Hmo Formulary
KAISER PERMANENTE OF GEORGIA HMO FORMULARY
This document includes Kaiser Permanente of Georgia’s HMO formulary as of September 9, 2021. For an updated formulary, please visit our website at members.kp.org or call 1-888-865- 5813, Monday through Friday 7:00 a.m. to 7:00 p.m. TTY/TDD users should call 1-800-255-0056. What is the Kaiser Permanente drug Medical Condition formulary? The formulary begins on page 5. The A formulary is a list of drugs determined drugs in this formulary are grouped into to be safe and effective for our categories depending on the type of members by our Pharmacy and medical condition that they are used to Therapeutics Committee. Use of treat. For example, drugs used to treat formulary drugs enables Kaiser a heart condition are listed under the Permanente to provide optimal care to category, “Cardiovascular Agents.” If you and your family at reasonable you know the medical condition your costs. Kaiser Permanente continually drug is used for, simply look for the updates the formulary throughout the category name in the list that begins on year based on new medical evidence, page 5. Then look under the category considering the recommendations of name for your drug. appropriate physician experts. Alphabetical Listing Does the formulary ever change? If you are not sure what category to Yes, Kaiser Permanente continually look under, you can look for the drug in updates the formulary based on new the Index that begins on page 53. The medical evidence, considering the Index provides an alphabetical list of all recommendations of appropriate of the drugs included in this document. physician experts and notifies our Both brand-name drugs and generic doctors, pharmacists, and other drugs are listed in the Index. Look in the clinicians about any changes. If a Index and find the drug. Next to the change in the formulary affects any of drug, you will see the page number your prescriptions, your doctor or where you can find coverage pharmacist will let you know. information. Turn to the page listed in the Index and find the name of the The enclosed formulary is current as of drug on the list. You may also use the September 9, 2021. To get updated search function on your computer to information about the drugs covered by search for the medication by name. Kaiser Permanente, please visit our website at members.kp.org or call What are generic drugs? Member Services at 1-888-865-5813, Kaiser Permanente covers both brand- Monday through Friday 7:00 a.m. to 7:00 name drugs and generic drugs. p.m. TTY/TDD users should call 1-800-255- Brand-name drugs are drugs that are 0056. produced and sold under the original How do I use the formulary? manufacturer’s brand name. There are two easy ways to find your drug within the formulary: *All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* Kaiser Permanente of Georgia HMO Formulary 1 Generic drugs are produced and sold benefit and some plans have a three under their chemical names after the tier open formulary benefit. patent of the brand-name drug expires. Open formulary means your pharmacy Although the price is lower, the quality benefit covers drugs that are on the and effectiveness of generic drugs is formulary as well as others that are not. the same as brand-name drugs. The Open formulary benefits have a generic Federal Food and Drug Administration cost sharing requirement. This means (FDA) requires that generic drugs that if you fill a brand name drug when contain the same active ingredients in a generic is available, that in addition the same amount as the brand-name to your standard copayment or drug. Kaiser Permanente pharmacies coinsurance, you will also pay the stock only generic drugs that have met difference in cost between the brand the high standards of both the FDA and name and generic drug. the experts in our quality assurance program. Coverage for prescription drugs is limited to drugs for which a prescription Generic drugs are listed in lower-case is required by law. Coverage is also italics (e.g., amoxicillin) within the limited to drugs that are listed on the formulary on page 5. If a drug is Kaiser Permanente drug formulary available as a generic, it is only listed unless your benefit provides coverage with the generic name. Brand-name for non-formulary (non-preferred) drugs are capitalized in the formulary medications. Certain diabetic supplies (e.g., FLOVENT). do not require a prescription, but must Generally, if a drug is available still be listed in our formulary in order to generically, the generic is on the be covered under the benefit. formulary and the brand is not. Because Each prescription refill is provided on all drug product strengths and package the same basis as the original sizes of a formulary drug may not be prescription. Copayments are applied included on the formulary, check with on a per prescription basis, for up to the your Kaiser Permanente pharmacist for lesser of the dispensing amount listed in clarification. the “Schedule of Benefits” or the How much will I pay for covered drugs? standard prescription amount. What you pay for covered drugs is The standard prescription amount for determined by the outpatient the following items is: prescription drug benefit outlined in • Migraine medications ― the smallest your Evidence of Coverage. Some package size commercially plans have a two tier closed formulary available
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* 2 Kaiser Permanente of Georgia HMO Formulary • Ophthalmic and otic medications ― formulary coverage, you have two the smallest package size options: commercially available • You can contact Member Services • Oral and nasal inhalers ― the at 1-888-865-5813, Monday through smallest standard package unit Friday 7:00 a.m. to 7:00 p.m. TTY/TDD Are there any other restrictions on users should call 1-800-255-0056 and coverage? ask Member Services for a list of Some covered drugs may have similar drugs that are covered. When additional requirements or limits on you receive the list, show it to your coverage. These requirements and limits doctor and ask him or her to may include: prescribe a similar drug that is covered under the Kaiser • Quantity Limits (QL): For certain drugs, Permanente formulary. Kaiser Permanente limits the amount of the drug that will be covered. • You can request an exception for coverage of your non-formulary • Age Restriction (Age): For certain drugs, drug. There are several types of Kaiser Permanente limits coverage exception requests you can submit. based on a designated age. o You can request coverage for • Prior Authorization (PA): For certain a drug, even though it is not drugs, Kaiser Permanente requires on our formulary. review and authorization prior to dispensing. Your Provider must o You can request that we obtain this review and authorization. waive coverage restrictions or The list of prescription drugs requiring limits on your drug. For review and authorization is subject to example, for certain drugs, we periodic review and modification by limit the amount of the drug our Pharmacy and Therapeutics that we will cover. If your drug Committee. This list begins on page has a quantity limit, you can 30. ask us to waive the limit and cover more. You can find out if the drug has any additional requirements or limits by What if I want or my doctor prescribes a looking in the formulary that begins on non-formulary drug? page 5 and the PA list on page 25. • If you request a non-formulary drug and a formulary alternative is What if my drug is not on the formulary? available, you will be responsible for If the drug is not on the formulary and the full cost of that drug. your benefit does not provide non-
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* Kaiser Permanente of Georgia HMO Formulary 3 • If your drug benefit does not provide If you have questions about Kaiser non-formulary coverage and your Permanente, please call Member prescribing physician identified a Services at 1-888-865-5813, Monday clear medical reason to use a non- through Friday 7:00 a.m. to 7:00 p.m. formulary rather than the similar TTY/TDD users should call 1-800-255-0056. formulary drug, such as an allergy to the formulary alternative, your Or visit members.kp.org. physician may request an exception for coverage of a non-formulary drug. In that case your regular pharmacy copay would apply.
Certain prescriptions require expert review before they can be dispensed.
Generally, Kaiser Permanente will only approve your request for an exception if the alternative drugs included on the plan’s formulary or additional utilization restrictions have not be as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact your physician to initiate the request for exception process. When you are requesting a formulary or utilization restriction exception, you should submit a statement from your physician supporting your request.
For more information For more detailed information about your Kaiser Permanente prescription drug coverage, please review your Evidence of Coverage and other plan materials.
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* 4 Kaiser Permanente of Georgia HMO Formulary
Kaiser Permanente of Georgia HMO Formulary Category/Drug Name Tier Level Restrictions ANTI-INFECTIVE AGENTS ANTHELMINTICS albendazole 1 ivermectin 1 ANTI-INFECTIVES azithromycin 1 CEFACLOR 1 ciprofloxacin hcl 1 clarithromycin 1 ANTIBACTERIALS amikacin sulfate 1 amoxicillin 1 amoxicillin & pot clavulanate 1 ampicillin 1 azithromycin 1 BACITRACIN 1 cefaclor 1 cefazolin sodium 1 cefdinir 1 ceftazidime 1 cefuroxime axetil 1 cephalexin 1 ciprofloxacin hcl 1 clarithromycin 1 clindamycin hcl 1 clindamycin palmitate hydrochloride 1 dicloxacillin sodium 1 doxycycline (monohydrate) 1 doxycycline hyclate 1 gentamicin sulfate 1 levofloxacin 1 linezolid 1 minocycline hcl 1 moxifloxacin hcl (ophth) 1 neomycin sulfate 1 ofloxacin (otic) 1 penicillin v potassium 1 SULFADIAZINE 1 sulfamethoxazole-trimethoprim 1 sulfasalazine 1 tetracycline hcl 1 tobramycin 1 tobramycin sulfate 1 vancomycin hcl 1 ANTIFUNGALS AMPHOTERICIN B 1 fluconazole 1
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* Kaiser Permanente of Georgia HMO Formulary 5
Kaiser Permanente of Georgia HMO Formulary Category/Drug Name Tier Level Restrictions flucytosine 1 griseofulvin microsize 1 griseofulvin ultramicrosize 1 itraconazole 1 ketoconazole 1 nystatin 1 nystatin (mouth-throat) 1 terbinafine hcl 1 ANTIMYCOBACTERIALS dapsone 1 ethambutol hcl 1 isoniazid 1 ketoconazole (topical) 1 pyrazinamide 1 rifabutin 1 rifampin 1 ANTIPROTOZOALS atovaquone 1 hydroxychloroquine sulfate 1 metronidazole 1 paromomycin sulfate 1 primaquine phosphate 1 ANTIVIRALS abacavir sulfate 1 QL abacavir sulfate-lamivudine 1 QL abacavir sulfate-lamivudine-zidovudine 1 QL acyclovir 1 APTIVUS 2 QL atazanavir sulfate 1, 2 QL BIKTARVY 2 QL cidofovir 1 CIMDUO 2 QL CRIXIVAN 2 DESCOVY 2 QL didanosine 1, 2 QL DOVATO 2 QL EDURANT 2 QL efavirenz 1 QL emtricitabine 1 QL emtricitabine-tenofovir disoproxil fumarate 1 QL entecavir 1 QL EPCLUSA 2 PA etravirine 1 QL fosamprenavir calcium 1 QL FUZEON 2 QL GENVOYA 2 QL INTRON A 2
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* 6 Kaiser Permanente of Georgia HMO Formulary
