... 10 vincristine sulfate soln 1 mg/ml ...... 20 vancomycin hcl solr 5 gm ...... 10 vinorelbine tartrate soln 10 mg/ml ...... 20 vancomycin hcl solr 500 mg ...... 10 vinorelbine tartrate soln 50 mg/5ml ...... 20 VAQTA SUSP 25 UNIT/0.5ML [hepatitis a VIRACEPT TABS 250 MG [nelfinavir mesylate] vaccine] ...... 79 ...... 5 VAQTA SUSP 50 UNIT/ML [hepatitis a VIRACEPT TABS 625 MG [nelfinavir mesylate] vaccine] ...... 79 ...... 5 VARITHENA FOAM 180 MG/18ML [polidocanol VIRAMUNE SUSP 50 MG/5ML [nevirapine] ..... 5 (laureth-9)] ...... 35 VIRAZOLE SOLR 6 GM [ribavirin] ...... 14 VARIVAX INJ 1350 PFU/0.5ML [varicella virus VIRTUSSIN DAC SOLN 30-10-100 MG/5ML vaccine live] ...... 79 [pseudoephedrine w/ codeine-gg] ...... 90 VAXCHORA SUSR [cholera vaccine live VISUDYNE SOLR 15 MG [verteporfin] ...... 60 attenuated] ...... 79 VITAMIN B-6 TABS 100 MG [pyridoxine hcl] 91 VECTICAL OINT 3 MCG/GM [calcitriol VITAMIN B-6 TABS 50 MG [pyridoxine hcl] .. 91 (topical)] ...... 83 vitamin d (ergocalciferol) caps 1.25 mg vecuronium bromide solr 10 mg ...... 23 (50000 ut) ...... 84 vecuronium bromide solr 20 mg ...... 23 vitamin k1 soln 1 mg/0.5ml ...... 84 VEKLURY SOLN 100 MG/20ML [remdesivir] 14 vitamin k1 soln 10 mg/ml ...... 84 VEKLURY SOLR 100 MG [remdesivir] ...... 14 VITAMINS ACD-FLUORIDE SOLN 0.25 MG/ML VELCADE SOLR 3.5 MG [bortezomib] ...... 20 [pediatric vitamins acd w/ fluoride] ...... 84 VENCLEXTA STARTING PACK TBPK 10 & 50 VIVOTIF CPDR [typhoid vaccine] ...... 79 & 100 MG [venetoclax] ...... 20 VOLUMEN SUSP 0.1 % [barium sulfate] ...... 52 VENCLEXTA TABS 10 MG [venetoclax] ...... 20 VORAXAZE SOLR 1000 UNIT [glucarpidase]58 VENCLEXTA TABS 100 MG [venetoclax] ...... 20 voriconazole solr 200 mg ...... 14 VENCLEXTA TABS 50 MG [venetoclax] ...... 20 voriconazole tabs 200 mg ...... 11 venlafaxine hcl er cp24 150 mg ...... 50 voriconazole tabs 50 mg ...... 11 venlafaxine hcl er cp24 37.5 mg ...... 50 VOSEVI TABS 400-100-100 MG [sofosbuvir- venlafaxine hcl er cp24 75 mg ...... 50 velpatasvir-voxilaprevir] ...... 14 venlafaxine hcl tabs 100 mg ...... 50 VOTRIENT TABS 200 MG [pazopanib hcl] .... 20 venlafaxine hcl tabs 25 mg ...... 50 VPRIV SOLR 400 UNIT [velaglucerase alfa] . 58 venlafaxine hcl tabs 37.5 mg ...... 50 VYVANSE CAPS 10 MG [lisdexamfetamine venlafaxine hcl tabs 50 mg ...... 50 dimesylate] ...... 40 venlafaxine hcl tabs 75 mg ...... 50 VYVANSE CAPS 20 MG [lisdexamfetamine VENOFER SOLN 20 MG/ML [iron sucrose] .. 25 dimesylate] ...... 40 VENTAVIS SOLN 10 MCG/ML [iloprost] ...... 36 VYVANSE CAPS 30 MG [lisdexamfetamine VENTAVIS SOLN 20 MCG/ML [iloprost] ...... 36 dimesylate] ...... 40 VENTOLIN HFA AERS 108 (90 Base) MCG/ACT VYVANSE CAPS 40 MG [lisdexamfetamine [albuterol sulfate] ...... 24 dimesylate] ...... 40 verapamil hcl er tbcr 120 mg ...... 33 VYVANSE CAPS 50 MG [lisdexamfetamine verapamil hcl er tbcr 180 mg ...... 33 dimesylate] ...... 40 verapamil hcl er tbcr 240 mg ...... 33 VYVANSE CAPS 60 MG [lisdexamfetamine VERAPAMIL HCL POWD [verapamil hcl] ..... 75 dimesylate] ...... 40 verapamil hcl soln 2.5 mg/ml ...... 33 VYVANSE CAPS 70 MG [lisdexamfetamine verapamil hcl tabs 120 mg ...... 33 dimesylate] ...... 41 verapamil hcl tabs 40 mg ...... 33 VYXEOS SUSR 44-100 MG [daunorubicin-

