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 Generic drugs Generic drugs Brand-name drugs Specialty 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 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 Member Services at 1-800-966-5955, Monday through Friday, 8 a.m. to 5 p.m., and Saturday, 8 a.m. to noon. For the deaf, hard of hearing, or speech impaired, call TTY 711. 7003MEM-17 | KAH2927 | September 2017 A ¢ Aminosalicylic ¢ Benazepril ¢ Canagliflozin ¢ Abacavir ¢ Amiodarone ¢ Benzonatate ¢ Canakinumab ¢ Abacavir-Dolutegravir- ¢ Amitriptyline ¢ Benzoyl peroxide-erythromycin ¢ Candesartan Lamivudine ¢ Amlexanox ¢ Benztropine ¢ Capecitabine ¢ Abacavir-Lamivudine ¢ Amlodipine ¢ Benztropine 2mg ¢ Captopril ¢ Abacavir-Lamivudine-Zidovudine ¢ Amoxapine ¢ Benzyl alcohol ¢ Carbamazepine 100mg ¢ Abatacept ¢ Amoxicillin-Clavulanate ¢ Bepotastine extended release tablet ¢ Abiraterone ¢ Amoxicillin ¢ Besifloxacin ¢ Carbamazepine ¢ Acamprosate ¢ Amphetamine- ¢ Betamethasone ¢ Carbidopa ¢ Acarbose Dextroamphetamine ¢ Betaxolol ¢ Carbidopa-Levodopa ¢ Acebutolol ¢ Ampicillin ¢ Bethanechol ¢ Carbinoxamine ¢ Acetaminophen-Caffeine- ¢ Anagrelide ¢ Bexarotene capsule ¢ Carisoprodol Dihydrocodeine ¢ Anakinra ¢ Bexarotene gel ¢ Carteolol ¢ Acetaminophen-Codeine ¢ Anastrozole ¢ Bicalutamide ¢ Carvedilol tablet ¢ Acetazolamide ¢ Antipyrine-Benzocaine ¢ Bimatoprost ¢ Carvedilol suspension ¢ Acetic acid ¢ Apomorphine ACA Bisacodyl ¢ Cefaclor ¢ Acetohydroxamic acid ¢ Apraclonidine ¢ Bisoprolol ¢ Cefadroxil ¢ Acetylcysteine ¢ Apremilast ¢ Bisoprolol-Hydrochlorothiazide ¢ Cefazolin ¢ Acitretin ¢ Aprepitant ¢ Boceprevir ¢ Cefdinir ¢ Acyclovir ¢ Arformoterol ¢ Bosentan ¢ Cefditoren ¢ Adalimumab ¢ Aripiprazole ¢ Bosutinib ¢ Cefixime ¢ Adapalene ¢ Armodafinil ¢ Brimonidine ophthalmic solution ¢ Cefpodoxime ¢ Adapalene-Benzoyl peroxide ¢ Artemether-Lumefantrine ¢ Brimonidine topical gel ¢ Cefprozil ¢ Adefovir ¢ Artificial tear ophthalmic ¢ Brimonidine-Timolol ¢ Ceftibuten ¢ Albendazole ¢ Asenapine ¢ Brinzolamide ¢ Cefuroxime ¢ Albuterol tablet ACA Aspirin ¢ Bromfenac ¢ Celecoxib ¢ Albuterol 2mg/5ml syrup ¢ Aspirin-Extended release ¢ Bromocriptine 0.8mg tablet ¢ Cephalexin ¢ Albuterol 0.083% dipyridamole ¢ Ceradroxil inhalation solution ¢ Bromocriptine 2.5mg tablet ¢ Atazanavir ¢ Budesonide capsule ¢ Certolizumab ¢ Albuterol 0.5% ¢ Atenolol inhalation solution ¢ Budesonide inhalation ¢ Cevimeline ¢ Atenolol suspension ¢ Albuterol 1.25mg/3ml suspension ¢ Chlorambucil inhalation solution ¢ Atomoxetine ¢ Budesonide 