Drug Formulary prescribe generic first

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9700 Stockdale Highway Bakersfield, California 93311-3617 1-800-391-2000 kernfamilyhealthcare.com

L NK Drug Formulary

March 2020

March 2020 The Kern Family Health Care Drug

Formulary includes information boxes prior

to some of the major therapeutic

categories. Please use these tools to assist

with your care of our members.

TM

This symbol indicates some or all of the dosage forms are available generically. Prescribing generic brands of medication is key to keeping the escalating medication costs down to a minimum. Kern Health Systems PMPM medication cost is approaching $35.

65 This symbol indicates a drug identified by National Committee for Quality Assurance (NCQA) as a high risk medication for the elderly and should generally be avoided for this population. Please consider a formulary alternative. Q This symbol indicates the drug should be billed to Medicare Part B as primary and Kern Family Health Care as a secondary payer. 1 This symbol indicates a tier. It will designate the tier only in regards to cost share. It does not reflect any step-therapy status. KFHC DRUG FORMULARY iii Preface FORMULARY

The member identification number will be the CIN number. This is a number assigned by the state and is not the social security number.

Kern Family Health Care (KHS Medi-Cal) BIN 600428 PCN 04970000 Pt. Number is CIN Number Formulary OTC’s Covered Formulary Prenatal Vitamins Covered (OTC included) Formulary Contraceptives Covered No copayments TAR’s allowed for OTC and legend

PHARMACY AND THERAPEUTICS COMMITTEE The Pharmacy and Therapeutics Committee is composed of Physician and Pharmacist community providers as well as staff from Kern Health Systems. We have primary care providers, specialty physicians, and community based pharmacists (both chain and independent). Meetings are usually held quarterly. Issues you feel could improve our formularies or systems can be forwarded to the Director of Pharmacy at the plan offices, 9700 Stockdale Highway, Bakersfield, CA, 93311, phone 661-664-5101, fax 661-664-5191. Input from providers is welcomed. If you would like to serve on the Pharmacy & Therapeutics Committee please advise our Director of Pharmacy or Medical Director.

NON-FORMULARY REQUESTS Requests for non-formulary medications or supplies may be submitted online (preferred), or state form 61-211. Please include the CIN number, medication failures, and non-formulary item requested as well as information on the patient. One drug per form please. Fax the information to Kern Health Systems at 661-664-5191. You may telephone Kern Health Systems about non-formulary requests but State Law does require information to be submitted (electronic or faxed).

SAMPLE MEDICATIONS Providers are discouraged from providing samples; however, if samples are given to the member, the entire course of therapy must be covered by the samples in accordance with Policy 2.24, Pharmaceutical Guidelines. Medications provided as samples do not establish continuity precedent, and therefore, do not obligate coverage by KHS.

TRIAL PERIOD Barring any medically adverse responses from the member, the trial period of a medication shall be determined per the recommended dosing titration guidelines presented to the FDA. iv KFHC DRUG FORMULARY

EMERGENCY DISPENSING During weekends, holidays, and non-business hours a pharmacy may choose to dispense enough medication (72 hours supply maximum) as an emergency supply to the member until the next working day, at the dispensing pharmacist's discretion according to pharmacy policy and procedures. If the medication is not on the Plan Formulary, a request must be submitted to payment processing stating the emergency and medication dispensed. TAR approval is not needed for reimbursement before dispensing of 72 hour emergency supply of non-Formulary drugs.

BRAND NAME MEDICATIONS WHEN EQUIVALENT GENERIC BRAND IS AVAILABLE If a medication is available as an AB rated generic, then the brand name version will become non-Formulary. If a generic brand becomes available during a patient's treatment, the patient will be expected to switch to the generic brand and must fail the generic brand prior to KHS granting authorization for the brand name. Providers with patients having untoward effects from a generic brand will be required to submit a completed FDA MedWatch form to KHS as part of the authorization for a request to allow a brand name version instead of a generic brand.

Biosimilars and drugs considered as Follow Ons will be treated in the same fashion as if they were a traditional generic of the innovator drug. Per FDA rules, they are not automatically substitutable, but from clinical perspectives they are viewed as a generic version.

PHARMACEUTICAL INDUSTRY SOLICITATION If a representative would like something to be considered by the P&T committee they need to submit the request and supporting documents to KHS. KHS permits contact from the pharmaceutical industry only in written form. All correspondence is to be directed to the KHS Pharmacy Department. Material may be submitted by fax, U.S. mail, or via e-mail. Unless specifically requested by KHS, face to face presentations, phone solicitations or any other means of communication are not allowed. KHS values the P&T committee members time and effort dedicated to the plan and its members. They should not be contacted for committee considerations and requests.

TIER STATUS All medications listed in the KHS Formulary are Tier 1 and are covered if there is no restriction or the restriction(s) is/are met. Any medication authorized through the TAR process is also considered Tier 1 for coverage purposes. Please note that claims may reject at the pharmacy point of service for reasons not listed in the KHS Formulary, such as drug interactions and therapeutic duplications.

IV SOLUTIONS Please see Formulary section for IV solution categories covered. KHS covers the stated infused agents in the categories listed. These are typically covered as part of a per diem case rate.

FORMULATIONS AND STRENGTHS Medications listed in the KHS formulary are identified by the stated formulations and strengths. A drug may have only certain strengths or formulations covered. Non stated formulations would require a TAR. KFHC DRUG FORMULARY v Table of Contents

Cardiovascular - Antiarrhythmic - Drugs for the heart ...... 16 LEGEND MEDICATIONS 'Central Nervous System - Antipsychotic - Drugs for the nervous system ..1 Cardiovascular - Antilipid (HMG - CoA Reductase Inhibitors) - Drugs for the Amyotrophic Lateral Sclerosis Agents ...... 1 heart ...... 16-17 Analgesics - Narcotics - Drugs for pain ...... 1-3 Cardiovascular - Antilipid/OTC - Drugs for the heart ...... 17 Analgesics - Non-narcotic/OTC - Drugs for pain ...... 3 Cardiovascular - Antilipid - Fibrates - Drugs for the heart ...... 17 Antiacne ...... 3 Cardiovascular - Antilipid - Lipotropics - Drugs for the heart ...... 17 Anti-bacterial - Cephalosporin - Drugs for infection ...... 3 Cardiovascular - Antilipid - Other Medications - Drugs for the heart ...... 17 Anti-bacterial - Drugs for infection ...... 3 Cardiovascular - Betablocker - Drugs for the heart ...... 17 Anti-bacterial - Macrolide - Drugs for infection ...... 4 Cardiovascular - Betablocker Thiazide Combination - Drugs for the heart 17 Anti-bacterial - Miscellaneous - Drugs for infection ...... 4-5 Cardiovascular - Calcium Channel Blocker - Drugs for the heart ...... 18 Anti-bacterial - Penicillin - Drugs for infection ...... 5 Cardiovascular - Diuretic - Drugs for the heart ...... 18 Anti-bacterial - Penicillinase Resistant Penicillin - Drugs for infection ...... 5 Cardiovascular - Electrolyte/OTC - Drugs for the heart ...... 18 Anti-bacterial - Quinolone - Drugs for infection ...... 5-6 Cardiovascular - Electrolyte Depleter - Drugs for the heart ...... 18-19 Anti-bacterial - Sulfonilamide - Drugs for infection ...... 6 Cardiovascular - Pulmonary Arterial Hypertension Endothelin Receptor Anti-bacterial - Tetracycline - Drugs for infection ...... 6 Antagonist - Drugs for the heart ...... 19 Anti-infective - Antifungal - Drugs for infection ...... 6-7 Cardiovascular - Pulmonary Arterial Hypertension Phosphodiesterase 5 Anti-infective - Antihelmintic - Drugs for infection ...... 7 Inhibitor - Drugs for the heart ...... 19 Anti-infective - Antimalarial - Drugs for infection ...... 7 Cardiovascular - Pulmonary Arterial Hypertension Prostacyclin type - Drugs Anti-infective - Antiprotozoal - Drugs for infection ...... 7 for the heart ...... 19 Anti-infective - Anti-tubercular - Drugs for infection ...... 7-8 Cardiovascular - Vasodilator - Drugs for the heart ...... 19 Anti-infective - Anti-viral - Drugs for infection ...... 8-9 Central Nervous System - Anticonvulsant - Drugs for the nervous system 20 Anti-infective - Drugs for infection ...... 9 Central Nervous System - Antidepressant - Antipsychotic - Drugs for the Anti-infective - Leprosy - Drugs for infection ...... 10 nervous system ...... 20 Antineoplastic - Drugs for Cancer ...... 10-13 Central Nervous System - Antidepressant - Norepinephrine Antagonist and Anti-Parkinsonism ...... 13 Serotonin Antagonist Antidepressants - Drugs for the nervous system . 20 Antirheumatiod and Disease Modifiers - Drugs for the immune system Central Nervous System - Antidepressant - Norepinephrine-Dopamine 13-14 Reuptake Inhibitors (NDRI) - Drugs for the nervous system ...... 21 Antiuricosuric - Drugs for gout ...... 14 Central Nervous System - Antidepressant - Selective Serotonin Reuptake Autonomic - Anticholinergic - Drugs to reduce GI motility ...... 14 Inhibitors (SSRI) - Drugs for the nervous system ...... 21 Autonomic - Cholinergic - Drugs to improve GI motility ...... 14 Central Nervous System - Antidepressant - Tricyclics (TCA) - Drugs for the Benign Prostate Hypertrophy - Drugs for the prostate ...... 14 nervous system ...... 21-22 Biologics & Biosimilars ...... 14-15 Central Nervous System - Antidepressant-Serotonin - Norepinephrine Cardiovascular - Alphablocker - Drugs for the heart ...... 15 Reuptake Inhibitors (SNRI) - Drugs for the nervous system ...... 22 Cardiovascular - Angiotensin Converting Enzyme Inhibtors - Drugs for the Central Nervous System - Anxiolytic - Drugs for the nervous system ..... 22 heart ...... 15 Central Nervous System - Migraine - Drugs for the nervous system ...... 23 Cardiovascular - Angiotensin Converting Enzyme Inhibtors Combination - Central Nervous System - Migraine-Triptan - Drugs for the nervous system Drugs for the heart ...... 16 23 Cardiovascular - Angiotensin II Receptor Blocker - Drugs for the heart ...16 Central Nervous System - Sedative - Drugs for the nervous system ..23-24 Cardiovascular - Angiotensin II Receptor Blocker Thiazide Combination - Central Nervous System - Stimulant - Drugs for the nervous system ..... 24 Drugs for the heart ...... 16 Cholinesterase Inhibitors - Drugs for memory loss ...... 24 vi KFHC DRUG FORMULARY

Drug Dependency Therapy ...... 24 Hormone - Antidiabetic Thiazolidinedione - Drugs for diabetes ...... 35 Enterals ...... 24 Hormone - Anti-thyroid ...... 35 Gastrointestinal - Antacid/OTC - Drugs for the stomach ...... 26 Hormone - Endocrine ...... 35 Gastrointestinal - Antidiarrhea/OTC - Drugs for the stomach ...... 26 Hormone - Estrogen - Androgen - Drugs for hormones ...... 35 Gastrointestinal - Antidiarrheal - Drugs for the stomach ...... 26 Hormone - Estrogen - Drugs for hormones ...... 35 Gastrointestinal - Antiemetic/OTC - Drugs for the stomach ...... 26 Hormone - Estrogen - Progestin - Drugs for hormones ...... 35-36 Gastrointestinal - Antiemetic - Drugs for the stomach ...... 27 Hormone - Glucocorticoid - Drugs for hormones ...... 36 Gastrointestinal - Digestant - Drugs for the stomach ...... 27 Hormone - Oxytoxic - Drugs for hormones ...... 36 Gastrointestinal - H2 Antagonist - Drugs for the stomach ...... 27 Hormone - Progestin - Drugs for hormones ...... 36 Gastrointestinal - H2 Antagonist/OTC - Drugs for the stomach ...... 27 Hormone - Thyroid ...... 37 Gastrointestinal - Helicobacter Pylori Treatment - Drugs for the stomach 28 Hormones - Antidiabetic/OTC - Drugs for diabetes ...... 37 Gastrointestinal - Laxative - Drugs for the stomach ...... 28 Immunosuppressant -Drugs for the immune system ...... 37 Gastrointestinal - Laxative /OTC - Drugs for the stomach ...... 28 Intravenous Solutions ...... 37-38 Gastrointestinal - Miscellaneous - Drugs for the stomach ...... 28-29 Muscle Relaxant ...... 38-39 Gastrointestinal - Protectant/OTC - Drugs for the stomach ...... 29 NSAID - Acetic Acids - Drugs for pain ...... 39 Gastrointestinal - Proton Pump Inhibitor - Drugs for the stomach .....29-30 NSAID - COX-2 Agents - Drugs for pain ...... 39 Hematinic/OTC - Drugs for the blood ...... 30 NSAID - Other - Drugs for pain ...... 39 Hematology - Anticoagulant - Drugs for the blood ...... 30 NSAID - Oxicam - Drugs for pain ...... 40 Hematology - Antiplatelet - Drugs for the blood ...... 30-31 NSAID - Propionic Acids - Drugs for pain ...... 40 Hematology - Coagulant - Drugs for the blood ...... 31 NSAID - Salicylate - Drugs for pain ...... 40 Hematology - Hematopoietic - Drugs for the blood ...... 31 Ophthalmic - Anesthetic - Drugs for the eyes ...... 40 Hematology - Miscellaneous - Drugs for the blood ...... 31 Ophthalmic - Anti-fungal - Drugs for the eyes ...... 40 Hormone - Androgen Drugs for hormones ...... 31 Ophthalmic - Antihistamine - Drugs for the eyes ...... 40 Hormone - Anti-Androgen ...... 31 Ophthalmic - Antihistamine/OTC - Drugs for the eyes ...... 40 Hormone - Antidiabetic - Amylin Analog - Drugs for diabetes ...... 32 Ophthalmic - Anti-infective - Drugs for the eyes ...... 40-41 Hormone - Antidiabetic - Dipeptidyl Peptidase-4 - Drugs for diabetes .....32 Ophthalmic - Anti-infective - Glucocorticoid - Drugs for the eyes ...... 41 Hormone - Antidiabetic - Dipeptidyl Peptidase-4 - Metformin - Drugs for Ophthalmic - Anti-viral - Drugs for the eyes ...... 41 diabetes ...... 32 Ophthalmic - Decongestant - Antihistamine/OTC Drugs for the eyes .... 41 Hormone - Antidiabetic - Dipeptidyl Peptidase-4 - Thiazolidinedione - Drugs Ophthalmic - Decongestant/OTC - Drugs for the eyes ...... 41 for diabetes ...... 32 Ophthalmic - Glaucoma - Drugs for the eyes ...... 42 Hormone - Antidiabetic Alpha-glucodiase Inhibitor - Drugs for diabetes ..32 Ophthalmic - Glucocorticoid - Drugs for the eyes ...... 42 Hormone - Antidiabetic Biguanide - Drugs for diabetes ...... 32 Ophthalmic - Miscellaneous - Drugs for the eyes ...... 43 Hormone - Antidiabetic GLP-1 Agonists - Drugs for diabetes ...... 32-33 Ophthalmic - Mydriatic - Drugs for the eyes ...... 43 Hormone - Antidiabetic GLP-1 Agonists glargine combination - Drugs for Ophthalmic - NSAID - Drugs for the eyes ...... 43 diabetes ...... 33 Oral Contraceptive - Biphasic - Drugs for women ...... 43 Hormone - Antidiabetic Insulin - Drugs for diabetes ...... 33 Oral Contraceptive - Drugs for women ...... 43-44 Hormone - Antidiabetic Meglitinide - Drugs for diabetes ...... 34 Oral Contraceptive - Progestin Only - Drugs for women ...... 44 Hormone - Antidiabetic Other Agents - Drugs for diabetes ...... 34 Oral Contraceptive - Triphasic - Drugs for women ...... 44-45 Hormone - Antidiabetic SGLT-2 Inhibitors - Drugs for diabetes ...... 34 Osteoporosis Drugs for bone loss ...... 45 Hormone - Antidiabetic SGLT-2 Inhibitors Combination - Drugs for diabetes Otic - Drugs for the ears ...... 45 34 Otic/ OTC - Drugs for the ears ...... 45 Hormone - Antidiabetic Sulfonylureas - Drugs for diabetes ...... 34-35 Rescue Agents - Antidotes ...... 45 KFHC DRUG FORMULARY vii

Respiratory - Antihistamine - Antitussive - Decongestant - Drugs for the Respiratory - Expectorant/OTC - Drugs for the lungs ...... 51 lungs ...... 46 Respiratory - Mast Cell Stabilizer - Drugs for the lungs ...... 51 Respiratory - Antihistamine - Antitussive - Drugs for the lungs ...... 46 Respiratory - Miscellaneous/OTC - Drugs for the lungs ...... 51 Respiratory - Antihistamine - Decongestant - Antitussive/OTC - Drugs for Respiratory - Mucolytic - Drugs for the lungs ...... 51 the lungs ...... 46 Respiratory - Nasal Antihistamine - Drugs for the lungs ...... 51 Respiratory - Antihistamine - Decongestant/OTC - Drugs for the lungs ...46 Respiratory - Nasal Glucocorticoids - Drugs for the lungs ...... 51 Respiratory - Antihistamine - Decongestant - Drugs for the lungs ...... 47 Respiratory - Nasal Glucocorticoids/OTC - Drugs for the lungs ...... 51 Respiratory - Antihistamine - Drugs for the lungs ...... 47 Respiratory - Xanthine - Drugs for the lungs ...... 51 Respiratory - Antihistamine/OTC - Drugs for the lungs ...... 47 Topical - Acne ...... 52 Respiratory - Antiserotonin - Drugs for the lungs ...... 47 Topical - Acne/OTC -Drugs for the skin ...... 52 Respiratory - Antitussive/OTC - Drugs for the lungs ...... 47 Topical - Anesthetic - Drugs for pain ...... 52 Respiratory - Antitussive - Drugs for the lungs ...... 48 Topical - Antibiotic/OTC -Drugs for the skin ...... 52 Respiratory - Antitussive - Expectorant - Drugs for the lungs ...... 48 Topical - Antifungal - Drugs for infection ...... 52 Respiratory - Antitussive - Expectorant/OTC - Drugs for the lungs ...... 48 Topical - Antifungal/OTC -Drugs for the skin ...... 52-53 Respiratory - Asthma - Drugs for the lungs ...... 48 Topical - Anti-infective - Drugs for infection ...... 53 Respiratory - Asthma - Step 1 -Short Acting Bronchodilator - Drugs for the Topical - Anti-Infective/OTC -Drugs for the skin ...... 53 lungs ...... 48 Topical - Antineoplastic - Drugs for cancer ...... 53 Respiratory - Asthma - Step 2 -Glucocorticoid - Drugs for the lungs ...... 49 Topical - Antiviral - Drugs for infection ...... 53 Respiratory - Asthma - Step 3 - Antileukotriene - (Step 2 Alternative) - Topical - Astringent/OTC -Drugs for the skin ...... 53 Drugs for the lungs ...... 49 Topical - Contraceptive - Drugs for women ...... 53 Respiratory - Asthma - Steps 3 & 4 - ICS/Long Acting Bronchodilator - Topical - Enzymes ...... 54 Drugs for the lungs ...... 49-50 Topical - Estrogens- Drugs for women ...... 54 Respiratory - Asthma Device ...... 50 Topical - Glucocorticoid/OTC -Drugs for the skin ...... 54 Respiratory - COPD - Anticholinergic bronchodilator - Drugs for the lungs 50 Topical - Glucocorticoid a Low Potency - Drugs for the skin ...... 54 Respiratory - COPD - Anticholinergic Bronchodilator Combination - Drugs for Topical - Glucocorticoid b Medium Potency - Drugs for the skin ...... 54 the lungs ...... 50 Topical - Glucocorticoid c High Potency - Drugs for the skin ...... 54 Respiratory - COPD - Anticholinergic Bronchodilator Long Acting - Drugs for Topical - Miscellaneous - Drugs for the skin ...... 55 the lungs ...... 50 Topical - Scabicide - Drugs for infection ...... 55 Respiratory - COPD - Anticholinergic Bronchodilator Long Acting Topical - Scabicide/OTC -Drugs for the skin ...... 55 Combination - Drugs for the lungs ...... 50 Urinary Tract - Drugs for bladder ...... 55 Respiratory - COPD - Long Acting Anticholinergic - Long Acting Vaccines - Immune Globulin ...... 55-57 Bronchodilator - ICS Combination - Drugs for the lungs ...... 50 Vaginal - Anti-infective/OTC - Drugs for infection ...... 57 Respiratory - Decongestant/OTC - Drugs for the lungs ...... 51 Vaginal - Anti-infective - Drugs for women ...... 57 viii KFHC DRUG FORMULARY

Vaginal - Estrogens - Drugs for women ...... 57 Device - Supplies/OTC ...... 59 Vitamins - Dietary Supplements ...... 58 Ostomy Items/OTC ...... 59 Supplies - Diabetic/OTC ...... 59-60 OVER THE COUNTER MEDICATIONS Vitamins/OTC ...... 60 Contraceptive/OTC ...... 59

Abbreviations cr continuous release oint ointment APPENDIX conc concentrate ophth ophthalmic DIABETIC TREATMENT CHARTS ec enteric coated sl sublingual ASTHMA TREATMENT CHARTS inh inhalation soln solution CARVE OUT LIST liq liquid supp suppository INDEX–GENERIC and BRAND mdi metered dose inhaler susp suspension NMT not more than KFHC DRUG FORMULARY 1

GENERIC BRAND FORMS

'Central Nervous System - Antipsychotic - Drugs for the nervous system^1^ For Kern Family Health Care (KHS Medi-Cal) most of the straight antipsychotic agents are carved out to Medi-Cal. Please see Appendix.

Amyotrophic Lateral Sclerosis Agents^2^ 1 Rilutek® 50mg tablet

Riluzole^3^ Restriction: Allowed for amyotrophic lateral sclerosis.

Analgesics - Narcotics - Drugs for pain^4^ Medications in this category may be restricted in one or more ways. The restrictions are noted under the individual medications. Those patients who require additional quantities, fills or restricted medications will need to have their physician provide monitoring tools such as prescription drug monitoring programs (CURES), urine drug screens, and others as appropriate, along with physician's progress notes and treatment plan accompanying the request. This will help KHS staff determine how to properly encode the prior authorization. A good resource for guidelines may be found at C.A.R.E.S Alliance, caresalliance.org. The CDC has issued guidance as well. The recommendations entail evaluating the need of an opioid versus other pharmacologic and non-pharmacologic alternatives. Members should be started on as low a dose and as short a duration as clinically appropriate. KHS members who are opioid naive are allowed up to seven days therapy. Regimens longer than that require prior authorization. Recently, focus on total daily dose based on morphine equivalents has been instituted by Medicare and Medicaid. The health plan limits to 120 mg MED for non-malignant pain. New opioid therapy regimens are limited to a seven day supply. Concurrent use with benzodiazepines, sedatives, and/or muscle relaxants is not recommended. Acetaminophen (APAP, Tylenol®) hepatotoxicity can result from frequent and/or high doses of those medications with an acetaminophen component. Maximum recommended daily dose of APAP for a patient who does not drink alcohol is 4000mg. Patients may also aggravate the problem by taking other OTC drugs with APAP or receiving prescriptions of other APAP combinations. It should be noted that the commonly prescribed Hydrocodone/APAP combinations are very limited on the KHS Formulary. KHS offers Oxycodone/APAP combinations such as Percocet® equivalents. Tramadol (Ultram®) although on the KHS formulary has many clinical limitations, including increasing risk of serotonin syndrome in addition to other centrally acting concerns. The FDA has recently added a new warning. Medications containing either codeine or tramadol are not to be prescribed to those under 18 years of age. Please consider morphine preparations before oxycodone or fentanyl formulations. Continued on next page 2 KFHC DRUG FORMULARY

GENERIC BRAND FORMS Analgesics - Narcotics - Drugs for pain, continued • SEE PREVIOUS PAGE 1 15mg, 30mg, 60mg tablet

Codeine sulfate^5^ Restriction: Limited to cancer patients or plan Pain Specialists. Authorization required for other diagnoses. Allowed for members > 18 years old. 1 Tylenol w/Codeine® 15mg-300mg, 30mg-300mg tablet, 12mg-120mg/5ml

Codeine w/Acetaminophen^6^ soln Restriction: NMT 60 tablets per month, NMT 3 dispensings per 90 day period. Allowed for members > 18 years old. 1 Duragesic® 12mcg, 25mcg, 50mcg, 75mcg, 100mcg patches

Fentanyl^7^ Restriction: Limited to cancer patients or plan Pain Specialist Physicians. Authorization required for other diagnoses. Allow 10 patches per 30 days. Allowed for members failing morphine sulfate ER or unable to take solid dosage forms. 12 mcg patches are not recommended as starting doses. 1 Norco® 5mg/325mg, 10mg/325mg tablet, 7.5-325/15ml liq

Hydrocodone/APAP^8^ Restriction: 5/325 mg, NMT 60 tablets per month, NMT 3 dispensings per 90 days. 10/325mg -- Limited to cancer patients or plan Pain Specialist Physicians. NMT 120 tablets per month, NMT 3 dispensings per 90 days. Liquid is limited to members < 18 years old and maximum of 3 day supply. 1 Dilaudid® 2mg, 4mg tablet, 3mg supp

Hydromorphone^9^ Restriction: Limited to cancer patients or plan Pain Specialist Physicians. Authorization required for other diagnoses. NMT 120 per month. 1 Levo-Dromoran® 2mg tablet

Levorphanol^10^ Restriction: Limited to cancer patients or plan Pain Specialist Physicians. Authorization required for other diagnoses. 1 MS-Contin® 10mg/5ml, 20mg/5ml oral soln, 20mg/ml conc, 15mg,

Morphine^11^ 30mg tablet, 15mg, 30mg, 60mg cr tablet Restriction: Limited to cancer patients or plan Pain Specialist Physicians. Authorization required for other diagnoses. NMT 90 per month. 1 Oxy-Contin® 5mg, 10mg tablet, 10mg, 15mg, 20mg, 40mg cr tablet

Oxycodone^12^ Restriction: Restricted to use by KHS plan Oncologists or Pain Specialist Physicians. Member needs to fail morphine ER. NMT 90 per month of immediate release, 60 per month of time release formulations. 1 Percocet® 5mg-325mg tablet

Oxycodone w/Acetaminophen^13^ Restriction: Limited to cancer patients or plan Pain Specialist Physicians. Authorization required for other diagnoses. NMT 120 per month. Continued on next page KFHC DRUG FORMULARY 3

GENERIC BRAND FORMS Analgesics - Narcotics - Drugs for pain, continued • SEE PREVIOUS PAGE 1 Ultram® 50mg tablet

Tramadol^14^ Restriction: Not indicated for members with abuse potential. Contraindicated with alcohol, hypnotics, centrally acting analgesics, opioids, and psychotropic agents. Seizures and serotonin syndrome may occur with antidepressants, triptans, lithium, enzyme inducing medications, and some antibiotics. Allowed for members > 18 years old.