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 137 of 145 cytarabine liposome] ...... 20 XYNTHA KIT 2000 UNIT [antihemophilic factor warfarin sodium tabs 1 mg ...... 29 (rcmb) moroctocog alfa(bdd-rfviii,mor)] ... 28 warfarin sodium tabs 10 mg ...... 29 XYNTHA KIT 250 UNIT [antihemophilic factor warfarin sodium tabs 2 mg ...... 29 (rcmb) moroctocog alfa(bdd-rfviii,mor)] ... 28 warfarin sodium tabs 2.5 mg ...... 30 XYNTHA KIT 500 UNIT [antihemophilic factor warfarin sodium tabs 3 mg ...... 30 (rcmb) moroctocog alfa(bdd-rfviii,mor)] ... 28 warfarin sodium tabs 4 mg ...... 30 XYNTHA SOLOFUSE KIT 3000 UNIT warfarin sodium tabs 5 mg ...... 30 [antihemophilic factor (rcmb) moroctocog warfarin sodium tabs 6 mg ...... 30 alfa(bdd-rfviii,mor)] ...... 28 warfarin sodium tabs 7.5 mg ...... 30 YERVOY SOLN 200 MG/40ML [ipilimumab] .. 20 WIDE-SEAL DIAPHRAGM 60 DPRH 2 % YERVOY SOLN 50 MG/10ML [ipilimumab] .... 21 [diaphragm wide seal] ...... 50 YF-VAX INJ [yellow fever vaccine] ...... 79 WIDE-SEAL DIAPHRAGM 65 DPRH 2 % YONDELIS SOLR 1 MG [trabectedin] ...... 21 [diaphragm wide seal] ...... 50 ZANOSAR SOLR 1 GM [streptozocin] ...... 21 WIDE-SEAL DIAPHRAGM 70 DPRH 2 % ZARXIO SOSY 300 MCG/0.5ML [filgrastim- [diaphragm wide seal] ...... 50 sndz] ...... 30 WIDE-SEAL DIAPHRAGM 75 DPRH 2 % ZARXIO SOSY 480 MCG/0.8ML [filgrastim- [diaphragm wide seal] ...... 50 sndz] ...... 30 WIDE-SEAL DIAPHRAGM 80 DPRH 2 % ZEJULA CAPS 100 MG [niraparib tosylate] .. 21 [diaphragm wide seal] ...... 50 ZELBORAF TABS 240 MG [vemurafenib] ...... 21 WIDE-SEAL DIAPHRAGM 85 DPRH 2 % ZENPEP CPEP 10000-32000 UNIT [diaphragm wide seal] ...... 50 [pancrelipase (lipase-protease-amylase)] 61 WIDE-SEAL DIAPHRAGM 90 DPRH 2 % ZENPEP CPEP 15000-47000 UNIT [diaphragm wide seal] ...... 50 [pancrelipase (lipase-protease-amylase)] 62 WIDE-SEAL DIAPHRAGM 95 DPRH 2 % ZENPEP CPEP 20000-63000 UNIT [diaphragm wide seal] ...... 50 [pancrelipase (lipase-protease-amylase)] 62 WILATE KIT 1000-1000 UNIT [antihemophilic ZENPEP CPEP 25000-79000 UNIT factor/von willebrand factor complex [pancrelipase (lipase-protease-amylase)] 62 (human)] ...... 28 ZENPEP CPEP 3000-10000 UNIT WILATE KIT 500-500 UNIT [antihemophilic [pancrelipase (lipase-protease-amylase)] 62 factor/von willebrand factor complex ZENPEP CPEP 40000-126000 UNIT (human)] ...... 28 [pancrelipase (lipase-protease-amylase)] 62 XALKORI CAPS 200 MG [crizotinib] ...... 20 ZENPEP CPEP 5000-24000 UNIT XALKORI CAPS 250 MG [crizotinib] ...... 20 [pancrelipase (lipase-protease-amylase)] 62 XELJANZ TABS 10 MG [tofacitinib citrate] ... 73 ZIAGEN SOLN 20 MG/ML [abacavir sulfate] ... 5 XELJANZ TABS 5 MG [tofacitinib citrate] ..... 73 zidovudine caps 100 mg ...... 5 XELJANZ XR TB24 11 MG [tofacitinib citrate] zidovudine syrp 50 mg/5ml ...... 5 ...... 73 zidovudine tabs 300 mg ...... 5 XERAC AC SOLN 6.25 % [aluminum chloride ZINC CHLORIDE SOLN 1 MG/ML [zinc in alcohol] ...... 90 chloride] ...... 57 XGEVA SOLN 120 MG/1.7ML [denosumab] .. 20 ZINC SULFATE GRAN [zinc sulfate]...... 75 XIFAXAN TABS 550 MG [rifaximin] ...... 10 ZINC SULFATE HEPTAHYDRATE POWD [zinc XOLAIR SOLR 150 MG [omalizumab] ...... 76 sulfate] ...... 89 XOLAIR SOSY 150 MG/ML [omalizumab] ..... 76 ZINC SULFATE MONOHYDRATE POWD [zinc XOLAIR SOSY 75 MG/0.5ML [omalizumab] .. 76 sulfate] ...... 90 XTANDI CAPS 40 MG [enzalutamide] ...... 20 ZINC SULFATE SOLN 1 MG/ML [zinc sulfate] XTANDI TABS 40 MG [enzalutamide]...... 20 ...... 57 XTANDI TABS 80 MG [enzalutamide]...... 20 ZINECARD SOLR 250 MG [dexrazoxane hcl]73 XYLOCAINE-MPF/EPINEPHRINE SOLN 1 %-1 ZINECARD SOLR 500 MG [dexrazoxane hcl]73 200000 [lidocaine w/ epinephrine] ...... 70 ziprasidone hcl caps 20 mg ...... 50 XYNTHA KIT 1000 UNIT [antihemophilic factor ziprasidone hcl caps 40 mg ...... 50 (rcmb) moroctocog alfa(bdd-rfviii,mor)] .. 28 ziprasidone hcl caps 60 mg ...... 50