Kaiser Permanente of Georgia HMO Formulary Category/Drug Name Tier Level Restrictions INVIRASE 2 QL ISENTRESS 2 lamivudine 1 QL lamivudine-zidovudine 1 QL lopinavir-ritonavir 1, 2 QL nevirapine 1 QL ODEFSEY 2 QL oseltamivir phosphate 1 QL PEG-INTRON 2 PEGASYS 2 QL PREZCOBIX 2 PREZISTA 2 QL RELENZA DISKHALER 2 QL RESCRIPTOR 2 QL ribavirin (hepatitis c) 1 RIMANTADINE HCL 1 QL ritonavir 1, 2 QL SELZENTRY 2 QL stavudine 1 QL SYMFI 2 SYMTUZA 2 QL tenofovir disoproxil fumarate 1 QL TIVICAY 2 valganciclovir hcl 1, 2 VIRACEPT 2 QL VOSEVI 2 PA zidovudine 1 QL URINARY ANTI-INFECTIVES nitrofurantoin macrocrystal 1 nitrofurantoin monohyd macro 1 trimethoprim 1 ANTIHISTAMINE DRUGS FIRST GENERATION ANTIHISTAMINES cyproheptadine hcl 1 promethazine hcl 1 ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS abiraterone acetate 1, 2 QL AFINITOR 2 anastrozole 1 bicalutamide 1 capecitabine 1 CAPRELSA 2 COTELLIC 2 CYCLOPHOSPHAMIDE 1 DROXIA 2 EMCYT 2
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* Kaiser Permanente of Georgia HMO Formulary 7
Kaiser Permanente of Georgia HMO Formulary Category/Drug Name Tier Level Restrictions erlotinib hcl 1 ETOPOSIDE 1 fluorouracil 1 flutamide 1 GLEEVEC 2 PA HYCAMTIN 2 hydroxyurea 1 IBRANCE 2 QL imatinib mesylate 1, 2 PA IMBRUVICA 2 PA, QL INTRON A 2 lapatinib ditosylate 1 LENVIMA (10 MG DAILY DOSE) 2 letrozole 1 LEUKERAN 2 LONSURF 2 LYSODREN 2 MATULANE 2 megestrol acetate 1 melphalan 1, 2 mercaptopurine 1 MESNEX 2 methotrexate sodium 1 MYLERAN 2 NEXAVAR 2 NINLARO 2 POMALYST 2 PROMACTA 2 REVLIMID 2 SPRYCEL 2 PA, QL STIVARGA 2 sunitinib malate 1, 2 TABLOID 2 tamoxifen citrate 1 TARGRETIN 2 TASIGNA 2 PA temozolomide 1 tretinoin (chemotherapy) 1 VOTRIENT 2 XALKORI 2 XTANDI 2 ZEJULA 2 PA ZOLINZA 2 ZYDELIG 2 MISCELLANEOUS THERAPEUTIC AGENTS ZELBORAF 2 AUTONOMIC DRUGS
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* 8 Kaiser Permanente of Georgia HMO Formulary
Kaiser Permanente of Georgia HMO Formulary Category/Drug Name Tier Level Restrictions ANTICHOLINERGIC AGENTS chlordiazepoxide hcl-clidinium bromide 1 dicyclomine hcl 1 glycopyrrolate 1 hyoscyamine sulfate 1 ipratropium bromide 1 ipratropium bromide (nasal) 1 PROPANTHELINE BROMIDE 1 PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS bethanechol chloride 1 donepezil hydrochloride 1 galantamine hydrobromide 1 pilocarpine hcl (oral) 1 PROSTIGMIN 1 pyridostigmine bromide 1 rivastigmine tartrate 1 SKELETAL MUSCLE RELAXANTS baclofen 1 chlorzoxazone 1 cyclobenzaprine hcl 1 methocarbamol 1 tizanidine hcl 1 SYMPATHOMIMETIC (ADRENERGIC) AGENTS albuterol sulfate 1 EPINEPHRINE 1 fluticasone-salmeterol 1 ipratropium-albuterol 1, 2 terbutaline sulfate 1 BLOOD FORMATION, COAGULATION, AND THROMBOSIS ANTIHEMORRHAGIC AGENTS AMICAR 1 ANTITHROMBOTIC AGENTS anagrelide hcl 1 cilostazol 1 enoxaparin sodium 1 PRADAXA 2 QL prasugrel hcl 1 warfarin sodium 1 HEMATOPOIETIC AGENTS ARANESP (ALBUMIN FREE) 2 LEUKINE 2 NEUMEGA 2 PROCRIT 2 PROMACTA 2 ZARXIO 2 HEMORRHEOLOGIC AGENTS pentoxifylline 1
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* Kaiser Permanente of Georgia HMO Formulary 9
Kaiser Permanente of Georgia HMO Formulary Category/Drug Name Tier Level Restrictions MISCELLANEOUS THERAPEUTIC AGENTS aminocaproic acid 1 warfarin sodium 1 CARDIOVASCULAR DRUGS ALPHA-ADRENERGIC BLOCKING AGENTS alfuzosin hcl 1 doxazosin mesylate 1 terazosin hcl 1 ANTILIPEMIC AGENTS atorvastatin calcium 1 cholestyramine 1 cholestyramine light 1 colestipol hcl 1 ezetimibe 1 fenofibrate 1 lovastatin 1 pravastatin sodium 1 rosuvastatin calcium 1 simvastatin 1 ANTIPLATELET AGENT BRILINTA 2 clopidogrel bisulfate 1 dipyridamole 1 BETA-ADRENERGIC BLOCKING AGENTS acebutolol hcl 1 atenolol 1 atenolol & chlorthalidone 1 bisoprolol & hydrochlorothiazide 1 bisoprolol fumarate 1 carvedilol 1 labetalol hcl 1 metoprolol succinate 1 metoprolol tartrate 1 nadolol 1 propranolol hcl 1 sotalol hcl 1 CALCIUM-CHANNEL BLOCKING AGENTS amlodipine besylate 1 diltiazem hcl 1 diltiazem hcl coated beads 1 enalapril maleate 1 felodipine 1 nifedipine 1 nimodipine 1 verapamil hcl 1 CARDIAC DRUGS amiodarone hcl 1
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* 10 Kaiser Permanente of Georgia HMO Formulary
Kaiser Permanente of Georgia HMO Formulary Category/Drug Name Tier Level Restrictions digoxin 1, 2 disopyramide phosphate 1, 2 dofetilide 1 flecainide acetate 1 mexiletine hcl 1 propafenone hcl 1 quinidine gluconate 1 QUINIDINE SULFATE 1 ramipril 1 DIURETICS hydrochlorothiazide 1 HYPOTENSIVE AGENTS amiloride & hydrochlorothiazide 1 chlorthalidone 1 clonidine hcl 1 diazoxide 1, 2 hydralazine hcl 1 indapamide 1 isosorbide dinitrate 1 methyldopa 1 minoxidil 1 MISCELLANEOUS THERAPEUTIC AGENTS triamterene & hydrochlorothiazide 1 RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS benazepril hcl 1 captopril 1 enalapril maleate 1 isosorbide dinitrate 1 lisinopril 1 lisinopril & hydrochlorothiazide 1 losartan potassium 1 losartan potassium & hydrochlorothiazide 1 ramipril 1 spironolactone 1 valsartan 1 valsartan-hydrochlorothiazide 1 VASODILATING AGENTS dipyridamole 1 hydralazine hcl 1 isosorbide dinitrate 1 isosorbide mononitrate 1 LETAIRIS 2 nitroglycerin 1, 2 olanzapine 1 OPSUMIT 2 PA REMODULIN 2 CENTRAL NERVOUS SYSTEM AGENTS
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* Kaiser Permanente of Georgia HMO Formulary 11
Kaiser Permanente of Georgia HMO Formulary Category/Drug Name Tier Level Restrictions ANALGESICS AND ANTIPYRETICS acetaminophen w/ codeine 1 butalbital-acetaminophen-caffeine 1 butalbital-acetaminophen-caffeine w/ codeine 1 butalbital-aspirin-caffeine 1 butalbital-aspirin-caffeine w/cod 1 diclofenac sodium 1 fentanyl 1 QL hydrocodone-acetaminophen 1 hydromorphone hcl 1 ibuprofen 1 indomethacin 1 meloxicam 1 methadone hcl 1 morphine sulfate 1, 2 nabumetone 1 naproxen 1 oxycodone w/ acetaminophen 1 oxycodone w/ aspirin 1 salsalate 1 sulindac 1 tolmetin sodium 1 tramadol hcl 1 ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS amphetamine-dextroamphetamine 1 dexmethylphenidate hcl 1 QL dextroamphetamine sulfate 1 QL methylphenidate hcl 1 QL modafinil 1 morphine sulfate 1 ANTICONVULSANTS carbamazepine 1 CELONTIN 2 clobazam 1 clonazepam 1 DIASTAT ACUDIAL 1 DILANTIN 1 divalproex sodium 1 ethosuximide 1 gabapentin 1 lamotrigine 1 levetiracetam 1 oxcarbazepine 1 phenytoin 1, 2 primidone 1 theophylline 1 topiramate 1
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* 12 Kaiser Permanente of Georgia HMO Formulary
Kaiser Permanente of Georgia HMO Formulary Category/Drug Name Tier Level Restrictions valproate sodium 1 valproic acid 1 zonisamide 1 ANTIMANIC AGENTS lithium carbonate 1 ANTIMIGRAINE AGENTS CAFERGOT 1, 2 naratriptan hcl 1 QL rizatriptan benzoate 1 QL sumatriptan 1 sumatriptan succinate 1 QL zolmitriptan 1 ANTIPARKINSONIAN AGENTS amantadine hcl 1 benztropine mesylate 1 bromocriptine mesylate 1 cabergoline 1 carbidopa-levodopa 1 CARBIDOPA-LEVODOPA-ENTACAPONE 1 entacapone 1 pramipexole dihydrochloride 1 ropinirole hydrochloride 1 selegiline hcl 1 tolcapone 1 trihexyphenidyl hcl 1 ANXIOLYTICS, SEDATIVES, AND HYPNOTICS alprazolam 1 bupropion hcl 1 buspirone hcl 1 chlordiazepoxide hcl 1 clonazepam 1 diazepam 1 doxepin hcl 1 hydroxyzine hcl 1 lorazepam 1 meprobamate 1 phenobarbital 1 temazepam 1 zaleplon 1 zolpidem tartrate 1 CENTRAL NERVOUS SYSTEM AGENTS, MISCELLANEOUS armodafinil 1 QL citalopram hydrobromide 1 EXTAVIA 1 galantamine hydrobromide 1 glatiramer acetate 1 guanfacine hcl (adhd) 1
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* Kaiser Permanente of Georgia HMO Formulary 13
Kaiser Permanente of Georgia HMO Formulary Category/Drug Name Tier Level Restrictions memantine hcl 1 riluzole 1 risperidone 1 OPIATE ANTAGONISTS naltrexone hcl 1 PSYCHOTHERAPEUTIC AGENTS amitriptyline hcl 1 aripiprazole 1 bupropion hcl 1 chlorpromazine hcl 1 citalopram hydrobromide 1 clozapine 1 desipramine hcl 1 doxepin hcl 1 duloxetine hcl 1 escitalopram oxalate 1 fluoxetine hcl 1 fluphenazine hcl 1 fluvoxamine maleate 1 haloperidol 1 haloperidol lactate 1 imipramine hcl 1 mirtazapine 1 nortriptyline hcl 1 olanzapine 1 paroxetine hcl 1 perphenazine 1 phenelzine sulfate 1 prochlorperazine maleate 1 quetiapine fumarate 1 risperidone 1 sertraline hcl 1 thioridazine hcl 1 thiothixene 1 tranylcypromine sulfate 1 trazodone hcl 1 trifluoperazine hcl 1 venlafaxine hcl 1 ziprasidone hcl 1 CONTRACEPTIVES (FOAMS, DEVICES) CONTRACEPTIVES (FOAMS, DEVICES) FEMCAP 2 ORTHO DIAPHRAGM ALL-FLEX/65MM 2 TODAY SPONGE 2 DEVICES DEVICES AEROCHAMBER PLUS FLO-VU 2
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* 14 Kaiser Permanente of Georgia HMO Formulary
Kaiser Permanente of Georgia HMO Formulary Category/Drug Name Tier Level Restrictions BD INSULIN SYRINGE MICROFINE 1, 2 NOVOFINE 2 ONETOUCH DELICA LANCETS 30G 2 ONETOUCH ULTRA 2 2 DIAGNOSTIC AGENTS DIABETES MELLITUS BAYER CONTOUR USB 2 BD INSULIN SYRINGE 1, 2 BD INSULIN SYRINGE U-40 1 BD PEN NEEDLE MINI U/F 1 CONTOUR TEST 2 DIASTIX 2 KETO-DIASTIX 2 URINE AND FECES CONTENTS KETOSTIX 2 ELECTROLYTIC, CALORIC, AND WATER BALANCE ALKALINIZING AGENTS potassium citrate (alkalinizer) 1 DIURETICS furosemide 1 hydrochlorothiazide 1 metolazone 1 torsemide 1 triamterene & hydrochlorothiazide 1 HYPEROSMOTIC AGENT lactulose 1 lactulose (encephalopathy) 1 ION-REMOVING AGENTS sodium polystyrene sulfonate 1 REPLACEMENT PREPARATIONS K-PHOS 2 PHOSLYRA 2 pot & sod citrates w/citric ac 1 pot phosphate monobasic w/ sod phosphate dibasic & 1 monobasic potassium chloride 1, 2 potassium chloride microencapsulated crystals cr 1 URICOSURIC AGENTS probenecid 1 ENZYMES ENZYMES PULMOZYME 2 EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS ANTI-INFECTIVES BACITRACIN 1 bacitracin-polymyxin b (ophth) 1 chlorhexidine gluconate (mouth-throat) 1 ciprofloxacin hcl (ophth) 1 *All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* Kaiser Permanente of Georgia HMO Formulary 15
Kaiser Permanente of Georgia HMO Formulary Category/Drug Name Tier Level Restrictions erythromycin (ophth) 1 gentamicin sulfate (ophth) 1 NATACYN 2 neomycin-bacitracin zn-polymyxin 1 NEOMYCIN-POLYMYXIN-GRAMICIDIN 1 ofloxacin (ophth) 1 ofloxacin (otic) 1 polymyxin b-trimethoprim 1 tobramycin (ophth) 1, 2 TRIFLURIDINE 1 ANTI-INFLAMMATORY AGENTS bacitracin-poly-neomycin-hc 1 BLEPHAMIDE 1, 2 ciprofloxacin-dexamethasone 1, 2 DEXAMETHASONE SODIUM PHOSPHATE 1 diclofenac sodium (ophth) 1 FLAREX 2 fluorometholone (ophth) 1 hydrocortisone w/acetic acid 1 MAXIDEX 2 neomycin-polymy-dexameth 1 NEOMYCIN-POLYMYXIN-HC 1 pramoxine-hc-chloroxylenol 1 PRED MILD 1, 2 PRED-G 2 tobramycin-dexamethasone 1, 2 ANTICHOLINERGIC AGENTS ISOPTO HYOSCINE 2 ANTIGLAUCOMA AGENTS acetazolamide 1 betaxolol hcl (ophth) 1, 2 brimonidine tartrate 1 dorzolamide hcl 1 dorzolamide hcl-timolol maleate 1 ISOPTO CARBACHOL 2 latanoprost 1 LEVOBUNOLOL HCL 1 methazolamide 1 PHOSPHOLINE IODIDE 2 pilocarpine hcl 1 timolol maleate (ophth) 1 EENT DRUGS, MISCELLANEOUS acetic acid (otic) 1 acetic acid-aluminum acetate 1 apraclonidine hcl 1 ketorolac tromethamine (ophth) 1 latanoprost 1
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* 16 Kaiser Permanente of Georgia HMO Formulary