Analgesics - Non-narcotic/OTC - Drugs for pain^15^ Acetaminophen (APAP, Tylenol®) hepatotoxicity can result from frequent and/or high doses of those medications with an acetaminophen component. Maximum recommended daily dose of APAP for a patient who does not drink alcohol is 4000mg. Patients may also aggravate the problem by taking other OTC drugs with APAP or receiving prescriptions of other APAP combinations (Norco®, Tylenol #3). 1 Tylenol® 325mg, 500mg, 650mg tablet, 100mg/ml, 160mg/5ml

Acetaminophen^16^ soln 1 ASA 81mg, 325mg, 650mg tablet & ec tablet, 325mg

Aspirin^17^ buffered tablet 1 Motrin® 100mg/5ml susp, 200mg tablet

Ibuprofen^18^ Restriction: FDA does not recommend in children < 6 months.

Antiacne^19^ 1 20 mg, 40 mg capsule

Isotretinoin^20^ Restriction: Prior authorization required. Allowed for Dermatologists.

Anti-bacterial - Cephalosporin - Drugs for infection^21^ 1 Omnicef® 125mg/5ml susp, 250mg/5ml susp

Cefdinir^22^ Restriction: Restricted to members with OM < 8 years old failing 1st line ABX’s or documented penicillin allergy. Documented ICD-10 code with provider's office required for online submission otherwise submit TAR with documentation. 1 250mg, 500mg tablet

Cefuroxime^23^ Restriction: Prior authorization required. 1 Keflex® 125mg/5ml, 250mg/5ml susp, 250mg, 500mg capsule

Cephalexin^24^

Anti-bacterial - Drugs for infection^25^ Inappropriate use of antibiotics is a concern nationwide. Resistance to antibiotics is growing nationally. Additionally, antibiotics are ineffective on viral infections. Uncomplicated bronchitis and viral infections do not warrant antibiotic use. Please reference www.AWARE.md or 916-779-6620 for more information on appropriate use of antibiotics. KHS has limits on days Continued on next page 4 KFHC DRUG FORMULARY

GENERIC BRAND FORMS Anti-bacterial - Drugs for infection, continued • SEE PREVIOUS PAGE supply and number of fills per month on many antibiotics to help ensure appropriate use. A 10 day supply every 30 days is in place for the cephalosporins, macrolides, penicillins, and quinolone classes. Prior authorization justifying the necessity for longer or more frequent dosing will be needed for therapies exceeding those limits.

Anti-bacterial - Macrolide - Drugs for infection^26^ Zithromax® 250mg tablets have a maximum of 6 (5 days therapy) as the drug continues working for a number of additional days. Therapy Days Supply Cost Erythromycin 500mg QID 10 $678 Azithromycin® 500mg x1, 250mg QD 5 $5 Clarithromycin® 500mg ii QD 10 $8 1 Zithromax® 100mg/5ml, 200mg/5ml susp, 250mg, 600mg tablet, 1

Azithromycin^27^ gm powder pack Restriction: 600mg Tablets – Restricted to members with MAC. 1 Biaxin® 125mg/5ml, 250mg/5ml susp, 250mg, 500mg tablet

Clarithromycin^28^ Restriction: Susp Restricted to members < 8 years old w/OM who have recently failed first line antibiotics. 500mg tablets recommended for members who cannot tolerate or failed azithromycin. 1 Cleocin® 75mg/5ml susp, 75mg, 150mg, 300mg capsule

Clindamycin^29^ 1 E-Mycin® 250mg, 333mg, 500mg ec tablet, 250mg ec particles

Erythromycin Base^30^ capsule Restriction: Prior authorization required. 1 Ery-tab® 250mg, 333mg, 500mg ec tablet, 250mg ec particles

Erythromycin Base^31^ capsule Restriction: Prior authorization required. 1 EES® 200mg/5ml, 400 mg/5 ml, 400mg tablet

Erythromycin Ethylsuccinate^32^ Restriction: Prior authorization required. 1 Erythrocin® 250mg, 500mg tablet

Erythromycin Stearate^33^ Restriction: Prior authorization required.

Anti-bacterial - Miscellaneous - Drugs for infection^34^ 1 Monurol® 3 gm pckt

Fosfomycin tromethamine^35^ Restriction: Limit to ID or urologist for ESBL urinary infections. 1 125mg/5ml soln, 500mg tablet

Neomycin^36^ Continued on next page KFHC DRUG FORMULARY 5

GENERIC BRAND FORMS Anti-bacterial - Miscellaneous - Drugs for infection, continued • SEE PREVIOUS PAGE 1 Macrobid® 100mg monohydrate macrocrystalline capsule

Nitrofurantoin^37^ Restriction: Limit to 10 day supply unless prescribed by ID or urologist. 1 Furadantin® 25mg/5ml susp

Nitrofurantoin^38^ Restriction: Limited to members <6 years old.

Anti-bacterial - Penicillin - Drugs for infection^39^ Augmentin® is restricted to children under 8 years of age. It will be approved for animal and human bites and severe sinusitis with prior authorization. Augmentin® is available in generic brands and there will be some cost savings by using the generic brands. Formulary strengths will be allowed to clear as first line up to age 8. Pneumonia, otitis media, and sinusitis are dosed at 45mg/kg/day divided twice daily and skin and UTIs are dosed at 25mg/kg/day divided twice a day. Instead of dosing three times a day, the plan recommends using a twice daily dosing schedule of 200mg and 400mg and 600mg, per AAP guidelines. Please prescribe the twice a day regimen. Costs Amoxicillin 250mg/5ml 150ml $5 Amoxicillin-clavulanate 250mg/5ml 150ml $89 Amoxicillin-clavulanate 400mg/5ml 200ml $21 1 Amoxil® 50mg/ml drops, 125mg/5ml, 250mg/5ml, 200

Amoxicillin^40^ mg/5ml, 400mg/5ml, 125mg, 250mg, 500mg capsule 1 Augmentin® 200mg/5ml, 400mg/5ml, 600mg/5ml susp, 500mg,

Amoxicillin/Clavulanate^41^ 875mg tablet Restriction: Restricted to children < 8 years old with OM. First line treatment for animal bites. 10 days maximum therapy. Documented ICD-10 code with provider's office required for online submission otherwise submit TAR with documentation. Available first line for prescriptions written by ENT. 1 Principen® 100mg/ml, 125mg/5ml, 250mg/5ml susp, 250mg,

Ampicillin^42^ 500mg capsule 1 Veetids® 125mg/5ml, 250mg/5ml oral soln, 125mg, 250mg,

Penicillin VK^43^ 500mg tablet

Anti-bacterial - Penicillinase Resistant Penicillin - Drugs for infection^44^ 1 Dynapen® 62.5mg/5ml susp, 125mg, 250mg, 500mg capsule

Dicloxacillin^45^

Anti-bacterial - Quinolone - Drugs for infection^46^ The medications in this category are limited to 10 days therapy. Patients who require therapy beyond that limit require prior authorization. Restricted in patients less than 18 years of age. Continued on next page 6 KFHC DRUG FORMULARY

GENERIC BRAND FORMS Anti-bacterial - Quinolone - Drugs for infection, continued • SEE PREVIOUS PAGE Levofloxacin (Levaquin®) probably has less resistance than ciprofloxacin (Cipro®) since Cipro® has been used in so many patients. A 28 day supply will be allowed of ciprofloxacin or levofloxacin for the management of prostatitis. 1 Cipro® 250mg, 500mg, 750mg tablet

Ciprofloxacin^47^ Restriction: Urologists allowed 28 day supply. 1 Levaquin® 250mg, 500mg, 750mg tablet

Levofloxacin^48^ Restriction: Urologists allowed 28 day supply.

Anti-bacterial - Sulfonilamide - Drugs for infection^49^ 1 Sulfamethoxazole & Bactrim®/Septra® 400mg-80mg, 800mg-160mg tablet, 200mg-40mg/5ml susp

Trimethoprim^50^

Anti-bacterial - Tetracycline - Drugs for infection^51^ 1 Vibramycin® 50mg, 100mg capsule, 100mg tablet

Doxycycline hyclate^52^ 1 Minocin® 50mg, 75mg, 100mg capsule

Minocycline^53^

Anti-infective - Antifungal - Drugs for infection^54^ Prior authorization will not be allowed for cosmetic purposes. Maximum therapy is 6 weeks for fingernails, 12 weeks for toenails. Sanford, et al, suggest that Terbinafine (Lamisil®) 250mg QD has one of the highest effectiveness rates (70-81%) of the FDA approved treatments. Sanford recommends ascertaining the ALT & AST levels prior to initiation of therapy since these drugs should not be used in chronic or active liver disease. KOH or positive culture required. Members with vaginal candidiasis, please use the fluconazole 200 mg tablet. 1 Mycelex® 10mg troche

Clotrimazole^55^ 1 Diflucan® 50mg, 100mg, 200mg tablet

Fluconazole^56^ Restriction: If needing the 150 mg dose, please use 200 mg. 1 125mg/5ml susp (microsize)

Griseofulvin^57^ Restriction: Suspension is for children < 12 years old. 1 Cresemba® 186mg capsule

Isavuconazounium sulfate^58^ Restriction: Prior authorization required. 1 Sporanox® 100mg capsule

Itraconazole^59^ Restriction: Trial and failure of fluconazole. Continued on next page KFHC DRUG FORMULARY 7

GENERIC BRAND FORMS Anti-infective - Antifungal - Drugs for infection, continued • SEE PREVIOUS PAGE 1 Mycostatin® 100,000 units/ml susp, 500,000 unit tablet

Nystatin^60^ 1 Noxafil® 40mg/ml susp, 100mg tablet

Posaconazole^61^ Restriction: Prior authorization required. 1 Lamisil® 250mg tablet

Terbinafine^62^ Restriction: 12 week therapy maximum duration. 1 Vfend® 50mg, 200mg tablet, 200mg/5 ml susp

Voriconazole^63^ Restriction: Prior authorization required.

Anti-infective - Antihelmintic - Drugs for infection^64^ 1 Albenza® 200 mg tablet

Albendazole^65^ Restriction: Prior authorization required. 1 Stromectol® 3 mg tablet

Imervectin^66^ 1 Pin-X® 50mg/ml susp, 250mg chewable tablet

Pyrantel^67^

Anti-infective - Antimalarial - Drugs for infection^68^ 1 250mg tablet

Chloroquine^69^ 1 26.3mg tablet

Primaquine^70^

Anti-infective - Antiprotozoal - Drugs for infection^71^ 1 Mepron® 750mg/5ml susp

Atovaquone^72^ Restriction: Prior authorization required. Sulfa allergy and diagnosis of PCP. 1 12.5mg, 100mg tablet

Benznidazole^73^ Restriction: Prior authorization required. 1 Humatin® 250mg capsule

Paromomycin^74^ 1 Daraprim® 25mg tablet

Pyrimethamine^75^ Restriction: Prior authorization required.

Anti-infective - Anti-tubercular - Drugs for infection^76^ 1 Seromycin® 250mg capsule

Cycloserine^77^ 1 Myambutal® 100mg, 400mg tablet

Ethambutal^78^ Continued on next page 8 KFHC DRUG FORMULARY

GENERIC BRAND FORMS Anti-infective - Anti-tubercular - Drugs for infection, continued • SEE PREVIOUS PAGE 1 INH® 50mg/5ml syrup, 50mg, 100mg, 300mg tablet

Isoniazid^79^ 1 500mg tablet

Pyrazinamide^80^ Restriction: Prior authorization required. 1 Mycobutin® 150mg capsule

Rifabutin^81^ Restriction: Restricted to prevention of MAC in patients with advanced HIV. 1 Rimactane® 150mg, 300mg capsule

Rifampin^82^

Anti-infective - Anti-viral - Drugs for infection^83^ Anti-viral agents for HIV related cases, with the exception of Zidovudine and Didanosine, are covered by fee for service Medi-Cal. Bill EDS, not KHS, for these patients. The carved out anti-viral agents are listed in the Appendix. Anti-virals for Hepatitis, both B and C are covered, but require prior authorization. Adherence to treatment is essential. These are generally restricted to specialists, and monitoring is required. Current guidelines for Hepatitis B suggest the use of tenofovir. Keep in mind that is billed to EDS. The state Medicaid program has outlined criteria that all Medicaid plans, including the managed care will follow for coverage of Hepatitis C medications. If a patient has Hepatitis C refer to Hepatitis C program as they case manage the KHS Hepatitis C patients. At minimum, the initial referral needs to include the viral load, genotype, lab results, liver function tests, CBC, Child-pugh assessment, Metavir score (or equivalent), biopsy results (if performed), and others as outlined by the DHCS criteria. A 4 week viral load is needed for determination if further treatment would be authorized. All medications require prior authorization. DHCS requires all current therapies to be considered based on current professional guidelines. Acyclovir is the only Formulary medication for Genital Herpes Therapy: Sanford, et al, in Guide to Anti-microbial Therapy - suggests there is little difference between antiviral agents for genital herpes. Valacyclovir is the prodrug of acyclovir; isolates resistant to acyclovir although low, (<1% in immunocompromised patients) are also resistant to valacyclovir. KHS only allows acyclovir at this time. An example of costs for these drugs for recurrent treatment is as follows: Medication & Days Therapy Cost Acyclovir 400mg TID x 5 days $6 Valtrex® 500mg BID x 3 days (non-formulary) $36 Famvir® 125mg BID x 5 days (non-formulary) $47 KHS requires failure of Acyclovir before the other agents would be allowed on prior authorization. Topical Antiviral Therapy requires prior authorization: Topical agents for antiviral therapy Continued on next page KFHC DRUG FORMULARY 9

GENERIC BRAND FORMS Anti-infective - Anti-viral - Drugs for infection, continued • SEE PREVIOUS PAGE (Zovirax™, Abreva®) require prior authorization because of their limited effect. Usually topical products will only slightly decrease the duration of infection (3.4 vs. 4.1 days). Severe infections may benefit more from systemic therapy. 1 Zovirax® 200mg/5ml susp, 200mg capsule, 200mg, 400mg,

Acyclovir^84^ 800mg tablet 1 Zepatier® 50-100 mg tablet

Elbasvir/grazoprevir^85^ Restriction: Prior authorization required. 1 Baraclude® 0.5 mg, 1 mg tablet

Entecavir^86^ Restriction: Prior authorization required. 1 Cytovene® 250mg, 500mg capsule

Ganciclovir^87^ Restriction: Prior authorization required. 1 various injection

Interferon alpha^88^ Restriction: Prior authorization required. 1 Tamiflu® 30 mg, 45 mg, 75 mg capsule, 6 mg/ml susp

Oseltamivir^89^ Restriction: Members that are clinically eligible are strongly encouraged to receive the flu vaccine. Exceeding 2 fills within one flu season will require confirmation of infection. 1 various tablet

Ribavirin^90^ Restriction: Prior authorization required. 1 Epclusa® 400mg-100mg tablet

Sofosbuvir/velpatasvir^91^ Restriction: Prior authorization required. 1 Retrovir® 50mg/5 ml syrup, 100mg capsule

Zidovudine^92^

Anti-infective - Drugs for infection^93^ 1 Zyvox® 600mg tablet

Linezolid^94^ Restriction: Prior authorization required. Reserved for members with VRE. 1 Flagyl® 250mg, 500mg tablet

Metronidazole^95^ 1 Tindamax® 500 mg tablet

Tinidazole^96^ Restriction: Prior authorization required. 1 Vancocin®, Firvanq® 25 mg/ml, 50 mg/ml soln, various vials

Vancomycin^97^ Restriction: Prior authorization required. 10 KFHC DRUG FORMULARY

GENERIC BRAND FORMS

Anti-infective - Leprosy - Drugs for infection^98^ 1 25mg, 100mg tablet

Dapsone^99^

Antineoplastic - Drugs for Cancer^100^ Kern Family Health Care covers all therapeutic categories of neoplastic agents. Many require authorization to ensure appropriate use in accordance with professional guidelines such as the National Comprehensive Cancer Network (NCCN) and FDA indications. Some sub-classes are covered through per diem or infusion arrangements and are not billed through the PBM. Many newer drugs are targeted therapies for very specific conditions. Proper documentation demonstrating the member is a candidate is required. Not every drug is listed in each category. The medications listed are representative only of the class/mechanism of action. Unless otherwise indicated, require prior authorization. 1 Panretin® 0.1% gel

Alitretinoin^101^ Restriction: Prior authorization required. 1 Hexalen® 50mg capsule

Altretamine^102^ 1 Arimidex® 1mg tablet

Anastrozole^103^ 1 Yescarta® plastic bag

Axicabtagene ciloleucel^104^ Restriction: Prior authorization required. 1 Avastin® 25 mg IV

Bevacizumab^105^ Restriction: Prior authorization required. 1 Targretin® 75 mg capsule

Bexarotene^106^ Restriction: Prior authorization required. 1 Casodex® 50 mg tablet

Bicalutamide^107^ 1 Leukeran® 2mg tablet

Chlorambucil^108^ 1 Cytoxan® 25mg, 50mg capsule

Cyclophosphamide^109^ Restriction: Prior authorization required. 1 5 mg, 20 mg IV

Daunorubicin^110^ Restriction: Prior authorization required. 1 Halaven® 1 mg/2 ml IV

Eribulin mesylate^111^ Restriction: Prior authorization required. Continued on next page KFHC DRUG FORMULARY 11

GENERIC BRAND FORMS Antineoplastic - Drugs for Cancer, continued • SEE PREVIOUS PAGE 1 Emcyt® 140mg capsule

Estramustine^112^ 1 Vepesid® 50mg capsule

Etoposide^113^ 1 Afinitor® 2.5 mg, 5 mg, 7.5 mg capsule

Everolimus^114^ Restriction: Prior authorization required. 1 Adrucil® 500 mg/ml, 2.5 G/50 ml, 5G/100 ml, various

Fluorouracil^115^ Restriction: Prior authorization required. 1 Eulexin® 125mg capsule

Flutamide^116^ 1 Mylotarg® 4.5 mg IV

Gemtuzumab ozogamicin^117^ Restriction: Prior authorization required. 1 Hyrea® 500mg capsule

Hydroxyurea^118^ 1 Gleevec® 100mg, 400mg tablet

Imatinib mesylate^119^ Restriction: Prior authorization required. 1 Yervoy® 50mg/10 ml, 200 mg/40 ml IV

Ipilimumab^120^ Restriction: Prior authorization required. 1 Camptosar® 100 mg/ 5 ml, 40 mg/2 ml, 300 mg/15 ml IV

Irinotecan^121^ Restriction: Prior authorization required. 1 Ixempra® 15 mg, 45 mg IV

Ixabepilone^122^ Restriction: Prior authorization required. 1 Revlimid® 2.5 mg, 5 mg, 10 mg, 15 mg, 20 mg, 25 mg capsule

Lenalidomide^123^ Restriction: Prior authorization required. 1 Femara® 2.5mg tablet

Letrozole^124^ 1 Lupron® 3.75-5 mg, 11.25-5 mg, 22.5 mg syringe

Leuprolide^125^ Restriction: Prior authorization required. 1 Gleostine® 10mg, 40mg, 100mg capsule

Lomustine^126^ 1 Megace® 40mg/ml susp, 20mg, 40mg tablet

Megestrol^127^ Continued on next page 12 KFHC DRUG FORMULARY

GENERIC BRAND FORMS Antineoplastic - Drugs for Cancer, continued • SEE PREVIOUS PAGE 1 Alkeran® 2mg tablet

Melphalan^128^ 1 Purinethol® 50mg tablet

Mercaptopurine^129^ 1 2.5mg tablet, 25mg/ml vial

Methotrexate^130^ 1 Lysodren® 500mg tablet

Mitotane^131^ 1 Opdivo® 40mg/4 ml, 100mg/10 ml IV

Nivolumab^132^ Restriction: Prior authorization required. 1 6 mg/ml vial

Paclitaxel^133^ Restriction: Prior authorization required. 1 Votrient® 200mg tablet

Pazopanib^134^ Restriction: Prior authorization required. 1 Photofrin® 75 mg IV

Porfimer sodium^135^ Restriction: Prior authorization required. 1 Matulane® 50mg capsule

Procarbazine^136^ 1 Cyramza® 100 mg/10 ml, 500 mg/50 ml IV

Ramucirumab^137^ Restriction: Prior authorization required. 1 Ruxience® 10mg IV

Rituximab- PVVR^138^ Restriction: Prior authorization required. 1 Nolvadex® 10mg, 20mg tablet

Tamoxifen^139^ 1 Temodar® 5mg, 20mg, 100mg, 140mg, 180mg, 250mg capsule

Temozolomide^140^ Restriction: Prior authorization required. 1 Thalomid® 50 mg, 100 mg, 150 mg, 200 mg capsule

Thalidomide^141^ Restriction: Prior authorization required. 1 40mg tablet

Thioguanine^142^ 1 Kanjinti® 150 mg, 440 mg IV

Trastuzumab-ANNS^143^ Restriction: Prior authorization required. Continued on next page KFHC DRUG FORMULARY 13

GENERIC BRAND FORMS Antineoplastic - Drugs for Cancer, continued • SEE PREVIOUS PAGE 1 Trelstar® 3.75 mg, 11.25 mg, 22.5 mg IV

Triptorelin^144^ Restriction: Prior authorization required. 1 1 mg/1 ml, 2 mg/ 2 ml IV

Vincristine^145^ Restriction: Prior authorization required. 1 Erivedge® 150 mg capsule

Vismodegib^146^ Restriction: Prior authorization required. 1 Zolinza® 100 mg capsule

Vorinostat^147^ Restriction: Prior authorization required. 1 Zaltrap® 100 mg/ 4 ml, 200 mg/8 ml IV

Ziv-Aflibercept^148^ Restriction: Prior authorization required.

Anti-Parkinsonism^149^ 1 Sinemet® 10mg-100mg, 25mg-100mg, 25mg-250mg tablet,

Carbidopa & Levodopa^150^ 25mg-100mg, 50mg-200mg cr tablet 1 Comtan® 200 mg tablet

Entacapone^151^ Restriction: Required trial and failure of carbidopa/levodopa alone. Works only in combination with levodopa. 1 250mg, 500mg capsule

Levodopa^152^ 1 Mirapex® 0.125mg, 0.25mg, 0.5mg, 1mg, 1.5mg tablet

Pramipexole^153^ Restriction: Restricted to Parkinsons only. Requires failure of levadopamine therapy. 1 Requip® 0.25mg, 0.5mg, 1mg, 2mg, 3mg, 4mg, 5mg tablet

Ropinirole^154^ Restriction: Restricted to Parkinsons only. Requires failure of levadopamine therapy.