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 138 of 145 ziprasidone hcl caps 80 mg ...... 50 ZOSYN SOLN 3-0.375 GM/50ML [piperacillin ZITHROMAX PACK 1 GM [azithromycin] ...... 10 sodium-tazobactam sodium in dextrose] . 10 zoledronic acid conc 4 mg/5ml ...... 73 ZYDELIG TABS 100 MG [idelalisib] ...... 21 zoledronic acid soln 5 mg/100ml ...... 73 ZYDELIG TABS 150 MG [idelalisib] ...... 21 zolpidem tartrate tabs 5 mg ...... 46 ZYKADIA CAPS 150 MG [ceritinib] ...... 21 zonisamide caps 100 mg ...... 42 ZYKADIA TABS 150 MG [ceritinib] ...... 21 zonisamide caps 25 mg ...... 42 ZYMAXID SOLN 0.5 % [gatifloxacin (ophth)] 58 zonisamide caps 50 mg ...... 42 ZYTIGA TABS 500 MG [abiraterone acetate] 21 ZOSYN SOLN 2-0.25 GM/50ML [piperacillin ZYVOX SUSR 100 MG/5ML [linezolid] ...... 10 sodium-tazobactam sodium in dextrose]. 10 ZYVOX TABS 600 MG [linezolid] ...... 10

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 139 of 145 NOTICE OF LANGUAGE ASSISTANCE

English: This is important information from Kaiser Permanente. If you need help understanding this information, please call 1-800-464-4000 and ask for language assistance. Help is available 24 hours a day, 7 days a week, excluding holidays.