Kaiser Permanente of Georgia HMO Formulary Category/Drug Name Tier Level Restrictions pramoxine-hc-chloroxylenol 1 LOCAL ANESTHETICS lidocaine hcl (mouth-throat) 1 proparacaine hcl 1 MYDRIATICS atropine sulfate (ophthalmic) 1 cyclopentolate hcl 1, 2 HOMATROPAIRE 1, 2 VASOCONSTRICTORS phenylephrine hcl (mydriatic) 1 GASTROINTESTINAL DRUGS ANTI-INFLAMMATORY AGENTS balsalazide disodium 1 mesalamine 1, 2 ANTIDIARRHEA AGENTS diphenoxylate w/ atropine 1 ANTIEMETICS AKYNZEO 2 dronabinol 1 ondansetron 1 ondansetron hcl 1 prochlorperazine maleate 1 ANTIULCER AGENTS AND ACID SUPPRESSANTS CIMETIDINE HCL 1 misoprostol 1 ranitidine hcl 1 sucralfate 1 CATHARTICS AND LAXATIVES peg 3350-kcl-sod bicarb-sod chloride-sod sulfate 1, 2 peg 3350-potassium chloride-sod bicarbonate-sod chloride 1 polyethylene glycol 3350 1, 2 CHOLELITHOLYTIC AGENTS ursodiol 1 DIGESTANTS CREON 1, 2 MISCELLANEOUS THERAPEUTIC AGENTS sucralfate 1 PROKINETIC AGENTS metoclopramide hcl 1 GOLD COMPOUNDS GOLD COMPOUNDS RIDAURA 2 HEAVY METAL ANTAGONISTS HEAVY METAL ANTAGONISTS CUPRIMINE 2 HORMONES AND SYNTHETIC SUBSTITUTES ADRENALS
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* Kaiser Permanente of Georgia HMO Formulary 17
Kaiser Permanente of Georgia HMO Formulary Category/Drug Name Tier Level Restrictions ALVESCO 2 ARISTOSPAN INTRA-ARTICULAR 2 ASMANEX HFA 2 budesonide (inhalation) 1 dexamethasone 1, 2 dexamethasone sodium phosphate 1 fludrocortisone acetate 1 hydrocortisone 1 methylprednisolone 1 prednisolone 1 prednisolone sodium phosphate 1 prednisone 1, 2 QVAR 2 QVAR REDIHALER 2 triamcinolone acetonide 1, 2 ANDROGENS ANDROXY 2 budesonide 1 danazol 1 METHITEST 1 testosterone 1 testosterone cypionate 1 TESTOSTERONE PROPIONATE 2 ANTIDIABETIC AGENTS acarbose 1 glimepiride 1 glipizide 1 HUMULIN 70/30 2 HUMULIN N 2 HUMULIN R 2 JARDIANCE 2 PA, QL metformin hcl 1 ANTIHYPOGLYCEMIC AGENTS glucagon (rdna) 1 CONTRACEPTIVES desogestrel & ethinyl estradiol 1 QL drospirenone-ethinyl estradiol 1 QL ELLA 2 ethynodiol diacet & eth estrad 1 QL IMPLANON 2 LEVONORGESTREL 1, 2 levonorgestrel & eth estradiol 1 QL levonorgestrel-eth estradiol (triphasic) 1 QL levonorgestrel-ethinyl estradiol (91-day) 1 QL NECON 1/50 (28) 1 QL norethin acet & estrad-fe 1 QL norethindrone & eth estradiol 1 QL
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* 18 Kaiser Permanente of Georgia HMO Formulary
Kaiser Permanente of Georgia HMO Formulary Category/Drug Name Tier Level Restrictions norethindrone (contraceptive) 1 QL norethindrone-eth estradiol (triphasic) 1 QL norgestimate-ethinyl estradiol 1 QL norgestimate-ethinyl estradiol (triphasic) 1 QL norgestrel & ethinyl estradiol 1 QL NUVARING 2 QL ESTROGENS AND ESTROGEN AGONISTS-ANTAGONISTS DEPO-ESTRADIOL 1 esterified estrogens & methyltestosterone 1 estradiol 1, 2 estradiol vaginal 1, 2 estradiol valerate 1 ESTROPIPATE 1 raloxifene hcl 1 GONADOTROPINS CHORIONIC GONADOTROPIN 2 SYNAREL 2 MISCELLANEOUS THERAPEUTIC AGENTS flutamide 1 PARATHYROID calcitonin (salmon) 1 cinacalcet hcl 1 PITUITARY desmopressin acetate 1 desmopressin acetate refrigerated 1 desmopressin acetate spray 1 desmopressin acetate spray refrigerated 1 PROGESTINS CRINONE 2 medroxyprogesterone acetate 1 medroxyprogesterone acetate (contraceptive) 1 QL norethindrone acetate 1 THYROID AND ANTITHYROID AGENTS levothyroxine sodium 1, 2 liothyronine sodium 1 methimazole 1 propylthiouracil 1 MISCELLANEOUS THERAPEUTIC AGENTS ANTI-INFLAMMATORY AGENTS ENBREL 2 PA ibuprofen 1 naproxen 1 ANTIDIABETIC AGENTS GVOKE HYPOPEN 1-PACK 2 AGE pioglitazone hcl 1 ANTIHYPOGLYCEMIC AGENTS GOLD COMPOUNDS
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* Kaiser Permanente of Georgia HMO Formulary 19
Kaiser Permanente of Georgia HMO Formulary Category/Drug Name Tier Level Restrictions RIDAURA 2 HEMATOPOIETIC AGENTS MOZOBIL 2 LOCAL ANESTHETICS alendronate sodium 1 MISCELLANEOUS THERAPEUTIC AGENTS ACTEMRA 2 ACTIMMUNE 2 alendronate sodium 1 allopurinol 1 aminocaproic acid 1 ATROPINE SULFATE 1 azathioprine 1 BAQSIMI ONE PACK 2 AGE BD INSULIN SYRINGE U-500 2 buprenorphine hcl 1 buprenorphine hcl-naloxone hcl dihydrate 1 QL calcium acetate (phosphate binder) 1 chlorhexidine gluconate (mouth-throat) 1 cinacalcet hcl 1 COSENTYX 2 PA cyclosporine 1, 2 cyclosporine modified (for microemulsion) 1 dalfampridine 1 deferasirox 1 dimethyl fumarate 1 PA disulfiram 1 ELMIRON 2 ENBREL 2 PA ERGOLOID MESYLATES 1 ETIDRONATE DISODIUM 1 FC FEMALE CONDOM 1, 2 finasteride 1 GEL-KAM 2 glipizide 1 HUMIRA 2 PA IODINE STRONG 2 leflunomide 1 leucovorin calcium 1 memantine hcl 1 mesalamine 1 methotrexate sodium 1 montelukast sodium 1 mycophenolate mofetil 1 mycophenolate sodium 1 NARCAN 2 QL NIVESTYM 2
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* 20 Kaiser Permanente of Georgia HMO Formulary
Kaiser Permanente of Georgia HMO Formulary Category/Drug Name Tier Level Restrictions ORENCIA 2 OTEZLA 2 oxycodone hcl 1 penicillamine 1 pioglitazone hcl 1 prednisone 1 salsalate 1 sevelamer carbonate 1 sirolimus 1 sodium fluoride 1 tacrolimus 1 tacrolimus (topical) 1 tamsulosin hcl 1 THALOMID 2 THYMOL 2 XELJANZ 2 zolmitriptan 1 PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS pyridostigmine bromide 1 OXYTOCICS OXYTOCICS methylergonovine maleate 1 PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS COAL TAR 2 RESPIRATORY TRACT AGENTS ANTITUSSIVES benzonatate 1 guaifenesin-codeine 1 hydrocodone w/ homatropine 1 MAST CELL STABILIZER cromolyn sodium 1 MISCELLANEOUS THERAPEUTIC AGENTS acetylcysteine 1 ALVESCO 2 DALIRESP 2 STRIVERDI RESPIMAT 2 MUCOLYTIC AGENTS acetylcysteine 1 RESPIRATORY SMOOTH MUSCLE RELAXANTS bosentan 1 SKIN AND MUCOUS MEMBRANE AGENTS ADRENALS betamethasone dipropionate augmented 1 hydrocortisone (topical) 1 mometasone furoate 1 ANTI-INFECTIVES
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* Kaiser Permanente of Georgia HMO Formulary 21
Kaiser Permanente of Georgia HMO Formulary Category/Drug Name Tier Level Restrictions clindamycin phosphate (topical) 1 clotrimazole 1 erythromycin (acne aid) 1 iodoquinol-hc 1 ketoconazole (topical) 1 lindane 1 metronidazole (topical) 1 mupirocin 1 permethrin 1 selenium sulfide 1 silver sulfadiazine 1 ANTI-INFLAMMATORY AGENTS alclometasone dipropionate 1 betamethasone dipropionate (topical) 1 betamethasone dipropionate augmented 1 betamethasone valerate 1 clindamycin phosphate (topical) 1 clobetasol propionate 1, 2 desonide 1 QL fluocinolone acetonide 1 fluocinonide 1 fluocinonide emulsified base 1 fluticasone propionate 1 hydrocortisone (intrarectal) 1 hydrocortisone (topical) 1 mometasone furoate 1 pimecrolimus 1 theophylline 1 triamcinolone acetonide (mouth) 1 triamcinolone acetonide (topical) 1 ANTIFUNGALS ciclopirox 1 ketoconazole (topical) 1 nystatin (topical) 1 NYSTATIN VAGINAL 1 ANTIPRURITICS AND LOCAL ANESTHETICS lidocaine-prilocaine 1 triamcinolone acetonide (topical) 1 ASTRINGENTS DRYSOL 2 CELL STIMULANTS AND PROLIFERANTS tretinoin 1 AGE DEPIGMENTING AND PIGMENTING AGENTS 8-MOP 2 METHOXSALEN RAPID 1 KERATOLYTIC AGENTS sulfacetamide sodium w/ sulfur 1
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* 22 Kaiser Permanente of Georgia HMO Formulary
Kaiser Permanente of Georgia HMO Formulary Category/Drug Name Tier Level Restrictions urea 1 VECTICAL 1 LOCAL ANESTHETICS LIDOCAINE HCL URETHRAL/MUCOSAL 1 SKIN AND MUCOUS MEMBRANE AGENTS, MISCELLANEOUS acitretin 1 benzoyl peroxide-erythromycin 1 calcipotriene 1 clindamycin phosphate-benzoyl peroxide (refrigerate) 1 clotrimazole w/ betamethasone 1 desoximetasone 1 fluorouracil (topical) 1, 2 imiquimod 1 isotretinoin 1 nystatin-triamcinolone 1 podofilox 1 REGRANEX 2 SANTYL 2 sulfacetamide sodium w/ sulfur 1 SULFACETAMIDE-SULFUR IN UREA 2 SMOOTH MUSCLE RELAXANTS GENITOURINARY SMOOTH MUSCLE RELAXANTS darifenacin hydrobromide 1 oxybutynin chloride 1 solifenacin succinate 1 trospium chloride 1 RESPIRATORY SMOOTH MUSCLE RELAXANTS SPIRIVA RESPIMAT 2 STIOLTO RESPIMAT 2 theophylline 1 VITAMINS MULTIVITAMIN PREPARATIONS ped multivitamins w/fl & iron 1 pediatric multivitamins w/fl 1 pediatric vitamins acd w/ fluoride 1 TRI-VIT/FLUORIDE/IRON 2 VITAMIN D calcitriol 1 ergocalciferol 1 VITAMIN K ACTIVITY phytonadione 1, 2
LIST OF DRUGS THAT REQUIRE PRIOR AUTHORIZATION (PA) REVIEW
ACTHAR GEL 80 UNIT/ML
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* Kaiser Permanente of Georgia HMO Formulary 23
Kaiser Permanente of Georgia HMO Formulary LIST OF DRUGS THAT REQUIRE PRIOR AUTHORIZATION (PA) REVIEW
ADLYXIN SOPN 20 MCG/0.2ML
ADLYXIN STARTER PACK PNKT 10 & 20 MCG/0.2ML
AFREZZA POWD 12 UNIT
AFREZZA POWD 4 & 8 & 12 UNIT
AFREZZA POWD 4 UNIT
AFREZZA POWD 8 UNIT
AFREZZA POWD 90 x 4 UNIT & 90X8 UNIT
AFREZZA POWD 90 x 8 UNIT & 90X12 UNIT
AIMOVIG (140 MG DOSE) SOAJ 70 MG/ML
AIMOVIG SOAJ 140 MG/ML
AIMOVIG SOAJ 70 MG/ML
AJOVY SOAJ 225 MG/1.5ML
AJOVY SOSY 225 MG/1.5ML
ALKINDI SPRINKLE CPSP 0.5 MG
ALKINDI SPRINKLE CPSP 1 MG
ALKINDI SPRINKLE CPSP 2 MG
ALKINDI SPRINKLE CPSP 5 MG
ARCALYST SOLR 220 MG
ARIKAYCE SUSP 590 MG/8.4ML
AUBAGIO TABS 14 MG
AUBAGIO TABS 7 MG
AUSTEDO TABS 12 MG
AUSTEDO TABS 6 MG
AUSTEDO TABS 9 MG
AUVI-Q SOAJ 0.1 MG/0.1ML
AUVI-Q SOAJ 0.15 MG/0.15ML
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* 24 Kaiser Permanente of Georgia HMO Formulary
Kaiser Permanente of Georgia HMO Formulary LIST OF DRUGS THAT REQUIRE PRIOR AUTHORIZATION (PA) REVIEW
AUVI-Q SOAJ 0.3 MG/0.3ML
AVONEX KIT 30 MCG
AVONEX KIT 30MCG
AVONEX PEN AJKT 30 MCG/0.5ML
AVONEX PREFILLED PSKT 30 MCG/0.5ML
BAFIERTAM CPDR 95 MG
BENLYSTA SOAJ 200 MG/ML
BENLYSTA SOSY 200 MG/ML
BERINERT KIT 500 UNIT
BOSULIF TABS 100 MG
BOSULIF TABS 400 MG
BOSULIF TABS 500 MG
BRUKINSA CAPS 80 MG
BYDUREON BCISE AUIJ 2 MG/0.85ML
BYDUREON PEN 2 MG
BYDUREON SRER 2 MG
BYETTA 10 MCG PEN SOPN 10 MCG/0.04ML
BYETTA 5 MCG PEN SOPN 5 MCG/0.02ML
BYNFEZIA PEN SOPN 2500 MCG/ML (2.8 ML)
CABLIVI KIT 11 MG
CERDELGA CAPS 84 MG
CHOLBAM CAPS 250 MG
CHOLBAM CAPS 50 MG
CIMZIA KIT 2 X 200 MG
CIMZIA PREFILLED KIT 2 X 200 MG/ML
CIMZIA STARTER KIT KIT 6 X 200 MG/ML
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* Kaiser Permanente of Georgia HMO Formulary 25
Kaiser Permanente of Georgia HMO Formulary LIST OF DRUGS THAT REQUIRE PRIOR AUTHORIZATION (PA) REVIEW
CINRYZE SOLR 500 UNIT
COSENTYX (300 MG DOSE) SOSY 150 MG/ML
COSENTYX SENSOREADY (300 MG) SOAJ 150 MG/ML
COSENTYX SENSOREADY PEN SOAJ 150 MG/ML
COSENTYX SOSY 150 MG/ML
COSENTYX SOSY 75 MG/0.5ML
CRESEMBA CAPS 186 MG
CUTAQUIG SOLN 1 GM/6ML
CUTAQUIG SOLN 1.65 GM/10ML
CUTAQUIG SOLN 2 GM/12ML
CUTAQUIG SOLN 3.3 GM/20ML
CUTAQUIG SOLN 4 GM/24ML
CUTAQUIG SOLN 8 GM/48ML
CUVITRU SOLN 1 GM/5ML
CUVITRU SOLN 10 GM/50ML
CUVITRU SOLN 2 GM/10ML
CUVITRU SOLN 4 GM/20ML
CUVITRU SOLN 8 GM/40ML
DAKLINZA TABS 30 MG
DAKLINZA TABS 60 MG
DAKLINZA TABS 90 MG
DARAPRIM TABS 25 MG
DARZALEX FASPRO SOLN 1800-30000 MG-UT/15ML
DIACOMIT CAPS 250 MG
DIACOMIT CAPS 500 MG
DIACOMIT PACK 250 MG
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* 26 Kaiser Permanente of Georgia HMO Formulary
Kaiser Permanente of Georgia HMO Formulary LIST OF DRUGS THAT REQUIRE PRIOR AUTHORIZATION (PA) REVIEW
DIACOMIT PACK 500 MG
DOJOLVI LIQD 100 %
DOPTELET TABS 20 MG
DUPIXENT SOPN 300 MG/2ML
DUPIXENT SOSY 200 MG/1.14ML
DUPIXENT SOSY 300 MG/2ML
ELMIRON CAPS 100 MG
EMFLAZA SUSP 22.75 MG/ML
EMFLAZA TABS 18 MG
EMFLAZA TABS 30 MG
EMFLAZA TABS 36 MG
EMFLAZA TABS 6 MG
EMGALITY (300 MG DOSE) SOSY 100 MG/ML
EMGALITY SOAJ 120 MG/ML
EMGALITY SOSY 120 MG/ML
ENBREL MINI SOCT 50 MG/ML
ENBREL SOLN 25 MG/0.5ML
ENBREL SOLN 25 MG/0.5ML
ENBREL SOLR 25 MG
ENBREL SOSY 25 MG/0.5ML
ENBREL SOSY 50 MG/ML
ENBREL SURECLICK SOAJ 50 MG/ML
ENDARI PACK 5 GM
ENSPRYNG SOSY 120 MG/ML
ENSTILAR FOAM 0.005-0.064 %
EPCLUSA TABS 200-50 MG