Antirheumatiod and Disease Modifiers - Drugs for the immune system^155^ 1 Otezla® 30mg tablet

Apremilast^156^ Restriction: Prior authorization required. 1 Ridaura® 3mg capsule

Auranofin^157^ Restriction: Prior authorization required. 1 Imuran® 50mg tablet

Azathioprine^158^ 1 Plaquenil® 200mg tablet

Hydroxychloroquine^159^ Continued on next page 14 KFHC DRUG FORMULARY

GENERIC BRAND FORMS Antirheumatiod and Disease Modifiers - Drugs for the immune system, continued • SEE PREVIOUS PAGE 1 Arava® 10mg, 20mg tablet

Leflunomide^160^ Restriction: Plan rheumatologists only. 1 2.5mg tablet, 25mg/ml vial

Methotrexate^161^ 1 Azulfidine® 250mg/5ml susp, 500mg tablet & ec tablet

Sulfasalazine^162^

Antiuricosuric - Drugs for gout^163^ 1 Zyloprim® 100mg, 300mg tablet

Allopurinol^164^ 1 ColBenemid® 0.5mg-500mg tablet

Colchicine & Probenecid^165^ 1 Benemid® 500mg tablet

Probenecid^166^

Autonomic - Anticholinergic - Drugs to reduce GI motility^167^ 1 Bentyl® 10mg/5ml syrup, 10mg, 20mg capsule, 20mg tablet

Dicyclomine^168^ 1 Robinul® 1mg, 2mg tablet

Glycopyrrolate^169^ 1 Levsin® 0.125mg/ml drops

Hyoscyamine^170^

Autonomic - Cholinergic - Drugs to improve GI motility^171^ 1 Urecholine® 5mg, 10mg, 25mg, 50mg tablet

Bethanechol^172^ 1 Prostigmin® 15mg tablet

Neostigmine^173^ 1 Mestinon® 60mg tablet

Pyridostigmine^174^

Benign Prostate Hypertrophy - Drugs for the prostate^175^ 1 Proscar® 5 mg tablet

Finasteride^176^ Restriction: Plan urologists only. 1 Flomax® 0.4mg capsule

Tamsulosin^177^ Restriction: Trial and failure of formulary alpha blockers.

Biologics & Biosimilars^178^ 1 Humira® 40mg/0.8ml

Adalimumab^179^ Restriction: Prior authorization required. Continued on next page KFHC DRUG FORMULARY 15

GENERIC BRAND FORMS Biologics & Biosimilars, continued • SEE PREVIOUS PAGE 1 Enbrel® 25 mg, 50 mg

Etanercept^180^ Restriction: Prior authorization required. 1 Glatopa® 20mg/ml, 40mg/ml syringe

Glatiramer acetate^181^ Restriction: Prior authorization required. 1 Renflexis® 100mg vial

Infliximab-ABDA^182^ Restriction: Prior authorization required. 1 Extavia® injection

Interferon beta^183^ Restriction: Prior authorization required. 1 Cosentyx® 150 mg, 300 mg injection

Secukinumab^184^ Restriction: Prior authorization required.

Cardiovascular - Alphablocker - Drugs for the heart^185^ 1 Catapres® 0.1mg, 0.2mg,0.3mg tablet

Clonidine^186^ 1 Cardura® 1mg, 2mg, 4mg, 8mg tablet

Doxazosin^187^ 1 Tenex® 1mg, 2mg tablet

Guanfacine^188^ 1 Aldomet® 125mg, 250mg, 500mg tablet

Methyldopa^189^ 1 Minipress® 1mg, 2mg, 5mg capsules

Prazosin^190^ 1 Hytrin® 1mg, 2mg, 5mg, 10mg tablet or capsule

Terazocin^191^

Cardiovascular - Angiotensin Converting Enzyme Inhibtors - Drugs for the heart^192^ 1 Lotensin® 5mg, 10mg, 20mg, 40mg tablet

Benazepril^193^ 1 Vasotec® 5mg, 10mg, 20mg tablet

Enalapril^194^ 1 Zestril® 10mg, 20mg, 30 mg, 40mg tablet

Lisinopril^195^ 1 Accupril® 10mg, 20mg, 40mg tablet

Quinapril^196^ 1 Altace® 1.25mg, 2.5mg, 5mg, 10mg capsule

Ramipril^197^ 16 KFHC DRUG FORMULARY

GENERIC BRAND FORMS

Cardiovascular - Angiotensin Converting Enzyme Inhibtors Combination - Drugs for the heart^198^ 1 5mg-6.25mg, 10mg-12.5mg, 20mg-12.5mg,

Benazepril - HCTZ^199^ 20mg-25mg tablet 1 10mg-12.5mg, 20mg-12.5mg, 20mg-25mg tablet

Lisinopril - HCTZ^200^

Cardiovascular - Angiotensin II Receptor Blocker - Drugs for the heart^201^ 1 Avapro® 150mg, 300 mg tablet

Irbesartan^202^ 1 Cozaar® 50 mg, 100 mg tablet

Losartan^203^ 1 Diovan® 80mg, 160mg, 320mg tablet

Valsartan^204^

Cardiovascular - Angiotensin II Receptor Blocker Thiazide Combination - Drugs for the heart^205^ 1 Avalide® 150-12.5mg, 300-25mg tablet

Irbesartan-hctz^206^ 1 Hyzaar® 50-12.5mg, 100-12.5mg, 100-50mg tablet

Losartan-hctz^207^ 1 DiovanHCT® 160-12.5mg, 160-25mg, 320-12.5mg, 320-25mg tablet

Valsartan-hctz^208^

Cardiovascular - Antiarrhythmic - Drugs for the heart^209^ 1 200mg tablet

Amiodarone^210^ 1 Lanoxin® 0.05mg/ml elixir, 0.125mg, 0.25mg tablet

Digoxin^211^ 1 Norpace® 100mg, 150mg capsule, 100mg, 150 cr capsule

Disopyramide^212^ Restriction: Restricted to plan cardiologists only, others require prior authorization. 1 Tambocor® 50mg, 100mg, 150 mg tablet

Flecainide^213^ Restriction: Restricted to plan cardiologists only, others require prior authorization. 1 Mexitil® 150mg, 200mg, 250mg capsule

Mexiletine^214^ 1 Rythmol® 150mg, 225mg, 300mg tablet

Propafenone^215^ Restriction: plan cardiologists only, others require prior authorization. 1 Betapace® 80mg, 120mg, 160mg, 240mg tablet

Sotalol^216^

Cardiovascular - Antilipid (HMG - CoA Reductase Inhibitors) - Drugs for the heart^217^ KHS currently has the “Statin” drugs listed below on the Formulary. Half tablet dosing is required on statins. 1 Lipitor® 20mg, 40mg, 80mg tablet

Atorvastatin^218^ Continued on next page KFHC DRUG FORMULARY 17

GENERIC BRAND FORMS Cardiovascular - Antilipid (HMG - CoA Reductase Inhibitors) - Drugs for the heart, continued • SEE PREVIOUS PAGE 1 Pravachol® 20mg, 40mg tablet

Pravastatin^219^ 1 Crestor® 10mg, 20mg, 40mg tablet

Rosuvastatin^220^ 1 Zocor® 10mg, 20mg, 40mg, 80mg tablet

Simvastatin^221^

Cardiovascular - Antilipid/OTC - Drugs for the heart^222^ 1 100mg, 250mg, 500mg tablet, 125mg cr capsule,

Niacin^223^ 125mg, 250mg cr tablet

Cardiovascular - Antilipid - Fibrates - Drugs for the heart^224^ 1 54mg, 145mg, 160mg tablet

Fenofibrate^225^ Restriction: Trial and failure of gemfibrozil. Ok first line if on statin therapy. 1 Lopid® 600mg tablet

Gemfibrozil^226^

Cardiovascular - Antilipid - Lipotropics - Drugs for the heart^227^ 1 Zetia® 10mg tablet

Ezetimibe^228^ Restriction: Prior authorization required. Should be adjunct to statin therapy.

Cardiovascular - Antilipid - Other Medications - Drugs for the heart^229^ 1 Questran® Powder (bulk can only)

Cholestyramine^230^ 1 Colestid® 1g tablet

Colestipol^231^

Cardiovascular - Betablocker - Drugs for the heart^232^ 1 Sectral® 200mg, 400mg capsule

Acebutolol^233^ 1 Tenormin® 25mg, 50mg, 100mg tablet

Atenolol^234^ 1 Coreg® 3.125mg, 6.25mg, 12.5mg tablet

Carvedilol^235^ 1 Trandate® 100mg, 200mg, 300mg tablet

Labetolol^236^ 1 Lopressor® 50mg, 100mg tablet

Metoprolol tartrate^237^ 1 Inderal® 20mg/5ml, 40mg/5ml oral soln, 10mg, 20mg, 40mg,

Propranolol^238^ 60mg, 80mg tablet

Cardiovascular - Betablocker Thiazide Combination - Drugs for the heart^239^ 1 2.5-6.25 mg, 5-6.25 mg, 10-6.25 mg tablet

Bisoprolol - HCTZ^240^ 18 KFHC DRUG FORMULARY

GENERIC BRAND FORMS

Cardiovascular - Calcium Channel Blocker - Drugs for the heart^241^ 1 Norvasc® 2.5mg, 5mg, 10mg tablet

Amlodipine^242^ 1 Cardizem® 30mg, 60mg, 90mg, 120mg tablet, 120mg/24hr,

Diltiazem^243^ 180mg/24hr, 240mg/24hr, 300mg/24hr, 360mg/24hr cr capsule 1 Adalat CC® 30mg, 60mg, 90mg cr tablet

Nifedipine^244^ 1 Calan®, Calan SR® 40mg, 80mg, 120mg tablet, 120mg cr tablet, 180mg cr

Verapamil^245^ tablet, 240mg cr tablet

Cardiovascular - Diuretic - Drugs for the heart^246^ 1 15mg, 25mg tablet

Chlorthalidone^247^ 1 Lasix® 8mg/ml, 10mg/ml soln, 20mg, 40mg, 80mg tablet

Furosemide^248^ 1 Esidrix® 25mg tablet

Hydrochlorothiazide^249^ 1 Lozol® 1.25mg, 2.5mg tablet

Indapamide^250^ 1 Zaroxolyn® 2.5mg, 5mg, 10mg tablet

Metolazone^251^ Restriction: Restricted to members on furosemide therapy. 1 Aldactone® 25mg, 50mg, 100mg tablet

Spironolactone^252^ 1 Dyrenium® 50mg, 100mg capsule

Triamterene^253^

1 Triamterene & Dyazide®, Maxide® 37.5mg-25mg capsule, 75mg-50mg tablet

Hydrochlorothiazide^254^

Cardiovascular - Electrolyte/OTC - Drugs for the heart^255^ 1 Pedialyte® Soln

Oral electrolyte Soln^256^ Restriction: Limited to 3000 ml per dispensing.

Cardiovascular - Electrolyte Depleter - Drugs for the heart^257^ 1 PhosLo® 667mg capsule

Calcium Acetate^258^ Restriction: For renal patients only. 1 Fosrenol® 500mg, 750mg, 1000mg tablet

Lanthunum Carbonate^259^ Restriction: Max 3000mg/day. Continued on next page KFHC DRUG FORMULARY 19

GENERIC BRAND FORMS Cardiovascular - Electrolyte Depleter - Drugs for the heart, continued • SEE PREVIOUS PAGE 1 Veltassa® 8.4 g, 16.8g, 25.2 gm powder

Patiromer^260^ Restriction: Prior authorization required. 1 8mEq,10mEq, 20mEq cr tablet, 10%, 20% liquid

Potassium Chloride^261^ 1 Renvela® 800mg tablet

Sevelamer Carbonate^262^ Restriction: Maximum of 12 tablets daily if prescribed by a nephrologist. Higher doses require prior authorization, support with lab values. 1 Kayexalate® 25% susp only

Sodium Polystyrene Sulfonate^263^

Cardiovascular - Pulmonary Arterial Hypertension Endothelin Receptor Antagonist - Drugs for the heart^264^ 1 Letairis® 5 mg, 10 mg tablet

Ambrisentan^265^ Restriction: Prior authorization required. 1 Tracleer® 62.5 mg, 125 mg tablet

Bosentan^266^ Restriction: Prior authorization required.

Cardiovascular - Pulmonary Arterial Hypertension Phosphodiesterase 5 Inhibitor - Drugs for the heart^267^ 1 Revatio® 20mg tablet

Sildenafil^268^ Restriction: Prior authorization required.

Cardiovascular - Pulmonary Arterial Hypertension Prostacyclin type - Drugs for the heart^269^ 1 Flolan® 0.5 mg, 1.5 mg vial

Epoprostenol^270^ Restriction: Prior authorization required.

Cardiovascular - Vasodilator - Drugs for the heart^271^ 1 Apresoline® 10mg, 25mg, 50mg, 100mg tablet

Hydralazine^272^ 1 Isordil® 5mg, 10mg, 20mg, 30mg tablet, 2.5mg, 5mg sl tablet,

Isosorbide Dinitrate^273^ 5mg, 10mg chewable tablet 1 Imdur® 60mg, 120mg tablet

Isosorbide Mononitrate^274^ 1 Loniten® 2.5mg, 10mg tablet

Minoxidil^275^ 1 Nitrostat® 0.3mg, 0.4mg, 0.6mg sl tablet

Nitroglycerin^276^ 1 0.1 mg/hr, 0.2 mg/hr, 0.3 mg/hr, 0.4 mg/hr, 0.6

Nitroglycerin^277^ mg/hr, 0.8 mg/hr patch 20 KFHC DRUG FORMULARY

GENERIC BRAND FORMS

Central Nervous System - Anticonvulsant - Drugs for the nervous system^278^ 1 Tegretol® 100mg chewable tablet, 200mg tablet, 100mg/5ml susp

Carbamazepine^279^ 1 Klonopin® 0.5mg, 1mg, 2mg tablet

Clonazepam^280^ 1 Depakote®, Depakote 125mg ec capule, 125mg, 250mg, 500mg ec tablet,

Divalproex^281^ ER® 500mg cr tablet, 250mg/5ml soln 1 Zarontin® 250mg/5ml syrup, 250mg capsule

Ethosuximide^282^ 1 Neurontin® 100mg, 300mg, 400mg capsule, 600mg, 800mg tablet

Gabapentin^283^ 1 Lamictal® 5mg, 25mg chewable tablet, 100mg,150mg, 200mg

Lamotrigine^284^ tablet 1 Keppra® 500mg, 750mg, 1000mg tablet, 500mg XR, 750mg XR

Levetiracetam^285^ tablet 1 Trileptal® 300mg, 600mg tablet

Oxcarbazepine^286^ 1 20mg/5ml elixir, 15mg, 30mg, 60mg, 100mg tablet

Phenobarbital^287^ 1 Dilantin®, Phenytek® 50mg chewable tablet, 30mg, 100mg capsule,

Phenytoin^288^ 30mg/5ml, 125mg/5ml susp 1 Lyrica® 25mg, 50mg, 75mg, 100mg, 150mg, 200mg, 225mg,

Pregabalin^289^ 300mg capsule 1 Mysoline® 250mg/5ml susp, 50mg, 250mg tablet

Primidone^290^ 1 Gabitril® 2mg, 4mg, 12mg, 16mg tablet

Tiagabine^291^ Restriction: Restricted to plan Neurologists. 1 Topamax® 15mg, 25mg sprinkle capsule, 25mg, 50 mg, 100mg,

Topiramate^292^ 200mg tablet Restriction: Capsules allowed for children < 10 years old. 1 Zonegran® 25mg, 50mg, 100mg capsule

Zonisamide^293^

Central Nervous System - Antidepressant - Antipsychotic - Drugs for the nervous system^294^ 1 Triavil® 2-10mg, 2-25mg, 4-10mg, 4-25mg tablet

Perphenazine & Amitriptyline^295^ Restriction: Prior authorization required. Central Nervous System - Antidepressant - Norepinephrine Antagonist and Serotonin Antagonist

Antidepressants - Drugs for the nervous system^296^ 1 Remeron® 15mg, 30mg, 45mg tablet

Mirtazapine^297^ KFHC DRUG FORMULARY 21

GENERIC BRAND FORMS Central Nervous System - Antidepressant - Norepinephrine-Dopamine Reuptake Inhibitors (NDRI) - Drugs

for the nervous system^298^ 1 Wellbutrin® 100 mg, 150 mg, 200 mg cr tablet, 150 mg, 300 mg xl

Bupropion^299^ tablet Restriction: Restricted to Depression formulation designation. 1 Desyrel® 50mg, 100mg, 150mg tablet

Trazodone^300^ Central Nervous System - Antidepressant - Selective Serotonin Reuptake Inhibitors (SSRI) - Drugs for the

nervous system^301^ Fluoxetine is the least expensive of the SSRIs. KHS recommends the generic Fluoxetine as the economic SSRI of choice. Only the 20mg capsules will be covered since they are so inexpensive compared to the 40mg. DHCS has age restrictions on use in pediatrics. Please consult FDA on specific guidelines. KHS formulary requires half tablet dosing for all tablets in this class except for citalopram. All generic formulations must be tried and considered before branded, non-formulary medications will be considered. Tablet splitters are covered for KHS patients. 1 Celexa® 10mg, 20mg, 40mg tablet

Citalopram^302^ Restriction: Allowed > 12 years old. 1 Lexapro® 5mg, 10mg, 20mg tablet

Escitalopram^303^ Restriction: Citalopram trial and failure required. Allowed > 12 years old. 1 Prozac® 10mg, 20mg capsule, 20mg/5ml soln

Fluoxetine^304^ Restriction: Restricted to 10mg NMT 1 daily, 20mg NMT 4 daily. Allowed > 7 years old. 1 Luvox® 50mg, 75mg, 100mg tablet, 100mg, 150mg er capsule

Fluvoxamine^305^ Restriction: 100mg and 150 mg ER capsule PA required. Allowed > 8 years old. 1 Paxil® 20mg, 30mg, 40mg tablets, 10mg/5ml susp

Paroxetine^306^ Restriction: Allowed > 18 years old. Suspension requires prior authorization. 1 Zoloft® 50mg, 100mg tablet

Sertraline^307^ Restriction: Allowed > 6 years old.

Central Nervous System - Antidepressant - Tricyclics (TCA) - Drugs for the nervous system^308^ 1 10mg, 25mg, 50mg, 75mg, 100mg, 150mg tablet

Amitriptyline^309^ Continued on next page 22 KFHC DRUG FORMULARY

GENERIC BRAND FORMS Central Nervous System - Antidepressant - Tricyclics (TCA) - Drugs for the nervous system, continued • SEE PREVIOUS PAGE 1 Anafranil® 25mg, 50mg, 75mg capsule

Clomipramine^310^ Restriction: Prior authorization required. 1 Norpramin® 10mg, 25mg, 50mg, 75mg, 100mg, 150mg tablet

Desipramine^311^ 1 Tofranil® 10mg, 25mg, 50mg tablet, 75mg, 100mg, 150mg

Imipramine^312^ capsule (pamoate) 1 Pamelor® 10mg, 25mg, 50mg, 75mg capsule, 10mg/5ml soln

Nortriptyline^313^ Central Nervous System - Antidepressant-Serotonin - Norepinephrine Reuptake Inhibitors (SNRI) - Drugs for the nervous system ^314^ 1 Cymbalta® 20mg, 30mg, 60mg capsule

Duloxetine^315^ 1 Effexor®, Effexor XR® 25mg, 37.5mg, 50mg, 75mg, 100mg tablet, 37.5mg,

Venlafaxine^316^ 75mg, 150mg cr capsule

Central Nervous System - Anxiolytic - Drugs for the nervous system^317^ The Benzodiazepine anxiolytic medications are restricted to prevent patients becoming habituated or addicted to them. Doses for physicians who are not mental health specialists are also restricted. Diazepam and lorazepam are restricted to an initial 90 days supply and have the following daily maximums. The SSRI’s are recommended for long term antianxiety therapy. Caution should be used when combining with opioids. Medication Daily Maximum Dose Diazepam 10mg Lorazepam 2mg 1 Buspar® 5mg, 10mg, 15mg tablet

Buspirone^318^ 1 Klonopin® 0.5mg, 1mg, 2mg tablet

Clonazepam^319^ 1 Valium® 2mg, 5mg, 10mg tablet

Diazepam^320^ Restriction: Restricted to 90 days therapy and 10mg maximum daily dose. 1 Ativan® 0.5mg, 1mg, 2mg tablet

Lorazepam^321^ Restriction: Restricted to 90 days therapy and 2mg maximum daily dose. KFHC DRUG FORMULARY 23

GENERIC BRAND FORMS

Central Nervous System - Migraine - Drugs for the nervous system^322^ 1 Butalbital, Caffeine, & Fioricet® 50mg-40mg-325mg tablet

Acetaminophen^323^ Restriction: 50 tablets maximum per month. 1 Fiorinal® 50mg-40mg-325mg capsule/tablet

Butalbital, Caffeine, & Aspirin^324^ Restriction: 50 capsules maximum per month. 1 Cafergot® 1mg-100mg tablet, 2mg-100mg supp

Ergotamine & Caffeine^325^ Restriction: 20 doses per month. 1 2mg sl tablet

Ergotamine Tartarate^326^

Central Nervous System - Migraine-Triptan - Drugs for the nervous system^327^ The Triptan medications are the largest expense category of the anti-migraine drugs. The Triptan medications are maximally restricted to 9 tablets per 30 day period and 3 dispensings in a 365 day period. Patients whose demand exceeds the 3 fills are recommended to be considered for prophylactic medications and for a Neurology referral. Medication Cost/9 tablets Sumatriptan (Imitrex®) 50-100mg $9 Naratriptan (Amerge®) 2.5mg $25 Rizatriptan (Maxalt®) 5mg $19 Zolmitriptan (Zomig®) 5mg $57 1 Amerge® 1mg, 2.5mg tablet

Naratriptan^328^ Restriction: 9 tablets in 30 days with a maximum of 3 fills in a 12 month period. 1 Maxalt® 5mg, 10mg tablet

Rizatriptan^329^ Restriction: 12 tablets in 40 days with a maximum of 2 fills in a 12 month period. 1 Imitrex® 50mg, 100mg tablet only

Sumatriptan^330^ Restriction: Restricted to 9 tablets in 30 days with a maximum of 3 fills in a 12 month period.

Central Nervous System - Sedative - Drugs for the nervous system^331^ Many references on insomnia recommend against prescribing sedative medication on a nightly basis. KHS will promote this utilization. These medications will be restricted to the treatment of insomnia and 15 per 30 days. For those patients experiencing morning drowsiness from the regular strengths of the Formulary medications low dose Temazepam (Restoril® 7.5mg) is offered. The FDA has issued recommendations for lower doses for women. Caution should be used in combination with opioids. Continued on next page 24 KFHC DRUG FORMULARY

GENERIC BRAND FORMS Central Nervous System - Sedative - Drugs for the nervous system, continued • SEE PREVIOUS PAGE 1 Restoril® 15mg, 30mg capsule

Temazepam^332^ Restriction: Allow 15 capsules in 30 days. 1 Ambien® 5mg, 10mg tablet

Zolpidem^333^ Restriction: Allow 15 tablets in 30 days. 5mg daily maximum allowed for women.