Arabic : ﺗﺣﺗوي ھذه اﻟوﺛﯾﻘﺔ ﻋﻠﻰ ﻣﻌﻠوﻣﺎت ﻣﮭﻣﺔ ﻣن Kaiser Permanente. إذا ﻛﻧت ﺑﺣﺎﺟﺔ ﻟﻠﻣﺳﺎﻋدة ﻓﻲ ﻓﮭم ھذه اﻟﻣﻌﻠوﻣﺎت، ﯾرﺟﻰ اﻻﺗﺻﺎل ﻋﻠﻰ اﻟرﻗم 4000-464-800-1 وطﻠب ﻣﺳﺎﻋدة ﻟﻐوﯾﺔ. اﻟﻣﺳﺎﻋدة ﻣﺗوﻓرة ﻋﻠﻰ ﻣدار اﻟﺳﺎﻋﺔ طﯾﻠﺔ أﯾﺎم اﻷﺳﺑوع، ﺑﺎﺳﺗﺛﻧﺎء أﯾﺎم اﻟﻌطﻼت اﻟرﺳﻣﯾﺔ.

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Chinese: 這是來自 Kaiser Permanente 的重要資訊。如果您需要協助瞭解此資訊，請致電 1-800-757-7585 尋 求語言協助。我們每週 7 天，每天 24 小時皆提供協助（節假日休息）。

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Hmong: Qhov xov xwm no tseem ceeb los ntawm Kaiser Permanente. Yog koj xav tau kev pab kom nkag siab cov xov xwm no, thov hu rau 1-800-464-4000 thiab thov kev pab txhais lus. Muaj kev pab 24 teev ib hnub twg, 7 hnub ib lim tiam twg, tsis xam cov hnub caiv.

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Khmer: េនះគឺ�ព័ត៌�នសំ�ន់ មកពី Kaiser Permanente។ េបើសិនអ�ក䮚ត�វ�រជំនួយ ឲ䮙�នយល់ដងព័ត៌�នេនះឹ សូ ម ទូ រ ស ័ព� េ�េលខ 1-800-464-4000 និងេស�ើសុំជំនួយ�ង��។ ជំនួយគឺ�ន 24 េ �៉ ង មួ យៃថ� 7 ៃថ�មួយ�ទិត䮙 រ ួម�ំងៃថ�បុណ䮙ផង។

Korean: 본 정보는 Kaiser Permanente 에서 전하는 중요한 메시지입니다. 본 정보를 이해하는 데 도움이 필요하시면, 1-800-464-4000 번으로 전화해 언어 지원 서비스를 요청하십시오. 요일 및 시간에 관계없이 언제든지 도움을 제공해 드립니다(공휴일 제외).

Laotian: ີນ້ ແມ່ ນໍຂ້ ມູ ນໍສາຄັ ນຈາກ Kaiser Permanente. ຖ້ າວ່ າ ທ່ ານຕ້ ອງການຄວາມຊ່ ວຍເຫືຼ ອໃນການຊ່ ວຍໃຫ້ ເ ຂ ົ ້ າ ໃຈໍຂ້ ມູ ນີນ້ , ກະຣຸ ນາໂທຣ 1-800-464-4000 ແລະຂໍ ເອົ າການຊ່ ວຍເຫືຼ ອດ້ ານພາສາ. ການຊ່ ວຍເ ຫື ຼ ອ ມີ ໃຫ້ ຕະຫຼ ອດ 24 ຊົ່ ວໂມງ, 7 ວັ ນຕໍ່ ອາທິ ດ,

ໍ່ບລວມວັ ນພັ ກຕ່ າງໆ.

Navajo: Díí éí hane’ bíhólníihii át’éego Kaiser Permanente yee nihalne’. Díí hane’ígíí doo hazhó’ó bik’i’diitįįhgóó t’áá shǫǫdí koji’ hodíílnih 1-800-464-4000 áko saad bee áká i’iilyeed yídííkił. Kwe’é áká aná’álwo’ t’áá áłahjį’ naadiindį́ į́ ’ ahéé’ílkidgóó dóó tsosts’id jį́ ąą’át’é. Dahodílzingóne’ éí dá’deelkaal.