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* Kaiser Permanente of Georgia HMO Formulary 27
Kaiser Permanente of Georgia HMO Formulary LIST OF DRUGS THAT REQUIRE PRIOR AUTHORIZATION (PA) REVIEW
EPIDIOLEX SOLN 100 MG/ML
EUCRISA OINT 2 %
EVRYSDI SOLR 0.75 MG/ML
EVRYSDI SOLR 0.75 MG/ML
FARXIGA TABS 10 MG
FARXIGA TABS 5 MG
FASENRA PEN SOAJ 30 MG/ML
FASENRA SOSY 30 MG/ML
FINTEPLA SOLN 2.2 MG/ML
FIRDAPSE TABS 10 MG
FORTEO SOPN 620 MCG/2.48ML
FOTIVIDA CAPS 0.89 MG
FOTIVDA CAPS 1.34 MG
GALAFOLD CAPS 123 MG
GAMMAGARD SOLN 1 GM/10ML
GAMMAGARD SOLN 1 GM/10ML
GAMMAGARD SOLN 10 GM/100ML
GAMMAGARD SOLN 10 GM/100ML
GAMMAGARD SOLN 2.5 GM/25ML
GAMMAGARD SOLN 2.5 GM/25ML
GAMMAGARD SOLN 20 GM/200ML
GAMMAGARD SOLN 20 GM/200ML
GAMMAGARD SOLN 30 GM/300ML
GAMMAGARD SOLN 30 GM/300ML
GAMMAGARD SOLN 5 GM/50ML
GAMMAGARD SOLN 5 GM/50ML
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* 28 Kaiser Permanente of Georgia HMO Formulary
Kaiser Permanente of Georgia HMO Formulary LIST OF DRUGS THAT REQUIRE PRIOR AUTHORIZATION (PA) REVIEW
GATTEX KIT 5 MG
GAVRETO CAPS 100 MG
GENOTROPIN MINIQUICK SOLR 0.2 MG
GENOTROPIN MINIQUICK SOLR 0.4 MG
GENOTROPIN MINIQUICK SOLR 0.6 MG
GENOTROPIN MINIQUICK SOLR 0.8 MG
GENOTROPIN MINIQUICK SOLR 1 MG
GENOTROPIN MINIQUICK SOLR 1.2 MG
GENOTROPIN MINIQUICK SOLR 1.4 MG
GENOTROPIN MINIQUICK SOLR 1.6 MG
GENOTROPIN MINIQUICK SOLR 1.8 MG
GENOTROPIN MINIQUICK SOLR 2 MG
GENOTROPIN SOLR 12 MG
GENOTROPIN SOLR 5 MG
GILENYA CAPS 0.25 MG
GILENYA CAPS 0.5 MG
GLYXAMBI TABS 10-5 MG
GLYXAMBI TABS 25-5 MG
HAEGARDA SOLR 2000 UNIT
HAEGARDA SOLR 3000 UNIT
HARVONI PACK 33.75-150 MG
HARVONI PACK 45-200 MG
HARVONI TABS 45-200 MG
HEMLIBRA SOLN 105 MG/0.7ML
HEMLIBRA SOLN 150 MG/ML
HEMLIBRA SOLN 30 MG/ML
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* Kaiser Permanente of Georgia HMO Formulary 29
Kaiser Permanente of Georgia HMO Formulary LIST OF DRUGS THAT REQUIRE PRIOR AUTHORIZATION (PA) REVIEW
HEMLIBRA SOLN 60 MG/0.4ML
HETLIOZ CAPS 20 MG
HETLIOZ LQ SUSP 4 MG/ML
HETLIOZ LQ SUSP 4 MG/ML
HIZENTRA SOLN 1 GM/5ML
HIZENTRA SOLN 10 GM/50ML
HIZENTRA SOLN 2 GM/10ML
HIZENTRA SOLN 4 GM/20ML
HIZENTRA SOSY 1 GM/5ML
HIZENTRA SOSY 2 GM/10ML
HIZENTRA SOSY 4 GM/20ML
HUMATROPE SOLR 12 MG
HUMATROPE SOLR 24 MG
HUMATROPE SOLR 5 MG
HUMATROPE SOLR 6 MG
HUMIRA PEDIATRIC CROHNS START PSKT 80 MG/0.8ML
HUMIRA PEDIATRIC CROHNS START PSKT 80 MG/0.8ML & 40MG/0.4ML
HUMIRA PEN PNKT 40 MG/0.4ML
HUMIRA PEN-CD/UC/HS STARTER PNKT 40 MG/0.8ML
HUMIRA PEN-CD/UC/HS STARTER PNKT 80 MG/0.8ML
HUMIRA PEN-PEDIATRIC UC START PNKT 80 MG/0.8ML
HUMIRA PEN-PSOR/UVEIT STARTER PNKT 80 MG/0.8ML & 40MG/0.4ML
HUMIRA PSKT 10 MG/0.1ML
HUMIRA PSKT 10 MG/0.2ML
HUMIRA PSKT 20 MG/0.2ML
HUMIRA PSKT 20 MG/0.4ML
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* 30 Kaiser Permanente of Georgia HMO Formulary
Kaiser Permanente of Georgia HMO Formulary LIST OF DRUGS THAT REQUIRE PRIOR AUTHORIZATION (PA) REVIEW
HUMIRA PSKT 40 MG/0.4ML
HUMIRA PSKT 40 MG/0.8ML
HYQVIA KIT 10 GM/100ML
HYQVIA KIT 2.5 GM/25ML
HYQVIA KIT 20 GM/200ML
HYQVIA KIT 30 GM/300ML
HYQVIA KIT 5 GM/50ML
ICLUSIG TABS 10 MG
ICLUSIG TABS 15 MG
ICLUSIG TABS 30 MG
ICLUSIG TABS 45 MG
ILARIS SOLR 150 MG
ILUMYA SOSY 100 MG/ML
IMCIVREE SOLN 10 MG/ML
IMPAVIDO CAPS 50 MG
INBRIJA CAPS 42 MG
INGREZZA CAPS 40 MG
INGREZZA CAPS 60 MG
INGREZZA CAPS 80 MG
INGREZZA CPPK 40 & 80 MG
INQOVI TABS 35-100 MG
INVOKAMET TABS 150-1000 MG
INVOKAMET TABS 150-500 MG
INVOKAMET TABS 50-1000 MG
INVOKAMET TABS 50-500 MG
INVOKAMET XR TB24 150-1000 MG
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* Kaiser Permanente of Georgia HMO Formulary 31
Kaiser Permanente of Georgia HMO Formulary LIST OF DRUGS THAT REQUIRE PRIOR AUTHORIZATION (PA) REVIEW
INVOKAMET XR TB24 150-500 MG
INVOKAMET XR TB24 50-1000 MG
INVOKAMET XR TB24 50-500 MG
INVOKANA TABS 100 MG
INVOKANA TABS 300 MG
ISTURISA TABS 1 MG
ISTURISA TABS 1 MG
ISTURISA TABS 10 MG
ISTURISA TABS 5 MG
JANUMET TABS 50-1000 MG
JANUMET TABS 50-500 MG
JANUMET XR TB24 100-1000 MG
JANUMET XR TB24 50-1000 MG
JANUMET XR TB24 50-500 MG
JANUVIA TABS 100 MG
JANUVIA TABS 25 MG
JANUVIA TABS 50 MG
JARDIANCE TABS 10 MG
JARDIANCE TABS 25 MG
JENTADUETO TABS 2.5-1000 MG
JENTADUETO TABS 2.5-500 MG
JENTADUETO TABS 2.5-850 MG
JENTADUETO XR TB24 2.5-1000 MG
JENTADUETO XR TB24 5-1000 MG
JUBLIA SOLN 10 %
JUXTAPID CAPS 10 MG
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* 32 Kaiser Permanente of Georgia HMO Formulary
Kaiser Permanente of Georgia HMO Formulary LIST OF DRUGS THAT REQUIRE PRIOR AUTHORIZATION (PA) REVIEW
JUXTAPID CAPS 20 MG
JUXTAPID CAPS 30 MG
JUXTAPID CAPS 40 MG
JUXTAPID CAPS 5 MG
JUXTAPID CAPS 60 MG
JYNARQUE TABS 15 MG
JYNARQUE TABS 30 MG
JYNARQUE TBPK 15 MG
JYNARQUE TBPK 30 & 15 MG
JYNARQUE TBPK 45 & 15 MG
JYNARQUE TBPK 60 & 30 MG
JYNARQUE TBPK 90 & 30 MG
KALYDECO PACK 25 MG
KALYDECO PACK 50 MG
KALYDECO PACK 75 MG
KALYDECO TABS 150 MG
KESIMPTA SOAJ 20 MG/0.4ML
KEVEYIS TABS 50 MG
KEVZARA SOAJ 150 MG/1.14ML
KEVZARA SOAJ 200 MG/1.14ML
KEVZARA SOSY 150 MG/1.14ML
KEVZARA SOSY 200 MG/1.14ML
KOMBIGLYZE XR TB24 2.5-1000 MG
KOMBIGLYZE XR TB24 5-1000 MG
KOMBIGLYZE XR TB24 5-500 MG
KORLYM TABS 300 MG
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* Kaiser Permanente of Georgia HMO Formulary 33
Kaiser Permanente of Georgia HMO Formulary LIST OF DRUGS THAT REQUIRE PRIOR AUTHORIZATION (PA) REVIEW
KOSELUGO CAPS 10 MG
KOSELUGO CAPS 25 MG
KYNAMRO SOSY 200 MG/ML
LUPKYNIS CAPS 7.9 MG
LYNPARZA CAPS 50 MG
LYNPARZA TABS 100 MG
LYNPARZA TABS 150 MG
MAVENCLAD (10 TABS) TBPK 10 MG
MAVENCLAD (10 TABS) TBPK 10 MG
MAVENCLAD (4 TABS) TBPK 10 MG
MAVENCLAD (5 TABS) TBPK 10 MG
MAVENCLAD (6 TABS) TBPK 10 MG
MAVENCLAD (7 TABS) TBPK 10 MG
MAVENCLAD (8 TABS) TBPK 10 MG
MAVENCLAD (9 TABS) TBPK 10 MG
MAVYRET TABS 100-40 MG
MAYZENT STARTER PACK TBPK 0.25 MG
MAYZENT TABS 0.25 MG
MAYZENT TABS 2 MG
MIRVASO GEL 0.33 %
MULPLETA TABS 3 MG
MYCAPSSA CPDR 20 MG
MYTESI TBEC 125 MG
NATPARA CART 100 MCG
NATPARA CART 25 MCG
NATPARA CART 50 MCG
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* 34 Kaiser Permanente of Georgia HMO Formulary
Kaiser Permanente of Georgia HMO Formulary LIST OF DRUGS THAT REQUIRE PRIOR AUTHORIZATION (PA) REVIEW
NATPARA CART 75 MCG
NEXLETOL TABS 180 MG
NEXLIZET TABS 180-10 MG
NORDITROPIN FLEXPRO SOPN 10 MG/1.5ML
NORDITROPIN FLEXPRO SOPN 15 MG/1.5ML
NORDITROPIN FLEXPRO SOPN 30 MG/3ML
NORDITROPIN FLEXPRO SOPN 5 MG/1.5ML
NOVOLIN 70/30 FLEXPEN SUPN (70-30) 100 UNIT/ML
NOVOLIN 70/30 SUSP (70-30) 100 UNIT/ML
NOVOLIN N FLEXPEN SUPN 100 UNIT/ML
NOVOLIN N RELION SUSP 100 UNIT/ML
NOVOLIN N SUSP 100 UNIT/ML
NOVOLIN R FLEXPEN SOPN 100 UNIT/ML
NOVOLIN R RELION SOLN 100 UNIT/ML
NOVOLIN R SOLN 100 UNIT/ML
NOXAFIL SUSP 40 MG/ML
NUBEQA TABS 300 MG
NUCALA SOAJ 100 MG/ML
NUCALA SOSY 100 MG/ML
NUEDEXTA CAPS 20-10 MG
NUPLAZID CAPS 34 MG
NUPLAZID TABS 10 MG
NUPLAZID TABS 17 MG
NURTEC TBDP 75 MG
NUTROPIN AQ NUSPIN 10 SOPN 10 MG/2ML
NUTROPIN AQ NUSPIN 20 SOPN 20 MG/2ML
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* Kaiser Permanente of Georgia HMO Formulary 35
Kaiser Permanente of Georgia HMO Formulary LIST OF DRUGS THAT REQUIRE PRIOR AUTHORIZATION (PA) REVIEW
NUTROPIN AQ NUSPIN 5 SOPN 5 MG/2ML
OLUMIANT TABS 1 MG
OLUMIANT TABS 2 MG
OMNITROPE SOCT 10 MG/1.5ML
OMNITROPE SOCT 5 MG/1.5ML
OMNITROPE SOLR 5.8 MG
ONEXTON GEL 1.2-3.75 %
ONEXTON GEL 1.2-3.75 %
ONGLYZA TABS 2.5 MG
ONGLYZA TABS 5 MG
ONUREG TABS 200 MG
ONUREG TABS 300 MG
OPSUMIT TABS 10 MG
ORIAHNN CPPK 300-1-0.5 & 300 MG
ORILISSA TABS 150 MG
ORILISSA TABS 200 MG
ORKAMBI PACK 100-125 MG
ORKAMBI PACK 150-188 MG
ORKAMBI TABS 100-125 MG
ORKAMBI TABS 200-125 MG
ORLADEYO CAPS 110 MG
ORLADEYO CAPS 150 MG
OTEZLA TAB 10/20/30
OTEZLA TABS 30 MG
OTEZLA TBPK 10 & 20 & 30 MG
OXBRYTA TABS 500 MG
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* 36 Kaiser Permanente of Georgia HMO Formulary
Kaiser Permanente of Georgia HMO Formulary LIST OF DRUGS THAT REQUIRE PRIOR AUTHORIZATION (PA) REVIEW
OXERVATE SOLN 0.002 %
OZEMPIC (0.25 OR 0.5 MG/DOSE) SOPN 2 MG/1.5ML
OZEMPIC (0.25 OR 0.5 MG/DOSE) SOPN 2 MG/1.5ML
OZEMPIC (1 MG/DOSE) SOPN 2 MG/1.5ML
OZEMPIC (1 MG/DOSE) SOPN 4 MG/3ML
PALFORZIA (12 MG DAILY DOSE) CSPK 2 x 1 MG & 10 MG
PALFORZIA (120 MG DAILY DOSE) CSPK 20 MG & 100 MG
PALFORZIA (160 MG DAILY DOSE) CSPK 3 x 20 MG & 100 MG
PALFORZIA (20 MG DAILY DOSE) CSPK 20 MG
PALFORZIA (200 MG DAILY DOSE) CSPK 2 x 100 MG
PALFORZIA (240 MG DAILY DOSE) CSPK 2 x 20 MG & 2 X 100 MG
PALFORZIA (3 MG DAILY DOSE) CSPK 3 x 1 MG
PALFORZIA (300 MG MAINTENANCE) PACK 300 MG
PALFORZIA (300 MG TITRATION) PACK 300 MG
PALFORZIA (40 MG DAILY DOSE) CSPK 2 x 20 MG
PALFORZIA (6 MG DAILY DOSE) CSPK 6 x 1 MG
PALFORZIA (80 MG DAILY DOSE) CSPK 4 x 20 MG
PALYNZIQ SOSY 10 MG/0.5ML
PALYNZIQ SOSY 2.5 MG/0.5ML
PALYNZIQ SOSY 20 MG/ML
PICATO GEL 0.015 %
PICATO GEL 0.05 %
PIQRAY (200 MG DAILY DOSE) TBPK 200 MG
PIQRAY (250 MG DAILY DOSE) TBPK 200 & 50 MG
PIQRAY (300 MG DAILY DOSE) TBPK 2 x 150 MG
PLEGRIDY SOPN 125 MCG/0.5ML
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* Kaiser Permanente of Georgia HMO Formulary 37
Kaiser Permanente of Georgia HMO Formulary LIST OF DRUGS THAT REQUIRE PRIOR AUTHORIZATION (PA) REVIEW
PLEGRIDY SOSY 125 MCG/0.5ML
PLEGRIDY SOSY 125 MCG/0.5ML
PLEGRIDY STARTER PACK SOPN 63 & 94 MCG/0.5ML
PLEGRIDY STARTER PACK SOSY 63 & 94 MCG/0.5ML
PONVORY STARTER PACK TBPK 2-3-4-5-6-7-8-9 & 10 MG
PONVORY TABS 20 MG
PRALUENT SOAJ 150 MG/ML
PRALUENT SOAJ 75 MG/ML
PREVYMIS TABS 240 MG
PREVYMIS TABS 480 MG
PROCYSBI CPDR 25 MG
PROCYSBI CPDR 75 MG
PROCYSBI PACK 300 MG
PROCYSBI PACK 75 MG
PROCYSBI PACK 75 MG
QBREXZA PADS 2.4 %
QTERN TABS 10-5 MG
QTERN TABS 5-5 MG
RAVICTI LIQD 1.1 GM/ML
REBIF REBIDOSE SOAJ 22 MCG/0.5ML
REBIF REBIDOSE SOAJ 44 MCG/0.5ML
REBIF REBIDOSE TITRATION PACK SOAJ 6X8.8 & 6X22 MCG
REBIF SOSY 22 MCG/0.5ML
REBIF SOSY 44 MCG/0.5ML
REBIF TITRATION PACK SOSY 6X8.8 & 6X22 MCG
RELISTOR SOLN 12 MG/0.6ML
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* 38 Kaiser Permanente of Georgia HMO Formulary
Kaiser Permanente of Georgia HMO Formulary LIST OF DRUGS THAT REQUIRE PRIOR AUTHORIZATION (PA) REVIEW
RELISTOR SOLN 12 MG/0.6ML
RELISTOR SOLN 8 MG/0.4ML
RELISTOR TABS 150 MG
REPATHA PUSHTRONEX SYSTEM SOCT 420 MG/3.5ML
REPATHA SOSY 140 MG/ML
REPATHA SURECLICK SOAJ 140 MG/ML
RETEVMO CAPS 40 MG
RETEVMO CAPS 80 MG
RETEVMO CAPS 80 MG
REYVOW TABS 100 MG
REYVOW TABS 50 MG
RHOPRESSA SOLN 0.02 %
RINVOQ TB24 15 MG
ROCKLATAN SOLN 0.02-0.005 %
ROZLYTREK CAPS 100 MG
ROZLYTREK CAPS 200 MG
RUBRACA TABS 200 MG
RUBRACA TABS 250 MG
RUBRACA TABS 300 MG
RUZURGI TABS 10 MG
RYBELSUS TABS 14 MG
RYBELSUS TABS 3 MG
RYBELSUS TABS 7 MG
SAIZEN SOLR 5 MG
SAIZENPREP SOLR 8.8 MG
SAXENDA SOPN 18 MG/3ML
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* Kaiser Permanente of Georgia HMO Formulary 39
Kaiser Permanente of Georgia HMO Formulary LIST OF DRUGS THAT REQUIRE PRIOR AUTHORIZATION (PA) REVIEW
SEGLUROMET TABS 2.5-1000 MG
SEGLUROMET TABS 2.5-500 MG
SEGLUROMET TABS 7.5-1000 MG
SEGLUROMET TABS 7.5-500 MG
SEROSTIM SOLR 4 MG
SEROSTIM SOLR 5 MG
SEROSTIM SOLR 6 MG
SILIQ SOSY 210 MG/1.5ML
SIMPONI SOAJ 100 MG/ML
SIMPONI SOAJ 50 MG/0.5ML
SIMPONI SOSY 100 MG/ML
SIMPONI SOSY 50 MG/0.5ML
SKYRIZI (150 MG DOSE) PSKT 75 MG/0.83ML
SKYRIZI PEN SOAJ 150 MG/ML
SKYRIZI SOSY 150 MG/ML
SOLIQUA SOPN 100-33 UNT-MCG/ML
SOMAVERT SOLR 10 MG
SOMAVERT SOLR 15 MG
SOMAVERT SOLR 20 MG
SOMAVERT SOLR 25 MG
SOMAVERT SOLR 30 MG
SOVALDI PACK 150 MG
SOVALDI PACK 200 MG
SOVALDI TABS 200 MG
SOVALDI TABS 400 MG
SPRYCEL TABS 100 MG