Central Nervous System - Stimulant - Drugs for the nervous system^334^ Restricted to members between the ages of 4 and 16 years old with ADD/ADHD. ER formulations limited to once daily dosing in accordance to FDA dosing guidelines. 1 Adderall®, Adderall XR® 5mg, 7.5mg, 10mg, 20mg, 30mg tablet, 5mg, 10mg,

Amphetamine Combination^335^ 15mg, 20mg, 25mg, 30mg cr tablet 1 Focalin®, Focalin XR® 5mg, 10mg tablet, 5mg, 10mg, 15mg, 20mg, 30mg

Dexmethylphenidate^336^ capsule 1 Dexedrine® 5mg, 10mg tablet, 10mg, 15mg, cr capsule

Dextro-amphetamine^337^ 1 Vyvanse® 20mg, 30mg, 40mg, 50mg, 60mg, 70mg capsule

Lisdexamfetamine^338^ Restriction: Must fail generic amphetamines first. 1 Ritalin® 5mg, 10mg, 20mg tablet, 20mg cr tablet

Methylphenidate^339^

Cholinesterase Inhibitors - Drugs for memory loss^340^ 1 Aricept® 5mg, 10mg tablet

Donepezil^341^ Restriction: Prior authorization required. MMSE

Drug Dependency Therapy^342^ 1 Nicorette®, Nicotrol®, 2mg, 4mg gum, 2mg, 4 mg lozenge, 10mg cartridge,

Nicotine^343^ Nicoderm CQ® 10mg/ml spray, 7mg, 14 mg, 21 mg patches 1 Chantix® 0.5mg, 1mg tablet

Varenicline^344^

Enterals^345^ Enterals are covered by KHS following the Medi-Cal guidelines for coverage and exclusion. Only products listed on the Fee-For-Service product list are covered. The products are grouped by the following product categories: • Elemental and Semi-Elemental • Metabolic • Specialized • Specialty Infant Continued on next page KFHC DRUG FORMULARY 25

GENERIC BRAND FORMS Enterals, continued • SEE PREVIOUS PAGE • Standard KHS members must meet the medical criteria for the product category specific to the product requested. Enteral nutrition products may be covered upon authorization when used as a therapeutic regimen to prevent serious disability or death in patients with medically diagnosed conditions that preclude the full use of regular food (California Code of Regulations [CCR], Title 22, Section 51313.3). Enteral nutrition products covered are subject to the Medi-Cal List of Enteral Nutrition Products and utilization controls (Welfare and Institutions Code [W&I Code], Sections 14132.86, 14105.8 and 14105.395). Enteral nutrition products provided to inpatients receiving inpatient hospital services are included in the hospital's reimbursement made under the CCR, Title 22, Section 51536. These products are not separately reimbursable. Enteral nutrition products provided to inpatients receiving Nursing Intermediate Care Facilities Facility Level A services or Nursing Facility Level B services are not separately reimbursable. Enteral nutrition products provided to patients in an Intermediate Care Facility for the Developmentally Disabled (ICF/DD), Intermediate Care Facility for the Developmentally Disabled/Habilitative (ICF/DD-H) or Intermediate Care Facility for the Developmentally Disabled/Nursing ICF/DD-N) are reimbursed as part of the facility's daily rate and are not separately reimbursable (CCR, Title 22, Sections 51510.1, 51510.2 and 51510.3). The following nutrition products are not covered by Medi-Cal: • Regular food, including solid, semi-solid, blenderized and pureed foods • Common household items • Regular infant formula as defined in the Federal Food, Drug and Cosmetic Act (FD&C Act) • Shakes, cereals, thickened products, puddings, bars, gels and other non-liquid products • Thickeners • Products for assistance with weight loss • Vitamin and/or mineral supplements, except for pregnancy and birth up to 5 years of age (Refer to the appropriate contract drugs list section in this manual for more information). • Enteral nutrition products used orally as a convenient alternative to preparing and/or consuming regular solid or pureed foods 26 KFHC DRUG FORMULARY

GENERIC BRAND FORMS

Gastrointestinal - Antacid/OTC - Drugs for the stomach^346^ 1 Aluminum & Magnesium Maalox® 200mg-200mg/5ml susp

Hydroxides^347^

1 Aluminum & Magnesium Mylanta® 200mg-200mg-25mg chewable tablet, 400mg-400mg-40mg/ 5ml susp

Hydroxides w/Simethicone^348^

1 Aluminum Hydroxide & Mag. Gaviscon® 80mg-14.2mg chewable tablet

Trisilicate^349^

1 Aluminum Hydroxide, Mag. Gaviscon® 160mg-105mg chewable tablet, 31.7mg-119.3mg/5ml susp

Carbonate^350^ 1 500mg tablet

Calcium^351^

1 Calcium Carbonate (20 mEq Tums® Os-Cal D® 650mg tablet, 1250mg tablet or capsule, 500mg tablet Ca++/Gm) Calcium Carbonate

w/Vitamin D^352^

1 Calcium Gluconate (4.5mEq 500mg, 650mg, 1 gm tablet

Ca++/Gm)^353^

1 Calcium acetate (12.5mEq 667mg tablet

Ca++/Gm)^354^

1 Calcium lactate (6.5mEq 325mg, 650mg tablet

Ca++/Gm)^355^ 1 Riopan® 540mg/5ml susp

Magaldrate^356^

Gastrointestinal - Antidiarrhea/OTC - Drugs for the stomach^357^ 1 Imodium® 2mg capsule, tablet, 1mg/5ml liquid

Loperamide^358^

Gastrointestinal - Antidiarrheal - Drugs for the stomach^359^ 1 Lomotil® 2.5mg/5ml liq, 2.5mg tablet

Diphenoxylate & Atropine^360^ 1 2mg/5ml liq

Paregoric^361^

Gastrointestinal - Antiemetic/OTC - Drugs for the stomach^362^ 1 25mg tablet

Doxylamine Succinate^363^ Restriction: Restricted to plan OB/GYN only. 1 Antivert® 25mg chewable tablet

Meclizine^364^ KFHC DRUG FORMULARY 27

GENERIC BRAND FORMS

Gastrointestinal - Antiemetic - Drugs for the stomach^365^ 1 Emend® 40mg, 80mg, 125mg, 125-80mg, 150mg vial

Aprepitant^366^ Restriction: Restricted to highly emetic chemotherapy such as 'platinum' therapy. Allow up to 3 days per treatment. 1 Marinol® 2.5mg, 5mg, 10mg capsule

Dronabinol^367^ Restriction: Restricted to use by KHS plan Oncologist. 1 Kytril® 1mg tablet

Granisetron^368^ Restriction: Prior authorization required. 1 Zofran® 4mg, 8mg tablet, ODT

Ondansetron^369^ Restriction: Allow up to 3 days of therapy per oncology treatment. 1 Compazine® 5mg, 10mg tablet, 15mg cr capsule, 2.5mg, 5mg, 10mg

Prochlorperazine^370^ supp, 5mg/5ml syrup 1 Phenergan® 6.25mg/5ml, 25mg/5ml syrup, 12.5mg, 25mg, 50mg

Promethazine^371^ tablet or supp Restriction: Restricted to members > 2 years old.

Gastrointestinal - Digestant - Drugs for the stomach^372^ 1 Creon®, Zenpep® varying strengths -capsule, tablet, chewable tablet, ec

Amylase, Lipase, & Protease^373^ tablet Restriction: Prior authorization required. 1 Actigall® 300mg capsule, 250 mg, 500 mg tablet

Ursodiol^374^ Restriction: Prior authorization required.

Gastrointestinal - H2 Antagonist/OTC - Drugs for the stomach^375^ 1 Pepcid AC® 10mg tablet

Famotidine^376^ Restriction: Minimum of 30/package.

Gastrointestinal - H2 Antagonist - Drugs for the stomach^377^ If the patient is on a PPI there is usually no advantage of also prescribing an H2 Antagonist. Some patients experiencing break through symptoms at night with a morning PPI may benefit from a night dose of an H2 Antagonist. If the drugs are given at the same time it may lessen the effectiveness of the PPI. Note that the OTC H2 Antagonists require a package size of 30 or more. 1 Pepcid® 10mg, 20mg, 40mg tablet

Famotidine^378^ 1 Zantac® 150mg tablet, 15mg/ml syrup

Ranitidine^379^ 28 KFHC DRUG FORMULARY

GENERIC BRAND FORMS

Gastrointestinal - Helicobacter Pylori Treatment - Drugs for the stomach^380^ Preferred Therapy according to the American College of Gastroenterology, 2017, is quadruple therapy. Quadruple Therapy PO for 10-14 days: bismuth subsalicylate 262mg QID + metronidazole 500mg TID-QID + doxycycline 100mg BID + PPI Concomitant Quadruple Therapy PO for 10-14 days: clarithromycin 500 mg BID +amoxicillin 1 g BID + metronidazole 500 mg BID + PPI Triple therapy PO x 7-14 days: clarithromycin 500 mg bid + amoxicillin 1 g bid (or metronidazole 500 mg bid) + a PPI* *PPI’s omeprazole 20 mg bid, pantoprazole 20mg bid

Gastrointestinal - Laxative - Drugs for the stomach^381^ 1 Cephulac® 10mg/15ml syrup

Lactulose^382^ 1 Miralax® powder

PEG^383^ 1 Go-Lytely® powder for soln

PEG-Electrolyte^384^

Gastrointestinal - Laxative /OTC - Drugs for the stomach^385^ 1 Dulcolax® 5mg tablet, 10mg supp

Bisacodyl^386^ Restriction: Tablet for colon diagnostic testing only. 1 Colace® 100mg, 250mg capsule, 10 mg/5 ml syrup for members

Docusate^387^ < 6 years old NMT 240 ml/ rx, 20 mg/5 ml, 50 mg/5 ml liq 1 solution

Magnesium citrate^388^ Restriction: For colon diagnostic testing only. 1 Fleets® enema

Mineral oil^389^ Restriction: For colon diagnostic testing only.

Gastrointestinal - Miscellaneous - Drugs for the stomach^390^ 1 Colazal® 750mg capsule

Balsalazide^391^

1 Hemorrhoidal Suppository Anusol-HC® supp

w/Hydrocortisone^392^ Restriction: Max 2/day, and 7 days every 30 days. 1 Cortenema® 100mg/60ml susp

Hydrocortisone enema^393^ Continued on next page KFHC DRUG FORMULARY 29

GENERIC BRAND FORMS Gastrointestinal - Miscellaneous - Drugs for the stomach, continued • SEE PREVIOUS PAGE 1 Asacol®, Delzicol®, 800mg er tablet, 400mg tablet, 1.2 g DR tablet

Mesalamine^394^ Lialda® Restriction: Try and fail balsalazide therapy before considering mesalamine. 1 Reglan® 5mg/5ml syrup, 5mg, 10mg tablet

Metoclopramide^395^ 1 Cytotec® 100mg, 200mg tablet

Misoprostol^396^ 1 Pro-Banthine® 15mg tablet

Propantheline^397^ Restriction: plan gastroenterologists only. 1 Carafate® 1gm tablet

Sucralfate^398^ Restriction: Restricted to members with duodenal ulcer, NMT 90 days therapy. 1 Azulfidine® 500mg tablet & ec tablet

Sulfasalazine^399^

Gastrointestinal - Protectant/OTC - Drugs for the stomach^400^ 1 Pepto-Bismal® 262mg tablet or chewable tablet, 525mg/15ml

Bismuth Subsalicylate^401^ 527mg/30ml susp

Gastrointestinal - Proton Pump Inhibitor - Drugs for the stomach^402^ Proton Pump Inhibitors (PPIs) are one of the highest expense medication categories for most health plans. The Plan PPIs of choice are omeprazole and pantoprazole. Other PPIs will only be allowed with a fair trial of up to BID dosing of the preferred PPIs. Prescription strength PPIs will be allowed in order of escalating cost. It is important to guide patients with life style changes to eliminate possible causes of GERD. Long term use of PPIs in management of GERD should be used with caution. KHS offers triple therapy for the treatment of Heliobacter Pylori (H. Pylori). See H. pylori section. While bedtime dosing of an H2 antagonist for break through reflux may be tried, usually taking a PPI and H2 antagonist together is not clinically justified and may actually make the PPI less effective. Cost of PPI per patient month to KHS Medication Drug Cost for 30 Omeprazole $4 Pantoprazole $5 Lansoprazole $19 Rabeprazole $19 Non-Formulary Monthly Annual Prescription PPIs Additional Cost Additional Cost Dexilent® $271 $3252 Continued on next page 30 KFHC DRUG FORMULARY

GENERIC BRAND FORMS Gastrointestinal - Proton Pump Inhibitor - Drugs for the stomach, continued • SEE PREVIOUS PAGE 1 Nexium 24HR (OTC)® 20mg capsule

Esomeprazole^403^ Restriction: Must fail omeprazole and pantoprazole therapy. 1 Prevacid® 30mg capsule

Lansoprazole^404^ Restriction: Must fail omeprazole and pantoprazole therapy. 1 Prilosec® 20mg, 40 mg capsule

Omeprazole^405^ 1 Protonix® 20mg, 40mg tablet

Pantoprazole^406^ 1 Aciphex® 20mg tablet

Rabeprazole^407^ Restriction: Must fail omeprazole and pantoprazole therapy.

Hematinic/OTC - Drugs for the blood^408^ 1 various 240mg, 324mg tablet

Ferrous Gluconate^409^ 1 Fer-in-Sol® 75mg/ml soln, 300mg/5ml syrup, 324mg tablet, 325mg

Ferrous Sulfate^410^ cr & ec tablet

Hematology - Anticoagulant - Drugs for the blood^411^ 1 Eliquis® 2.5mg, 5mg tablet, Starter pack

Apixaban^412^ 1 Lovenox® 30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml,

Enoxaparin^413^ 100mg/1m, 120mg/1ml, 150mg/1ml injection Restriction: Restricted to a 14 day supply. Authorization is required for additional amounts. 1 1000 units/ml, 5000 units/ml, 10,000 units/ml

Heparin^414^ (bovine), 1000 units/ml, 5000 units/ml, 10,000 units/ml, 20,000 units/ml, 40,000 units/ml, 100 units/ml lock flush (porcine) Restriction: Lock flush billed as Medical claim. 1 Xarelto® 10mg, 15mg, 20mg tablet, Starter pack

Rivaroxaban^415^ 1 Coumadin® 1mg, 2mg, 2.5mg, 3mg, 4mg, 5mg, 6mg, 7.5mg,10mg

Warfarin^416^ tablet

Hematology - Antiplatelet - Drugs for the blood^417^ 1 Agrylin® 1mg capsule

Anagrelide^418^ Restriction: Prior authorization required. Continued on next page KFHC DRUG FORMULARY 31

GENERIC BRAND FORMS Hematology - Antiplatelet - Drugs for the blood, continued • SEE PREVIOUS PAGE 1 Plavix® 75mg tablet

Clopidogrel^419^ 1 Persantine® 25mg, 50mg, 75mg tablet

Dipyridamole^420^ 1 Effient® 5mg, 10mg tablet

Prasugrel^421^ Restriction: Prior authorization required. Available first line if written by cardiologist. Up to 12 month therapy allowed. 1 Brilinta® 60mg, 90mg tablet

Ticagrelor^422^ Restriction: Prior authorization required. Available first line if written by cardiologist. Up to 12 month therapy allowed.

Hematology - Coagulant - Drugs for the blood^423^ 1 Mephyton® 5mg tablet

Phytonadione^424^

Hematology - Hematopoietic - Drugs for the blood^425^ 1 Aranesp® 25mcg/ml, 40mcg/ml, 60mcg/ml, 100mcg/ml and

Darbepoetin^426^ 200mcg/ml. 1 Retacrit® 2000 units/ml, 3000 units/ml, 4000 units/ml, 10,000

Epoetin, Alpha^427^ units/ml, 20,000 units/ml, 40,000 units/ml injection Restriction: Restricted to patients with anemia from Zidovudine therapy or CRF. Epogen allowed for 20,000 unit/ml.

Hematology - Miscellaneous - Drugs for the blood^428^ 1 50mg, 100mg tablet

Cilostazol^429^ Restriction: Restricted to members > 65 years old with intermittant claudication or diabetic of any age with intermittant claudication. 1 Trental® 400mg tablet

Pentoxifylline^430^ Restriction: Restricted to members > 65 years old with intermittant claudication or diabetic of any age with intermittant claudication.

Hormone - Androgen Drugs for hormones^431^ 1 Depo-Testosterone® 100mg/ml, 200mg/ml vial

Testosterone^432^ Restriction: Prior authorization required.

Hormone - Anti-Androgen^433^ 1 Danocrine® 50mg, 100mg, 200mg capsule

Danazol^434^ Restriction: Prior authorization required. 32 KFHC DRUG FORMULARY

GENERIC BRAND FORMS

Hormone - Antidiabetic - Amylin Analog - Drugs for diabetes^435^ 1 Symlin® Pen injector

Pramalintide^436^ Restriction: Prior authorization required.

Hormone - Antidiabetic - Dipeptidyl Peptidase-4 - Drugs for diabetes^437^ 1 Nesina® 6.25mg, 12.5mg, 25mg tablet

Alogliptin^438^ Restriction: Restricted to members on metformin or cannot take or failed metformin. Please consider when initiating DPP-4 therapy. 1 Tradjenta® 5mg tablet

Linagliptin^439^ Restriction: Restricted to members adherent on metformin or cannot take or failed metformin. PA required. DPP-4 therapy is expected to use Alogliptin unless CHF contraindications exist demonstrated by supporting documentation.

Hormone - Antidiabetic - Dipeptidyl Peptidase-4 - Metformin - Drugs for diabetes^440^ 1 Kazano® 12.5-500mg, 12.5-1000mg tablet

Alogliptin/metformin^441^ Restriction: Restricted to members on metformin.

Hormone - Antidiabetic - Dipeptidyl Peptidase-4 - Thiazolidinedione - Drugs for diabetes^442^ 1 Oseni® 12.5-15mg, 12.5-30mg, 12.5-45mg, 25-15mg,

Alogliptin/pioglitazone^443^ 25-30mg, 25-45mg tablet Restriction: Restricted to members on metformin or cannot take or failed metformin.

Hormone - Antidiabetic Alpha-glucodiase Inhibitor - Drugs for diabetes^444^ 1 Precose® 25mg, 50mg, 100 mg tablet

Acarbose^445^ Restriction: Restricted to endocrinologists.

Hormone - Antidiabetic Biguanide - Drugs for diabetes^446^ Metformin is a valuable medication for the treatment of diabetes. A specific advantage of Metformin is that it can help minimize weight gain. Patients who try generic Metformin and have nausea may be considered for Glucophage XR®. 1 Glucophage®, Glucophage 500mg, 850mg, 1000mg tablet, 500mg cr tablet

Metformin^447^ XR®

Hormone - Antidiabetic GLP-1 Agonists - Drugs for diabetes^448^ 1 Trulicity® 0.75mg/0.5, 1.5mg/0.5 injection

Dulaglutide^449^ Restriction: Restricted to members adherent to > 90 of SGLT-2 therapy or members seen by endocrinologists with history of SGLT-2 therapy. Continued on next page KFHC DRUG FORMULARY 33

GENERIC BRAND FORMS Hormone - Antidiabetic GLP-1 Agonists - Drugs for diabetes, continued • SEE PREVIOUS PAGE 1 Bydureon® 2mg vial, pen, Bcise

Exenatide^450^ Restriction: Restricted to members adherent to > 90 of SGLT-2 therapy or members seen by endocrinologists with history of SGLT-2 therapy. 1 Victoza® 0.6mg/0.1 injection

Liraglutide^451^ Restriction: Restricted to members seen by endocrinologists on SGLT-2 therapy of any duration also demonstrating concurrent cardiovascular disease with supporting clinical documentation. 1 Adlyxin® 20 mcg injection, starter

Lixisenatide^452^ Restriction: Restricted to members adherent to > 90 of SGLT-2 therapy or members seen by endocrinologists with history of SGLT-2 therapy. 1 Ozempic® Rybelsus® 3 mg, 7 mg, 14 mg tablet, 1 mg injection

Semaglutide^453^ Restriction: Restricted to members seen by endocrinologists on SGLT-2 therapy of any duration.

Hormone - Antidiabetic GLP-1 Agonists glargine combination - Drugs for diabetes^454^ 1 Soliqua® 100-33/ml injection

Insulin glargine/lixisenatide^455^ Restriction: Restricted to members currently on insulin glargine or GLP-1.

Hormone - Antidiabetic Insulin - Drugs for diabetes^456^ 1 Novolog® 100 units/ml, 70-30 mix

Insulin aspart^457^ 1 Tresiba® 100 units/ml, 200 units/ml

Insulin degludec^458^ Restriction: Restricted to endocrinologists. 1 Levemir® 100 units/ml

Insulin detemir^459^ Restriction: Restricted to adverse reactions to glargine or for use in pregnant women. 1 Basaglar®, Toujeo® 100 units/ml, 300 units/ml

Insulin glargine^460^ Restriction: Toujeo therapy reserved for endocrinologist for members failing maximum dosed Basaglar. 1 Apidra® 100 units/ml

Insulin glulisine^461^ 1 Admelog®, Humalog® 100 units/ml, 50-50mix, 75-25 mix

Insulin lispro^462^ Restriction: Admelog allowed for single ingredient formulation. Humalog for mixed formulations. 1 Humulin® Novolin® 100 units/ml Regular, Lente, NPH, 50-50, 70-30 mix,

Insulin, Human^463^ 500 unit/ml Regular Restriction: U-500 restricted to endocrinology. 34 KFHC DRUG FORMULARY

GENERIC BRAND FORMS

Hormone - Antidiabetic Meglitinide - Drugs for diabetes^464^ 1 Starlix® 60mg, 120mg tablet

Nateglinide^465^ Restriction: Restricted to plan endocrinologists.

Hormone - Antidiabetic Other Agents - Drugs for diabetes^466^ 1 1mg kit

Glucagon^467^ Restriction: Limit 2 per dispensing, 2 dispensings per 12 months.

Hormone - Antidiabetic SGLT-2 Inhibitors - Drugs for diabetes^468^ 1 Farxiga® 5mg, 10 mg tablet

Dapagliflozin^469^ Restriction: Restricted to members adherent to > 90 days of metformin therapy. PA required. Steglatro is expected for initiating SGLT-2 therapy unless demonstrating concurrent cardiovascular disease with supporting clinical documentation. 1 Jardiance® 10mg, 25mg tablet

Empagliflozin^470^ Restriction: Restricted to members adherent to > 90 days of metformin therapy. PA required. Steglatro is expected for initiating SGLT-2 therapy unless demonstrating concurrent cardiovascular disease with supporting clinical documentation. 1 Steglatro® 5mg, 15 mg tablet

Ertugliflozin^471^ Restriction: Restricted to members adherent to > 90 days of metformin therapy. Preferred SGLT-2. Please consider when initiating SGLT-2 therapy.

Hormone - Antidiabetic SGLT-2 Inhibitors Combination - Drugs for diabetes^472^ 1 Xigduo XR® 5mg-500mg, 5mg-1000mg, 10mg-500mg,

Dapagliflozin/metformin^473^ 10mg-1000mg tablet Restriction: Restricted to members adherent to > 90 days of metformin therapy. PA required. Segluromet is expected for initiating SGLT-2 therapy unless demonstrating concurrent cardiovascular disease with supporting clinical documentation. 1 Synjardy® 5mg-500mg, 5mg-1000mg, 12.5mg-500mg,

Empagliflozin/metformin^474^ 12.5mg-1000mg tablet Restriction: Restricted to members adherent to > 90 days of metformin therapy. PA required. Segluromet is expected for initiating SGLT-2 therapy unless demonstrating concurrent cardiovascular disease with supporting clinical documentation. 1 Segluromet® 2.5-500mg, 7.5-500mg, 2.5-1000mg, 7.5-1000mg

Ertugliflozin/metformin^475^ tablet Restriction: Restricted to members adherent to > 90 days of metformin therapy. Preferred SGLT-2/metformin combination.

Hormone - Antidiabetic Sulfonylureas - Drugs for diabetes^476^ 1 Amaryl® 1mg, 2mg, 4mg tablet

Glimepiride^477^ 1 Glucotrol® 5mg, 10mg tablet

Glipizide^478^ Continued on next page KFHC DRUG FORMULARY 35

GENERIC BRAND FORMS Hormone - Antidiabetic Sulfonylureas - Drugs for diabetes, continued • SEE PREVIOUS PAGE 1 Diabeta® 1.25mg, 2.5mg, 5mg tablet

Glyburide^479^

Hormone - Antidiabetic Thiazolidinedione - Drugs for diabetes^480^ These agents are reserved for patients who fail or cannot take Metformin. KHS recommends using Metformin prior to “Glitazone” therapy for diabetic patients since it helps patients minimize weight gain. Prior authorization will be considered for patients who cannot tolerate Metformin or should not take Metformin (renal patients and those over 80 years old). 1 Actos® 15mg, 30mg, 45mg tablet

Pioglitazone^481^ Restriction: Restricted to members on metformin or cannot take or have failed metformin.

Hormone - Anti-thyroid^482^ 1 50mg tablet

Propylthiouracil^483^

Hormone - Endocrine^484^ 1 Parlodel® 2.5mg tablet, 5mg capsule

Bromocriptine^485^ Restriction: Restricted to patients with amenorhhea, galactorrhea, or acromegaly. 1 0.5 mg tablet

Cabergoline^486^ Restriction: Restricted to plan endocrinologists. 1 Sensipar® 30mg, 60mg, 90mg, tablet

Cinacalcet^487^ Restriction: Prior authorization required. 1 DDAVP® 0.1mg, 0.2mg tablet

Desmopressin^488^ Restriction: Prior authorization required. Not covered for enuresis.

