Kaiser Permanente Hawaii PRESCRIPTION DRUG LIST Four-tier drug benefit This formulary list provides coverage information about the drugs covered under our Four-Tier Pharmacy Plan. The list is organized in alphabetical order and each drug name includes a color box that shows which tier the drug falls within. If your prescription drug is not on this list, it is not covered under our four-tier benefit structure. TIER 1 TIER 2 TIER 3 TIER 4 Specialty Generic drugs Generic drugs Brand-name drugs brand-name drugs on the published list. not included in Tier 1. on the published list. on the published list. Under the four-tier benefit structure, you pay a lower copayment for medically necessary generic medications and a higher copayment for specialty brand-name medications. Your copayments depend on your plan. For information about your prescription copayments, please review your Summary of Benefits. If your physician has prescribed a medically necessary generic medication, but you prefer to have the brand-name drug, you will pay the full member rate for the brand-name medication. Certain drugs may deviate from the four-tier benefit structure. See the following definitions for abbreviations linked to certain drugs on this list: • ACA = Under the Affordable Care Act (ACA), certain over-the-counter and prescription drugs are covered at no charge when prescribed by a physician for preventative purposes. • HCR = Certain Food and Drug Administration-approved contraceptive drugs and devices are available at no charge under health care reform (HCR). • PAH = There are some drugs that are covered only for pulmonary arterial hypertension (PAH). • TC = There are no charges for approved tobacco cessation (TC) products. This drug list is subject to change and drugs may be added or removed without notice. Some drugs fall in different tiers depending on strength and dosage form. For the most up-to-date listing of formulary drugs, including strengths and dosage forms available, visit kp.org/formulary and select “Covered drugs in your area”. You’ll find the Kaiser Permanente Hawaii Drug Formulary under the “Our formularies” section. Check back often for updates. QUESTIONS? Please contact your employer or call our Customer Service Center at 1-800-966-5955. For the deaf, hard of hearing, or speech impaired, call TTY 711 or 1-877-447-5990 (toll free). Member & Marketing Communications 4867MEM-15 KAH2338 August 2015 rev. A ¢ Amoxicillin-Clavulanate ¢ Benztropine 2mg ¢ Carbidopa ¢ Abacavir ¢ Amoxicillin ¢ Benzyl alcohol ¢ Carbidopa-Levodopa ¢ Abacavir-Lamivudine ¢ Amphetamin- ¢ Bepotastine ¢ Carbinoxamine ¢ Abacavir-Lamivudine-Zidovudine Dextroamphetamine ¢ Besifloxacin ¢ Carisoprodol ¢ Abatacept ¢ Anagrelide ¢ Betamethasone ¢ Carteolol ¢ Abiraterone ¢ Anakinra ¢ Betaxolol ¢ Carvedilol tablet ¢ Acamprosate ¢ Anastrozole ¢ Bethanechol ¢ Carvedilol suspension ¢ Acarbose ¢ Antipyrine-Benzocaine ¢ Bexarotene ¢ Cefaclor ¢ Acebutolol ¢ Apomorphine ¢ Bicalutamide ¢ Cefazolin ¢ Acetaminophen-Codeine ¢ Apraclonidine ¢ Bimatoprost ¢ Cefdinir ¢ Acetazolamide ¢ Apremilast ¢ Bisoprolol ¢ Cefpodoxime ¢ Acetic acid ¢ Aprepitant ¢ Bisoprolol-Hydrochlorothiazide ¢ Celecoxib ¢ Acetohydroxamic