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 140 of 145 Punjabi: ਇਹ Kaiser Permanente ਵਲ� ਜ਼ਰੂਰੀ ਜਾਣਕਾਰੀ ਹੈ। ਜੇ ਤੁਹਾਨੂੰ ਇਸ ਜਾਣਕਾਰੀ ਨੂੰ ਸਮਝਣ ਲਈ ਮਦਦ ਦੀ ਲੋ ੜ ਹੈ, ਤਾਂ ਿਕਰਪਾ ਕਰਕੇ 1-800-464-4000 'ਤੇ ਫ਼ੋਨ ਕਰੋ ਅਤੇ ਭਾਸ਼ਾ ਸਹਾਇਤਾ ਲਈ ਪੁੱਛੋ। ਮਦਦ, ਛੁੱਟੀਆਂ ਨੂੰ ਛੱਡ ਕੇ, ਹਫ਼ਤੇ ਦੇ 7 ਿਦਨ, ਅਤੇ ਿਦਨ ਦੇ 24 ਘੰਟੇ ਮੌਜੂਦ ਹੈ।

Russian: Это важная информация от Kaiser Permanente. Если Вам требуется помощь, чтобы понять эту информацию, позвоните по номеру 1-800-464-4000 и попросите предоставить Вам услуги переводчика. Помощь доступна 24 часа в сутки, 7 дней в неделю, кроме праздничных дней.

Spanish: La presente incluye información importante de Kaiser Permanente. Si necesita ayuda para entender esta información, llame al 1-800-788-0616 y pida ayuda linguística. Hay ayuda disponible 24 horas al día, siete días a la semana, excluidos los días festivos.

Tagalog: Ito ay importanteng impormasyon mula sa Kaiser Permanente. Kung kailangan ninyo ng tulong para maunawan ang impormasyong ito, mangyaring tumawag sa 1-800-464-4000 at humingi ng tulong kaugnay sa lengguwahe. May makukuhang tulong 24 na oras bawat araw, 7 araw bawat linggo, maliban sa mga araw na pista opisyal.

Thai: นี่เป็นข ้อมูลสาคัญจากํ Kaiser Permanente หากคุณต ้องการความชวยเหลือในการทําความเข่ ้าใจข ้อมูลนี้ กรุณาโทร ไปยังหมายเลข 1-800-464-4000 เพื่อขอความชวยเหลือด่ ้านภาษา สามารถโทรติดต่อได ้ตลอด 24 ชวโมงทุกวันั่ ยกเว ้นวันหยุดเทศกาล.

Vietnamese: Đây là thông tin quan trọng từ Kaiser Permanente. Nếu quý vị cần được giúp đỡ để hiểu rõ thông tin này, vui lòng gọi số 1-800-464-4000 và yêu cầu được cấp dịch vụ về ngôn ngữ. Quý vị sẽ được giúp đỡ 24 giờ trong ngày, 7 ngày trong tuần, trừ ngày lễ.

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 141 of 145 Nondiscrimination Notice

Kaiser Permanente does not discriminate on the basis of age, race, ethnicity, color, national origin, cultural background, ancestry, religion, sex, gender identity, gender expression, sexual orientation, marital status, physical or mental disability, source of payment, genetic information, citizenship, primary language, or immigration status.

Language assistance services are available from our Member Services Contact Center 24 hours a day, seven days a week (except closed holidays). Interpreter services, including sign language, are available at no cost to you during all hours of operation. Auxiliary aids and services for individuals with disabilities are available at no cost to you during all hours of operation. We can also provide you, your family, and friends with any special assistance needed to access our facilities and services. You may request materials translated in your language, and may also request these materials in large text or in other formats to accommodate your needs at no cost to you. For more information, call 1-800-464-4000 (TTY users call 711).