Hormone - Estrogen - Androgen - Drugs for hormones^489^ 1 Esterified Estrogens & Estratest® 6.25mg-1.2mg, 1.25mg-2.5mg tablet

Methyltestosterone^490^

Hormone - Estrogen - Drugs for hormones^491^ 1 Estrace® 0.5mg, 1mg, 2mg tablet

Estradiol^492^ 1 Premarin® 0.3mg, 0.45mg, 0.625mg, 0.9mg, 1.25mg, 2.5mg tablet

Estrogens, Conjugated^493^

Hormone - Estrogen - Progestin - Drugs for hormones^494^ 1 Estrogen, Conjugated & Prempro® 0.625mg-5mg, 0.3mg-1.5 mg, 0.45mg-1.5 mg tablet

Medroxyprogesterone^495^ Continued on next page 36 KFHC DRUG FORMULARY

GENERIC BRAND FORMS Hormone - Estrogen - Progestin - Drugs for hormones, continued • SEE PREVIOUS PAGE 1 Estrogen, Conjugated & Premphase® 0.625mg Estrogen (14) & 0.625mg-5mg Estrogen-Medroxyprogesterone (14) tablet

Medroxyprogesterone^496^

Hormone - Glucocorticoid - Drugs for hormones^497^ 1 Decadron® 0.5mg, 0.75mg, 1mg, 1.5mg, 2mg, 4mg, 6mg tablet

Dexamethasone^498^ 1 Florinef® 0.1mg tablet

Flurocortisone^499^ 1 5mg,10mg, 20mg tablet, 25mg supp, 100mg/60ml

Hydrocortisone^500^ enema 1 Medrol® 4mg tablet in dosepack

Methylprednisolone^501^ 1 Prelone® 5mg/5ml, 6.7mg/5ml, 15mg/5ml soln, 5mg tablet

Prednisolone^502^ 1 1mg/1ml oral soln or syrup, 5mg/ml conc, 1mg,2.5mg,

Prednisone^503^ 5mg, 10mg, 20mg, 25mg, 50mg tablet 5mg, 10mg dose pack

Hormone - Oxytoxic - Drugs for hormones^504^ 1 Methergine® 0.2mg tablet

Methylergonovine^505^

Hormone - Progestin - Drugs for hormones^506^ 1 Orilissa® 150 mg, 200 mg tablet

Elagolix^507^ Restriction: Prior authorization required. 1 Hydroxyprogesterone Makena® 250mg/ml

Caproate^508^ Restriction: Prior authorization required--FDA indication only for singleton pregnancies. Not FDA indicated for incompetent cervix. 1 Lupaneta® 3.75-5 mg, 11.25-5 mg syringe-tab

Leuprolide/norethindrone^509^ Restriction: Prior authorization required. 1 Provera®, 2.5mg,10mg tablet, 150mg/ml depo injection

Medroxyprogesterone^510^ Depo-Provera® Restriction: Depo-Provera® allowed for maximum of 24 months. 1 Crinone® 4%, 8% vaginal gel

Progesterone miconized^511^ Restriction: Restricted to plan OB/GYN. KFHC DRUG FORMULARY 37

GENERIC BRAND FORMS

Hormone - Thyroid^512^ 1 Levoxyl® 0.025mg, 0.05mg, 0.075mg, 0.088mg, 0.1mg,

Levothyroxine^513^ 0.112mg, 0.125mg, 0.137mg, 0.15mg, 0.175mg, 0.2mg, 0.3mg tablet 1 Cytomel® 5mcg, 25mcg, 50mcg tablet

Liothyronine^514^ Restriction: Prior authorization required. 1 Tapazole® 5mg, 10mg tablet

Methimazole^515^ 1 Armour® 15mg, 30mg, 60mg, 90mg, 120mg, 180mg, 240mg,

Thyroid--dessicated^516^ 300mg tablet Restriction: Plan endocrinologists. Prior authorization required.

Hormones - Antidiabetic/OTC - Drugs for diabetes^517^ 1 Humulin®, Novolin® 100 units/ml

Insulin, human^518^

Immunosuppressant -Drugs for the immune system^519^ 1 Imuran® 50mg tablet

Azathioprine^520^

1 Cyclosporine, Neoral® 25mg, 100mg capsule

Microemulsion^521^ 1 Zortress® 0.25mg, 0.5mg, 0.75mg tablet

Everolimus^522^ Restriction: Prior authorization required. 1 Prograf® 0.5mg, 1mg, 5 mg capsule

Tacrolimus^523^ Restriction: Prior authorization required.

Intravenous Solutions^524^ The following intravenous solutions are available to plan members. These solutions are covered under per diem arrangements and typically not billed through the PBM. Authorization is required to coordinate with the infusion services and centers.

1 Antibacterial/Antifungal various

Agents^525^ Restriction: Prior authorization required. Bill per diem. 1 various

Electrolyte Maintenance^526^ Restriction: Prior authorization required. Bill per diem. Continued on next page 38 KFHC DRUG FORMULARY

GENERIC BRAND FORMS Intravenous Solutions, continued • SEE PREVIOUS PAGE 1 IV solutions: Dextrose-water, various Dextrose-saline, Dextrose and

Lactated Ringer's^527^ Restriction: Prior authorization required. Bill per diem. 1 various

Intravenous lipids^528^ Restriction: Prior authorization required. Bill per diem. 1 Parenteral Amino Acid various

Solutions and Combinations^529^ Restriction: Prior authorization required. Bill per diem. 1 various

Potassium Replacement^530^ Restriction: Prior authorization required. Bill per diem. 1 various

Protein Replacement^531^ Restriction: Prior authorization required. Bill per diem. 1 Sodium and Saline various

Preparations^532^ Restriction: Prior authorization required. Bill per diem.

Muscle Relaxant^533^ Methocarbamol (Robaxin®) and Diazepam (Valium®) can be habituating and should be given with caution to patients with abuse potential. Diazepam is restricted to patients with cerebral palsy or severe spinal column injury. Diazepam is limited to 90 days’ supply and 10mg daily maximum dose without prior authorization. Limited to FDA maximum daily dosing guidelines. Caution in use with combination with opioids. FDA and other professional societies provide guidance statements of the usefulness of muscle relaxants for short periods of time, typically 2-3 weeks. Beyond that the effectiveness seems to diminish. The plan will allow up to 90 days of antispasmodics. Medications treating spasticity will not have this limitation. 1 10mg, 20mg tablet

Baclofen^534^ 1 10mg tablet

Cyclobenzaprine^535^ Restriction: Restricted to 90 days therapy. 1 Valium® 2mg, 5mg, 10mg tablet

Diazepam^536^ Restriction: Restricted to 90 days therapy and 10mg maximum daily dose. Continued on next page KFHC DRUG FORMULARY 39

GENERIC BRAND FORMS Muscle Relaxant, continued • SEE PREVIOUS PAGE 1 Robaxin® 500mg, 750mg tablet

Methocarbamol^537^ Restriction: Restricted to 90 days therapy. 1 Zanaflex® 2 mg, 4 mg tablet

Tizanidine^538^

NSAID - Acetic Acids - Drugs for pain^539^ 1 Voltaren® 50mg, 75mg ec tablet

Diclofenac Na^540^ Restriction: Restricted to members with RA. 1 Indocin® 25mg, 50mg capsule

Indomethacin^541^ 1 Clinoril® 150mg, 200mg tablet

Sulindac^542^ Restriction: Restricted to members with RA.

NSAID - COX-2 Agents - Drugs for pain^543^ Celecoxib (Celebrex®) is allowed without prior authorization for patients over the age of 65 or who are currently taking Warfarin (Coumadin®). Other indications require prior authorization. Only one daily is allowed - Celebrex® 100mg or 200mg. KHS requires that patients start at the lowest dose possible. Patients who fail a reasonable trial of two other Formulary NSAIDs will be considered for a COX-2 agent. Effectiveness: COX-2 medications are not more effective than other NSAIDs. NSAIDs cannot provide an unlimited amount of pain relief. While NSAIDs do provide pain relief and have anti-inflammatory ability, they do not alter the course of arthritis or prevent joint destruction. Safety: COX-2 medications are not risk free. Data does seem to reflect a lower incidence of GI toxicity but that may be diminished by concurrent aspirin therapy. Vioxx® had been allowed by the FDA to add to their product insert a statement of safety for GI problems. Celebrex® was denied a similar request. Adding another NSAID such as aspirin to COX-2 therapy will probably increase risk. (CLASS Study) COX-2 agents have renal liability as other NSAIDs. This risk may be less, but there is some potential for renal problems. These drugs can cause sodium and fluid retention like other NSAIDs. Cardiovascular safety with COX-2 drugs is being questioned. 1 Celebrex® 100mg, 200mg capsule

Celecoxib^544^ Restriction: Restricted to members > 65 years old or members on warfarin. Limited to one dose daily. Members not at risk are required to fail two other Formulary NSAIDs first. Other members and doses require prior authorization.

NSAID - Other - Drugs for pain^545^ 1 Relafen® 500mg, 750mg tablet

Nabumetone^546^ 40 KFHC DRUG FORMULARY

GENERIC BRAND FORMS

NSAID - Oxicam - Drugs for pain^547^ 1 Mobic® 7.5mg, 15mg tablet

Meloxicam^548^

NSAID - Propionic Acids - Drugs for pain^549^ 1 Motrin® 100mg/5ml susp, 400mg, 600mg, 800mg tablet

Ibuprofen^550^ Restriction: FDA does not recommend in children < 6 months. 1 Orudis® 25mg, 50mg, 75mg capsule

Ketoprofen^551^ Restriction: Restricted to members with RA. 1 Naprosyn® 125mg/5ml susp, 250mg, 375mg, 500mg tablet

Naproxen^552^

NSAID - Salicylate - Drugs for pain^553^ 1 Disalcid® 500mg capsule, tablet or cr tablet, 750mg tablet

Salsalate^554^

Ophthalmic - Anesthetic - Drugs for the eyes^555^ 1 0.5% ophth soln

Proparacaine^556^ Restriction: Prior authorization required.

Ophthalmic - Anti-fungal - Drugs for the eyes^557^ 1 Natacyn® 5% ophth susp

Natamycin^558^

Ophthalmic - Antihistamine - Drugs for the eyes^559^ 1 Optivar® 0.05% ophth soln

Azelastine ophth soln^560^ Restriction: Trial and failure of Zaditor required. 1 Patanol® 0.1% ophth soln

Olopatadine^561^ Restriction: Restricted to plan ophthalmologists only.

Ophthalmic - Antihistamine/OTC - Drugs for the eyes^562^ 1 Zaditor® 0.025% ophth soln

Ketotifen^563^

Ophthalmic - Anti-infective - Drugs for the eyes^564^ 1 ophth oint

Bacitracin^565^ 1 Polysporin® ophth oint

Bacitracin & Polymyxin^566^ 1 Besivance® 0.6% ophth susp

Besifloxacin^567^ Restriction: Patients must have recently failed first line ophth antibiotics. Allow 1st line for ophthalmologists. Continued on next page KFHC DRUG FORMULARY 41

GENERIC BRAND FORMS Ophthalmic - Anti-infective - Drugs for the eyes, continued • SEE PREVIOUS PAGE 1 Ciloxan® 0.3% ophth soln

Ciprofloxacin^568^ 1 Ilotycin® 0.5% ophth oint

Erythromycin^569^ 1 Garamycin® 0.3% ophth oint & soln

Gentamicin^570^

1 Neomycin, Bacitracin & Neo-Polycin® 3.5mg-400 units (or 500 units)-10000 units ophth oint

Polymyxin^571^

1 Neomycin,Polymyxin & Neosporin® ophth soln

Gramicidin^572^ 1 Ocuflox® 0.3% ophth soln

Ofloxacin^573^ 1 Polytrim® ophth soln

Polymyxin & Trimethaprim^574^ 1 Sulamyd® 10% ophth soln & oint

Sodium Sulfacetamide^575^ 1 Tobrex® 0.3% ophth soln

Tobramycin^576^

Ophthalmic - Anti-infective - Glucocorticoid - Drugs for the eyes^577^ 1 Neomycin, Polymyxin & Maxitrol® ophth susp, ophth oint

Dexamethasone^578^

1 Neomycin,Polymyxin & Poly-Pred® ophth susp

Prednisolone^579^ 1 Tobradex® 0.3%-0.1% ophth susp

Tobramyin & Dexamethasone^580^ Restriction: Consider second line to neomycin/steroid preparations.

Ophthalmic - Anti-viral - Drugs for the eyes^581^ 1 Zirgan® 0.15% gel

Ganciclovir^582^ Restriction: Restricted to plan ophthalmologists only. 1 Viroptic® 1% ophth soln

Trifluridine^583^

Ophthalmic - Decongestant - Antihistamine/OTC Drugs for the eyes^584^ 1 Naphcon-A® 0.025%-0.3% ophth soln

Naphazoline & Pheniramine^585^

Ophthalmic - Decongestant/OTC - Drugs for the eyes^586^ 1 Albalon® 0.1% ophth soln

Naphazoline^587^ 42 KFHC DRUG FORMULARY

GENERIC BRAND FORMS

Ophthalmic - Glaucoma - Drugs for the eyes^588^ 1 Diamox® 125mg, 250mg tablet, 500mg cr capsule

Acetazolamide^589^ 1 Betopic® 0.25%, 0.5% ophth soln or susp

Betaxolol^590^ 1 Lumigan® 0.01%, 0.03% ophth soln

Bimatoprost^591^ Restriction: Limited to 2.5ml size only. 1 bottle per dispensing. 1 Alphagan® Alphagan P® 0.2% ophth soln

Brimonidine^592^ 1 Combigan® 0.2%-0.5% ophth drops

Brimonidine tartrate/timolol^593^ 1 Azopt® 1% ophth susp

Brinzolamide^594^ Restriction: Prior authorization required. 1 Trusopt® 2% ophth soln

Dorzolamide^595^ 1 Cosopt® 2%-0.5% ophth drops

Dorzolamide/timolol^596^ 1 Xalatan® 0.005% ophth soln

Latanoprost^597^ 1 Betagan® 0.25% ophth soln

Levobunolol^598^ 1 Neptazane® 25mg, 50 mg tablet

Methazolamide^599^ 1 Optipranolol® 0.3% ophth soln

Metipranolol^600^ 1 Isopto-Carpine® 1%, 2%, 4% ophth soln

Pilocarpine^601^ 1 Isopto-Hyosine® 0.25% ophth soln

Scopolamine^602^ 1 Timoptic® 0.25%, 0.5% ophth soln

Timolol^603^

Ophthalmic - Glucocorticoid - Drugs for the eyes^604^ 1 Durezol® 0.05% ophth susp

Difluprednate^605^ Restriction: Restricted to plan ophthalmologists only. 1 FML® 0.1%, 0.25% ophth susp

Fluorometholone^606^ 1 Lotemax® 0.5% ophth susp

Loteprednol^607^ Restriction: Prior authorization required. 1 Pred Mild®, Pred Forte® 0.12%, 1% ophth susp

Prednisolone^608^ KFHC DRUG FORMULARY 43

GENERIC BRAND FORMS

Ophthalmic - Miscellaneous - Drugs for the eyes^609^ 1 Crolom® 4% ophth drops

Cromolyn^610^ 1 Restasis® 0.05% ophth emulsion

Cyclosporine^611^ Restriction: Prior authorization required. 1 Muro® (128) 2% ophth soln, 5% ophth oint or soln

Sodium Chloride^612^

Ophthalmic - Mydriatic - Drugs for the eyes^613^ 1 Isopto-Atropine® 1% ophth soln

Atropine^614^ 1 Cyclogyl® 0.5%, 1%, 2% ophth soln

Cyclopentolate^615^ 1 Isopto-Homatropine® 2%, 5% ophth soln

Homatropine^616^

Ophthalmic - NSAID - Drugs for the eyes^617^ 1 Voltaren® 0.1% ophth drops

Diclofenac^618^ 1 Acular®, Acular LS 0.4%, 0.5% ophth soln

Ketorolac^619^ Restriction: Restricted to plan ophthalmologist only. 1 Nevanac® 0.1% ophth susp

Nepafanac^620^ Restriction: Restricted to plan ophthalmologist only.

Oral Contraceptive - Biphasic - Drugs for women^621^ 1 Mircette® 0.15mg/20mcg (21), 10mcg (7) tablet

Desogestrel & Ethinyl Estradiol^622^

1 Norethindrone & Ethinyl Ortho-Novum 10/11® 0.5mg-35mcg (10), 1mg-35mcg (11) tablet

Estradiol^623^

1 Norethindrone & Ethinyl Ortho-Novum 7/14® 0.5mg-35mcg (7), 1mg-35mcg(14) tablet

Estradiol^624^

Oral Contraceptive - Drugs for women^625^ 1 Desogen® 0.15mg-30mcg tablet

Desogestrel & Ethinyl Estradiol^626^

1 Drospirenone & Ethinyl Yasmin®, Yaz® 0.03-3mg, 0.02-3mg tablet

Estradiol^627^ Restriction: Prior authorization required. 1 Demulen® 1mg-35mcg tablet

Ethynodiol & Ethinyl Estradiol^628^ Continued on next page 44 KFHC DRUG FORMULARY

GENERIC BRAND FORMS Oral Contraceptive - Drugs for women, continued • SEE PREVIOUS PAGE 1 Levonorgestrel & Ethinyl Levlen® 0.15mg-30mcg tablet

Estradiol^629^

1 Levonorgestrel & Ethinyl Alesse® 0.1mg-20mcg tablet

Estradiol^630^

1 Norethindrone & Ethinyl Ortho-Novum 1/35®, 35mcg-1mg, 50mcg-1mg tablet Demulen 1/50®

Estradiol^631^ 1 Ortho-Novum 1/50® 1mg-50mcg tablet

Norethindrone & Mestranol^632^

1 Norethindrone Acetate & Loestrin 1/20®, 1/20 1mg-20mcg, 1mg-20mcg, 1mg-10mcg w/iron tablet Fe®, Lo Loestrin Fe®

Ethinyl Estradiol^633^ Restriction: Lo Loestrin prior authorization required. 1 Norethindrone Acetate & Norlestrin 1/50®, 1/50 1mg-50mcg tablet, 1mg-50mcg w/iron tablet Fe®

Ethinyl Estradiol^634^

1 Norethindrone Acetate & Loestrin 1.5/30®, 1.5/30 1.5mg-30mcg tablet, 1.5mg-30mcg w/iron tablet Fe®

Ethinyl Estradiol^635^

1 Norgestimate & Ethinyl Ortho-Cyclen® 0.25mg-35mcg tablet

Estradiol^636^ 1 Lo-Ovral® 0.3mg-30mcg tablet

Norgestrel & Ethinyl Estradiol^637^ 1 Ovral® 0.5mg-50mcg tablet

Norgestrel & Ethinyl Estradiol^638^

Oral Contraceptive - Progestin Only - Drugs for women^639^ 1 Plan B One Step® 1.5mg tablet

Levonorgestrel^640^ Restriction: Maximum of 2 fills in 30 days. 1 Micronor® 0.35mg tablet

Norethindrone^641^

Oral Contraceptive - Triphasic - Drugs for women^642^ 1 Levonorgestrel & Ethinyl Triphasil® 0.05mg-30mcg, 0.075mg-40mcg, 0.125mg-30mcg tablet

Estradiol^643^

1 Norethindrone & Ethinyl Ortho-Novum 7/7/7® 0.5mg-35mcg(7), 0.75mg-35mcg(7), 1mg-35mcg(7) tablet

Estradiol^644^ Continued on next page KFHC DRUG FORMULARY 45

GENERIC BRAND FORMS Oral Contraceptive - Triphasic - Drugs for women, continued • SEE PREVIOUS PAGE 1 Estrostep® 1mg-20mcg(5), 1mg-30mcg(7), 1mg-35mcg(9) tablet

Norethindrone & Ethinyl Estradiol^645^

1 Norgestimate & Ethinyl Ortho-Tricyclen® 0.18mg-35mcg/0.215mg-35mcmg/0.25mg-35mcg tablet

Estradiol^646^

1 Norgestimate & Ethinyl Ortho-Tricyclen Lo® 0.18mg-25mcg/0.215mg-25mcmg/0.25mg-25mcg tablet

Estradiol^647^

Osteoporosis Drugs for bone loss^648^ 1 Fosamax® 35mg, 70mg weekly tablet only

Alendronate^649^ Restriction: Restricted to members > 61 years old or having T-score < – 2.5. 1 Miacalcin® 200unit/spray

Calcitonin-salmon^650^ Restriction: Allowed for osteoporosis failing bisphosphonates. 1 Actonel® 35 mg tablet

Risdronate^651^ Restriction: Prior authorization required.

Otic - Drugs for the ears^652^ 1 Ciprodex® 0.3%-0.4% otic susp

Ciprofloxacin- Dexamethasone^653^ Restriction: Restricted to plan ENT providers. If the patient recently failed Cortisporin® or Floxin® Otic, consideration will be given to a prior authorization request. 1 Acetasol HC® otic soln

Hydrocortisone & acetic acid^654^

1 Neomycin, Polymyxin & Cortisporin® otic susp

Hydrocortisone^655^ 1 Floxin® Otic 0.3% otic soln

Ofloxacin^656^ Restriction: Restricted to 5 mls per dispensing.

Otic/ OTC - Drugs for the ears^657^ 1 Debrox® 6.5% soln

Carbamide Peroxide^658^

Rescue Agents - Antidotes^659^ 1 0.15mg/0.3, 0.3mg/0.3 auto injection

Epinephrine^660^ 1 5mg, 25mg tablet

Leucovorin^661^ 1 Chemet® 100mg capsule

Succimer^662^ 46 KFHC DRUG FORMULARY

GENERIC BRAND FORMS

Respiratory - Antihistamine - Antitussive - Decongestant - Drugs for the lungs^663^ 1 Phenylephrine, Phenergan-VC Codeine® 5mg-6.25mg-10mg/5ml syrup

Promethazine & Codeine^664^ Restriction: Only for patients >18 years old. Plan allows maximum 240 mls per 30 days, 3 fills per 12 months. 1 Pseudoephedrine, Cardec-DM® 15mg-12.5mg-4mg syrup Chlorpheniramine &

Dextromethorphan^665^ Restriction: Only for patients < 6 years old.

Respiratory - Antihistamine - Antitussive - Drugs for the lungs^666^ 1 Phenergan w/Codeine® 6.25mg-10mg/5ml syrup

Promethazine & Codeine^667^ Restriction: Only for patients > 18 years old. Plan allows maximum 240 mls per 30 days, 3 fills per 12 months. 1 Promethazine & Phenergan DM® 6.25mg-15mg/5ml syrup

Dextromethorphan^668^ Restriction: Only for patients > 2 years old.

Respiratory - Antihistamine - Decongestant - Antitussive/OTC - Drugs for the lungs^669^ Restricted to members between the ages 4-21 years.

1 Pseudoephedrine, Dimetane DX® 30mg-2mg-10mg/5ml syrup Brompheniramine &

Dextromethorphan^670^

1 Pseudoephedrine, Pediacare® 15mg-1mg- 5mg/5ml, 15mg-1mg-7.5mg/5ml, Chlorpheniramine & 30mg-2mg-10mg/5ml liquid & syrup

Dextromethorphan^671^

Respiratory - Antihistamine - Decongestant/OTC - Drugs for the lungs^672^ Restricted to members between the ages 4-21 years.

1 Brompheniramine & Dimetapp® new 1mg-2.5mg/5ml elixir formualtion

Phenylephrine^673^

1 Chlorpheniramine & Contac® 1mg-2.5mg/5ml, 2mg-5mg/5ml, 4mg-10mg/5ml, syrup, 2mg-5mg tablet, 4mg-20mg cr tablet

Phenylephrine^674^

1 Chlorpheniramine & Sudafed Plus® 2mg-30mg, 4mg-60mg tablet

Pseudoephedrine^675^ KFHC DRUG FORMULARY 47

GENERIC BRAND FORMS

Respiratory - Antihistamine - Decongestant - Drugs for the lungs^676^ 1 Promethazine & Phenergan-VC® 6.25mg-5mg/5ml syrup

Phenylephrine^677^ Restriction: Only for patients > 2 years old.

Respiratory - Antihistamine - Drugs for the lungs^678^ 1st generation antihistamines are considered to be more effective than the later generations. National guidelines suggest better outcomes with treatment with nasal steroids as opposed to antihistamines. The FDA recommends not to use antihistamines and cough preparations in individuals less than 2 years of age. Allergic Rhinitis adult patients are recommended to be treated with Nasal Steroids. 1 Atarax® 10mg/5ml syrup, 10mg, 25mg, 50mg tablet, 25mg,

Hydroxyzine^679^ 50mg capsule

Respiratory - Antihistamine/OTC - Drugs for the lungs^680^ The FDA does not recommend antihistamines and other cough/cold products in individuals under the age of 2 years old. These products are restricted to members 2 years old and older. Unless a single antihistamine product, the following are allowed up to age 21 by DHCS. 1 2mg/5ml elixir

Brompheniramine^681^ 1 Zyrtec® 5 mg, 10 mg tablet, 1 mg/ml liq

Cetirizine^682^ Restriction: Limited to patients < 18 years old. Liquid allowed < 5 years old. 1 Chlortrimeton® 1mg/5ml liquid, 2mg/5ml syrup, 2mg, 4mg chewable

Chlorpheniramine^683^ tablet, 4mg tablet, 8mg, 12mg cr tablet, 6mg, 8mg, 12mg cr capsule 1 Benadryl® 12.5mg/5ml elixir or syrup, 25mg, 50mg capsule or

Diphenhydramine^684^ tablet 1 Claritin® 10mg quick dissolving tablet, 10mg tablet, 5mg/5ml

Loratadine^685^ syrup Restriction: Liquid allowed < 5 years old.

Respiratory - Antiserotonin - Drugs for the lungs^686^ 1 Periactin® 2mg/5ml syrup, 4mg tablet

Cyproheptadine^687^

Respiratory - Antitussive/OTC - Drugs for the lungs^688^ Restricted to members between the ages 4-21 years. 1 Robitussin Pediatric® 7.5mg/5ml, 10mg/5ml syrup

Dextromethorphan^689^ 48 KFHC DRUG FORMULARY

GENERIC BRAND FORMS

Respiratory - Antitussive - Drugs for the lungs^690^ 1 Tessalon® 100mg perles

Benzonatate^691^ Restriction: Prior authorization required. 1 Saturated soln of potassium SSKI® 1g/ml soln

iodide^692^ Restriction: Prior authorization required.

