HMO Formulary
(List of Covered Drugs)
Last Update: 3/01/2016
Please Note: This formulary drug list is applicable to the following plan types: Signature HMO, Select HMO, Deductible HMO, and
HSA-Qualified Deductible HMO. Please note that this formulary does NOT apply to members who purchased their plans on the District
of Columbia, Maryland, or Virginia marketplaces, Federal Employee Health Benefit (FEHB) members, Flexible Choice members, Outof-Area (OOA) members, Maryland HealthChoice members, or Virginia Medicaid and FAMIS members. Formularies for these groups
can be found at www.kp.org/formulary and then by selecting ‘Covered drugs in your area, Maryland, Virginia, and Washington, D.C.’
HMO Formulary Drug List
The following list contains the formulary, also known as the preferred drug list, approved by the Kaiser
Permanente Pharmacy and Therapeutics Committee.
This formulary applies only to outpatient drugs and self-administered drugs. It does not apply to
medications used in inpatient settings or administered in one of the Kaiser Permanente medical
centers.
You may have specific exclusions, copays, or coinsurance amounts that are not reflected in the
formulary drug list. Please consult your Evidence of Coverage or Membership Agreement, for
additional information regarding your pharmacy benefits, including any specific limitations or
exclusions.
Some plans have a separate specialty drug tier with specialty tier copay. Specialty drugs are high
cost, prescription medications used to treat serious or chronic medical conditions and require
special handling, administration or monitoring. The details of your outpatient prescription drug
benefit, including any specific limitations or exclusions can be found in your Evidence of Coverage
or Membership Agreement. A listing of specialty tier drugs can be found at kp.org/formulary and
then by selecting ‘Covered drugs in your area, Maryland, Virginia, and Washington, D.C’.
Generic and Brand Name Medications
Kaiser Permanente covers generic and brand name drugs. A generic drug is approved by the Food
and Drug Administration (FDA) as having the same active ingredient as the brand name drug.
Brand name drugs are manufactured and sold by the pharmaceutical company that originally
researched and developed the drug. When the patent on a brand name drug expires, other
pharmaceutical companies may then manufacture and sell the FDA- approved generic version of the
drug at lower prices. In most cases, your doctor will prescribe a generic drug if one is available.
Generic drugs generally cost less than brand name drugs.
Non-Formulary Medications
The listing only includes drugs on the formulary. Any drug not found on this list is considered nonformulary. A non-formulary medication or non-preferred medication is generally available at a higher
cost. Please consult your Evidence of Coverage or Membership Agreement for additional
information regarding coverage of non-formulary medications specific to your plan.
140301_HMO Formulary
1
Using the Kaiser Permanente Formulary List
When you look through the formulary drug listing beginning on page 3, you will see that products
available in a generic form are listed by their generic names. Medications that are only available as
a brand name product are listed in BOLD AND ALL CAPITAL letters, except where multiple
branded products exist.
You can search the formulary drug list by using the “FIND” function in Adobe Reader, or by
referencing the therapeutic drug category.
Some drugs have multiple dosage forms. Not all dosage forms and strengths for a particular
drug listed are on the Formulary.
Please remember that this list is subject to change and will be updated from time to time during
the year. Any product not found on the list will be considered non-formulary or non-preferred.
Please also note that this formulary applies only to outpatient drugs and self-administered drugs.
It does not apply to medical service drugs or medications used in inpatient settings or
administered in one of the Kaiser Permanente medical centers.
Restrictions on medication coverage
Some covered drugs may have additional requirements or limits on coverage. Please consult
your Evidence of Coverage or Membership Agreement for additional information regarding your
pharmacy benefits, including any specific limitations or exclusions.
•
Limited distribution: Some drugs may be subject to limited distribution or restricted access. A drug that
is a limited distribution drug may only be available at one or a limited number of pharmacies.
•
Oral chemotherapy drugs: Drugs that fall under the District of Columbia and State of Maryland Oral
Chemotherapy Parity Act.