A grievance is any expression of dissatisfaction expressed by you or your authorized representative through the grievance process. For example, if you believe that we have discriminated against you, you can file a grievance. Please refer to your Evidence of Coverage or Certificate of Insurance or speak with a Member Services representative for the dispute-resolution options that apply to you. This is especially important if you are a Medicare, Medi-Cal, MRMIP, Medi-Cal Access, FEHBP, or CalPERS member because you have different dispute-resolution options available.

You may submit a grievance in the following ways: By completing a Complaint or Benefit Claim/Request form at a Member Services office located at a Plan Facility (please refer to Your Guidebook or the facility directory on our website at kp.org for addresses) By mailing your written grievance to a Member Services office at a Plan Facility (please refer to Your Guidebook or the facility directory on our website at kp.org for addresses) By calling our Member Service Contact Center toll free at 1-800-464-4000 (TTY users call 711) By completing the grievance form on our website at kp.org

Please call our Member Service Contact Center if you need help submitting a grievance.

The Kaiser Permanente Civil Rights Coordinator will be notified of all grievances related to discrimination on the basis of race, color, national origin, sex, age, or disability. You may also contact the Kaiser Permanente Civil Rights Coordinator directly at One Kaiser Plaza, 12th Floor, Suite 1223, Oakland, CA 94612.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1–800–368–1019, 800– 537–7697 (TDD). Complaint forms are available at hhs.gov/ocr/office/file/index.html.

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 142 of 145 Aviso de no discriminación

Kaiser Permanente no discrimina a ninguna persona por su edad, raza, etnia, color, país de origen, antecedentes culturales, ascendencia, religión, sexo, identidad de género, expresión de género, orientación sexual, estado civil, discapacidad física o mental, fuente de pago, información genética, ciudadanía, lengua materna o estado migratorio.

La Central de Llamadas de Servicio a los Miembros brinda servicios de asistencia con el idioma las 24 horasdel día, los siete días de la semana (excepto los días festivos). Se ofrecen servicios de interpretación sin costo alguno para usted durante el horario de atención, incluido el lenguaje de señas. Se ofrecen aparatos y servicios auxiliares para personas con discapacidades sin costo alguno durante el horario de atención. También podemos ofrecerle a usted, a sus familiares y amigos cualquier ayuda especial que necesiten para acceder a nuestros centros de atención y servicios. Puede solicitar los materiales traducidos a su idioma, y también los puede solicitar con letra grande o en otros formatos que se adapten a sus necesidades sin costo para usted. Para obtener más información, llame al 1-800-788-0616 (los usuarios de la línea TTY deben llamar al 711).

Una queja es una expresión de inconformidad que manifiesta usted o su representante autorizado a través del proceso de quejas. Por ejemplo, si usted cree que ha sufrido discriminación de nuestra parte, puede presentar una queja. Consulte su Evidencia de Cobertura (Evidence of Coverage) o Certificado de Seguro (Certificate of Insurance), o comuníquese con un representante de Servicio a los Miembros para conocer las opciones de resolución de disputas que le corresponden. Esto tiene especial importancia si es miembro de Medicare, Medi-Cal, el Programa de Seguro Médico para Riesgos Mayores (Major Risk Medical Insurance Program MRMIP), Medi-Cal Access, el Programa de Beneficios Médicos para los Empleados Federales (Federal Employees Health Benefits Program, FEHBP) o CalPERS, ya que dispone de otras opciones para resolver disputas.

Puede presentar una queja de las siguientes maneras: • Completando un formulario de queja o de reclamación/solicitud de beneficios en una oficina de Servicio a los Miembros ubicada en un centro del plan (consulte las direcciones en Su Guía o en el directorio de centros de atención en nuestro sitio web en kp.org/espanol) • Enviando por correo su queja por escrito a una oficina de Servicio a los Miembros en un centro del plan (consulte las direcciones en Su Guía o en el directorio de centros de atención en nuestro sitio web en kp.org/espanol) • Llamando a la línea telefónica gratuita de la Central de Llamadas de Servicio a los Miembros al 1-800-788-0616 (los usuarios de la línea TTY deben llamar al 711) • Completando el formulario de queja en nuestro sitio web en kp.org/espanol

Llame a nuestra Central de Llamadas de Servicio a los Miembros si necesita ayuda para presentar una queja.