Respiratory - Antitussive - Expectorant/OTC - Drugs for the lungs^693^ Restricted to members between the ages 4-21 years.

1 Dextromethorphan & Robitussin DM® 10mg-100mg/5ml, 15mg-200mg/5ml, 30mg-200mg/ 5ml liquid, 3.33mg-33.3mg/5ml, 6.67mg-66.7mg/5ml

Guaifenesin^694^ syrup

Respiratory - Antitussive - Expectorant - Drugs for the lungs^695^ 1 Robitussin AC® 10mg-100mg/5ml soln or syrup

Codeine & Guaifenesin^696^ Restriction: Only for patients > 18 years old. Plan allows maximum 240 mls per 30 days, 3 fills per 12 months. 1 Codeine, Guaifenesin, Robitussin DAC® 10mg-100mg-30mg/5ml syrup

Pseudoephedrine^697^ Restriction: Only for patients > 18 years old. Plan allows maximum 240 mls per 30 days, 3 fills per 12 months.

Respiratory - Asthma - Drugs for the lungs^698^ There are National Guidelines for treating Asthma. KHS has a Pocket Guide for Asthma Management and Prevention available. Some of the tables in that text are in the Formulary. Asthma is a chronic inflammatory disease. It is important to remember this inflammatory process and that the inhaled steroids are recommended to be the second step in treatment. Please review the step tables of Asthma Treatment at the end of this Formulary. Spacers (Aerochambers®), with or without masks, and peak flow meters are available by prescription. Preference for referrals for low or non-sedating antihistamines will be given to asthma patients.

Respiratory - Asthma - Step 1 -Short Acting Bronchodilator - Drugs for the lungs^699^ 1 0.083% & 0.5% inh soln, 2mg/5ml syrup

Albuterol^700^ Restriction: Individual nebulized vial limited to 360 mls per month, the concentrated nebulized solution limited to 60 mls. 1 Ventolin HFA®, ProAir® 90mcg/dose MDI

Albuterol HFA^701^ Restriction: NMT 2 inhalers in 30 days or greater than 3 consecutive months without an inhaled steroid. 1 Brethine® 2.5mg, 5mg tablet

Terbutaline^702^ KFHC DRUG FORMULARY 49

GENERIC BRAND FORMS

Respiratory - Asthma - Step 2 -Glucocorticoid - Drugs for the lungs^703^ 1 Qvar Redihaler® 40mcg/dose, 80mcg/dose MDI

Beclomethasone^704^ 1 Pulmicort® 90mcg/dose, 180mcg/dose breath activated device,

Budesonide^705^ 0.25mg/2ml, 0.5mg/2ml inh susp Restriction: 0.25mg nebulizer susp is restricted to once daily dosing. Doses of 0.25 BID are required to fail 0.5mg once daily. Allowed in members < 5 years old. 1 Aerospan® 80mcg/dose MDI

Flunisolide^706^ 1 Flovent HFA® 44mcg, 110mcg, 220mcg/dose MDI, 50 mcg, 100mcg,

Fluticasone^707^ 250mcg/dose breath activated device 1 Arnuity Ellipta® 50 mcg, 100 mcg, 200 mcg breath activated device

Fluticasone furoate^708^ Preferred fluticasone inhalation product. 1 Armonair Respiclick® 55 mcg, 113 mcg, 232 mcg breath activated device

Fluticasone propionate^709^

Respiratory - Asthma - Step 3 - Antileukotriene - (Step 2 Alternative) - Drugs for the lungs^710^ Restricted to members with asthma--requires member to be on a beta-agonist mdi. Inhaled steroids should be considered for second line (Step 2) treatment before antileukotriene. Allowed for children < 5 years old as Step 2. Not authorized for allergic rhinitis by plan. Prior authorization not required by ENT. 1 Singulair® 4mg, 5mg chewable tablet, 10mg tablet

Montelukast^711^ 1 Accolate® 10mg, 20mg tablet

Zafirlukast^712^

Respiratory - Asthma - Steps 3 & 4 - ICS/Long Acting Bronchodilator - Drugs for the lungs^713^ 1 Symbicort® 80/4.5 mcg, 160/4.5 mcg inhaler

Budesonide/formoterol^714^ Restriction: Restricted to patients failing a 30-day trial of inhaled steroids alone (see National Asthma Guidelines). Consider generic AirDuo® for asthma management; Wixela Inhub for COPD. 1 Advair®, Wixela Inhub® , 100/50 mcg, 250/50 mcg, 500/50 mcg breath

Fluticasone/salmeterol^715^ AirDuo® activated device, 45/21 mcg, 115/21 mcg, 230/21 mcg HFA; 55-14 mcg, 113-14 mcg, 232-14 mcg inhalation Restriction: Restricted to patients failing a 30-day trial of inhaled steroids alone (see National Asthma Guidelines). Consider generic AirDuo® for asthma management; Wixela Inhub for COPD. 1 Breo Ellipta® 100-25 mcg, 200-25 mcg breath activated device

Fluticasone/vilanterol^716^ Restriction: Restricted to patients failing a 30-day trial of inhaled steroids alone (see National Asthma Guidelines). Consider generic AirDuo first, Wixela Inhub for COPD. Continued on next page 50 KFHC DRUG FORMULARY

GENERIC BRAND FORMS Respiratory - Asthma - Steps 3 & 4 - ICS/Long Acting Bronchodilator - Drugs for the lungs, continued • SEE PREVIOUS PAGE 1 Dulera® 100/5 mcg, 200/5 mcg MDI

Mometasone/formoterol^717^ Restriction: Restricted to patients failing a 30-day trial of inhaled steroids alone (see National Asthma Guidelines). Consider generic AirDuo first, Wixela Inhub for COPD.

Respiratory - Asthma Device^718^ 1 Peak Flow Meter

Monitoring Device^719^ Restriction: $35 max per unit. 1 With or without mask

Spacer Device^720^ Restriction: Spacers with a mask are available to members under < 6 years old. Please make sure of the fit for the spacers with masks. $35 max per unit without mask. $50 max per unit with mask.

Respiratory - COPD - Anticholinergic bronchodilator - Drugs for the lungs^721^ 1 Atrovent HFA® 18mcg/dose MDI, 0.02% inhalation soln

Ipratropium^722^

Respiratory - COPD - Anticholinergic Bronchodilator Combination - Drugs for the lungs^723^ 1 Ipratropium- albuterol 0.5-3mg/3ml inhalation soln

Ipratropium - Albuterol^724^

1 Ipratropium- albuterol Combivent Respimat® 18mcg-90mcg/spray MDI

Respimat^725^

Respiratory - COPD - Anticholinergic Bronchodilator Long Acting - Drugs for the lungs^726^ 1 Spiriva® Spiriva 18 mcg inhalation capsule, 1.25mcg, 2.5 mcg Respimat

Tiotropium bromide^727^ Respimat® 1 Incruse Ellipta® 62.5mcg inhalation tablet

Umeclidinium^728^

Respiratory - COPD - Anticholinergic Bronchodilator Long Acting Combination - Drugs for the lungs^729^ 1 Stiolto Respimat® 2.5-2.5 mcg breath activated device

Tiotropium bromide - Olodaterol^730^ 1 Anoro Ellipta® 62.5-25 mcg MDI

Umeclidinium - Vilanterol^731^ Respiratory - COPD - Long Acting Anticholinergic - Long Acting Bronchodilator - ICS Combination - Drugs for

the lungs^732^ 1 Fluticasone - Umeclindium - Trelegy Ellipta® 100-62.5-25 mcg breath activated device

Vilanterol^733^ Restriction: Long acting cholinergic/bronchodilator or ICS/bronchodilator required first. KFHC DRUG FORMULARY 51

GENERIC BRAND FORMS

Respiratory - Decongestant/OTC - Drugs for the lungs^734^ Restricted to members between the ages 4-21 years. 1 Sudafed® 30mg, 60mg, 120mg tablet, 15mg/5ml, 30mg/5ml

Pseudoephedrine^735^ liquid

Respiratory - Expectorant/OTC - Drugs for the lungs^736^ Restricted to members between the ages 4-21 years. 1 Robitussin® 100mg/5ml, 200mg/5ml syrup

Guaifenesin^737^

Respiratory - Mast Cell Stabilizer - Drugs for the lungs^738^ 1 Intal® 20mg/2ml inhalation soln

Cromolyn^739^

Respiratory - Miscellaneous/OTC - Drugs for the lungs^740^ 1 0.9% nebulizer soln

Sodium Chloride^741^

Respiratory - Mucolytic - Drugs for the lungs^742^ 1 Mucomyst® 10%, 20% soln

Acetylcysteine^743^

Respiratory - Nasal Antihistamine - Drugs for the lungs^744^ 1 Astelin® 137 mcg/spray

Azelastine^745^ Restriction: Trial and failure of nasal steroids required.

Respiratory - Nasal Glucocorticoids - Drugs for the lungs^746^ Nasal Steroids are recommended for the initial treatment of allergic rhinitis. For patients over 12 years of age it is required they fail a 30 day trial of nasal steroids before a prior authorization of non-sedating antihistamines will be approved. Plan requires generic nasal steroids to be used first. Nasonex will be allowed for individuals between the ages of 2-4 as first line. 1 25 mcg/spray

Flunisolide^747^ 1 Flonase® 50 mcg/spray

Fluticasone^748^ 1 Nasonex® 50mcg/spray

Mometasone^749^ Restriction: Allowed as first line for members age 2-4 years old.

Respiratory - Nasal Glucocorticoids/OTC - Drugs for the lungs^750^ 1 Nasacort Allergy 24 HR 55 mcg mdi

Triamcinolone^751^ OTC®

Respiratory - Xanthine - Drugs for the lungs^752^ 1 Theodur, Uniphyl® 80mg/15ml, 100mg, 200mg, 300mg, 400mg cr capsule,

Theophylline^753^ 100mg, 200mg, 300mg, 400mg, 450mg cr tablet 52 KFHC DRUG FORMULARY

GENERIC BRAND FORMS

Topical - Acne^754^ 1 Retin-A® 0.025%, 0.05%, 0.1% cream

Tretinoin^755^ Restriction: Restricted to plan dermatologists. 20g maximum. Secondary to trial and failure of Differin 0.1% gel OTC.

Topical - Acne/OTC -Drugs for the skin^756^ 1 Differin® 0.1% gel

Adapalene^757^ Restriction: Max 45 g per dispensing per 30 days. 1 Benzagel® 5%, 10% gel

Benzoyl Peroxide^758^

Topical - Anesthetic - Drugs for pain^759^ 1 Xylocaine® 2% gel

Viscous lidocaine^760^ Restriction: Restricted to 100ml every 30 days.

Topical - Antibiotic/OTC -Drugs for the skin^761^ 1 ointment

Bacitracin^762^

1 Neomycin, Bacitracin & Neosporin® ointment

Polymyxin^763^

Topical - Antifungal - Drugs for infection^764^ 1 Spectazole® 1% cream

Econazole^765^ Restriction: Restricted to members who have recently failed first line agents (Clotrimazole, Miconazole). 1 Nizoral® 2% cream

Ketoconazole^766^ 1 Nizoral AD® 1% OTC, 2% shampoo

Ketoconazole^767^ 1 Mycostatin® 100,000 units/gm cream & oint, powder

Nystatin^768^ 1 Oxistat® 1% cream

Oxiconazole^769^ Restriction: Prior authorization required. 1 Lamisil® 1% cream

Terbinafine^770^ Restriction: Restricted to members who have recently failed first line agents (Clotrimazole, Miconazole).

Topical - Antifungal/OTC -Drugs for the skin^771^ 1 Lotrimin® 1% cream, oint, soln

Clotrimazole^772^ Restriction: Solution allowed by ENT. Continued on next page KFHC DRUG FORMULARY 53

GENERIC BRAND FORMS Topical - Antifungal/OTC -Drugs for the skin, continued • SEE PREVIOUS PAGE 1 Micatin® 2% cream

Miconazole^773^ 1 Tinactin® 1% cream and soln

Tolnaftate^774^

Topical - Anti-infective - Drugs for infection^775^ 1 Cleocin-T® 1% soln, gel

Clindamycin^776^ 1 2% soln

Erythromycin^777^ 1 Bactroban® 2% oint

Mupirocin^778^ Efficacy of decolonization in preventing re-infection or transmission in the outpatient setting is not documented, and NOT routinely recommended. Consultation with an infectious disease specialist is recommended before eradication of colonization is initiated. Plan allows 1 tube per dispensing per infectious episode. 1 Selsun® 2.5% shampoo

Selenium^779^ 1 Silvadene® 1% cream

Silver Sulfadiazine^780^

Topical - Anti-Infective/OTC -Drugs for the skin^781^ 1 plain, phenolated lotion

Calamine^782^

Topical - Antineoplastic - Drugs for cancer^783^ 1 Efudex® 1%, 5% cream, 2%, 5% soln

Fluorouracil^784^

Topical - Antiviral - Drugs for infection^785^ 1 Aldara® 5% cream

Imiquimod^786^ Restriction: 12 packets per 30 days. Preferred for genital warts. 1 Condylox® 0.5% soln

Podofilox^787^ Restriction: Consider second line to imiquimod.

Topical - Astringent/OTC -Drugs for the skin^788^ 1 Domeboro’s Soln® Powder

Aluminum Acetate^789^

Topical - Contraceptive - Drugs for women^790^ 1

Diaphragm^791^ 1 Nuvaring® 0.12-0.15 mg vaginal ring

Etonogestrel/ethinyl estradiol^792^ 1 Xulane® 150mcg/20mcg/day patch

Norelgestromin- ethinyl estradiol^793^ Restriction: Plan does not cover replacement patches. Limited to 3 patches/28 days or 6 patches/56 days. 54 KFHC DRUG FORMULARY

GENERIC BRAND FORMS

Topical - Enzymes^794^ 1 various

Hyaluronidase^795^ Restriction: Used for skin test, dehydration, dispersion/absorption enhancement of injected drugs.

Topical - Estrogens- Drugs for women^796^ 1 Climara®, Vivelle® Biweekly- 0.025mg, 0.0375mg, 0.075mg, 0.1mg patch

Estradiol^797^ Weekly- 0.025mg, 0.05mg, 0.06mg, 0.075mg, 0.1mg patch

Topical - Glucocorticoid/OTC -Drugs for the skin^798^ 1 0.5%,1% cream, oint, lotion

Hydrocortisone^799^

Topical - Glucocorticoid a Low Potency - Drugs for the skin^800^ 1 Valisone® 0.05% cream, oint, lotion, 0.1% cream, 0.1% oint,

Betamethasone^801^ 0.05%, 0.1% lotion 1 Synalar® 0.01%, 0.025% cream, 0.01% soln

Fluocinolone^802^ 1 Cordran® 0.05% cream, oint, lotion

Flurandrenolide^803^ 1 0.5%, 1% cream, 2.5% cream, oint & lotion are also

Hydrocortisone^804^ available OTC 1 Kenalog® 0.025% cream, oint, lotion

Triamcinolone^805^

Topical - Glucocorticoid b Medium Potency - Drugs for the skin^806^ 1 Elocon® 0.1% cream, oint, lotion

Mometasone^807^ Restriction: Prior authorization required. 1 Kenalog® 0.1% cream, oint, lotion

Triamcinolone^808^

Topical - Glucocorticoid c High Potency - Drugs for the skin^809^ 1 Diprosone® 0.05% cream, oint

Betamethasone dipropionate^810^ 1 Temovate® 0.05% cream, oint, soln, lotion

Clobetasol^811^ Restriction: Prior authorization required. 1 Lidex® 0.05% cream, oint, soln, gel

Fluocinonide^812^ 1 Kenalog® 0.5% cream, oint

Triamcinolone^813^ KFHC DRUG FORMULARY 55

GENERIC BRAND FORMS

Topical - Miscellaneous - Drugs for the skin^814^ 1 0.25% soln

Acetic Acid^815^ 1 Drithocreme HP® 1% cream

Anthralin^816^ 1 Dovonex® 0.005% cream

Calcipotriene^817^ Restriction: Member needs to fail topical steroids (triamcinolone, betamethasone). 120g maximum. 1 0.9% soln

Sodium Chloride^818^

Topical - Scabicide - Drugs for infection^819^ 1 Eurax® 10% cream and lotion

Crotamiton^820^ Restriction: Prior authorization required. 1 Elimite® 5% cream

Permethrin^821^ Restriction: Prior authorization required.

Topical - Scabicide/OTC -Drugs for the skin^822^ 1 Nix® 1% cream rinse

Permethrin^823^ 1 Rid® 4%-0.33% liquid

Pyrethrins-Piperonyl^824^

Urinary Tract - Drugs for bladder^825^ 1 Ditropan® 5mg tablet

Oxybutynin^826^ 1 Elmiron® 100mg capsule

Pentosan^827^ 1 Pyridium® 100mg, 200mg tablet

Phenazopyridine^828^ Restriction: Maximum therapy allowed is three days.

Vaccines - Immune Globulin^829^ Vaccines play an important part in enhancing one's health. The plan allows the following vaccines without authorization. As many of these are covered under the Vaccines For Children program, the ingredient cost is carved out from the plan. They should be billed to the VFC program. Extensive documentation is required for reporting to the California Immunization Registry (CAIR), member consent, and provider notification. This documentation is required to be available. The vaccines below are billed to KHS for members over the age of 19 unless otherwise noted. In addition to age limits, limits exist on number per lifetime, and limits per injection. Vaccines needed for employment or travel are not covered benefits. Continued on next page 56 KFHC DRUG FORMULARY

GENERIC BRAND FORMS Vaccines - Immune Globulin, continued • SEE PREVIOUS PAGE 1 Havrix® various

Hepatitis A^830^ Restriction: Coordinate with other payers (ex Vaccines for Children, Medicare, CCS, others). Limit 2 per lifetime. 1 Twinrix® various

Hepatitis A & B^831^ Restriction: Coordinate with other payers (ex Vaccines for Children, Medicare, CCS, others). Limit 3 per lifetime. 1 Engerix-B®, Heplisav-B® various

Hepatitis B^832^ Restriction: Coordinate with other payers (ex Vaccines for Children, Medicare, CCS, others). Limit 3 per lifetime, 2 for Heplisav-B. 1 Fluzone®, Fluvirin®, various

Influenza^833^ Fluvarix®, others Restriction: Coordinate with other payers (ex Vaccines for Children, Medicare, CCS, others). Limit 1 per flu season. 1 M-M-R II® various

Measles, Mumps, Rubella^834^ Restriction: Coordinate with other payers (ex Vaccines for Children, Medicare, CCS, others). Limit 2 per lifetime. 1 Menveo®, Menomune®, various

Menigitits^835^ Bexsero®, Trumenba®, others Restriction: Coordinate with other payers (ex Vaccines for Children, Medicare, CCS, others). 1 Gardasil®, Cervarix® various

Papillomavirus^836^ Restriction: Coordinate with other payers (ex Vaccines for Children, Medicare, CCS, others). Limit 3 per lifetime. Maximum age 26 years. 1 Prevnar 13®, Prevnar various

Pneumococcal^837^ 23® Restriction: Coordinate with other payers (ex Vaccines for Children, Medicare, CCS, others). 1 Hyperrab®, Imogam various

Rabies^838^ rabies® Restriction: Coordinate with other payers (ex Vaccines for Children, Medicare, CCS, others). 1 Boostrix® various

TDAP^839^ Restriction: Coordinate with other payers (ex Vaccines for Children, Medicare, CCS, others). 1 Adacel®, Tenivac®, various

Tetanus^840^ others Restriction: Coordinate with other payers (ex Vaccines for Children, Medicare, CCS, others). Continued on next page KFHC DRUG FORMULARY 57

GENERIC BRAND FORMS Vaccines - Immune Globulin, continued • SEE PREVIOUS PAGE 1 Varivax® various

Varicella^841^ Restriction: Coordinate with other payers (ex Vaccines for Children, Medicare, CCS, others). Limit 2 per lifetime. 1 Shingrix® 50 mcg

Varicella-zoster^842^ Restriction: Coordinate with other payers (ex Vaccines for Children, Medicare, CCS, others). >50 years. Limit 2 per lifetime. 1 Zostavax® various

Zoster^843^ Restriction: Coordinate with other payers (ex Vaccines for Children, Medicare, CCS, others). Limit 1 per lifetime. >50 years.

Vaginal - Anti-infective/OTC - Drugs for infection^844^ 1 Gynazole 1® 2% vaginal cream

Butoconazole^845^ 1 Gyne-lotrimin® 1% vaginal cream

Clotrimazole^846^ 1 Monistat® 2% vaginal cream, vaginal kit, 100mg vaginal supp

Miconazole^847^

Vaginal - Anti-infective - Drugs for women^848^ 1 Gynazole-1® 2% vaginal cream

Butoconazole^849^ Restriction: Restricted to patients who have failed first line agents (Clotrimazole, Miconazole). 1 Cleocin® 2% vaginal cream

Clindamycin^850^ 1 Metrogel® 0.75% Vaginal Gel

Metronidazole^851^ 1 Mycostatin® 100,000 units vaginal tablet

Nystatin^852^ 1 Sultrin® 15% vaginal cream, 1.05 gm vaginal supp

Sulfanilamide^853^ 1 Terazol® 0.4%, 0.8% vaginal cream, 80mg vaginal supp

Terconazole^854^ Restriction: Restricted to patients who have failed first line agents (Clotrimazole, Miconazole). 1 Vagistat 1® 6.5% vaginal oint

Tioconazole^855^ Restriction: Restricted to members who have recently failed first line agents (Clotrimazole, Miconazole).

Vaginal - Estrogens - Drugs for women^856^ 1 Estrace® 0.01% cream

Estradiol^857^ 1 Premarin Vaginal Cream® 0.625mg/gm cream

Estrogens, Conjugated^858^ Restriction: Prior authorization required. 58 KFHC DRUG FORMULARY

GENERIC BRAND FORMS

Vitamins - Dietary Supplements^859^ 1 Rocaltrol® 0.25mcg, 0.5mcg capsule

Calcitriol^860^ 1 1000mcg injection

Cyanocobalamin^861^ Restriction: Restricted to documented deficiency. Consider sublingual supplementation. 1 Drisdol® 50,000 IU capsule

Ergocalciferol^862^ 1 1mg tablet

Folic acid^863^ Restriction: Pregnant women and those on MTX therapy. 1 Carnitor® 10% soln, 330mg tablet

Levocarnitine^864^ Restriction: Prior authorization required. 1 Poly-Vi-Flor®, 0.25mg/ml, 0.5mg/ml drops, 0.25mg, 0.5mg, 1mg

Pediatric Vitamins w/Fluoride^865^ Tri-Vi-Flor® chewable tablet Restriction: Restricted to members < 5 years old. 1 Pediatric Vitamins w/Fluoride Poly-Vi-Flor w/Iron®, 0.25mg-10mg/ml drops Tri-Vi-Flor w/Iron®

& Iron^866^ Restriction: Restricted to members < 5 years old. 1 Prenatal Vitamins w/Minerals, capsule or tablet

Iron & Folic Acid^867^ Restriction: Pregnant females only. 1 Luride® 0.55mg(0.25mgF), 1.1mg(0.5mgF), 2.2mg(1mgF)

Sodium Fluoride^868^ chewable tablet, 0.125mg/drop, 0.275mg/drop, 0.55mg/drop, 1.1mg/ml drops OVER THE COUNTER DRUGS KFHC DRUG FORMULARY 59

GENERIC BRAND FORMS

Contraceptive/OTC^869^ 1

Condoms-Male^870^ Restriction: Limited to 12 per 30 days. 1 Emko® 8%,12.5% foam, 2% gel

Nonoxynol-9^871^

Device - Supplies/OTC^872^ 1

Blood pressure monitor^873^ Restriction: One per member per 5 years. $50 maximum per unit. 1 various (knee, ankle, wrist)

Braces^874^ Restriction: One per affected area per member per 12 months. $50 maximum per unit. 1 various

Crutches^875^ Restriction: One pair per member per 12 months 1 various

Nebulizer^876^ Restriction: One per member per 3 years. $65 maximum per unit. 1

Tablet Splitter^877^ 1

Thermometer^878^ 1

Vaporizer^879^

Ostomy Items/OTC^880^ 1 various

Ostomy supplies^881^ Restriction: Pouches are allowed 30 per 30 days.