•
Quantity limit: For certain drugs, Kaiser Permanente Pharmacy and Therapeutics Committee limit
the amount of medication dispensed to a certain quantity per copay.
Key:
LD = Limited Distribution Drugs
OC = Oral Chemotherapy Drugs
QL = A drug that has a quantity limit
For more information about the HMO Formulary Drug List, you may contact Member Services at 301468-6000 or 800-777-7902 (TTY 711). Representatives are available Monday through Friday, 7:30
a.m. until 9 p.m.
2
March 2016
DRUG NAME
REQUIREMENTS
AND LIMITS
Antihistamine Drugs
Cyproheptadine HCl
DRUG NAME
Penicillin V Potassium
Sulfadiazine
Promethazine HCL
Sulfasalazine
Sulfamethoxazole- Trimethoprim
Anti-infective Agents
Tetracycline HCL
Anthelmintics
Tobramycin Neb
ALBENZA
Vancomycin HCL
BILTRICIDE
VIVOTIF BERNA
YODOXIN
ZYVOX
Antibacterials
Antifungals
Amoxicillin
Fluconazole
Amoxicillin & Pot Clavulanate
Griseofulvin Microsize
Ampicillin
Griseofulvin Ultramicrosize
Azithromycin
Itraconazole
Cefaclor
Ketoconazole
Cefdinir
Nystatin
Cefixime
Terbinafine
Cefuroxime Axetil
Voriconazole
Cephalexin
Antimycobacterials
Ciprofloxacin
DAPSONE
Clarithromycin
Ethambutol HCL
Clindamycin
Isoniazid
Clindamycin Palmitate HCL
Pyrazinamide
Dicloxacillin Sodium
Rifabutin
Doxycycline Monohydrate
Rifampin
Erythromycin Base
Antiprotozoals
Erythromycin Ethylsuccinate
Erythromycin-Sulfisoxazole
Levofloxacin
Linezolid
Minocycline HCL
Neomycin Sulfate
REQUIREMENTS
AND LIMITS
Atovaquone
Atovaquone-Proguanil HCL
COARTEM
Chloroquine Phosphate
DARAPRIM
LD
Hydroxychloroquine Sulfate
Mefloquine HCL
LEGEND
• Brand-name drugs are in bold type and all capital letters
•For drugs not indicated in bold, generic drugs
will be dispensed as the formularyagent
• Limited Distribution-LD
• Quantity Limits-QL
•Oral Chemo Drugs-OC
3
March 2016
DRUG NAME
REQUIREMENTS
AND LIMITS
Metronidazole
DRUG NAME
RESCRIPTOR
NEBUPENT INH
REYATAZ
Primaquine Phosphate
Ribavirin
Antivirals
Rimantadine HCL
Abacavir
SELZENTRY
Abacavir-Lamivudine- Zidovudine
SOVALDI
Adefovir Dipivoxil
STRIBILD
Amantadine HCL
SUSTIVA
APTIVUS
TAMIFLU
ATRIPLA
TIVICAY
COMPLERA
TRIUMEQ
CRIXIVAN
TRUVADA
Didanosine
VALCYTE SOLUTION
EDURANT
Valganciclovir
EMTRIVA
VICTRELIS
Entecavir
VIRACEPT
EPZICOM
Zidovudine
INTELENCE
Urinary Anti-Infectives
INVIRASE
Methenamine Hippurate
ISENTRESS
HARVONI
REQUIREMENTS
AND LIMITS
QL
QL
Nitrofurantoin
QL
KALETRA
Nitrofurantoin
Monohydrate Macro
Lamivudine
Nitrofurantoin Macrocrystals
Lamivudine-Zidovudine
Trimethoprim
LEXIVA
ANTINEOPLASTIC AGENTS
Nevirapine
Antineoplastic Agents
NORVIR
PEGASYS
QL
PEGASYS PROCLICK
QL
PEG-INTRON
QL