9mg tablet ¢ Chlordiazepoxide ¢ Albuterol 108mcg-actuation ¢ Atorvastatin ¢ Bumetanide ¢ Chlordiazepoxide-Clidinium inhaler ¢ Atovaquone ¢ Buprenorphine patch ¢ Chlorhexidine ¢ Alcaftadine ¢ Atovaquone-Proguanil ¢ Buprenorphine sublingual tablet ¢ Chloroquine ¢ Alclometasone ¢ Atropine ¢ Buprenorphine-Naloxone ¢ Chlorothiazide ¢ Alendronate ¢ Axitinib ¢ Bupropion ¢ Chlorpromazine ¢ Alfuzosin ¢ Azathioprine TC Bupropion 150mg ¢ Chlorpropamide ¢ Aliskiren ¢ Azelaic sustained release tablet ¢ Chlorthalidone ¢ Alitretinoin ¢ Azelastine ¢ Buspirone ¢ Chlorzoxazone ¢ Allopurinol ¢ Azelastine-Fluticasone ¢ Buspirone 5mg, 10mg tablet ACA Cholecalciferol ¢ Almotriptan ¢ Azilsartan ¢ Butalbital-Acetaminophen- ¢ Cholestyramine ¢ Alosetron ¢ Azithromycin Caffeine ¢ Choriogonadotropin alfa ¢ Alprazolam ¢ Azithromycin ophthalmic ¢ Butalbital-Aspirin-Caffeine ¢ Ciclesonide ¢ Altretamine solution ¢ Butamben-Tetracaine- ¢ Ciclopirox ¢ Benzocaine ¢ Aluminum acetate-Acetic acid Aztreonam ¢ Cilostazol ¢ Aluminum chloride B C ¢ Cimetidine ¢ Cabozantinib ¢ Alvimopan ¢ Bacitracin ¢ Cinacalcet ¢ Caffeine ¢ Amantadine ¢ Bacitracin-Neomycin- ¢ Cincalcet 30 mg tablet Polymyxin B ¢ Calcipotriene ¢ Ambrisentan ¢ Ciprofloxacin ¢ Baclofen ¢ Calcipotriene-Betamethasone ¢ Amcinonide ¢ Ciprofloxacin-Dexamethasone ¢ Balsalazide ¢ Calcitonin injection ¢ Amiloride ¢ Ciprofloxacin-Hydrocortisone ¢ Becaplermin ¢ Calcitonin nasal spray ¢ Aminocaproic ¢ Citalopram ¢ Beclomethasone ¢ Calcitriol ¢ Aminophylline ¢ Belladonna-Opium ¢ Calcium acetate ¢ = Tier 1 ¢= Tier 2 ¢ = Tier 3 ¢ = Tier 4 ¢ Citalopram 20mg, 40mg tablet ¢ Denosumab 120 mg/1.7 ml ¢ Doxycycline suspension ¢ Estradiol Vaginal Ring ¢ Citric acid injection ¢ Dronabinol ¢ Estradiol Vaginal Tablet ¢ Clarithromycin ¢ Desipramine ¢ Dronedarone ¢ Estramustine ¢ Clemastine ¢ Desloratadine ¢ Duloxetine ¢ Estrogens conjugated ¢ Clindamycin ¢ Desmopressin ¢ Dutasteride ¢ Estropipate ¢ Clindamycin-Benzoyl peroxide ¢ Desonide ¢ Dyphylline ¢ Eszopiclone ¢ Desoximetasone ¢ Clindamycin-Tretinoin E ¢ Etanercept 25 mg injection ¢ Clobetasol ¢ Desvenlafaxine ¢ Echothiophate ¢ Etanercept 50 mg/ml injection ¢ Clocortolone ¢ Desvenlafaxine 100mg tablet ¢ Econazole ¢ Ethacrynic acid ¢ Clomipramine ¢ Dexamethasone ¢ Efavirenz ¢ Ethambutol ¢ Clonazepam ¢ Dexlansoprazole ¢ Efavirenz-Emtricitabine-Tenofovir HCR Ethinyl estradiol-Drospirenone ¢ Clonidine tablet ¢ Dexmethylphenidate ¢ Eletriptan HCR Ethinyl estradiol-Ethynodiol ¢ Clonidine suspension ¢ Dextroamphetamine ¢ Eltrombopag diacetate ¢ Clopidogrel ¢ Dextromethorphan-Quinidine ¢ Elvitegravir-Cobicistat- ¢ Ethionamide ¢ Clorazepate HCR Diaphragm Emtricitabine-Tenofovir ¢ Ethosuximide ¢ Clotrimazole ¢ Diazepam ¢ Emedastine ¢ Ethotoin ¢ Clotrimazole-Betamethasone ¢ Diazoxide ¢ Empagliflozin ¢ Alcohol (Ethanol) 70% Lock ¢ Clozapine ¢ Diclofenac ¢ Emtricitabine ¢ Etidronate ¢ Codeine ¢ Diclofenac gel ¢ Emtricitabine-Rilpivirine- ¢ Etodolac ¢ Colchicine ¢ Dicloxacillin Tenofovir ¢ Etoposide ¢ Colchicine-Probenecid ¢ Dicyclomine ¢ Emtricitabine-Tenofovir ¢ Etravirine ¢ Colesevelam ¢ Didanosine ¢ Enalapril ¢ Everolimus ¢ Colestipol ¢ Diethylpropion ¢ Enalapril suspension ¢ Exemestane ¢ Collagenase ¢ Difenoxin-Atropine ¢ Enfuvirtide ¢ Exenatide ACA Condoms: Female ¢ Diflorasone ¢ Enoxaparin ¢ Ezetimibe ACA Contraceptive sponge ¢ Diflunisal ¢ Entacapone ¢ Ezogabine ¢ Corticotropin ¢ Difluprednate ¢ Entecavir F ¢ Cortisone ¢ Digoxin ¢ Entecavir solution ¢ Famciclovir ¢ Crizotinib ¢ Digoxin solution ¢ Enzalutamide ¢ Famotidine Suspension ¢ Cromolyn ¢ Dihydroergotamine ¢ Epinastine ¢ Febuxostat ¢ Crotamiton ¢ Diltiazem ¢ Epinephrine ¢ Felbamate ¢ Cyclobenzaprine ¢ Dimethyl fumarate ¢ Epinephrine injection ¢ Felodipine ¢ Cyclophosphamide ¢ Diphenhydramine-Lidocaine- ¢ Eplerenone ¢ Fenofibrate ¢ Cycloserine Aluminum hydroxide- ¢ Epoetin ¢ Fenoprofen Magnesium hydroxide- ¢ Eprosartan ¢ Fentanyl ¢ Cyclosporine ophthalmic and Simethicone solution ¢ Ergocalciferol ACA Ferrous sulfate ¢ Diphenoxylate-Atropine ¢ Cyclosporine capsule (by prescription/legend) ¢ Fesoterodine ¢ Dipyridamole ¢ Cyproheptadine ACA Ergocalciferol (over the counter) ¢ Fidaxomicin ¢ Disopyramide ¢ Cysteamine ¢ Ergoloid ¢ Filgrastim injection ¢ Disopyramide controlled release ¢ Ergotamine ¢ Filgrastim Solution Prefilled D ¢ Disulfiram ¢ Dabigatran ¢ Ergotamine-Caffeine Syringe ¢ Divalproex ¢ Dalfampridine ¢ Erlotinib ¢ Finasteride ACA Docusate sodium ¢ Danazol ¢ Erythromycin tablet, ophthalmic ¢ Fingolimod ¢ Dofetilide ¢ Dantrolene ointment, topical solution ¢ Flavoxate ¢ Dolasetron ¢ Dapagliflozin ¢ Erythromycin suspension ¢ Flecainide ¢ Dolutegravir ¢ Dapsone ¢ Escitalopram ¢ Fluconazole ¢ Donepezil ¢ Darifenacin ¢ Esomeprazole ¢ Flucytosine ¢ Dornase ¢ Darunavir ¢ Esterified estrogens ¢ Fludrocortisone ¢ Dorzolamide ¢ Dasatinib ¢ Esterified estrogens- ¢ Fluocinolone ¢ Dorzolamide-Timolol Methyltestosterone ¢ Deferasirox ¢ Fluocinonide ¢ Doxazosin ¢ Esterified estrogens- ¢ Deferiprone ¢ Fluorometholone suspension ¢ Doxepin Methyltestosterone ¢ Delavirdine 1.2mg-2.5mg tablet