Se le informará al coordinador de derechos civiles de Kaiser Permanente (Civil Rights Coordinator) de todas las quejas relacionadas con la discriminación por motivos de raza, color, país de origen, género, edad o discapacidad. También puede comunicarse directamente con el coordinador de derechos civiles de Kaiser Permanente en One Kaiser Plaza, 12th Floor, Suite 1223, Oakland, CA 94612.

También puede presentar una queja formal de derechos civiles de forma electrónica ante la Oficina de Derechos Civiles (Office for Civil Rights) en el Departamento de Salud y Servicios Humanos de los Estados Unidos (U.S. Department of Health and Human Services) mediante el portal de quejas formales de la Oficina de Derechos Civiles (Office for Civil Rights Complaint Portal), en ocrportal.hhs.gov/ocr/portal/lobby.jfs (en inglés) o por correo postal o por teléfono a: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 1-800-537-7697 (línea TDD). Los formularios de queja formal están disponibles en hhs.gov/ocr/office/file/index.html (en inglés).

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 143 of 145 無歧視公告

Kaiser Permanente禁止以年齡、人種、族裔、膚色、原國籍、文化背景、血統、宗教、性別、性別認 同、性別表達、性取向、婚姻狀況、生理或心理殘障、付款來源、遺傳資訊、公民身份、主要語言或 移民身份為由而歧視任何人。

會員服務聯絡中心每週七天每天24小時提供語言協助服務（節假日除外）。本機構在全部營業時間內 免費為您提供口譯，包括手語服務，以及殘障人士輔助器材和服務。我們還可為您和您的親友提供使 用本機構設施與服務所需要的任何特別協助。您還可免費索取翻譯成您的語言的資料，以及符合您需 求的大號字體或其他格式的版本。若需更多資訊，請致電 1-800-757-7585（TTY專線使用者請撥 711）。

申訴指任何您或您的授權代表透過申訴程序來表達不滿的做法。例如，如果您認為自己受到歧視，即可提出申 訴。若需瞭解適用於自己的爭議解決選項，請參閱《承保範圍說明書》(Evidence of Coverage) 或《保險證明 書》(Certificate of Insurance)，或咨詢會員服務代表。如果您是 Medicare、Medi-Cal、高風險醫療保險計劃 (Major Risk Medical Insurance Program, MRMIP)、Medi-Cal Access、聯邦僱員健康保險計劃 (Federal Employees Health Benefits Program, FEHBP) 或 CalPERS 會員，採取上述行動尤其重要，因為您可能有不同 的爭議解決選項。

您可透過以下方式提出申訴： • 在健康保險計劃服務設施的會員服務處填寫《投訴或福利索賠/申請表》（地址見《健康服務指南》 (Your Guidebook) 或我們網站kp.org上的服務設施名錄） • 將書面申訴信郵寄到健康保險計劃服務設施的會員服務處（地址見《健康服務指南》或我們網站 kp.org上的服務設施名錄） • 致電我們的會員服務聯絡中心，免費電話號碼是1-800-757-7585（TTY專線請撥711） • 在我們的網站上填寫申訴表，網址是kp.org

如果您在提交申訴時需要協助，請致電我們的會員服務聯絡中心。

涉及人種、膚色、原國籍、性別、年齡或殘障歧視的一切申訴都將通知Kaiser Permanente的民權事務協 調員。您也可與Kaiser Permanente的民權事務協調員直接聯絡，地址： One Kaiser Plaza, 12th Floor, Suite 1223, Oakland, CA 94612。

您還可以電子方式透過民權辦公室的投訴入口網站向美國健康與公共服務部民權辦公室提出民權投 訴，網址是 ocrportal.hhs.gov/ocr/portal/lobby.jsf 或者按照如下資訊採用郵寄或電話方式聯絡：U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 1-800-537-7697（TDD）。投訴表可 從網站 hhs.gov/ocr/office/file/index.html 下載。

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 144 of 145

California Member Services 24 hours a day, seven days a week (closed holidays) 1-800-464-4000 English 1- 800-788-0616 Spanish 1-800-757-7585 Chinese dialects 711 TTY for the hearing/speech impaired Please recycle. MOM 60379021 09/2015

Kaiser Permanente 2021 California Medi-Cal Managed Care Formulary • Page 145 of 145