PREZISTA
PREZCOBIX
RELENZA
QL
LEGEND
• Brand-name drugs are in bold type and all capital letters
•For drugs not indicated in bold, generic drugs
will be dispensed as the formularyagent
AFINITOR
OC
ALKERAN
OC
Anastrozole
OC
Bicalutamide
OC
Capecitabine
CEENU
CYTOXAN
OC
OC
OC
• Limited Distribution-LD
• Quantity Limits-QL
•Oral Chemo Drugs-OC
4
March 2016
DRUG NAME
REQUIREMENTS
AND LIMITS
DRUG NAME
REQUIREMENTS
AND LIMITS
EMCYT
OC
TASIGNA
OC
Etoposide
Exemestane
OC
OC
Temozolomide
Tretinoin (Chemotherapy)
OC
Flutamide
OC
TYKERB
OC
OC
GLEEVEC
OC
VANDETANIB
OC
HEXALEN
OC
VOTRIENT
OC
HYCAMTIN
OC
XALKORI
OC
Hydroxyurea
OC
XTANDI
OC
IBRANCE
OC
ZELBORAF
OC
ICLUSIG
OC
ZYKADIA
OC
IMBRUVICA
OC
ZYTIGA
OC
INLYTA
OC
INTRON-A
QL
JAKAFI
OC
LENVIMA
OC
Letrozole
OC
LEUKERAN
OC
Benzodiazepines
LUPRON
QL
Alprazolam
LUPRON DEPOT
QL
Chlordiazepoxide HCL
LUPRON DEPOT-PED
QL
Clonazepam
LYSODREN
OC
Clorazepate Dipotassium
Megestrol Acetate
OC
Diazepam
Mercaptopurine
OC
Lorazepam
ANXIOLYTICS, SEDATIVES,
AND HYPNOTICS
Barbiturates
Phenobarbital
Oxazepam
Methotrexate Sodium
MYLERAN
OC
Temazepam
NEXAVAR
OC
AUTONOMIC DRUGS
Procarbazine HCL
OC
SPRYCEL
OC
SUTENT
OC
TABLOID
OC
Tamoxifen Citrate
OC
TARCEVA
OC
TARGRETIN
OC
LEGEND
• Brand-name drugs are in bold type and all capital letters
•For drugs not indicated in bold, generic drugs
will be dispensed as the formularyagent
Anticholinergic Agents
ATROVENT HFA
Benztropine Mesylate
Dicyclomine HCL
Hyoscyamine
Ipratropium Bromide (Nasal)
Trihexyphenidyl HCL
• Limited Distribution-LD
• Quantity Limits-QL
•Oral Chemo Drugs-OC
5
March 2016
DRUG NAME
REQUIREMENTS
AND LIMITS
Autonomic Drugs, Miscellaneous
SPIRIVA
Ergoloid Mesylates
Nicotrol Inhaler
DRUG NAME
REQUIREMENTS
AND LIMITS
Anagrelide HCL
Aminocaproic Acid
Aspirin/Dipyridamole
HC
Phenoxybenzamine
BRILINTA
Cilostazol
Clopidogrel
Parasympathomimetic (Cholinergic)
Agents
Bethanechol Chloride
Donepezil HCL
Galantamine Hydrobromide
Dipyridamole
EFFIENT
Fondaparinux
QL
LOVENOX
QL
Pentoxifylline
Neostigmine Bromide
PRADAXA
Pilocarpine HCL (ORAL)
Warfarin Sodium
Pyridostigmine Bromide
Hematopoietic Agents
Skeletal Muscle Relaxants
Baclofen
Cyclobenzaprine HCL
NEUPOGEN
QL
PROCRIT/EPOGEN
QL
PROMACTA
Dantrolene Sodium
ZARXIO
Methocarbamol
QL
Sympathomimetic (Adrenergic) Agents
CARDIOVASCULAR DRUGS
ADVAIR DISKUS 100/50
Alpha-Adrenergic Blocking Agents
Albuterol Neb
Terazosin HCL
COMBIVENT RESPIMAT
Tamsulosin HCL
Epinephrine HCL
QL
Antilipemic Agents
EPIPEN
QL
Atorvastatin Calcium
PROAIR HFA
Cholestyramine
SEREVENT DISKUS AER
Cholestyramine Light
STRIVERDI
Colestipol
Terbutaline Sulfate