acid ¢ Arformoterol ¢ Boceprevir ¢ Cephalexin ¢ Acetylcysteine ¢ Aripiprazole ¢ Bosentan ¢ Certolizumab ¢ Acitretin ¢ Aripiprazole oral solution ¢ Bosutinib ¢ Cevimeline ¢ Acyclovir ¢ Armodafinil ¢ Brimonidine ophthalmic solution ¢ Chlorambucil ¢ Adalimumab ¢ Artemether-Lumefantrine ¢ Brimonidine topical gel ¢ Chlordiazepoxide ¢ Adapalene ¢ Artificial tear ophthalmic ¢ Brimonidine-Timolol ¢ Chlordiazepoxide-Clidinium ¢ Adapalene-Benzoyl peroxide ¢ Asenapine ¢ Brinzolamide ¢ Chlorhexidine ¢ Adefovir ACA Aspirin ¢ Bromfenac ¢ Chloroquine ¢ Albendazole ¢ Aspirin-Extended release ¢ Bromocriptine 0.8mg tablet ¢ Chlorothiazide ¢ Albuterol tablet dipyridamole ¢ Bromocriptine 2.5mg tablet ¢ Chlorpromazine ¢ Albuterol 2mg/5ml syrup ¢ Atazanavir ¢ Budesonide ¢ Chlorpropamide ¢ Albuterol 0.083% ¢ Atenolol ¢ Budesonide 9mg tablet ¢ Chlorthalidone inhalation solution ¢ Atenolol suspension ¢ Bumetanide ¢ Chlorzoxazone ¢ Albuterol 0.5% ¢ Atomoxetine ¢ Buprenorphine patch ACA Cholecalciferol inhalation solution ¢ Atorvastatin ¢ Buprenorphine sublingual tablet ¢ Cholestyramine ¢ Albuterol 1.25mg/3ml ¢ Atovaquone inhalation solution ¢ Buprenorphine-Naloxone ¢ Ciclesonide ¢ Atovaquone-Proguanil ¢ Bupropion ¢ Ciclopirox ¢ Albuterol 108mcg-actuation 62.5mg-25mg TC Bupropion 150mg ¢ Cilostazol inhaler ¢ Atovaquone-Proguanil sustained release tablet ¢ Cimetidine ¢ Alcaftadine ¢ Atropine ¢ Buspirone ¢ Cinacalcet ¢ Alclometasone ¢ Axitinib ¢ Buspirone 5mg, 10mg tablet ¢ Ciprofloxacin ¢ Alendronate ¢ Azathioprine ¢ Butalbital-Acetaminophen- ¢ Ciprofloxacin-Dexamethasone ¢ Alfuzosin ¢ Azelaic Caffeine ¢ Ciprofloxacin-Hydrocortisone ¢ Aliskiren ¢ Azelastine ¢ Butalbital-Aspirin-Caffeine ¢ Citalopram ¢ Alitretinoin ¢ Azelastine-Fluticasone ¢ Butamben-Tetracaine- ¢ Citalopram 20mg, 40mg tablet ¢ Allopurinol ¢ Azilsartan Benzocaine ¢ Citric acid ¢ Almotriptan ¢ Azithromycin ¢ Clarithromycin ¢ Alosetron ¢ Aztreonam C ¢ Alprazolam ¢ Cabozantinib ¢ Clemastine ¢ Altretamine B ¢ Caffeine ¢ Clindamycin ¢ Aluminum acetate-Acetic acid ¢ Bacitracin ¢ Calcipotriene ¢ Clindamycin-Benzoyl peroxide ¢ Aluminum chloride ¢ Bacitracin-Neomycin- ¢ Calcipotriene-Betamethasone ¢ Clindamycin-Tretinoin ¢ Alvimopan Polymyxin B ¢ Calcitonin injection ¢ Clobetasol ¢ Amantadine ¢ Baclofen ¢ Calcitonin nasal spray ¢ Clocortolone ¢ Ambrisentan ¢ Balsalazide ¢ Calcitriol ¢ Clomipramine ¢ Amcinonide ¢ Becaplermin ¢ Calcium acetate ¢ Clonazepam ¢ Amiloride ¢ Beclomethasone ¢ Canakinumab ¢ Clonidine tablet ¢ Aminocaproic ¢ Belladonna-Opium ¢ Candesartan ¢ Clonidine suspension ¢ Aminosalicylic ¢ Benazepril ¢ Capecitabine ¢ Clopidogrel ¢ Amiodarone ¢ Benzonatate ¢ Captopril ¢ Clorazepate ¢ Amitriptyline ¢ Benzoyl peroxide-erythromycin ¢ Carbamazepine 100mg ¢ Clotrimazole ¢ Amlodipine ¢ Benztropine extended release tablet ¢ Clotrimazole-Betamethasone ¢ Amoxapine ¢ Carbamazepine ¢ Clozapine ¢ = Tier 1 ¢= Tier 2 ¢ = Tier 3 ¢ = Tier 4 ¢ Codeine ¢ Diethylpropion ¢ Enfuvirtide ¢ Exenatide ¢ Colchicine ¢ Difenoxin-Atropine ¢ Enoxaparin ¢ Ezetimibe ¢ Colchicine-Probenecid ¢ Diflorasone ¢ Entacapone ¢ Ezogabine ¢ Colesevelam ¢ Diflunisal ¢ Entecavir ¢ Colestipol ¢ Difluprednate ¢ Entecavir solution F ¢ Famciclovir ¢ Collagenase ¢ Digoxin ¢ Enzalutamide ¢ Febuxostat ACA Condoms: Female ¢ Digoxin solution ¢ Epinastine ¢ Felbamate ACA Contraceptive sponge ¢ Dihydroergotamine ¢ Epinephrine ¢ Felodipine ¢ Corticotropin ¢ Diltiazem ¢ Eplerenone ¢ Fenofibrate ¢ Cortisone ¢ Dimethyl fumarate ¢ Epoetin ¢ Fenoprofen ¢ Crizotinib ¢ Diphenhydramine-Lidocaine- ¢ Eprosartan ¢ Fentanyl ¢ Cromolyn Aluminum hydroxide- ¢ Ergocalciferol ACA Ferrous sulfate ¢ Crotamiton Magnesium hydroxide- (by prescription/legend) Simethicone ¢ Fesoterodine ¢ Cyclobenzaprine ACA Ergocalciferol (over the counter) ¢ Diphenoxylate-Atropine ¢ Fidaxomicin ¢ Cyclophosphamide ¢ Ergoloid ¢ Dipyridamole ¢ Filgrastim ¢ Cycloserine ¢ Ergotamine ¢ Disopyramide ¢ Finasteride ¢ Cyclosporine ophthalmic and ¢ Ergotamine-Caffeine solution ¢ Disopyramide controlled release ¢ Erlotinib ¢ Fingolimod ¢ Cyclosporine capsule ¢ Disulfiram ¢ Erythromycin 333mg ¢ Flavoxate ¢ Cyproheptadine ¢ Divalproex enteric coated tablet ¢ Flecainide ¢ Dofetilide ¢ Erythromycin 400mg tablet, ¢ Fluconazole D ¢ Dolasetron 250mg enteric coated tablet, ¢ Flucytosine ¢ Dabigatran ¢ Dolutegravir 400mg/5ml suspension ¢ Fludrocortisone ¢ Dalfampridine ¢ Donepezil ¢ Erythromycin topical solution, ¢ Fluocinolone ¢ Danazol ¢ Dornase 200mg/5ml suspension, ¢ ophthalmic ointment Fluocinonide ¢ Dapsone ¢ Dorzolamide ¢ ¢ Escitalopram Fluorometholone ointment ¢ Darifenacin ¢ Dorzolamide-Timolol ¢ ¢ Esomeprazole Fluorometholone suspension ¢ Darunavir ¢ Doxazosin ¢ ¢ Esterified estrogens Fluorouracil ¢ Dasatinib ¢ Doxepin ¢ ¢ Fluorouracil 1% cream ¢ Esterified estrogens- Deferasirox ¢ Doxepin cream Methyltestosterone ¢ Fluoxetine ¢ Deferiprone ¢ Doxercalciferol ¢ Esterified estrogens- ¢ Fluoxymesterone ¢ Delavirdine ¢ Doxycycline Methyltestosterone ¢ Fluphenazine ¢ Demeclocycline ¢ Doxycycline suspension 1.2mg-2.5mg tablet ¢ Flurandrenolide ¢ Denosumab ¢ Dronabinol ¢ Estradiol ¢ Flurbiprofen ¢ Desipramine ¢ Dronedarone ¢ Estradiol 0.5mg tablet ¢ Flutamide ¢ Desloratadine ¢ Duloxetine ¢ Estradiol vaginal tablet and ring ¢ Fluticasone nasal ¢ Desmopressin ¢ Dutasteride ¢ Estramustine ¢ Fluticasone ointment ¢ Desonide ¢ Dyphylline ¢ Estrogens conjugated ¢ Fluticasone-Salmeterol ¢ Desoximetasone ¢ Estropipate ¢ Fluvastatin ¢ Desvenlafaxine E ¢ Eszopiclone ¢ Fluvoxamine ¢ Echothiophate ¢ Desvenlafaxine 100mg tablet ¢ Etanercept ¢ Folic acid ¢ Econazole ¢ Dexamethasone ¢ Ethacrynic acid ACA Folic acid 400mcg, 800mcg ¢ Efavirenz ¢ Dexlansoprazole ¢ Ethambutol tablet ¢ Efavirenz-Emtricitabine-Tenofovir ¢ Dexmethylphenidate HCR Ethinyl estradiol-Drospirenone ¢ Formoterol ¢ Eletriptan ¢ Dextroamphetamine HCR Ethinyl estradiol-Ethynodiol ¢ Fosamprenavir ¢ Eltrombopag ¢ Dextromethorphan-Quinidine diacetate ¢ Fosinopril ¢ Elvitegravir-Cobicistat- HCR Diaphragm ¢ Ethionamide ¢ Frovatriptan Emtricitabine-Tenofovir ¢ Diazepam ¢ Ethosuximide ¢ Furosemide ¢ Emedastine ¢ Diazoxide ¢ Ethotoin ¢ Furosemide solution ¢ Emtricitabine ¢ Diclofenac ¢ Etidronate ¢ Emtricitabine-Rilpivirine- ¢ Diclofenac gel ¢ Etodolac G Tenofovir ¢ Gabapentin ¢ Dicloxacillin ¢ Etoposide ¢ Emtricitabine-Tenofovir ¢ Gabapentin enacarbil ¢ Dicyclomine ¢ Enalapril ¢ Etravirine ¢ ¢ Galantamine