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* 40 Kaiser Permanente of Georgia HMO Formulary
Kaiser Permanente of Georgia HMO Formulary LIST OF DRUGS THAT REQUIRE PRIOR AUTHORIZATION (PA) REVIEW
SPRYCEL TABS 140 MG
SPRYCEL TABS 20 MG
SPRYCEL TABS 50 MG
SPRYCEL TABS 70 MG
SPRYCEL TABS 80 MG
STEGLATRO TABS 15 MG
STEGLATRO TABS 5 MG
STEGLUJAN TABS 15-100 MG
STEGLUJAN TABS 5-100 MG
STELARA SOLN 45 MG/0.5ML
STELARA SOSY 45 MG/0.5ML
STELARA SOSY 90 MG/ML
SUNOSI TABS 150 MG
SUNOSI TABS 75 MG
SYMDEKO TBPK 100-150 & 150 MG
SYMDEKO TBPK 50-75 & 75 MG
SYMLINPEN 120 SOPN 2700 MCG/2.7ML
SYMLINPEN 60 SOPN 1500 MCG/1.5ML
SYNJARDY TABS 12.5-1000 MG
SYNJARDY TABS 12.5-500 MG
SYNJARDY TABS 5-1000 MG
SYNJARDY TABS 5-500 MG
SYNJARDY XR TB24 10-1000 MG
SYNJARDY XR TB24 12.5-1000 MG
SYNJARDY XR TB24 25-1000 MG
SYNJARDY XR TB24 5-1000 MG
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* Kaiser Permanente of Georgia HMO Formulary 41
Kaiser Permanente of Georgia HMO Formulary LIST OF DRUGS THAT REQUIRE PRIOR AUTHORIZATION (PA) REVIEW
TABRECTA TABS 150 MG
TABRECTA TABS 200 MG
TAKHZYRO SOLN 300 MG/2ML
TALTZ SOAJ 80 MG/ML
TALTZ SOSY 80 MG/ML
TALZENNA CAPS 0.25 MG
TALZENNA CAPS 1 MG
TASIGNA CAPS 150 MG
TASIGNA CAPS 200 MG
TASIGNA CAPS 50 MG
TAVALISSE TABS 100 MG
TAVALISSE TABS 150 MG
TECHNIVIE TABS 12.5-75-50 MG
TEGSEDI SOSY 284 MG/1.5ML
TEPMETKO TABS 225 MG
TERIPARATIDE (RECOMBINANT) SOPN 620 MCG/2.48ML
TRADJENTA TABS 5 MG
TREMFYA SOPN 100 MG/ML
TREMFYA SOSY 100 MG/ML
TRIKAFTA TBPK 100-50-75 & 150 MG
TRIKAFTA TBPK 50-25-37.5 & 75 MG
TRULICITY SOPN 0.75 MG/0.5ML
TRULICITY SOPN 1.5 MG/0.5ML
TRULICITY SOPN 3 MG/0.5ML
TRULICITY SOPN 3 MG/0.5ML
TRULICITY SOPN 4.5 MG/0.5ML
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* 42 Kaiser Permanente of Georgia HMO Formulary
Kaiser Permanente of Georgia HMO Formulary LIST OF DRUGS THAT REQUIRE PRIOR AUTHORIZATION (PA) REVIEW
TRULICITY SOPN 4.5 MG/0.5ML
TUKYSA TABS 150 MG
TUKYSA TABS 50 MG
TURALIO CAPS 200 MG
TYMLOS SOPN 3120 MCG/1.56ML
UBRELVY TABS 100 MG
UBRELVY TABS 50 MG
VASCEPA CAPS 0.5 GM
VEMLIDY TABS 25 MG
VIBERZI TABS 100 MG
VIBERZI TABS 75 MG
VICTOZA SOPN 18 MG/3ML
VIEKIRA PAK TBPK 12.5-75-50 &250 MG
VIEKIRA XR TB24 200-8.33-50- 33.33 MG
VITRAKVI CAPS 100 MG
VITRAKVI CAPS 25 MG
VITRAKVI SOLN 20 MG/ML
VOSEVI TABS 400-100-100 MG
VUMERITY (STARTER) CPDR 231 MG
VUMERITY CPDR 231 MG
VYNDAMAX CAPS 61 MG
VYNDAQEL CAPS 20 MG
VYZULTA SOLN 0.024 %
VYZULTA SOLN 0.024 %
WAKIX TABS 17.8 MG
WAKIX TABS 4.45 MG
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* Kaiser Permanente of Georgia HMO Formulary 43
Kaiser Permanente of Georgia HMO Formulary LIST OF DRUGS THAT REQUIRE PRIOR AUTHORIZATION (PA) REVIEW
XEMBIFY SOLN 1 GM/5ML
XEMBIFY SOLN 10 GM/50ML
XEMBIFY SOLN 2 GM/10ML
XEMBIFY SOLN 4 GM/20ML
XGEVA SOLN 120 MG/1.7ML
XHANCE EXHU 93 MCG/ACT
XIGDUO XR TB24 10-1000 MG
XIGDUO XR TB24 10-500 MG
XIGDUO XR TB24 2.5-1000 MG
XIGDUO XR TB24 5-1000 MG
XIGDUO XR TB24 5-500 MG
XOLAIR SOLR 150 MG
XOLAIR SOSY 150 MG/ML
XOLAIR SOSY 75 MG/0.5ML
XPOVIO (100 MG ONCE WEEKLY) TBPK 20 MG
XPOVIO (100 MG ONCE WEEKLY) TBPK 50 MG
XPOVIO (40 MG ONCE WEEKLY) TBPK 20 MG
XPOVIO (40 MG ONCE WEEKLY) TBPK 20 MG
XPOVIO (40 MG ONCE WEEKLY) TBPK 40 MG
XPOVIO (40 MG TWICE WEEKLY) TBPK 20 MG
XPOVIO (40 MG TWICE WEEKLY) TBPK 20 MG
XPOVIO (40 MG TWICE WEEKLY) TBPK 40 MG
XPOVIO (60 MG ONCE WEEKLY) TBPK 20 MG
XPOVIO (60 MG ONCE WEEKLY) TBPK 60 MG
XPOVIO (60 MG TWICE WEEKLY) TBPK 20 MG
XPOVIO (60 MG TWICE WEEKLY) TBPK 20 MG
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* 44 Kaiser Permanente of Georgia HMO Formulary
Kaiser Permanente of Georgia HMO Formulary LIST OF DRUGS THAT REQUIRE PRIOR AUTHORIZATION (PA) REVIEW
XPOVIO (80 MG ONCE WEEKLY) TBPK 20 MG
XPOVIO (80 MG ONCE WEEKLY) TBPK 40 MG
XPOVIO (80 MG TWICE WEEKLY) TBPK 20 MG
XULTOPHY SOPN 100-3.6 UNIT-MG/ML
XYREM SOLN 500 MG/ML
XYWAV SOLN 500 MG/ML
ZEJULA CAPS 100 MG
ZEPATIER TABS 50-100 MG
ZEPOSIA 7-DAY STARTER PACK CPPK 4 x 0.23MG & 3 X 0.46MG
ZEPOSIA CAPS 0.92 MG
ZEPOSIA STARTER KIT CPPK 0.23MG & 0.46MG & 0.92MG
ZOMACTON SOLR 10 MG
ZORBTIVE SOLR 8.8 MG
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* Kaiser Permanente of Georgia HMO Formulary 45
Kaiser Permanente of Georgia HMO Formulary
Index of Drugs
allopurinol ...... 20 8 alprazolam ...... 13 ALVESCO ...... 18, 21 8-MOP ...... 22 amantadine hcl ...... 13 AMICAR ...... 9 A amikacin sulfate ...... 5 amiloride & hydrochlorothiazide ...... 11 abacavir sulfate ...... 6 aminocaproic acid ...... 10, 20 abacavir sulfate-lamivudine ...... 6 amiodarone hcl ...... 10 abacavir sulfate-lamivudine-zidovudine ...... 6 amitriptyline hcl ...... 14 abiraterone acetate ...... 7 amlodipine besylate...... 10 acarbose ...... 18 amoxicillin ...... 2, 5 acebutolol hcl ...... 10 amoxicillin & pot clavulanate ...... 5 acetaminophen w/ codeine ...... 12 amphetamine-dextroamphetamine ...... 12 acetazolamide ...... 16 AMPHOTERICIN B ...... 5 acetic acid (otic) ...... 16 ampicillin ...... 5 acetic acid-aluminum acetate ...... 16 anagrelide hcl ...... 9 acetylcysteine ...... 21 anastrozole ...... 7 acitretin ...... 23 ANDROXY ...... 18 ACTEMRA ...... 20 apraclonidine hcl ...... 16 ACTHAR GEL 80 UNIT/ML ...... 23 APTIVUS...... 6 ACTIMMUNE...... 20 ARANESP (ALBUMIN FREE) ...... 9 acyclovir ...... 6 ARCALYST SOLR 220 MG ...... 24 ADLYXIN SOPN 20 MCG/0.2ML ...... 24 ARIKAYCE SUSP 590 MG/8.4ML ...... 24 ADLYXIN STARTER PACK PNKT 10 & 20 MCG/0.2ML .. 24 aripiprazole ...... 14 AEROCHAMBER PLUS FLO-VU...... 14 ARISTOSPAN INTRA-ARTICULAR ...... 18 AFINITOR ...... 7 armodafinil ...... 13 AFREZZA POWD 12 UNIT ...... 24 ASMANEX HFA ...... 18 AFREZZA POWD 4 & 8 & 12 UNIT ...... 24 atazanavir sulfate ...... 6 AFREZZA POWD 4 UNIT ...... 24 atenolol ...... 10 AFREZZA POWD 8 UNIT ...... 24 atenolol & chlorthalidone ...... 10 AFREZZA POWD 90 x 4 UNIT & 90X8 UNIT...... 24 atorvastatin calcium...... 10 AFREZZA POWD 90 x 8 UNIT & 90X12 UNIT ...... 24 atovaquone ...... 6 AIMOVIG (140 MG DOSE) SOAJ 70 MG/ML ...... 24 ATROPINE SULFATE ...... 20 AIMOVIG SOAJ 140 MG/ML ...... 24 atropine sulfate (ophthalmic) ...... 17 AIMOVIG SOAJ 70 MG/ML ...... 24 AUBAGIO TABS 14 MG ...... 24 AJOVY SOAJ 225 MG/1.5ML ...... 24 AUBAGIO TABS 7 MG ...... 24 AJOVY SOSY 225 MG/1.5ML ...... 24 AUSTEDO TABS 12 MG ...... 24 AKYNZEO ...... 17 AUSTEDO TABS 6 MG ...... 24 albendazole ...... 5 AUSTEDO TABS 9 MG ...... 24 albuterol sulfate...... 9 AUVI-Q SOAJ 0.1 MG/0.1ML ...... 24 alclometasone dipropionate ...... 22 AUVI-Q SOAJ 0.15 MG/0.15ML ...... 24 alendronate sodium ...... 20 AUVI-Q SOAJ 0.3 MG/0.3ML ...... 25 alfuzosin hcl ...... 10 AVONEX KIT 30 MCG ...... 25 ALKINDI SPRINKLE CPSP 0.5 MG ...... 24 AVONEX KIT 30MCG ...... 25 ALKINDI SPRINKLE CPSP 1 MG ...... 24 AVONEX PEN AJKT 30 MCG/0.5ML ...... 25 ALKINDI SPRINKLE CPSP 2 MG ...... 24 AVONEX PREFILLED PSKT 30 MCG/0.5ML ...... 25 ALKINDI SPRINKLE CPSP 5 MG ...... 24 azathioprine ...... 20 *All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* 46 Kaiser Permanente of Georgia HMO Formulary
Kaiser Permanente of Georgia HMO Formulary azithromycin ...... 5 butalbital-aspirin-caffeine w/cod ...... 12 BYDUREON BCISE AUIJ 2 MG/0.85ML ...... 25 B BYDUREON PEN 2 MG ...... 25 BYDUREON SRER 2 MG ...... 25 BACITRACIN...... 5, 15 BYETTA 10 MCG PEN SOPN 10 MCG/0.04ML ...... 25 bacitracin-polymyxin b (ophth) ...... 15 BYETTA 5 MCG PEN SOPN 5 MCG/0.02ML ...... 25 bacitracin-poly-neomycin-hc ...... 16 BYNFEZIA PEN SOPN 2500 MCG/ML (2.8 ML) ...... 25 baclofen ...... 9 BAFIERTAM CPDR 95 MG ...... 25 C balsalazide disodium ...... 17 BAQSIMI ONE PACK ...... 20 cabergoline ...... 13 BAYER CONTOUR USB ...... 15 CABLIVI KIT 11 MG ...... 25 BD INSULIN SYRINGE ...... 15, 20 CAFERGOT ...... 13 BD INSULIN SYRINGE MICROFINE ...... 15 calcipotriene ...... 23 BD INSULIN SYRINGE U-40 ...... 15 calcitonin (salmon)...... 19 BD INSULIN SYRINGE U-500...... 20 calcitriol ...... 23 BD PEN NEEDLE MINI U/F ...... 15 calcium acetate (phosphate binder) ...... 20 benazepril hcl ...... 11 capecitabine ...... 7 BENLYSTA SOAJ 200 MG/ML ...... 25 CAPRELSA ...... 7 BENLYSTA SOSY 200 MG/ML ...... 25 captopril ...... 11 benzonatate ...... 21 carbamazepine ...... 12 benzoyl peroxide-erythromycin ...... 23 carbidopa-levodopa ...... 13 benztropine mesylate ...... 13 CARBIDOPA-LEVODOPA-ENTACAPONE ...... 13 BERINERT KIT 500 UNIT ...... 25 carvedilol ...... 10 betamethasone dipropionate (topical) ...... 22 cefaclor ...... 5 betamethasone dipropionate augmented...... 21, 22 CEFACLOR ...... 5 betamethasone valerate ...... 22 cefazolin sodium ...... 5 betaxolol hcl (ophth) ...... 16 cefdinir ...... 5 bethanechol chloride ...... 9 ceftazidime ...... 5 bicalutamide ...... 7 cefuroxime axetil ...... 5 BIKTARVY ...... 6 CELONTIN ...... 12 bisoprolol & hydrochlorothiazide ...... 10 cephalexin...... 5 bisoprolol fumarate ...... 10 CERDELGA CAPS 84 MG ...... 25 BLEPHAMIDE ...... 16 chlordiazepoxide hcl ...... 9, 13 bosentan ...... 21 chlordiazepoxide hcl-clidinium bromide ...... 9 BOSULIF TABS 100 MG ...... 25 chlorhexidine gluconate (mouth-throat) ...... 15, 20 BOSULIF TABS 400 MG ...... 25 chlorpromazine hcl ...... 14 BOSULIF TABS 500 MG ...... 25 chlorthalidone ...... 10, 11 BRILINTA ...... 10 chlorzoxazone ...... 9 brimonidine tartrate ...... 16 CHOLBAM CAPS 250 MG ...... 25 bromocriptine mesylate ...... 13 CHOLBAM CAPS 50 MG ...... 25 BRUKINSA CAPS 80 MG ...... 25 cholestyramine ...... 10 budesonide ...... 18 cholestyramine light...... 10 budesonide (inhalation) ...... 18 CHORIONIC GONADOTROPIN ...... 19 buprenorphine hcl ...... 20 ciclopirox ...... 22 buprenorphine hcl-naloxone hcl dihydrate ...... 20 cidofovir ...... 6 bupropion hcl ...... 13, 14 cilostazol ...... 9 buspirone hcl ...... 13 CIMDUO ...... 6 butalbital-acetaminophen-caffeine ...... 12 CIMETIDINE HCL ...... 17 butalbital-acetaminophen-caffeine w/ codeine ...... 12 CIMZIA KIT 2 X 200 MG ...... 25 butalbital-aspirin-caffeine...... 12 CIMZIA PREFILLED KIT 2 X 200 MG/ML ...... 25
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* Kaiser Permanente of Georgia HMO Formulary 47