Supplies - Diabetic/OTC^882^ 1 70%, 91% topical soln

Alcohol^883^ 1 TRUE Metrix® strip

Blood Glucose Strips^884^ Restriction: Restricted to True Metrix ® or Fora®. True Metrix® meters are billed with a special code from Trividia and are preferred. Fora® meters are ordered directly from the manufacturer. Please write prescriptions for strips, lancets, etc. The members should then have the pharmacy fill the meter and strips together so as to ensure the correct products are given. Plan allows up to #100/30 days for Type I, #100/90 days for Type II, and #150/30 days for gestational diabetics. 1

Lancets^885^ Continued on next page OVER THE COUNTER DRUGS 60 KFHC DRUG FORMULARY

GENERIC BRAND FORMS Supplies - Diabetic/OTC, continued • SEE PREVIOUS PAGE 1 Syringes, Syringes w/Needles, TRUEplus®

Pen Needles^886^ Restriction: Requires insulin to clear. Coinsides with insulin vial, pen. Limit up to 200 per 40 days. 1 Keto-Diastix®, Ketostix® strip

Urine Test Strips^887^

Vitamins/OTC^888^ 1 Tri-Vi-Sol® ADC plain and w/iron drops

Pediatric Vitamins^889^ Restriction: Restricted to patients < 5 years old. 1 Prenatal Vitamins w/Minerals, 0.1mg, 1mg Folic Acid capsule, 0.4mg, 0.8mg, 1mg Folic Acid tablet

Iron & Folic Acid^890^ Restriction: Pregnant female members only. 1 Prenatal Vitamins w/Minerals, 0.1mg, 1mg Folic Acid capsule, 0.4mg, 0.8mg, 1mg Folic Acid tablet

Iron & Folic Acid, w/DHA^891^ Restriction: Pregnant female members only. 1 25mg, 50mg, 100mg tablet

Pyridoxine (Vitamin B-6)^892^ 1 400 international units, 1000 international unit capsule

Vitamin E^893^ KFHC DRUG FORMULARY 61 Appendix

These medications are carved out by Medi-Cal as stated in the Medi-Cal bulletin. The prescriptions for any of the carved out medications are transmitted to Medi-Cal. If the claim for the listed drugs is rejected by EDS for a Kern Family Health Care patient with a message stating to bill the primary insurance it is likely the patient has insurance in addition to Kern Health Systems. Some prescriptions may require a TAR from Medi-Cal. Psychotherapeutic Agents

Amantadine Olanzapine ...... Zyprexa® Aripipazole ...... Abilify® Olanzapine & fluoxetine ...... Symbyax® Asenapine ...... Saphris® Paliperidone ...... Invega® Benztropine ...... Cogentin® Perphenazine ...... Trilafon® Biperidin ...... Akineton® Phenelzine ...... Nardil® Brexpiprazole ...... Rexulti® Pimozide ...... Orap® Cariprazine ...... Vraylar® Promazine ...... Sparine® Chlorpromazine ...... Thorazine® Quetiapine ...... Seroquel® Clozapine ...... Clozaril® Risperidone ...... Risperdal® Fluphenazine ...... Prolixin® Selegiline ...... Emsam® Haloperidol ...... Haldol® Thioridazine ...... Mellaril® Iloperidone ...... Fanapt® Thiothixene ...... Navane® Isocarboxazid ...... Marplan® Tranylcypromine ...... Parnate® Lithium Trifluoperazine ...... Stelazine® Loxapine ...... Loxitane® Trifluopromazine ...... Vesprin® Lurasidone ...... Latuda® Trihexyphenidyl ...... Artane® Molindone ...... Moban® Ziprasidone ...... Geodon®

Alcohol, Heroin Detoxification and Dependency Treatement Drugs

Acamposate ...... Campral® Disulfiram ...... Antabuse® Buprenorphrine ...... Subutex®, Butrans® Naloxone ...... Narcan® Buprenorphrine/naloxone ...... Suboxone® Naltrexone ...... Revia® 62 KFHC DRUG FORMULARY

Antiviral Agents

Abacavir ...... Ziagen® Elvitegravir, cobicistat, Abacavir, dolutegravir emitricitabine & tenofovir ...... Stribild®, Genvoya® & lamivudine ...... Trimeq® Emicitabine ...... Emitriva® Abacavir, lamivudine ...... Epzicom® Emicitabine, rilpivirine Abacavir, lamivudine & tenofivir ...... Complera®, Odefsey® & zidovudine ...... Trizivir® Emtricitabine, tenofovir ...... Descovy® Amprenavir ...... Agenerase® Enfuvirtide ...... Fuzeon® Atazanivir ...... Reyataz® Etravirine ...... Itelence® Atazanivir & cobicistat ...... Evotaz® Fosamprenavir ...... Levixa® Bictegravir, emtricitabine, Ibalizumab-uiyk ...... Trogarzo® tenofovir, alafenamide ...... Biktarvy® Indinavir ...... Crixivan® Cobicistat ...... Tybost® Lamivudine ...... Epivir HBR®, Epivir® Darunavir ...... Prezista® Lamivudine & zidovudine ...... Combivir® Darunavir & cobicistat ...... Prezcobix® Lopinavir & ritonavir ...... Kaletra® Darunavir, cobicistat, Maraviroc ...... Selzentry® emtricitabine, tenofovir, alafenamide ...... Symtuza® Nelfinavir ...... Viracept® Delavirdine ...... Rescriptor® Nevirapine ...... Viramune® Dolutegravir ...... Tivicay® Raltegravir ...... Isentress® Dolutegravir, rilpivirine ...... Juluca® Rilpivirine ...... Edurant® Doravine ...... Pifeltro® Ritonavir ...... Norvir® Doravine, lamivudine, tenofovir ...... Delstrigo® Saquinavir ...... Invirase® Efavirenz ...... Sustiva® Stavudine ...... Zerit® Efavirenz, emtricitabine Tenofivir ...... Viread® & tenofivir ...... Atripla® Tenofivir & emtricitabine ...... Truvada® Efavirenz, lamivudine, tenofovir ...... Symfi® Tipranavir ...... Aptivus® Elvitegravir ...... Vitekta®

Blood Factors Please refer to FFS Medi-Cal for full listing. KFHC DRUG FORMULARY 63

Management of Type 2 Diabetes Treatment

Algorithm for the metabolic management of Type 2 diabetes Tier 1: Well validated core therapies

Lifestyle + Metformin Lifestyle + Metformin At Diagnosis: plus plus Basal Insulin Intensive Insulin Lifestyle Plus Metformin Lifestyle + Metformin plus Sulfonylurea STEP 1 STEP 2 STEP 3 Tier 2: Less well validated core therapies Lifestyle + Metformin Lifestyle + Metformin + + Pioglitazone Pioglitazone No hypoglycemia + Edema/CHF Sulfonylurea Bone loss

Lifestyle + Metformin Lifestyle + Metformin + + GLP-1agonist Basal Insulin No hypoglycemia Weight loss Nausea/vomiting

Type 2 Diabetes is treated in a step wise manner from the time of diagnosis:

Always included in the treatment is Lifestyle Intervention and Exercise. These components are always complementary to medication therapies and include medical nutrition therapy, weight loss and regular daily exercise. The most convincing long term data that weight loss effectively lowers glycemia have been generated in the follow up of type 2 diabetic patients who have had bariactric surgery. In this setting, with a mean sustained weight loss of > 20 kg, diabetes is virtually eliminated. 64 KFHC DRUG FORMULARY

Management of Type 2 Diabetes Treatment, continued... Intervention A1C response (%) Advantages Disadvantages TIER 1: Well validated core Rx • Step 1: Initial Therapy Lifestyle to decrease 1.0-2.0 Broad benefits Insufficient for weight & increase most in 1 year activity • Metformin 1.0-2.0 Weight neutral GI side effects; contraindicated renal insufficiency Titration of Metformin 1. Begin with low dose metformin 3. If gastrointestinal side effects may limit the dose that can (500 mg) taken once or twice appear as doses advanced, be used. per day with meals (breakfast decrease to previous lower dose 5. Based on cost considerations, and/or dinner) or 850 mgm and try to advance the dose at a generic metformin is the first once per day. later time. choice of therapy. A longer 2. After 5-7 days, if 4. The maximum effective dose can acting formulation is available gastrointestinal side effects be up to 1,000 mg twice per day in some countries and can be have not occurred, advance but is often 850 mg twice per day. given once per day. dose to 850 mg, or two 500 mg Modestly greater tablets, twice per day effectiveness has been The major action of metformin (medication to be taken before observed with doses up to is to decrease hepatic breakfast and/or dinner) about 2,500 mg/day. glucose output and lower Gastrointestinal side effects fasting glycemia.

• Step 2: additional therapy if A1C is 7 or greater after 2-3 months of step one: Insulin 1.5-3.5 No dose limit; 1-4 injections (basal insulin-Lantus) Rapidly effective daily, wt.+, Humalog, Apidra, Improved lipid profile. Monitoring; Novolog Hypoglycemia hypoglycemia, Wt. gain expensive med Sulfonylurea 1.0-2.0 Rapidly effective

TIER 2: less well validated. Oral therapy without insulin TZDs 0.5-1.4 Improved lipid profile Fluid retention (actos) Potential CHF, Wt. +, decrease in MI bone fxs; (actos) Potential MI increase (avandia)

GLP-1 Agonist (exenatide) 0.5-1.0 Wt. - 2 injections daily (Byetta) frequent GI side effects Long term safety??? Expensive

Other therapy (all expensive) DPP-4 inhibitor 0.5-0.8 Wt. neutral Long term safety? (Januvia) Pramlintide 0.5-1.0 Wt. - 3 injections daily, (Amylin) Long term safety? Frequent GI side effects KFHC DRUG FORMULARY 65

Management of Type 2 Diabetes Treatment, continued...

Step 2: Addition of a second medication. If to reduce postprandial glucose excursions. When lifestyle intervention and the maximal tolerated insulin injections are started, insulin secretagogues dose of metformin fail to achieve or sustain the (sulfonylureas or glinides) should be discontinued, glycemic goals, another medication should be or tapered and then discontinued, since they are added within 2-3 months of the initiation of not considered to be synergistic. Although therapy or at any time the target A1C level is not addition of a third agent can be considered, achieved. Another medication may also be especially if the A1C level is close to target (A1C necessary if metformin is contraindicated or not <8.0%), this approach is usually not preferred, as it tolerated. The consensus regarding the second is no more effective in lowering glycemia, and is medication was to choose either insulin or a more costly, than initiation or intensifying insulin. sulfonylurea. The A1C level will determine in part which agent is selected next, with consideration Special considerations/patients. In the setting of given to the more effective glycemia-lowering severely uncontrolled diabetes with catabolism, agent, insulin, for patients with an A1C level >8.5% defined as fasting plasma glucose levels > or with symptoms secondary to ehyperglycemia. 13.9mmol/l (250 mg/dl), random glucose levels Insulin may be initiated with a basal (intermediate consistently above 16.7 mmol/l (300 mg/dl), A1C to long acting) insulin. However, many newly above 10%, or the presence of ketonuria, or as diagnosed type 2 diabetic patients will usually symptomatic diabetes with polyuria, polydipsia respond to oral medications, even if symptoms of and weight loss, insulin therapy in combination ehyperglycemia are present. with lifestyle intervention is the treatment of choice. Some patients with these characteristics Step 3: Further adjustments. If lifestyle, metformin, will have unrecognized type 1 diabetes; others will and sulfonylurea or basal insulin do not result in have type 2 diabetes with severe insulin achievement of target glycemia, the next step deficiency. Insulin can be titrated rapidly and is should be to start, or intensify, insulin therapy. associated with the greatest likelihood of Intensification of insulin therapy usually consists of returning glucose levels rapidly to target levels. additional injections that might include a short- or After symptoms are relieved and glucose levels rapid-acting insulin given before selected meals decreased, oral agents can often be added and it may be possible to withdraw insulin, if preferred. Insulin Therapy Start with bedtime intermediate-acting insulin If fasting bg is in target range (3.9 -7.2 mmol/l Or bedtime or morning long-acting insulin (can [70-130mg/dl], check bg before lunch, dinner, and Initiate with 10 units or 0.2 units per kg) bed. Depending on bg results, add second injection as below. Can usually begin with around 4 units and Check fasting glucose (fingerstick) usually daily and adjust by 2 units every 3 days until bg is in range increase dose, typically by 2 units every 3 days until fasting • Pre lunch bg out of range- Add rapid-acting insulin levels are at breakfast consistently in target range (3.9-7.2 mmol/l [70-130 • Pre-dinner bg out of range-Add NPH insulin at mg/dl]). Can increase dose in larger increments, e.g., breakfast or rapid-acting at lunch by 4 units every 3 days, if fasting glucose is >10 mmol/l • Pre-bed bg out of range- Add rapid-acting insulin (180mg/dl) at dinner

If hypoglycemia occurs, or if fasting glucose level < A1C >7% after 3 months 3.9mmol/l [70mg/dl], Reduce bedtime dose by 4 units or 10% - whichever is greater. Recheck pre-meal bg levels and if out of range, may need to add another injection. If A1C continues to If A1C is <7%, continue regimen and check A1C every be out of range, check 2 h postprandial levels and 3 months. adjust preprandial rapid acting insulin.

If A1C >7% after 2-3 months 66 KFHC DRUG FORMULARY

Management of Type 2 Diabetes Treatment, continued...

Insulin Types and Action Times

There are five main types of insulin. They each work at different speeds. Most people who take insulin use two types of insulin and take at least two shots a day.

Type of Insulin/ Name Letter on Bottle Starts Working* Works Hardest* Stops Working* Quick acting, Humalog Insulin lispro H 5-15 minutes 45-90 minutes 3-4 hours Short acting, Regular Insulin R 30 minutes 2-5 hours 5-8 hours Intermediate acting, NPH N 1-3 hours 6-12 hours 16-24 hours Long acting, Ultralente Insulin U 4-6 hours 8-20 hours 24-28 hours NPH and Regular Insulin mixtures (2 Insulins combined) 70/30 or 50/50 30 minutes 7-12 hours 16-24 hours

*Action times of insulins are based on average responses. How insulin works in an individual body may vary. Work with your doctor and diabetes educator to understand how insulin works in each individual case. Insulin Effect 0 6 12 18 24 30 Time In Hours

Lispro Regular NPH Ultralente

Provided by Kern Health Systems KFHC DRUG FORMULARY 67

TREATMENT FOR INFANTS AND YOUNG CHILDREN (5 years or younger) Preferred treatments are in bold print. *Patient education is essential at every step

Long-Term Preventive Quick-Relief

Daily medication: • Inhaled short-acting bronchodilator: inhaled Beta2- • Inhaled corticosteroid agonist or ipratropium bromide, or Beta2-agonist STEP 4 - MDI with spacer and face mask >1 mg tablets or syrup as needed for symptoms, not to daily or exceed 3-4 times in one day. Severe - Nebulized budesonide >1 mg bid Persistent - If needed, add oral steroids-lowest possible dose on an alternate-day, early morning schedule.

Daily medication: • Inhaled short-acting bronchodilator: inhaled Beta2- STEP 3 • Inhaled corticosteroid agonist or ipratropium bromide, or Beta2-agonist - MDI with spacer and face mask tablets or syrup as needed for symptoms, not to Moderate 400-800 mcg daily or exceed 3-4 times in one day. Persistent - Nebulized budesonide <=1 mg bid

Daily medication: • Inhaled short-acting bronchodilator: inhaled Beta2- STEP 2 • Either inhaled corticosteroid, agonist or ipratropium bromide, or Beta2-agonist Mild Persistent (200-400 mcg) or cromoglycate (use tablets or syrup as needed for symptoms, not to exceed MDI with a spacer and face mask or 3-4 times in one day. use a nebulizer) • None needed. • Inhaled short-acting bronchodilator: inhaled Beta2- agonist or ipratropium bromide, as needed for STEP 1 symptoms, but not more than three times a week • Intensity of treatment will depend on severity of attack Intermittent (see figures on management of asthma attacks).

➡ Stepdown Stepup Review treatment every 3 to 6 months. If control is If control is not achieved, consider stepup. But first: review sustained for at least 3 months, a gradual stepwise ➡ patient medication technique, reduction in treatment may be possible. compliance, and environmental control (avoidance of allergens or other trigger factors). 68 KFHC DRUG FORMULARY

TREATMENT: ADULTS & CHILDREN OVER 5 YEARS OLD Preferred treatments are in bold print. * Patient education is essential at every step Long-Term Preventive Quick-Relief

Daily medications: • Inhaled corticosteroid, 800-2,000 mcg or more, • Short-acting bronchodilator: inhaled Beta2- STEP 4 and agonist as needed for symptoms. • Long-acting bronchodilator: either long-acting inhaled Severe Beta2-agonist, and/or sustained-release theophylline, and/or long-acting Beta2-agonist tablets or syrup, and Persistent • Corticosteroid tablets or syrup long term.

Daily medications: • Short-acting bronchodilator: inhaled Beta2- • Inhaled corticosteroid, >500 mcg AND, if needed agonist as needed for symptoms, not to exceed • Long-acting bronchodilator: either long-acting in- 3-4 times in one day. haled Beta2-agonist, sustained-release theophylline, or long-acting Beta2-agonist tablets or syrup. (Long-acting STEP 3 Beta2-agonist may provide more effective symptom control when added to low-medium dose steroid compared to Moderate increasing the steroid dose). • Consider adding anti-leukotriene, especially for aspirin- sensitive patients and for preventing exercise-induced Persistent bronchospasm.

Daily medication: • Short-acting bronchodilator: inhaled Beta2- STEP 2 • Either Inhaled corticosteroid, 200-500 mcg, agonist as needed for symptoms, not to exceed 3-4 cromoglycate, nedocromil, or sustained-release theophylline. times in one day. Mild Antileukotrienes may be considered, but their position in therapy has not been fully established. Persistent

• None needed. • Short-acting bronchodilator: inhaled Beta2-agonist as needed for symptoms, but less than once a week STEP 1 • Intensity of treatment will depend on severity of attack (see figures on management of asthma attacks) Intermittent • Inhaled Beta2-agonist or cromoglycate before exercise or exposure to allergen.

➡ Stepdown Stepup Review treatment every 3 to 6 months. If control is sustained If control is not achieved, consider stepup. But first: review ➡ for at least 3 months, a gradual stepwise reduction in treatment patient medication technique, compliance, and environmental may be possible. control (avoidance of allergens or other trigger factors).

*Dosage note: Steroid doses are for Beclomethasone Dipropionate (on the WHO list of “Essential Drugs”). Other preparations have equal effect, but adjust the dose because inhaled steroids are not equivalent on a microgram or per puff basis. KFHC DRUG FORMULARY 69 INDEX–GENERIC and BRAND A Alkeran® 12 Aranesp® 31 Benazepril - HCTZ 16 Allopurinol 14 Arava® 14 Benemid® 14 ASA 3 Alogliptin 32 Aricept® 24 Bentyl® 14 Acarbose 32 Alogliptin/metformin 32 Arimidex® 10 Benzagel® 52 Accolate® 49 Alogliptin/pioglitazone 32 Armonair Respiclick® 49 Benznidazole 7 Accupril® 15 Alphagan® Alphagan P® 42 Armour® 37 Benzonatate 48 Acebutolol 17 Altace® 15 Arnuity Ellipta® 49 Benzoyl Peroxide 52 Acetaminophen 3 Altretamine 10 Asacol®, Delzicol®, Lialda® 29 Besifloxacin 40 Acetasol HC® 45 Aluminum & Magnesium Aspirin 3 Besivance® 40 Acetazolamide 42 Hydroxides 26 Astelin® 51 Betagan® 42 Acetic Acid 55 Aluminum & Magnesium Atarax® 47 Betamethasone 54 Acetylcysteine 51 Hydroxides w/Simethicone 26 Atenolol 17 Betamethasone dipropionate 54 Aciphex® 30 Aluminum Acetate 53 Ativan® 22 Betapace® 16 Actigall® 27 Aluminum Hydroxide & Mag. Atorvastatin 16 Betaxolol 42 Actonel® 45 Trisilicate 26 Atovaquone 7 Bethanechol 14 INDEX – GENERIC and BRAND Actos® 35 Aluminum Hydroxide, Mag. Atropine 43 Betopic® 42 Acular®, Acular LS 43 Carbonate 26 Atrovent HFA® 50 Bevacizumab 10 Acyclovir 9 Amaryl® 34 Augmentin® 5 Bexarotene 10 Adacel®, Tenivac®, others 56 Ambien® 24 Auranofin 13 Biaxin® 4 Adalat CC® 18 Ambrisentan 19 Avalide® 16 Bicalutamide 10 Adalimumab 14 Amerge® 23 Avapro® 16 Bimatoprost 42 Adapalene 52 Amiodarone 16 Avastin® 10 Bisacodyl 28 Adderall®, Adderall XR® 24 Amitriptyline 21 Axicabtagene ciloleucel 10 Bismuth Subsalicylate 29 Adlyxin® 33 Amlodipine 18 Azathioprine 13, 37 Bisoprolol - HCTZ 17 Admelog®, Humalog® 33 Amoxicillin 5 Azelastine 51 Blood Glucose Strips 59 Adrucil® 11 Amoxicillin/Clavulanate 5 Azelastine ophth soln 40 Blood pressure monitor 59 Advair®, Wixela Inhub® , Amoxil® 5 Azithromycin 4 Boostrix® 56 AirDuo® 49 Amphetamine Combination 24 Azopt® 42 Bosentan 19 Aerospan® 49 Ampicillin 5 Azulfidine® 14, 29 Braces 59 Afinitor® 11 Amylase, Lipase, & Protease 27 Breo Ellipta® 49 Agrylin® 30 Anafranil® 22 B Brethine® 48 Albalon® 41 Anagrelide 30 Brilinta® 31 Albendazole 7 Anastrozole 10 Bacitracin 40 Brimonidine 42 Albenza® 7 Anoro Ellipta® 50 Bacitracin & Polymyxin 40 Brimonidine tartrate/timolol 42 Albuterol 48 Anthralin 55 Baclofen 38 Brinzolamide 42 Albuterol HFA 48 Antibacterial/Antifungal Agents 37 Bactrim®/Septra® 6 Bromocriptine 35 Alcohol 59 Antivert® 26 Bactroban® 53 Brompheniramine 47 Aldactone® 18 Anusol-HC® 28 Balsalazide 28 Brompheniramine & Phenylephrine Aldara® 53 Apidra® 33 Baraclude® 9 46 Aldomet® 15 Apixaban 30 Basaglar®, Toujeo® 33 Budesonide 49 Alendronate 45 Apremilast 13 Beclomethasone 49 Budesonide/formoterol 49 Alesse® 44 Aprepitant 27 Benadryl® 47 Bupropion 21 Alitretinoin 10 Apresoline® 19 Benazepril 15 Buspar® 22 70 KFHC DRUG FORMULARY

Buspirone 22 Cephulac® 28 Colestipol 17 Dapagliflozin 34 Butalbital, Caffeine, & Cetirizine 47 Combigan® 42 Dapagliflozin/metformin 34 Acetaminophen 23 Chantix® 24 Combivent Respimat® 50 Dapsone 10 Butalbital, Caffeine, & Aspirin 23 Chemet® 45 Compazine® 27 Daraprim® 7 Butoconazole 57 Chlorambucil 10 Comtan® 13 Darbepoetin 31 Bydureon® 33 Chloroquine 7 Condoms-Male 59 Daunorubicin 10 Chlorpheniramine 47 Condylox® 53 Debrox® 45 C Chlorpheniramine & Phenylephrine Contac® 46 Decadron® 36 46 Cordran® 54 Demulen® 43 Cabergoline 35 Chlorpheniramine & Coreg® 17 Depakote®, Depakote ER® 20 Cafergot® 23 Pseudoephedrine 46 Cortenema® 28 Depo-Testosterone® 31 Calamine 53 Chlorthalidone 18 Cortisporin® 45 Desipramine 22 Calan®, Calan SR® 18 Chlortrimeton® 47 Cosentyx® 15 Desmopressin 35 Calcipotriene 55 Cholestyramine 17 Cosopt® 42 Desogen® 43 Calcitonin-salmon 45 Cilostazol 31 Coumadin® 30 Desogestrel & Ethinyl Estradiol 43 Calcitriol 58 Ciloxan® 41 Cozaar® 16 Desyrel® 21 Calcium 26 Cinacalcet 35 Creon®, Zenpep® 27 Dexamethasone 36

Calcium Acetate 18 Ciprodex® 45 Cresemba® 6 Dexedrine® 24 INDEX – GENERIC and BRAND Calcium Carbonate (20 mEq Ciprofloxacin 6 Crestor® 17 Dexmethylphenidate 24 Ca++/Gm) Calcium Carbonate Ciprofloxacin- Dexamethasone 45 Crinone® 36 Dextro-amphetamine 24 w/Vitamin D 26 Cipro® 6 Crolom® 43 Dextromethorphan 47 Calcium Gluconate (4.5mEq Citalopram 21 Cromolyn 43 Dextromethorphan & Guaifenesin Ca++/Gm) 26 Clarithromycin 4 Crotamiton 55 48 Calcium acetate (12.5mEq Claritin® 47 Crutches 59 Diabeta® 35 Ca++/Gm) 26 Cleocin-T® 53 Cyanocobalamin 58 Diamox® 42 Calcium lactate (6.5mEq Cleocin® 4, 57 Cyclobenzaprine 38 Diaphragm 53 Ca++/Gm) 26 Climara®, Vivelle® 54 Cyclogyl® 43 Diazepam 22, 38 Camptosar® 11 Clindamycin 4, 57 Cyclopentolate 43 Diclofenac 43 Carafate® 29 Clinoril® 39 Cyclophosphamide 10 Diclofenac Na 39 Carbamazepine 20 Clobetasol 54 Cycloserine 7 Dicloxacillin 5 Carbamide Peroxide 45 Clomipramine 22 Cyclosporine 43 Dicyclomine 14 Carbidopa & Levodopa 13 Clonazepam 20, 22 Cyclosporine, Microemulsion 37 Differin® 52 Cardec-DM® 46 Clonidine 15 Cymbalta® 22 Diflucan® 6 Cardizem® 18 Clopidogrel 31 Cyproheptadine 47 Difluprednate 42 Cardura® 15 Clotrimazole 6 Cyramza® 12 Digoxin 16 Carnitor® 58 Codeine & Guaifenesin 48 Cytomel® 37 Dilantin®, Phenytek® 20 Carvedilol 17 Codeine sulfate 2 Cytotec® 29 Dilaudid® 2 Casodex® 10 Codeine w/Acetaminophen 2 Cytovene® 9 Diltiazem 18 Catapres® 15 Codeine, Guaifenesin, Cytoxan® 10 Dimetane DX® 46 Cefdinir 3 Pseudoephedrine 48 Dimetapp® new formualtion 46 Cefuroxime 3 ColBenemid® 14 D DiovanHCT® 16 Celebrex® 39 Colace® 28 Diovan® 16 Celecoxib 39 Colazal® 28 DDAVP® 35 Diphenhydramine 47 Celexa® 21 Colchicine & Probenecid 14 Danazol 31 Diphenoxylate & Atropine 26 Cephalexin 3 Colestid® 17 Danocrine® 31 Diprosone® 54 KFHC DRUG FORMULARY 71