Kaiser Permanente of Georgia HMO Formulary CIMZIA STARTER KIT KIT 6 X 200 MG/ML ...... 25 cyclosporine ...... 20 cinacalcet hcl ...... 19, 20 cyclosporine modified (for microemulsion) ...... 20 CINRYZE SOLR 500 UNIT ...... 26 cyproheptadine hcl ...... 7 ciprofloxacin hcl ...... 5, 15 ciprofloxacin hcl (ophth) ...... 15 D ciprofloxacin-dexamethasone ...... 16 citalopram hydrobromide ...... 13, 14 DAKLINZA TABS 30 MG ...... 26 clarithromycin ...... 5 DAKLINZA TABS 60 MG ...... 26 clindamycin hcl ...... 5 DAKLINZA TABS 90 MG ...... 26 clindamycin palmitate hydrochloride ...... 5 dalfampridine ...... 20 clindamycin phosphate (topical) ...... 22 DALIRESP ...... 21 clindamycin phosphate-benzoyl peroxide (refrigerate) ...... 23 danazol ...... 18 clobazam...... 12 dapsone ...... 6 clobetasol propionate ...... 22 DARAPRIM TABS 25 MG ...... 26 clonazepam ...... 12, 13 darifenacin hydrobromide ...... 23 clonidine hcl ...... 11 DARZALEX FASPRO SOLN 1800-30000 MG-UT/15ML .. 26 clopidogrel bisulfate...... 10 deferasirox ...... 20 clotrimazole ...... 22, 23 DEPO-ESTRADIOL...... 19 clotrimazole w/ betamethasone ...... 23 DESCOVY ...... 6 clozapine ...... 14 desipramine hcl ...... 14 COAL TAR ...... 21 desmopressin acetate ...... 19 colestipol hcl ...... 10 desmopressin acetate refrigerated...... 19 CONTOUR TEST ...... 15 desmopressin acetate spray ...... 19 COSENTYX ...... 20, 26 desmopressin acetate spray refrigerated ...... 19 COSENTYX (300 MG DOSE) SOSY 150 MG/ML ...... 26 desogestrel & ethinyl estradiol ...... 18 COSENTYX SENSOREADY (300 MG) SOAJ 150 MG/ML desonide ...... 22 ...... 26 desoximetasone ...... 23 COSENTYX SENSOREADY PEN SOAJ 150 MG/ML ...... 26 dexamethasone ...... 16, 18 COSENTYX SOSY 150 MG/ML ...... 26 dexamethasone sodium phosphate ...... 18 COSENTYX SOSY 75 MG/0.5ML ...... 26 DEXAMETHASONE SODIUM PHOSPHATE ...... 16 COTELLIC ...... 7 dexmethylphenidate hcl ...... 12 CREON ...... 17 dextroamphetamine sulfate ...... 12 CRESEMBA CAPS 186 MG ...... 26 DIACOMIT CAPS 250 MG ...... 26 CRINONE ...... 19 DIACOMIT CAPS 500 MG ...... 26 CRIXIVAN ...... 6 DIACOMIT PACK 250 MG ...... 26 cromolyn sodium ...... 21 DIACOMIT PACK 500 MG ...... 27 CUPRIMINE ...... 17 DIASTAT ACUDIAL...... 12 CUTAQUIG SOLN 1 GM/6ML ...... 26 DIASTIX ...... 15 CUTAQUIG SOLN 1.65 GM/10ML...... 26 diazepam ...... 13 CUTAQUIG SOLN 2 GM/12ML ...... 26 diazoxide ...... 11 CUTAQUIG SOLN 3.3 GM/20ML ...... 26 diclofenac sodium ...... 12, 16 CUTAQUIG SOLN 4 GM/24ML ...... 26 diclofenac sodium (ophth) ...... 16 CUTAQUIG SOLN 8 GM/48ML ...... 26 dicloxacillin sodium ...... 5 CUVITRU SOLN 1 GM/5ML...... 26 dicyclomine hcl ...... 9 CUVITRU SOLN 10 GM/50ML ...... 26 didanosine ...... 6 CUVITRU SOLN 2 GM/10ML ...... 26 digoxin ...... 11 CUVITRU SOLN 4 GM/20ML ...... 26 DILANTIN ...... 12 CUVITRU SOLN 8 GM/40ML ...... 26 diltiazem hcl ...... 10 cyclobenzaprine hcl ...... 9 diltiazem hcl coated beads ...... 10 cyclopentolate hcl ...... 17 dimethyl fumarate ...... 20 CYCLOPHOSPHAMIDE ...... 7 diphenoxylate w/ atropine ...... 17 *All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* 48 Kaiser Permanente of Georgia HMO Formulary
Kaiser Permanente of Georgia HMO Formulary dipyridamole ...... 10, 11 enoxaparin sodium ...... 9 disopyramide phosphate ...... 11 ENSPRYNG SOSY 120 MG/ML ...... 27 disulfiram...... 20 ENSTILAR FOAM 0.005-0.064 % ...... 27 divalproex sodium ...... 12 entacapone ...... 13 dofetilide ...... 11 entecavir ...... 6 DOJOLVI LIQD 100 % ...... 27 EPCLUSA ...... 6, 27 donepezil hydrochloride ...... 9 EPCLUSA TABS 200-50 MG ...... 27 DOPTELET TABS 20 MG ...... 27 EPIDIOLEX SOLN 100 MG/ML ...... 28 dorzolamide hcl ...... 16 EPINEPHRINE ...... 9 dorzolamide hcl-timolol maleate ...... 16 ergocalciferol ...... 23 DOVATO ...... 6 ERGOLOID MESYLATES ...... 20 doxazosin mesylate ...... 10 erlotinib hcl ...... 8 doxepin hcl ...... 13, 14 erythromycin (acne aid) ...... 22 doxycycline (monohydrate) ...... 5 erythromycin (ophth) ...... 16 doxycycline hyclate ...... 5 escitalopram oxalate ...... 14 dronabinol ...... 17 esterified estrogens & methyltestosterone ...... 19 drospirenone-ethinyl estradiol ...... 18 estradiol ...... 18, 19 DROXIA ...... 7 estradiol vaginal ...... 19 DRYSOL ...... 22 estradiol valerate ...... 19 duloxetine hcl ...... 14 ESTROPIPATE ...... 19 DUPIXENT SOPN 300 MG/2ML ...... 27 ethambutol hcl ...... 6 DUPIXENT SOSY 200 MG/1.14ML ...... 27 ethosuximide ...... 12 DUPIXENT SOSY 300 MG/2ML ...... 27 ethynodiol diacet & eth estrad ...... 18 ETIDRONATE DISODIUM ...... 20 E ETOPOSIDE ...... 8 etravirine ...... 6 EDURANT ...... 6 EUCRISA OINT 2 % ...... 28 efavirenz ...... 6 EVRYSDI SOLR 0.75 MG/ML ...... 28 ELLA ...... 18 EXTAVIA ...... 13 ELMIRON ...... 20, 27 ezetimibe...... 10 ELMIRON CAPS 100 MG ...... 27 EMCYT ...... 7 F EMFLAZA SUSP 22.75 MG/ML ...... 27 EMFLAZA TABS 18 MG ...... 27 FARXIGA TABS 10 MG ...... 28 EMFLAZA TABS 30 MG ...... 27 FARXIGA TABS 5 MG ...... 28 EMFLAZA TABS 36 MG ...... 27 FASENRA PEN SOAJ 30 MG/ML ...... 28 EMFLAZA TABS 6 MG ...... 27 FASENRA SOSY 30 MG/ML ...... 28 EMGALITY (300 MG DOSE) SOSY 100 MG/ML ...... 27 FC FEMALE CONDOM ...... 20 EMGALITY SOAJ 120 MG/ML ...... 27 felodipine...... 10 EMGALITY SOSY 120 MG/ML ...... 27 FEMCAP ...... 14 emtricitabine ...... 6 fenofibrate ...... 10 emtricitabine-tenofovir disoproxil fumarate ...... 6 fentanyl ...... 12 enalapril maleate ...... 10, 11 finasteride ...... 20 ENBREL ...... 19, 20, 27 FINTEPLA SOLN 2.2 MG/ML ...... 28 ENBREL MINI SOCT 50 MG/ML ...... 27 FIRDAPSE TABS 10 MG ...... 28 ENBREL SOLN 25 MG/0.5ML ...... 27 FLAREX ...... 16 ENBREL SOLR 25 MG ...... 27 flecainide acetate ...... 11 ENBREL SOSY 25 MG/0.5ML...... 27 fluconazole ...... 5 ENBREL SOSY 50 MG/ML ...... 27 flucytosine ...... 6 ENBREL SURECLICK SOAJ 50 MG/ML ...... 27 fludrocortisone acetate ...... 18 ENDARI PACK 5 GM ...... 27 fluocinolone acetonide ...... 22
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* Kaiser Permanente of Georgia HMO Formulary 49
Kaiser Permanente of Georgia HMO Formulary fluocinonide ...... 22 glimepiride ...... 18 fluocinonide emulsified base ...... 22 glipizide ...... 18, 20 fluorometholone (ophth)...... 16 glucagon (rdna) ...... 18 fluorouracil ...... 8, 23 glycopyrrolate ...... 9 fluorouracil (topical) ...... 23 GLYXAMBI TABS 10-5 MG ...... 29 fluoxetine hcl ...... 14 GLYXAMBI TABS 25-5 MG ...... 29 fluphenazine hcl ...... 14 griseofulvin microsize ...... 6 flutamide ...... 8, 19 griseofulvin ultramicrosize ...... 6 fluticasone propionate ...... 22 guaifenesin-codeine ...... 21 fluticasone-salmeterol ...... 9 guanfacine hcl (adhd) ...... 13 fluvoxamine maleate ...... 14 GVOKE HYPOPEN 1-PACK ...... 19 FORTEO SOPN 620 MCG/2.48ML ...... 28 fosamprenavir calcium ...... 6 H FOTIVDA CAPS 1.34 MG ...... 28 FOTIVIDA CAPS 0.89 MG ...... 28 HAEGARDA SOLR 2000 UNIT ...... 29 furosemide ...... 15 HAEGARDA SOLR 3000 UNIT ...... 29 FUZEON ...... 6 haloperidol ...... 14 haloperidol lactate ...... 14 G HARVONI PACK 33.75-150 MG ...... 29 HARVONI PACK 45-200 MG ...... 29 gabapentin ...... 12 HARVONI TABS 45-200 MG ...... 29 GALAFOLD CAPS 123 MG ...... 28 HEMLIBRA SOLN 105 MG/0.7ML ...... 29 galantamine hydrobromide ...... 9, 13 HEMLIBRA SOLN 150 MG/ML ...... 29 GAMMAGARD SOLN 1 GM/10ML...... 28 HEMLIBRA SOLN 30 MG/ML ...... 29 GAMMAGARD SOLN 10 GM/100ML ...... 28 HEMLIBRA SOLN 60 MG/0.4ML ...... 30 GAMMAGARD SOLN 2.5 GM/25ML ...... 28 HETLIOZ CAPS 20 MG ...... 30 GAMMAGARD SOLN 20 GM/200ML ...... 28 HETLIOZ LQ SUSP 4 MG/ML ...... 30 GAMMAGARD SOLN 30 GM/300ML ...... 28 HIZENTRA SOLN 1 GM/5ML ...... 30 GAMMAGARD SOLN 5 GM/50ML...... 28 HIZENTRA SOLN 10 GM/50ML ...... 30 GATTEX KIT 5 MG ...... 29 HIZENTRA SOLN 2 GM/10ML ...... 30 GAVRETO CAPS 100 MG ...... 29 HIZENTRA SOLN 4 GM/20ML ...... 30 GEL-KAM ...... 20 HIZENTRA SOSY 1 GM/5ML ...... 30 GENOTROPIN MINIQUICK SOLR 0.2 MG ...... 29 HIZENTRA SOSY 2 GM/10ML ...... 30 GENOTROPIN MINIQUICK SOLR 0.4 MG ...... 29 HIZENTRA SOSY 4 GM/20ML ...... 30 GENOTROPIN MINIQUICK SOLR 0.6 MG ...... 29 HOMATROPAIRE ...... 17 GENOTROPIN MINIQUICK SOLR 0.8 MG ...... 29 HUMATROPE SOLR 12 MG ...... 30 GENOTROPIN MINIQUICK SOLR 1 MG ...... 29 HUMATROPE SOLR 24 MG ...... 30 GENOTROPIN MINIQUICK SOLR 1.2 MG ...... 29 HUMATROPE SOLR 5 MG ...... 30 GENOTROPIN MINIQUICK SOLR 1.4 MG ...... 29 HUMATROPE SOLR 6 MG ...... 30 GENOTROPIN MINIQUICK SOLR 1.6 MG ...... 29 HUMIRA ...... 20, 30, 31 GENOTROPIN MINIQUICK SOLR 1.8 MG ...... 29 HUMIRA PEDIATRIC CROHNS START PSKT 80 GENOTROPIN MINIQUICK SOLR 2 MG ...... 29 MG/0.8ML ...... 30 GENOTROPIN SOLR 12 MG ...... 29 HUMIRA PEDIATRIC CROHNS START PSKT 80 GENOTROPIN SOLR 5 MG ...... 29 MG/0.8ML & 40MG/0.4ML...... 30 gentamicin sulfate ...... 5, 16 HUMIRA PEN PNKT 40 MG/0.4ML ...... 30 gentamicin sulfate (ophth) ...... 16 HUMIRA PEN-CD/UC/HS STARTER PNKT 40 MG/0.8ML GENVOYA ...... 6 ...... 30 GILENYA CAPS 0.25 MG ...... 29 HUMIRA PEN-CD/UC/HS STARTER PNKT 80 MG/0.8ML GILENYA CAPS 0.5 MG ...... 29 ...... 30 glatiramer acetate ...... 13 HUMIRA PEN-PEDIATRIC UC START PNKT 80 GLEEVEC ...... 8 MG/0.8ML ...... 30
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* 50 Kaiser Permanente of Georgia HMO Formulary
Kaiser Permanente of Georgia HMO Formulary HUMIRA PEN-PSOR/UVEIT STARTER PNKT 80 INGREZZA CAPS 40 MG ...... 31 MG/0.8ML & 40MG/0.4ML...... 30 INGREZZA CAPS 60 MG ...... 31 HUMIRA PSKT 10 MG/0.1ML ...... 30 INGREZZA CAPS 80 MG ...... 31 HUMIRA PSKT 10 MG/0.2ML ...... 30 INGREZZA CPPK 40 & 80 MG ...... 31 HUMIRA PSKT 20 MG/0.2ML ...... 30 INQOVI TABS 35-100 MG ...... 31 HUMIRA PSKT 20 MG/0.4ML ...... 30 INTRON A ...... 6, 8 HUMIRA PSKT 40 MG/0.4ML ...... 31 INVIRASE ...... 7 HUMIRA PSKT 40 MG/0.8ML ...... 31 INVOKAMET TABS 150-1000 MG...... 31 HUMULIN 70/30 ...... 18 INVOKAMET TABS 150-500 MG ...... 31 HUMULIN N ...... 18 INVOKAMET TABS 50-1000 MG ...... 31 HUMULIN R ...... 18 INVOKAMET TABS 50-500 MG ...... 31 HYCAMTIN ...... 8 INVOKAMET XR TB24 150-1000 MG ...... 31 hydralazine hcl ...... 11 INVOKAMET XR TB24 150-500 MG ...... 32 hydrochlorothiazide ...... 10, 11, 15 INVOKAMET XR TB24 50-1000 MG ...... 32 hydrocodone w/ homatropine...... 21 INVOKAMET XR TB24 50-500 MG ...... 32 hydrocodone-acetaminophen ...... 12 INVOKANA TABS 100 MG ...... 32 hydrocortisone...... 16, 18, 21, 22 INVOKANA TABS 300 MG ...... 32 hydrocortisone (intrarectal) ...... 22 IODINE STRONG ...... 20 hydrocortisone (topical) ...... 21, 22 iodoquinol-hc ...... 22 hydrocortisone w/acetic acid ...... 16 ipratropium bromide ...... 9 hydromorphone hcl ...... 12 ipratropium bromide (nasal) ...... 9 hydroxychloroquine sulfate ...... 6 ipratropium-albuterol ...... 9 hydroxyurea ...... 8 ISENTRESS ...... 7 hydroxyzine hcl ...... 13 isoniazid ...... 6 hyoscyamine sulfate ...... 9 ISOPTO CARBACHOL ...... 16 HYQVIA KIT 10 GM/100ML ...... 31 ISOPTO HYOSCINE ...... 16 HYQVIA KIT 2.5 GM/25ML ...... 31 isosorbide dinitrate ...... 11 HYQVIA KIT 20 GM/200ML ...... 31 isosorbide mononitrate ...... 11 HYQVIA KIT 30 GM/300ML ...... 31 isotretinoin ...... 23 HYQVIA KIT 5 GM/50ML...... 31 ISTURISA TABS 1 MG ...... 32 ISTURISA TABS 10 MG ...... 32 I ISTURISA TABS 5 MG ...... 32 itraconazole ...... 6 IBRANCE ...... 8 ivermectin ...... 5 ibuprofen ...... 12, 19 ICLUSIG TABS 10 MG ...... 31 J ICLUSIG TABS 15 MG ...... 31 ICLUSIG TABS 30 MG ...... 31 JANUMET TABS 50-1000 MG ...... 32 ICLUSIG TABS 45 MG ...... 31 JANUMET TABS 50-500 MG...... 32 ILARIS SOLR 150 MG ...... 31 JANUMET XR TB24 100-1000 MG ...... 32 ILUMYA SOSY 100 MG/ML ...... 31 JANUMET XR TB24 50-1000 MG ...... 32 imatinib mesylate ...... 8 JANUMET XR TB24 50-500 MG ...... 32 IMBRUVICA ...... 8 JANUVIA TABS 100 MG ...... 32 IMCIVREE SOLN 10 MG/ML ...... 31 JANUVIA TABS 25 MG ...... 32 imipramine hcl ...... 14 JANUVIA TABS 50 MG ...... 32 imiquimod ...... 23 JARDIANCE ...... 18, 32 IMPAVIDO CAPS 50 MG ...... 31 JARDIANCE TABS 10 MG ...... 32 IMPLANON ...... 18 JARDIANCE TABS 25 MG ...... 32 INBRIJA CAPS 42 MG ...... 31 JENTADUETO TABS 2.5-1000 MG ...... 32 indapamide ...... 11 JENTADUETO TABS 2.5-500 MG ...... 32 indomethacin ...... 12 JENTADUETO TABS 2.5-850 MG ...... 32
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* Kaiser Permanente of Georgia HMO Formulary 51
Kaiser Permanente of Georgia HMO Formulary JENTADUETO XR TB24 2.5-1000 MG ...... 32 lapatinib ditosylate ...... 8 JENTADUETO XR TB24 5-1000 MG ...... 32 latanoprost ...... 16 JUBLIA SOLN 10 % ...... 32 leflunomide ...... 20 JUXTAPID CAPS 10 MG...... 32 LENVIMA (10 MG DAILY DOSE) ...... 8 JUXTAPID CAPS 20 MG...... 33 LETAIRIS ...... 11 JUXTAPID CAPS 30 MG...... 33 letrozole ...... 8 JUXTAPID CAPS 40 MG...... 33 leucovorin calcium ...... 20 JUXTAPID CAPS 5 MG ...... 33 LEUKERAN ...... 8 JUXTAPID CAPS 60 MG...... 33 LEUKINE...... 9 JYNARQUE TABS 15 MG ...... 33 levetiracetam ...... 12 JYNARQUE TABS 30 MG ...... 33 LEVOBUNOLOL HCL ...... 16 JYNARQUE TBPK 15 MG ...... 33 levofloxacin ...... 5 JYNARQUE TBPK 30 & 15 MG ...... 33 LEVONORGESTREL ...... 18 JYNARQUE TBPK 45 & 15 MG ...... 33 levonorgestrel & eth estradiol ...... 18 JYNARQUE TBPK 60 & 30 MG ...... 33 levonorgestrel-eth estradiol (triphasic) ...... 18 JYNARQUE TBPK 90 & 30 MG ...... 33 levonorgestrel-ethinyl estradiol (91-day) ...... 18 levothyroxine sodium ...... 19 K lidocaine hcl (mouth-throat) ...... 17 LIDOCAINE HCL URETHRAL/MUCOSAL ...... 23 KALYDECO PACK 25 MG ...... 33 lidocaine-prilocaine ...... 22 KALYDECO PACK 50 MG ...... 33 lindane ...... 22 KALYDECO PACK 75 MG ...... 33 linezolid ...... 5 KALYDECO TABS 150 MG ...... 33 liothyronine sodium ...... 19 KESIMPTA SOAJ 20 MG/0.4ML ...... 33 lisinopril ...... 11 ketoconazole ...... 6, 22 lisinopril & hydrochlorothiazide ...... 11 ketoconazole (topical) ...... 6, 22 lithium carbonate ...... 13 KETO-DIASTIX ...... 15 LONSURF ...... 8 ketorolac tromethamine (ophth) ...... 16 lopinavir-ritonavir ...... 7 KETOSTIX ...... 15 lorazepam ...... 13 KEVEYIS TABS 50 MG ...... 33 losartan potassium ...... 11 KEVZARA SOAJ 150 MG/1.14ML ...... 33 losartan potassium & hydrochlorothiazide ...... 11 KEVZARA SOAJ 200 MG/1.14ML ...... 33 lovastatin ...... 10 KEVZARA SOSY 150 MG/1.14ML...... 33 LUPKYNIS CAPS 7.9 MG ...... 34 KEVZARA SOSY 200 MG/1.14ML...... 33 LYNPARZA CAPS 50 MG ...... 34 KOMBIGLYZE XR TB24 2.5-1000 MG ...... 33 LYNPARZA TABS 100 MG ...... 34 KOMBIGLYZE XR TB24 5-1000 MG ...... 33 LYNPARZA TABS 150 MG ...... 34 KOMBIGLYZE XR TB24 5-500 MG ...... 33 LYSODREN ...... 8 KORLYM TABS 300 MG ...... 33 KOSELUGO CAPS 10 MG ...... 34 M KOSELUGO CAPS 25 MG ...... 34 K-PHOS ...... 15 MATULANE ...... 8 KYNAMRO SOSY 200 MG/ML ...... 34 MAVENCLAD (10 TABS) TBPK 10 MG ...... 34 MAVENCLAD (4 TABS) TBPK 10 MG ...... 34 L MAVENCLAD (5 TABS) TBPK 10 MG ...... 34 MAVENCLAD (6 TABS) TBPK 10 MG ...... 34 labetalol hcl ...... 10 MAVENCLAD (7 TABS) TBPK 10 MG ...... 34 lactulose ...... 15 MAVENCLAD (8 TABS) TBPK 10 MG ...... 34 lactulose (encephalopathy) ...... 15 MAVENCLAD (9 TABS) TBPK 10 MG ...... 34 lamivudine...... 6, 7 MAVYRET TABS 100-40 MG ...... 34 lamivudine-zidovudine ...... 6, 7 MAXIDEX ...... 16 lamotrigine ...... 12 MAYZENT STARTER PACK TBPK 0.25 MG...... 34
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* 52 Kaiser Permanente of Georgia HMO Formulary
Kaiser Permanente of Georgia HMO Formulary MAYZENT TABS 0.25 MG ...... 34 N MAYZENT TABS 2 MG ...... 34 medroxyprogesterone acetate ...... 19 nabumetone ...... 12 medroxyprogesterone acetate (contraceptive) ...... 19 nadolol ...... 10 megestrol acetate ...... 8 naltrexone hcl ...... 14 meloxicam ...... 12 naproxen ...... 12, 19 melphalan ...... 8 naratriptan hcl ...... 13 memantine hcl ...... 14, 20 NARCAN ...... 20 meprobamate ...... 13 NATACYN ...... 16 mercaptopurine ...... 8 NATPARA CART 100 MCG ...... 34 mesalamine ...... 17, 20 NATPARA CART 25 MCG ...... 34 MESNEX ...... 8 NATPARA CART 50 MCG ...... 34 metformin hcl ...... 18 NATPARA CART 75 MCG ...... 35 methadone hcl...... 12 NECON 1/50 (28) ...... 18 methazolamide ...... 16 neomycin sulfate ...... 5 methimazole ...... 19 neomycin-bacitracin zn-polymyxin ...... 16 METHITEST ...... 18 neomycin-polymy-dexameth ...... 16 methocarbamol ...... 9 NEOMYCIN-POLYMYXIN-GRAMICIDIN ...... 16 methotrexate sodium ...... 8, 20 NEOMYCIN-POLYMYXIN-HC ...... 16 METHOXSALEN RAPID ...... 22 NEUMEGA ...... 9 methyldopa ...... 11 nevirapine ...... 7 methylergonovine maleate ...... 21 NEXAVAR ...... 8 methylphenidate hcl ...... 12 NEXLETOL TABS 180 MG ...... 35 methylprednisolone ...... 18 NEXLIZET TABS 180-10 MG ...... 35 metoclopramide hcl ...... 17 nifedipine...... 10 metolazone ...... 15 nimodipine ...... 10 metoprolol succinate ...... 10 NINLARO ...... 8 metoprolol tartrate ...... 10 nitrofurantoin macrocrystal ...... 7 metronidazole ...... 6, 22 nitrofurantoin monohyd macro ...... 7 metronidazole (topical) ...... 22 nitroglycerin ...... 11 mexiletine hcl...... 11 NIVESTYM ...... 20 minocycline hcl ...... 5 NORDITROPIN FLEXPRO SOPN 10 MG/1.5ML ...... 35 minoxidil ...... 11 NORDITROPIN FLEXPRO SOPN 15 MG/1.5ML ...... 35 mirtazapine ...... 14 NORDITROPIN FLEXPRO SOPN 30 MG/3ML ...... 35 MIRVASO GEL 0.33 % ...... 34 NORDITROPIN FLEXPRO SOPN 5 MG/1.5ML ...... 35 misoprostol ...... 17 norethin acet & estrad-fe ...... 18 modafinil ...... 12 norethindrone & eth estradiol ...... 18 mometasone furoate ...... 21, 22 norethindrone (contraceptive) ...... 19 montelukast sodium ...... 20 norethindrone acetate ...... 19 morphine sulfate ...... 12 norethindrone-eth estradiol (triphasic) ...... 19 moxifloxacin hcl (ophth) ...... 5 norgestimate-ethinyl estradiol ...... 19 MOZOBIL ...... 20 norgestimate-ethinyl estradiol (triphasic) ...... 19 MULPLETA TABS 3 MG ...... 34 norgestrel & ethinyl estradiol ...... 19 mupirocin ...... 22 nortriptyline hcl ...... 14 MYCAPSSA CPDR 20 MG ...... 34 NOVOFINE ...... 15 mycophenolate mofetil ...... 20 NOVOLIN 70/30 FLEXPEN SUPN (70-30) 100 UNIT/ML . 35 mycophenolate sodium ...... 20 NOVOLIN 70/30 SUSP (70-30) 100 UNIT/ML ...... 35 MYLERAN ...... 8 NOVOLIN N FLEXPEN SUPN 100 UNIT/ML ...... 35 MYTESI TBEC 125 MG ...... 34 NOVOLIN N RELION SUSP 100 UNIT/ML...... 35 NOVOLIN N SUSP 100 UNIT/ML ...... 35 NOVOLIN R FLEXPEN SOPN 100 UNIT/ML ...... 35 *All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* Kaiser Permanente of Georgia HMO Formulary 53
Kaiser Permanente of Georgia HMO Formulary NOVOLIN R RELION SOLN 100 UNIT/ML...... 35 ORLADEYO CAPS 110 MG ...... 36 NOVOLIN R SOLN 100 UNIT/ML ...... 35 ORLADEYO CAPS 150 MG ...... 36 NOXAFIL SUSP 40 MG/ML ...... 35 ORTHO DIAPHRAGM ALL-FLEX/65MM ...... 14 NUBEQA TABS 300 MG ...... 35 oseltamivir phosphate ...... 7 NUCALA SOAJ 100 MG/ML ...... 35 OTEZLA ...... 21, 36 NUCALA SOSY 100 MG/ML ...... 35 OTEZLA TAB 10/20/30 ...... 36 NUEDEXTA CAPS 20-10 MG ...... 35 OTEZLA TABS 30 MG ...... 36 NUPLAZID CAPS 34 MG ...... 35 OTEZLA TBPK 10 & 20 & 30 MG ...... 36 NUPLAZID TABS 10 MG...... 35 OXBRYTA TABS 500 MG ...... 36 NUPLAZID TABS 17 MG...... 35 oxcarbazepine ...... 12 NURTEC TBDP 75 MG ...... 35 OXERVATE SOLN 0.002 % ...... 37 NUTROPIN AQ NUSPIN 10 SOPN 10 MG/2ML...... 35 oxybutynin chloride ...... 23 NUTROPIN AQ NUSPIN 20 SOPN 20 MG/2ML...... 35 oxycodone hcl ...... 21 NUTROPIN AQ NUSPIN 5 SOPN 5 MG/2ML ...... 36 oxycodone w/ acetaminophen ...... 12 NUVARING ...... 19 oxycodone w/ aspirin ...... 12 nystatin ...... 6, 22, 23 OZEMPIC (0.25 OR 0.5 MG/DOSE) SOPN 2 MG/1.5ML .. 37 nystatin (mouth-throat) ...... 6 OZEMPIC (1 MG/DOSE) SOPN 2 MG/1.5ML ...... 37 nystatin (topical) ...... 22 OZEMPIC (1 MG/DOSE) SOPN 4 MG/3ML ...... 37 NYSTATIN VAGINAL ...... 22 nystatin-triamcinolone ...... 23 P O PALFORZIA (12 MG DAILY DOSE) CSPK 2 x 1 MG & 10 MG ...... 37 ODEFSEY ...... 7 PALFORZIA (120 MG DAILY DOSE) CSPK 20 MG & 100 ofloxacin (ophth) ...... 16 MG ...... 37 ofloxacin (otic) ...... 5, 16 PALFORZIA (160 MG DAILY DOSE) CSPK 3 x 20 MG & olanzapine ...... 11, 14 100 MG...... 37 OLUMIANT TABS 1 MG ...... 36 PALFORZIA (20 MG DAILY DOSE) CSPK 20 MG ...... 37 OLUMIANT TABS 2 MG ...... 36 PALFORZIA (200 MG DAILY DOSE) CSPK 2 x 100 MG .. 37 OMNITROPE SOCT 10 MG/1.5ML ...... 36 PALFORZIA (240 MG DAILY DOSE) CSPK 2 x 20 MG & 2 OMNITROPE SOCT 5 MG/1.5ML ...... 36 X 100 MG ...... 37 OMNITROPE SOLR 5.8 MG ...... 36 PALFORZIA (3 MG DAILY DOSE) CSPK 3 x 1 MG ...... 37 ondansetron ...... 17 PALFORZIA (300 MG MAINTENANCE) PACK 300 MG ... 37 ondansetron hcl ...... 17 PALFORZIA (300 MG TITRATION) PACK 300 MG ...... 37 ONETOUCH DELICA LANCETS 30G ...... 15 PALFORZIA (40 MG DAILY DOSE) CSPK 2 x 20 MG ...... 37 ONETOUCH ULTRA 2...... 15 PALFORZIA (6 MG DAILY DOSE) CSPK 6 x 1 MG ...... 37 ONEXTON GEL 1.2-3.75 % ...... 36 PALFORZIA (80 MG DAILY DOSE) CSPK 4 x 20 MG ...... 37 ONGLYZA TABS 2.5 MG ...... 36 PALYNZIQ SOSY 10 MG/0.5ML ...... 37 ONGLYZA TABS 5 MG ...... 36 PALYNZIQ SOSY 2.5 MG/0.5ML ...... 37 ONUREG TABS 200 MG...... 36 PALYNZIQ SOSY 20 MG/ML ...... 37 ONUREG TABS 300 MG...... 36 paromomycin sulfate ...... 6 OPSUMIT ...... 11, 36 paroxetine hcl ...... 14 OPSUMIT TABS 10 MG ...... 36 ped multivitamins w/fl & iron ...... 23 ORENCIA ...... 21 pediatric multivitamins w/fl ...... 23 ORIAHNN CPPK 300-1-0.5 & 300 MG ...... 36 pediatric vitamins acd w/ fluoride ...... 23 ORILISSA TABS 150 MG ...... 36 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ...... 17 ORILISSA TABS 200 MG ...... 36 peg 3350-potassium chloride-sod bicarbonate-sod chloride ORKAMBI PACK 100-125 MG ...... 36 ...... 17 ORKAMBI PACK 150-188 MG ...... 36 PEGASYS...... 7 ORKAMBI TABS 100-125 MG ...... 36 PEG-INTRON ...... 7 ORKAMBI TABS 200-125 MG ...... 36 penicillamine ...... 21
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* 54 Kaiser Permanente of Georgia HMO Formulary
Kaiser Permanente of Georgia HMO Formulary penicillin v potassium ...... 5 PREVYMIS TABS 240 MG ...... 38 pentoxifylline ...... 9 PREVYMIS TABS 480 MG ...... 38 permethrin...... 22 PREZCOBIX ...... 7 perphenazine ...... 14 PREZISTA ...... 7 phenelzine sulfate ...... 14 primaquine phosphate ...... 6 phenobarbital ...... 13 primidone ...... 12 phenylephrine hcl (mydriatic) ...... 17 probenecid ...... 15 phenytoin ...... 12 prochlorperazine maleate ...... 14, 17 PHOSLYRA ...... 15 PROCRIT ...... 9 PHOSPHOLINE IODIDE ...... 16 PROCYSBI CPDR 25 MG ...... 38 phytonadione ...... 23 PROCYSBI CPDR 75 MG ...... 38 PICATO GEL 0.015 % ...... 37 PROCYSBI PACK 300 MG ...... 38 PICATO GEL 0.05 % ...... 37 PROCYSBI PACK 75 MG ...... 38 pilocarpine hcl ...... 9, 16 PROMACTA ...... 8, 9 pilocarpine hcl (oral) ...... 9 promethazine hcl ...... 7 pimecrolimus ...... 22 propafenone hcl ...... 11 pioglitazone hcl ...... 19, 21 PROPANTHELINE BROMIDE ...... 9 PIQRAY (200 MG DAILY DOSE) TBPK 200 MG ...... 37 proparacaine hcl ...... 17 PIQRAY (250 MG DAILY DOSE) TBPK 200 & 50 MG ...... 37 propranolol hcl...... 10 PIQRAY (300 MG DAILY DOSE) TBPK 2 x 150 MG ...... 37 propylthiouracil ...... 19 PLEGRIDY SOPN 125 MCG/0.5ML ...... 37 PROSTIGMIN ...... 9 PLEGRIDY SOSY 125 MCG/0.5ML ...... 38 PULMOZYME ...... 15 PLEGRIDY STARTER PACK SOPN 63 & 94 MCG/0.5ML pyrazinamide ...... 6 ...... 38 pyridostigmine bromide ...... 9, 21 PLEGRIDY STARTER PACK SOSY 63 & 94 MCG/0.5ML ...... 38 Q podofilox ...... 23 polyethylene glycol 3350 ...... 17 QBREXZA PADS 2.4 %...... 38 polymyxin b-trimethoprim ...... 16 QTERN TABS 10-5 MG ...... 38 POMALYST ...... 8 QTERN TABS 5-5 MG ...... 38 PONVORY STARTER PACK TBPK 2-3-4-5-6-7-8-9 & 10 quetiapine fumarate...... 14 MG ...... 38 quinidine gluconate ...... 11 PONVORY TABS 20 MG ...... 38 QUINIDINE SULFATE ...... 11 pot & sod citrates w/citric ac ...... 15 QVAR ...... 18 pot phosphate monobasic w/ sod phosphate dibasic & QVAR REDIHALER...... 18 monobasic ...... 15 potassium chloride...... 15, 17 R potassium chloride microencapsulated crystals cr ...... 15 potassium citrate (alkalinizer) ...... 15 raloxifene hcl ...... 19 PRADAXA ...... 9 ramipril ...... 11 PRALUENT SOAJ 150 MG/ML ...... 38 ranitidine hcl ...... 17 PRALUENT SOAJ 75 MG/ML ...... 38 RAVICTI LIQD 1.1 GM/ML ...... 38 pramipexole dihydrochloride ...... 13 REBIF REBIDOSE SOAJ 22 MCG/0.5ML ...... 38 pramoxine-hc-chloroxylenol ...... 16, 17 REBIF REBIDOSE SOAJ 44 MCG/0.5ML ...... 38 prasugrel hcl ...... 9 REBIF REBIDOSE TITRATION PACK SOAJ 6X8.8 & 6X22 pravastatin sodium ...... 10 MCG ...... 38 PRED MILD ...... 16 REBIF SOSY 22 MCG/0.5ML ...... 38 PRED-G ...... 16 REBIF SOSY 44 MCG/0.5ML ...... 38 prednisolone ...... 18 REBIF TITRATION PACK SOSY 6X8.8 & 6X22 MCG ...... 38 prednisolone sodium phosphate ...... 18 REGRANEX ...... 23 prednisone ...... 18, 21 RELENZA DISKHALER ...... 7