Dipyridamole 31 Emend® 27 Etoposide 11 Fluticasone propionate 49 Disalcid® 40 Emko® 59 Eulexin® 11 Fluticasone/salmeterol 49 Disopyramide 16 Empagliflozin 34 Eurax® 55 Fluticasone/vilanterol 49 Ditropan® 55 Empagliflozin/metformin 34 Everolimus 11 Fluvoxamine 21 Divalproex 20 Enalapril 15 Exenatide 33 Fluzone®, Fluvirin®, Fluvarix®, Docusate 28 Enbrel® 15 Extavia® 15 others 56 Domeboro’s Soln® 53 Engerix-B®, Heplisav-B® 56 Ezetimibe 17 Focalin®, Focalin XR® 24 Donepezil 24 Enoxaparin 30 Folic acid 58 Dorzolamide 42 Entacapone 13 F Fosamax® 45 Dorzolamide/timolol 42 Entecavir 9 Fosfomycin tromethamine 4 Dovonex® 55 Epclusa® 9 FML® 42 Fosrenol® 18 Doxazosin 15 Epinephrine 45 Famotidine 27 Furadantin® 5 Doxycycline hyclate 6 Epoetin, Alpha 31 Farxiga® 34 Furosemide 18 Doxylamine Succinate 26 Epoprostenol 19 Femara® 11 Drisdol® 58 Ergocalciferol 58 Fenofibrate 17 G Drithocreme HP® 55 Ergotamine & Caffeine 23 Fentanyl 2 Dronabinol 27 Ergotamine Tartarate 23 Fer-in-Sol® 30 Gabapentin 20

INDEX – GENERIC and BRAND Drospirenone & Ethinyl Estradiol Eribulin mesylate 10 Ferrous Gluconate 30 Gabitril® 20 43 Erivedge® 13 Ferrous Sulfate 30 Ganciclovir 9 Dulaglutide 32 Ertugliflozin 34 Finasteride 14 Garamycin® 41 Dulcolax® 28 Ertugliflozin/metformin 34 Fioricet® 23 Gardasil®, Cervarix® 56 Dulera® 50 Ery-tab® 4 Fiorinal® 23 Gaviscon® 26 Duloxetine 22 Erythrocin® 4 Flagyl® 9 Gemfibrozil 17 Duragesic® 2 Erythromycin 41 Flecainide 16 Gemtuzumab ozogamicin 11 Durezol® 42 Erythromycin Base 4 Fleets® 28 Gentamicin 41 Dyazide®, Maxide® 18 Erythromycin Ethylsuccinate 4 Flolan® 19 Glatiramer acetate 15 Dynapen® 5 Erythromycin Stearate 4 Flomax® 14 Glatopa® 15 Dyrenium® 18 Escitalopram 21 Flonase® 51 Gleevec® 11 Esidrix® 18 Florinef® 36 Gleostine® 11 E Esomeprazole 30 Flovent HFA® 49 Glimepiride 34 Esterified Estrogens & Floxin® Otic 45 Glipizide 34 E-Mycin® 4 Methyltestosterone 35 Fluconazole 6 Glucagon 34 EES® 4 Estrace® 35, 57 Flunisolide 49 Glucophage®, Glucophage XR® Econazole 52 Estradiol 35, 57 Fluocinolone 54 32 Effexor®, Effexor XR® 22 Estramustine 11 Fluocinonide 54 Glucotrol® 34 Effient® 31 Estratest® 35 Fluorometholone 42 Glyburide 35 Efudex® 53 Estrogen, Conjugated & Fluorouracil 11 Glycopyrrolate 14 Elagolix 36 Medroxyprogesterone 35 Fluoxetine 21 Go-Lytely® 28 Elbasvir/grazoprevir 9 Estrogens, Conjugated 35 Flurandrenolide 54 Granisetron 27 Electrolyte Maintenance 37 Estrostep® 45 Flurocortisone 36 Griseofulvin 6 Elimite® 55 Etanercept 15 Flutamide 11 Guaifenesin 51 Eliquis® 30 Ethambutal 7 Fluticasone 49 Guanfacine 15 Elmiron® 55 Ethosuximide 20 Fluticasone - Umeclindium - Gynazole 1® 57 Elocon® 54 Ethynodiol & Ethinyl Estradiol 43 Vilanterol 50 Gynazole-1® 57 Emcyt® 11 Etonogestrel/ethinyl estradiol 53 Fluticasone furoate 49 Gyne-lotrimin® 57 72 KFHC DRUG FORMULARY

H Imiquimod 53 J Levobunolol 42 Imitrex® 23 Levocarnitine 58 Halaven® 10 Imodium® 26 Jardiance® 34 Levodopa 13 Havrix® 56 Imuran® 13, 37 Levofloxacin 6 Hemorrhoidal Suppository Incruse Ellipta® 50 K Levonorgestrel 44 w/Hydrocortisone 28 Indapamide 18 Levonorgestrel & Ethinyl Estradiol Heparin 30 Inderal® 17 Kanjinti® 12 44 Hepatitis A 56 Indocin® 39 Kayexalate® 19 Levorphanol 2 Hepatitis A & B 56 Indomethacin 39 Kazano® 32 Levothyroxine 37 Hepatitis B 56 Infliximab-ABDA 15 Keflex® 3 Levoxyl® 37 Hexalen® 10 Influenza 56 Kenalog® 54 Levsin® 14 Homatropine 43 Insulin aspart 33 Keppra® 20 Lexapro® 21 Humatin® 7 Insulin degludec 33 Keto-Diastix®, Ketostix® 60 Lidex® 54 Humira® 14 Insulin detemir 33 Ketoconazole 52 Linagliptin 32 Humulin® Novolin® 33 Insulin glargine 33 Ketoprofen 40 Linezolid 9 Humulin®, Novolin® 37 Insulin glargine/lixisenatide 33 Ketorolac 43 Liothyronine 37 Hyaluronidase 54 Insulin glulisine 33 Ketotifen 40 Lipitor® 16

Hydralazine 19 Insulin lispro 33 Klonopin® 20, 22 Liraglutide 33 INDEX – GENERIC and BRAND Hydrochlorothiazide 18 Insulin, Human 33 Kytril® 27 Lisdexamfetamine 24 Hydrocodone/APAP 2 Insulin, human 37 Lisinopril 15 Hydrocortisone 36 Intal® 51 L Lisinopril - HCTZ 16 Hydrocortisone & acetic acid 45 Interferon alpha 9 Lixisenatide 33 Hydrocortisone enema 28 Interferon beta 15 Labetolol 17 Lo-Ovral® 44 Hydromorphone 2 Intravenous lipids 38 Lactulose 28 Loestrin 1.5/30®, 1.5/30 Fe® Hydroxychloroquine 13 Ipilimumab 11 Lamictal® 20 44 Hydroxyprogesterone Caproate 36 Ipratropium 50 Lamisil® 7, 52 Loestrin 1/20®, 1/20 Fe®, Lo Hydroxyurea 11 Ipratropium - Albuterol 50 Lamotrigine 20 Loestrin Fe® 44 Hydroxyzine 47 Ipratropium- albuterol 50 Lancets 59 Lomotil® 26 Hyoscyamine 14 Ipratropium- albuterol Respimat 50 Lanoxin® 16 Lomustine 11 Hyperrab®, Imogam rabies® 56 Irbesartan 16 Lansoprazole 30 Loniten® 19 Hyrea® 11 Irbesartan-hctz 16 Lanthunum Carbonate 18 Loperamide 26 Hytrin® 15 Irinotecan 11 Lasix® 18 Lopid® 17 Hyzaar® 16 Isavuconazounium sulfate 6 Latanoprost 42 Lopressor® 17 Isoniazid 8 Leflunomide 14 Loratadine 47 I Isopto-Atropine® 43 Lenalidomide 11 Lorazepam 22 Isopto-Carpine® 42 Letairis® 19 Losartan 16 INH® 8 Isopto-Homatropine® 43 Letrozole 11 Losartan-hctz 16 IV solutions: Dextrose-water, Isopto-Hyosine® 42 Leucovorin 45 Lotemax® 42 Dextrose-saline, Dextrose and Isordil® 19 Leukeran® 10 Lotensin® 15 Lactated Ringer's 38 Isosorbide Dinitrate 19 Leuprolide 11 Loteprednol 42 Ibuprofen 3, 40 Isosorbide Mononitrate 19 Leuprolide/norethindrone 36 Lotrimin® 52 Ilotycin® 41 Isotretinoin 3 Levaquin® 6 Lovenox® 30 Imatinib mesylate 11 Itraconazole 6 Levemir® 33 Lozol® 18 Imdur® 19 Ixabepilone 11 Levetiracetam 20 Lumigan® 42 Imervectin 7 Ixempra® 11 Levlen® 44 Lupaneta® 36 Imipramine 22 Levo-Dromoran® 2 KFHC DRUG FORMULARY 73

Lupron® 11 Methylprednisolone 36 Nabumetone 39 Nizoral® 52 Luride® 58 Metipranolol 42 Naphazoline 41 Nolvadex® 12 Luvox® 21 Metoclopramide 29 Naphazoline & Pheniramine 41 Nonoxynol-9 59 Lyrica® 20 Metolazone 18 Naphcon-A® 41 Norco® 2 Lysodren® 12 Metoprolol tartrate 17 Naprosyn® 40 Norelgestromin- ethinyl estradiol Metrogel® 57 Naproxen 40 53 M Metronidazole 9 Naratriptan 23 Norethindrone 44 Mexiletine 16 Nasacort Allergy 24 HR OTC® 51 Norethindrone & Ethinyl Estradiol M-M-R II® 56 Mexitil® 16 Nasonex® 51 43 MS-Contin® 2 Miacalcin® 45 Natacyn® 40 Norethindrone & Mestranol 44 Maalox® 26 Micatin® 53 Natamycin 40 Norethindrone Acetate & Ethinyl Macrobid® 5 Miconazole 53 Nateglinide 34 Estradiol 44 Magaldrate 26 Micronor® 44 Nebulizer 59 Norgestimate & Ethinyl Estradiol Magnesium citrate 28 Mineral oil 28 Neo-Polycin® 41 44 Makena® 36 Minipress® 15 Neomycin 4 Norgestrel & Ethinyl Estradiol 44 Marinol® 27 Minocin® 6 Neomycin, Bacitracin & Polymyxin Norlestrin 1/50®, 1/50 Fe® Matulane® 12 Minocycline 6 41, 52 44

INDEX – GENERIC and BRAND Maxalt® 23 Minoxidil 19 Neomycin, Polymyxin & Norpace® 16 Maxitrol® 41 Miralax® 28 Dexamethasone 41 Norpramin® 22 Measles, Mumps, Rubella 56 Mirapex® 13 Neomycin, Polymyxin & Nortriptyline 22 Meclizine 26 Mircette® 43 Hydrocortisone 45 Norvasc® 18 Medrol® 36 Mirtazapine 20 Neomycin,Polymyxin & Gramicidin Novolog® 33 Medroxyprogesterone 36 Misoprostol 29 41 Noxafil® 7 Megace® 11 Mitotane 12 Neomycin,Polymyxin & Nuvaring® 53 Megestrol 11 Mobic® 40 Prednisolone 41 Nystatin 7, 52, 57 Meloxicam 40 Mometasone 51 Neoral® 37 Melphalan 12 Mometasone/formoterol 50 Neosporin® 41, 52 O Menigitits 56 Monistat® 57 Neostigmine 14 Menveo®, Menomune®, Monitoring Device 50 Nepafanac 43 Ocuflox® 41 Bexsero®, Trumenba®, others Montelukast 49 Neptazane® 42 Ofloxacin 41 56 Monurol® 4 Nesina® 32 Olopatadine 40 Mephyton® 31 Morphine 2 Neurontin® 20 Omeprazole 30 Mepron® 7 Motrin® 3, 40 Nevanac® 43 Omnicef® 3 Mercaptopurine 12 Mucomyst® 51 Nexium 24HR (OTC)® 30 Ondansetron 27 Mesalamine 29 Mupirocin 53 Niacin 17 Opdivo® 12 Mestinon® 14 Muro® (128) 43 Nicorette®, Nicotrol®, Nicoderm Optipranolol® 42 Metformin 32 Myambutal® 7 CQ® 24 Optivar® 40 Methazolamide 42 Mycelex® 6 Nicotine 24 Oral electrolyte Soln 18 Methergine® 36 Mycobutin® 8 Nifedipine 18 Orilissa® 36 Methimazole 37 Mycostatin® 7, 52, 57 Nitrofurantoin 5 Ortho-Cyclen® 44 Methocarbamol 39 Mylanta® 26 Nitroglycerin 19 Ortho-Novum 1/35®, Demulen Methotrexate 12 Mylotarg® 11 Nitrostat® 19 1/50® 44 Methyldopa 15 Mysoline® 20 Nivolumab 12 Ortho-Novum 1/50® 44 Methylergonovine 36 Nix® 55 Ortho-Novum 10/11® 43 Methylphenidate 24 N Nizoral AD® 52 Ortho-Novum 7/14® 43 74 KFHC DRUG FORMULARY

Ortho-Novum 7/7/7® 44 Pentosan 55 Pravachol® 17 Pseudoephedrine 51 Ortho-Tricyclen Lo® 45 Pentoxifylline 31 Pravastatin 17 Pseudoephedrine, Ortho-Tricyclen® 45 Pepcid AC® 27 Prazosin 15 Brompheniramine & Orudis® 40 Pepcid® 27 Precose® 32 Dextromethorphan 46 Oseltamivir 9 Pepto-Bismal® 29 Pred Mild®, Pred Forte® 42 Pseudoephedrine, Oseni® 32 Percocet® 2 Prednisolone 36 Chlorpheniramine & Ostomy supplies 59 Periactin® 47 Prednisone 36 Dextromethorphan 46 Otezla® 13 Permethrin 55 Pregabalin 20 Pulmicort® 49 Ovral® 44 Perphenazine & Amitriptyline 20 Prelone® 36 Purinethol® 12 Oxcarbazepine 20 Persantine® 31 Premarin Vaginal Cream® 57 Pyrantel 7 Oxiconazole 52 Phenazopyridine 55 Premarin® 35 Pyrazinamide 8 Oxistat® 52 Phenergan DM® 46 Premphase® 36 Pyrethrins-Piperonyl 55 Oxy-Contin® 2 Phenergan w/Codeine® 46 Prempro® 35 Pyridium® 55 Oxybutynin 55 Phenergan-VC Codeine® 46 Prenatal Vitamins w/Minerals, Pyridostigmine 14 Oxycodone 2 Phenergan-VC® 47 Iron & Folic Acid 58 Pyridoxine (Vitamin B-6) 60 Oxycodone w/Acetaminophen 2 Phenergan® 27 Prenatal Vitamins w/Minerals, Pyrimethamine 7 Ozempic® Rybelsus® 33 Phenobarbital 20 Iron & Folic Acid, w/DHA 60 Phenylephrine, Promethazine & Prevacid® 30 Q INDEX – GENERIC and BRAND P Codeine 46 Prevnar 13®, Prevnar 23® 56 Phenytoin 20 Prilosec® 30 Questran® 17 PEG 28 PhosLo® 18 Primaquine 7 Quinapril 15 PEG-Electrolyte 28 Photofrin® 12 Primidone 20 Qvar Redihaler® 49 Paclitaxel 12 Phytonadione 31 Principen® 5 Pamelor® 22 Pilocarpine 42 Pro-Banthine® 29 R Panretin® 10 Pin-X® 7 Probenecid 14 Pantoprazole 30 Pioglitazone 35 Procarbazine 12 Rabeprazole 30 Papillomavirus 56 Plan B One Step® 44 Prochlorperazine 27 Rabies 56 Paregoric 26 Plaquenil® 13 Progesterone miconized 36 Ramipril 15 Parenteral Amino Acid Solutions Plavix® 31 Prograf® 37 Ramucirumab 12 and Combinations 38 Pneumococcal 56 Promethazine 27 Ranitidine 27 Parlodel® 35 Podofilox 53 Promethazine & Codeine 46 Reglan® 29 Paromomycin 7 Poly-Pred® 41 Promethazine & Relafen® 39 Paroxetine 21 Poly-Vi-Flor w/Iron®, Tri-Vi-Flor Dextromethorphan 46 Remeron® 20 Patanol® 40 w/Iron® 58 Promethazine & Phenylephrine 47 Renflexis® 15 Patiromer 19 Poly-Vi-Flor®, Tri-Vi-Flor® 58 Propafenone 16 Renvela® 19 Paxil® 21 Polymyxin & Trimethaprim 41 Propantheline 29 Requip® 13 Pazopanib 12 Polysporin® 40 Proparacaine 40 Restasis® 43 Peak Flow Meter 50 Polytrim® 41 Propranolol 17 Restoril® 24 Pediacare® 46 Porfimer sodium 12 Propylthiouracil 35 Retacrit® 31 Pedialyte® 18 Posaconazole 7 Proscar® 14 Retin-A® 52 Pediatric Vitamins 60 Potassium Chloride 19 Prostigmin® 14 Retrovir® 9 Pediatric Vitamins w/Fluoride 58 Potassium Replacement 38 Protein Replacement 38 Revatio® 19 Pediatric Vitamins w/Fluoride & Pramalintide 32 Protonix® 30 Revlimid® 11 Iron 58 Pramipexole 13 Provera®, Depo-Provera® 36 Ribavirin 9 Penicillin VK 5 Prasugrel 31 Prozac® 21 Ridaura® 13 KFHC DRUG FORMULARY 75

Rid® 55 Silver Sulfadiazine 53 TRUEplus® 60 Tobrex® 41 Rifabutin 8 Simvastatin 17 Tablet Splitter 59 Tofranil® 22 Rifampin 8 Sinemet® 13 Tacrolimus 37 Tolnaftate 53 Rilutek® 1 Singulair® 49 Tambocor® 16 Topamax® 20 Riluzole 1 Sodium Chloride 43 Tamiflu® 9 Topiramate 20 Rimactane® 8 Sodium Fluoride 58 Tamoxifen 12 Tracleer® 19 Riopan® 26 Sodium Polystyrene Sulfonate 19 Tamsulosin 14 Tradjenta® 32 Risdronate 45 Sodium Sulfacetamide 41 Tapazole® 37 Tramadol 3 Ritalin® 24 Sodium and Saline Preparations Targretin® 10 Trandate® 17 Rituximab- PVVR 12 38 Tegretol® 20 Trastuzumab-ANNS 12 Rivaroxaban 30 Sofosbuvir/velpatasvir 9 Temazepam 24 Trazodone 21 Rizatriptan 23 Soliqua® 33 Temodar® 12 Trelegy Ellipta® 50 Robaxin® 39 Sotalol 16 Temovate® 54 Trelstar® 13 Robinul® 14 Spacer Device 50 Temozolomide 12 Trental® 31 Robitussin AC® 48 Spectazole® 52 Tenex® 15 Tresiba® 33 Robitussin DAC® 48 Spiriva® Spiriva Respimat® 50 Tenormin® 17 Tretinoin 52 Robitussin DM® 48 Spironolactone 18 Terazocin 15 Tri-Vi-Sol® 60

INDEX – GENERIC and BRAND Robitussin Pediatric® 47 Sporanox® 6 Terazol® 57 Triamcinolone 51 Robitussin® 51 Starlix® 34 Terbinafine 7, 52 Triamterene 18 Rocaltrol® 58 Steglatro® 34 Terbutaline 48 Triamterene & Hydrochlorothiazide Ropinirole 13 Stiolto Respimat® 50 Terconazole 57 18 Rosuvastatin 17 Stromectol® 7 Tessalon® 48 Triavil® 20 Ruxience® 12 Succimer 45 Testosterone 31 Trifluridine 41 Rythmol® 16 Sucralfate 29 Tetanus 56 Trileptal® 20 Sudafed Plus® 46 Thalidomide 12 Triphasil® 44 S Sudafed® 51 Thalomid® 12 Triptorelin 13 Sulamyd® 41 Theodur, Uniphyl® 51 Trulicity® 32 SSKI® 48 Sulfamethoxazole & Trimethoprim Theophylline 51 Trusopt® 42 Salsalate 40 6 Thermometer 59 Tums® Os-Cal D® 26 Saturated soln of potassium iodide Sulfanilamide 57 Thioguanine 12 Twinrix® 56 48 Sulfasalazine 14, 29 Thyroid--dessicated 37 Tylenol w/Codeine® 2 Scopolamine 42 Sulindac 39 Tiagabine 20 Tylenol® 3 Sectral® 17 Sultrin® 57 Ticagrelor 31 Secukinumab 15 Sumatriptan 23 Timolol 42 U Segluromet® 34 Symbicort® 49 Timoptic® 42 Selenium 53 Symlin® 32 Tinactin® 53 Ultram® 3 Selsun® 53 Synalar® 54 Tindamax® 9 Umeclidinium 50 Semaglutide 33 Synjardy® 34 Tinidazole 9 Umeclidinium - Vilanterol 50 Sensipar® 35 Syringes, Syringes w/Needles, Tioconazole 57 Urecholine® 14 Seromycin® 7 Pen Needles 60 Tiotropium bromide 50 Urine Test Strips 60 Sertraline 21 Tiotropium bromide - Olodaterol 50 Ursodiol 27 Sevelamer Carbonate 19 T Tizanidine 39 Shingrix® 57 Tobradex® 41 V Sildenafil 19 TDAP 56 Tobramycin 41 Silvadene® 53 TRUE Metrix® 59 Tobramyin & Dexamethasone 41 Vagistat 1® 57 76 KFHC DRUG FORMULARY

Valisone® 54 Y Valium® 22, 38 Valsartan 16 Yasmin®, Yaz® 43 Valsartan-hctz 16 Yervoy® 11 Vancocin®, Firvanq® 9 Yescarta® 10 Vancomycin 9 Vaporizer 59 Z Varenicline 24 Varicella 57 Zaditor® 40 Varicella-zoster 57 Zafirlukast 49 Varivax® 57 Zaltrap® 13 Vasotec® 15 Zanaflex® 39 Veetids® 5 Zantac® 27 Veltassa® 19 Zarontin® 20 Venlafaxine 22 Zaroxolyn® 18 Ventolin HFA®, ProAir® 48 Zepatier® 9 Vepesid® 11 Zestril® 15

Verapamil 18 Zetia® 17 INDEX – GENERIC and BRAND Vfend® 7 Zidovudine 9 Vibramycin® 6 Zirgan® 41 Victoza® 33 Zithromax® 4 Vincristine 13 Ziv-Aflibercept 13 Viroptic® 41 Zocor® 17 Viscous lidocaine 52 Zofran® 27 Vismodegib 13 Zolinza® 13 Vitamin E 60 Zoloft® 21 Voltaren® 39 Zolpidem 24 Voriconazole 7 Zonegran® 20 Vorinostat 13 Zonisamide 20 Votrient® 12 Zortress® 37 Vyvanse® 24 Zostavax® 57 various 9 Zoster 57 Zovirax® 9 Zyloprim® 14 W Zyrtec® 47 Warfarin 30 Zyvox® 9 Wellbutrin® 21

X Xalatan® 42 Xarelto® 30 Xigduo XR® 34 Xulane® 53 Xylocaine® 52 Notes Notes TM

Kern Family Health Care complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kern Family Health Care cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-800-391-2000 (TTY: 711). ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-391-2000 (TTY: 711). 注意：如果您使用繁體中文，您可以免費獲得語言援助 服務。請致電 1-800-391-2000 (TTY: 711)。 Drug Formulary prescribe generic first

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9700 Stockdale Highway Bakersfield, California 93311-3617 1-800-391-2000 kernfamilyhealthcare.com

L NK Drug Formulary

March 2020

March 2020