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* Kaiser Permanente of Georgia HMO Formulary 55
Kaiser Permanente of Georgia HMO Formulary RELISTOR SOLN 12 MG/0.6ML ...... 38, 39 selenium sulfide ...... 22 RELISTOR SOLN 8 MG/0.4ML ...... 39 SELZENTRY ...... 7 RELISTOR TABS 150 MG ...... 39 SEROSTIM SOLR 4 MG ...... 40 REMODULIN ...... 11 SEROSTIM SOLR 5 MG ...... 40 REPATHA PUSHTRONEX SYSTEM SOCT 420 MG/3.5ML SEROSTIM SOLR 6 MG ...... 40 ...... 39 sertraline hcl ...... 14 REPATHA SOSY 140 MG/ML ...... 39 sevelamer carbonate ...... 21 REPATHA SURECLICK SOAJ 140 MG/ML ...... 39 SILIQ SOSY 210 MG/1.5ML ...... 40 RESCRIPTOR...... 7 silver sulfadiazine ...... 22 RETEVMO CAPS 40 MG ...... 39 SIMPONI SOAJ 100 MG/ML ...... 40 RETEVMO CAPS 80 MG ...... 39 SIMPONI SOAJ 50 MG/0.5ML ...... 40 REVLIMID ...... 8 SIMPONI SOSY 100 MG/ML ...... 40 REYVOW TABS 100 MG ...... 39 SIMPONI SOSY 50 MG/0.5ML ...... 40 REYVOW TABS 50 MG...... 39 simvastatin ...... 10 RHOPRESSA SOLN 0.02 % ...... 39 sirolimus ...... 21 ribavirin (hepatitis c) ...... 7 SKYRIZI (150 MG DOSE) PSKT 75 MG/0.83ML ...... 40 RIDAURA ...... 17, 20 SKYRIZI PEN SOAJ 150 MG/ML ...... 40 rifabutin ...... 6 SKYRIZI SOSY 150 MG/ML ...... 40 rifampin ...... 6 sodium fluoride ...... 21 riluzole ...... 14 sodium polystyrene sulfonate ...... 15 RIMANTADINE HCL ...... 7 solifenacin succinate ...... 23 RINVOQ TB24 15 MG ...... 39 SOLIQUA SOPN 100-33 UNT-MCG/ML ...... 40 risperidone ...... 14 SOMAVERT SOLR 10 MG ...... 40 ritonavir ...... 7 SOMAVERT SOLR 15 MG ...... 40 rivastigmine tartrate ...... 9 SOMAVERT SOLR 20 MG ...... 40 rizatriptan benzoate ...... 13 SOMAVERT SOLR 25 MG ...... 40 ROCKLATAN SOLN 0.02-0.005 % ...... 39 SOMAVERT SOLR 30 MG ...... 40 ropinirole hydrochloride ...... 13 sotalol hcl ...... 10 rosuvastatin calcium ...... 10 SOVALDI PACK 150 MG ...... 40 ROZLYTREK CAPS 100 MG ...... 39 SOVALDI PACK 200 MG ...... 40 ROZLYTREK CAPS 200 MG ...... 39 SOVALDI TABS 200 MG ...... 40 RUBRACA TABS 200 MG ...... 39 SOVALDI TABS 400 MG ...... 40 RUBRACA TABS 250 MG ...... 39 SPIRIVA RESPIMAT ...... 23 RUBRACA TABS 300 MG ...... 39 spironolactone ...... 11 RUZURGI TABS 10 MG ...... 39 SPRYCEL ...... 8, 40, 41 RYBELSUS TABS 14 MG ...... 39 SPRYCEL TABS 100 MG ...... 40 RYBELSUS TABS 3 MG ...... 39 SPRYCEL TABS 140 MG ...... 41 RYBELSUS TABS 7 MG ...... 39 SPRYCEL TABS 20 MG ...... 41 SPRYCEL TABS 50 MG ...... 41 S SPRYCEL TABS 70 MG ...... 41 SPRYCEL TABS 80 MG ...... 41 SAIZEN SOLR 5 MG ...... 39 stavudine...... 7 SAIZENPREP SOLR 8.8 MG...... 39 STEGLATRO TABS 15 MG ...... 41 salsalate ...... 12, 21 STEGLATRO TABS 5 MG ...... 41 SANTYL ...... 23 STEGLUJAN TABS 15-100 MG ...... 41 SAXENDA SOPN 18 MG/3ML...... 39 STEGLUJAN TABS 5-100 MG ...... 41 SEGLUROMET TABS 2.5-1000 MG ...... 40 STELARA SOLN 45 MG/0.5ML ...... 41 SEGLUROMET TABS 2.5-500 MG ...... 40 STELARA SOSY 45 MG/0.5ML ...... 41 SEGLUROMET TABS 7.5-1000 MG ...... 40 STELARA SOSY 90 MG/ML ...... 41 SEGLUROMET TABS 7.5-500 MG ...... 40 STIOLTO RESPIMAT ...... 23 selegiline hcl ...... 13 STIVARGA ...... 8 *All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* 56 Kaiser Permanente of Georgia HMO Formulary
Kaiser Permanente of Georgia HMO Formulary STRIVERDI RESPIMAT ...... 21 TEGSEDI SOSY 284 MG/1.5ML ...... 42 sucralfate ...... 17 temazepam ...... 13 sulfacetamide sodium w/ sulfur ...... 22, 23 temozolomide ...... 8 SULFACETAMIDE-SULFUR IN UREA ...... 23 tenofovir disoproxil fumarate ...... 6, 7 SULFADIAZINE ...... 5 TEPMETKO TABS 225 MG ...... 42 sulfamethoxazole-trimethoprim ...... 5 terazosin hcl ...... 10 sulfasalazine ...... 5 terbinafine hcl ...... 6 sulindac ...... 12 terbutaline sulfate ...... 9 sumatriptan ...... 13 TERIPARATIDE (RECOMBINANT) SOPN 620 sumatriptan succinate ...... 13 MCG/2.48ML ...... 42 sunitinib malate ...... 8 testosterone ...... 18 SUNOSI TABS 150 MG ...... 41 testosterone cypionate ...... 18 SUNOSI TABS 75 MG ...... 41 TESTOSTERONE PROPIONATE ...... 18 SYMDEKO TBPK 100-150 & 150 MG ...... 41 tetracycline hcl ...... 5 SYMDEKO TBPK 50-75 & 75 MG ...... 41 THALOMID ...... 21 SYMFI ...... 7 theophylline ...... 12, 22, 23 SYMLINPEN 120 SOPN 2700 MCG/2.7ML ...... 41 thioridazine hcl ...... 14 SYMLINPEN 60 SOPN 1500 MCG/1.5ML ...... 41 thiothixene ...... 14 SYMTUZA ...... 7 THYMOL ...... 21 SYNAREL ...... 19 timolol maleate (ophth) ...... 16 SYNJARDY TABS 12.5-1000 MG ...... 41 TIVICAY ...... 7 SYNJARDY TABS 12.5-500 MG ...... 41 tizanidine hcl ...... 9 SYNJARDY TABS 5-1000 MG ...... 41 tobramycin ...... 5, 16 SYNJARDY TABS 5-500 MG ...... 41 tobramycin (ophth)...... 16 SYNJARDY XR TB24 10-1000 MG ...... 41 tobramycin sulfate ...... 5 SYNJARDY XR TB24 12.5-1000 MG ...... 41 tobramycin-dexamethasone ...... 16 SYNJARDY XR TB24 25-1000 MG ...... 41 TODAY SPONGE ...... 14 SYNJARDY XR TB24 5-1000 MG ...... 41 tolcapone ...... 13 tolmetin sodium ...... 12 T topiramate ...... 12 torsemide ...... 15 TABLOID...... 8 TRADJENTA TABS 5 MG ...... 42 TABRECTA TABS 150 MG ...... 42 tramadol hcl ...... 12 TABRECTA TABS 200 MG ...... 42 tranylcypromine sulfate ...... 14 tacrolimus ...... 21 trazodone hcl ...... 14 tacrolimus (topical) ...... 21 TREMFYA SOPN 100 MG/ML ...... 42 TAKHZYRO SOLN 300 MG/2ML ...... 42 TREMFYA SOSY 100 MG/ML ...... 42 TALTZ SOAJ 80 MG/ML ...... 42 tretinoin ...... 8, 22 TALTZ SOSY 80 MG/ML ...... 42 tretinoin (chemotherapy) ...... 8 TALZENNA CAPS 0.25 MG ...... 42 triamcinolone acetonide ...... 18, 22 TALZENNA CAPS 1 MG ...... 42 triamcinolone acetonide (mouth) ...... 22 tamoxifen citrate ...... 8 triamcinolone acetonide (topical) ...... 22 tamsulosin hcl ...... 21 triamterene & hydrochlorothiazide ...... 11, 15 TARGRETIN ...... 8 trifluoperazine hcl ...... 14 TASIGNA ...... 8, 42 TRIFLURIDINE ...... 16 TASIGNA CAPS 150 MG ...... 42 trihexyphenidyl hcl ...... 13 TASIGNA CAPS 200 MG ...... 42 TRIKAFTA TBPK 100-50-75 & 150 MG ...... 42 TASIGNA CAPS 50 MG ...... 42 TRIKAFTA TBPK 50-25-37.5 & 75 MG ...... 42 TAVALISSE TABS 100 MG ...... 42 trimethoprim ...... 5, 7, 16 TAVALISSE TABS 150 MG ...... 42 TRI-VIT/FLUORIDE/IRON ...... 23 TECHNIVIE TABS 12.5-75-50 MG ...... 42 trospium chloride ...... 23 *All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* Kaiser Permanente of Georgia HMO Formulary 57
Kaiser Permanente of Georgia HMO Formulary TRULICITY SOPN 0.75 MG/0.5ML ...... 42 warfarin sodium ...... 9, 10 TRULICITY SOPN 1.5 MG/0.5ML ...... 42 TRULICITY SOPN 3 MG/0.5ML ...... 42 X TRULICITY SOPN 4.5 MG/0.5ML ...... 42, 43 TUKYSA TABS 150 MG ...... 43 XALKORI ...... 8 TUKYSA TABS 50 MG ...... 43 XELJANZ ...... 21 TURALIO CAPS 200 MG ...... 43 XEMBIFY SOLN 1 GM/5ML ...... 44 TYMLOS SOPN 3120 MCG/1.56ML ...... 43 XEMBIFY SOLN 10 GM/50ML ...... 44 XEMBIFY SOLN 2 GM/10ML...... 44 U XEMBIFY SOLN 4 GM/20ML...... 44 XGEVA SOLN 120 MG/1.7ML ...... 44 UBRELVY TABS 100 MG ...... 43 XHANCE EXHU 93 MCG/ACT ...... 44 UBRELVY TABS 50 MG ...... 43 XIGDUO XR TB24 10-1000 MG ...... 44 urea...... 23 XIGDUO XR TB24 10-500 MG ...... 44 ursodiol ...... 17 XIGDUO XR TB24 2.5-1000 MG ...... 44 XIGDUO XR TB24 5-1000 MG ...... 44 V XIGDUO XR TB24 5-500 MG ...... 44 XOLAIR SOLR 150 MG ...... 44 valganciclovir hcl ...... 7 XOLAIR SOSY 150 MG/ML ...... 44 valproate sodium ...... 13 XOLAIR SOSY 75 MG/0.5ML ...... 44 valproic acid ...... 13 XPOVIO (100 MG ONCE WEEKLY) TBPK 20 MG ...... 44 valsartan ...... 11 XPOVIO (100 MG ONCE WEEKLY) TBPK 50 MG ...... 44 valsartan-hydrochlorothiazide ...... 11 XPOVIO (40 MG ONCE WEEKLY) TBPK 20 MG ...... 44 vancomycin hcl ...... 5 XPOVIO (40 MG ONCE WEEKLY) TBPK 40 MG ...... 44 VASCEPA CAPS 0.5 GM ...... 43 XPOVIO (40 MG TWICE WEEKLY) TBPK 20 MG ...... 44 VECTICAL ...... 23 XPOVIO (40 MG TWICE WEEKLY) TBPK 40 MG ...... 44 VEMLIDY TABS 25 MG ...... 43 XPOVIO (60 MG ONCE WEEKLY) TBPK 20 MG ...... 44 venlafaxine hcl ...... 14 XPOVIO (60 MG ONCE WEEKLY) TBPK 60 MG ...... 44 verapamil hcl ...... 10 XPOVIO (60 MG TWICE WEEKLY) TBPK 20 MG ...... 44 VIBERZI TABS 100 MG...... 43 XPOVIO (80 MG ONCE WEEKLY) TBPK 20 MG ...... 45 VIBERZI TABS 75 MG ...... 43 XPOVIO (80 MG ONCE WEEKLY) TBPK 40 MG ...... 45 VICTOZA SOPN 18 MG/3ML ...... 43 XPOVIO (80 MG TWICE WEEKLY) TBPK 20 MG ...... 45 VIEKIRA PAK TBPK 12.5-75-50 &250 MG ...... 43 XTANDI ...... 8 VIEKIRA XR TB24 200-8.33-50- 33.33 MG ...... 43 XULTOPHY SOPN 100-3.6 UNIT-MG/ML ...... 45 VIRACEPT ...... 7 XYREM SOLN 500 MG/ML ...... 45 VITRAKVI CAPS 100 MG ...... 43 XYWAV SOLN 500 MG/ML ...... 45 VITRAKVI CAPS 25 MG ...... 43 VITRAKVI SOLN 20 MG/ML ...... 43 Z VOSEVI ...... 7, 43 VOSEVI TABS 400-100-100 MG ...... 43 zaleplon ...... 13 VOTRIENT ...... 8 ZARXIO ...... 9 VUMERITY (STARTER) CPDR 231 MG ...... 43 ZEJULA ...... 8, 45 VUMERITY CPDR 231 MG ...... 43 ZEJULA CAPS 100 MG ...... 45 VYNDAMAX CAPS 61 MG ...... 43 ZELBORAF ...... 8 VYNDAQEL CAPS 20 MG ...... 43 ZEPATIER TABS 50-100 MG ...... 45 VYZULTA SOLN 0.024 % ...... 43 ZEPOSIA 7-DAY STARTER PACK CPPK 4 x 0.23MG & 3 X 0.46MG ...... 45 W ZEPOSIA CAPS 0.92 MG ...... 45 ZEPOSIA STARTER KIT CPPK 0.23MG & 0.46MG & WAKIX TABS 17.8 MG ...... 43 0.92MG...... 45 WAKIX TABS 4.45 MG ...... 43 zidovudine...... 6, 7
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* 58 Kaiser Permanente of Georgia HMO Formulary
Kaiser Permanente of Georgia HMO Formulary ziprasidone hcl ...... 14 ZOMACTON SOLR 10 MG ...... 45 ZOLINZA ...... 8 zonisamide ...... 13 zolmitriptan ...... 13, 21 ZORBTIVE SOLR 8.8 MG ...... 45 zolpidem tartrate ...... 13 ZYDELIG...... 8
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* Kaiser Permanente of Georgia HMO Formulary 59
Kaiser Permanente of Georgia HMO Formulary
NONDISCRIMINATION NOTICE Kaiser Foundation Health Plan of Georgia, Inc. (Kaiser Health Plan) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We also:
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HELP IN YOUR LANGUAGE
ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-888-865-5813 (TTY: 711).
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* 60 Kaiser Permanente of Georgia HMO Formulary
Kaiser Permanente of Georgia HMO Formulary
አማርኛ (Amharic) ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-888-865-5813 (TTY: 711). . ملحوظة: إذا كنت ت تح دث العر بي ة، فإ ن خدمات ا ل مساعدة ا للغو ية تتوا فر لك بالمجان (Arabic) ا لعر بية اتصل ب رق م TTY( 1-888-865-5813: 711(.
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60577109_ACA_1557_MarCom_GA_2017_Taglines
Kaiser Permanente of Georgia HMO Formulary Pусский (Russian) ВНИМАНИЕ: eсли вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-888-865-5813 (TTY: 711).
Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-865-5813 (TTY: 711). Tagalog (Tagalog) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-888-865-5813 (TTY: 711).
Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-888-865-5813 (TTY: 711).
*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.* 62 Kaiser Permanente of Georgia HMO Formulary