Fenofibrate 54mg, 160mg
BLOOD FORM ATION, COAGULATION,
AND THROMBOSIS
Coagulants And Anticoagulants
LEGEND
• Brand-name drugs are in bold type and all capital letters
•For drugs not indicated in bold, generic drugs
will be dispensed as the formularyagent
Gemfibrozil
Lovastatin
Niacin
Pravastatin Sodium 20mg,
40mg, 80mg
• Limited Distribution-LD
• Quantity Limits-QL
•Oral Chemo Drugs-OC
6
March 2016
DRUG NAME
REQUIREMENTS
AND LIMITS
Simvastatin 20mg, 40mg, 80mg
Beta-Adrenergic Blocking Agents
Acebutolol HCL
Atenolol/Chlorthalidone
Atenolol HCL
Bisoprolol/
Hydrochlorothiazide
DRUG NAME
REQUIREMENTS
AND LIMITS
Hypotensive Agents
Acetazolamide
Clonidine HCL
Guanfacine HCL
Hydralazine HCL
Methazolamide
Methyldopa
Bisoprolol Fumarate
Minoxidil
Carvedilol
Reserpine
Labetalol HCL
Metoprolol Succinate
Renin-Angiotensin-Aldosterone
System Inhibitors
Metoprolol Tartrate
Captopril
Nadolol
Enalapril Maleate
Propranolol HCL
Lisinopril
Sotalol HCL
Lisinopril/Hydrochlorothiazide
Timolol Maleate
Losartan Potassium
Calcium-Channel Blocking Agents
Losartan Potassium/HCTZ
Amlodipine Besylate
Diltiazem HCL
Nifedipine
Verapamil HCL
Cardiac Drugs
Amiodarone HCL
Digoxin
Disopyramide Phosphate
Flecainide Acetate
Mexiletine HCL
Propafenone HCL
Quinidine Gluconate
Spironolactone
Spironolactone/
Hydrochlorothiazide
Vasodilating Agents
ADEMPAS
LD
Isosorbide Dinitrate
Isosorbide Mononitrate
Nitroglycerin Patch
Nitroglycerin
NITROSTAT SL
OPSUMIT
LD
Papaverine HCL
Sildenafil Citrate
Quinidine Sulfate
Quinidine Sulfate ER
CENTRAL NERVOUS SYSTEM AGENTS
TIKOSYN
Analgesics and Antipyretics
Acetaminophen/Codeine
LEGEND
• Brand-name drugs are in bold type and all capital letters
•For drugs not indicated in bold, generic drugs
will be dispensed as the formularyagent
QL
• Limited Distribution-LD
• Quantity Limits-QL
•Oral Chemo Drugs-OC
7
March 2016
DRUG NAME
Buprenorphine HCL/
Naloxone HCL SL
Butalbital/Acetaminophen/
Caffeine
REQUIREMENTS
AND LIMITS
QL
DRUG NAME
Dextroamphetamine Sulfate
Methylphenidate HCL
Methylphenidate HCL CD, ER
Anticonvulsants
Butalbital/Aspirin/Caffeine
Codeine Phosphate
QL
BANZEL
Codeine Sulfate
QL
Carbamazepine
Carbamazepine ER
Diclofenac Sodium
EMBEDA
QL
Diazepam (Anticonvulsant)
Divalproex Sodium
Etodolac
Fentanyl
QL
Ethosuximide
Hydrocodone/
Acetaminophen
QL
Gabapentin
Hydromorphone HCL
QL
Lamotrigine
Levetiracetam
Ibuprofen
Levetiracetam XR
Indomethacin
Methsuximide
Meloxicam
Oxcarbazepine
Meperidine HCL
QL
Phenobarbital
Methadone HCL
QL
Phenytoin Sodium
Morphine Sulfate
QL
Primidone
Nabumetone
Topiramate
Naproxen
Valproate Sodium
Oxycodone HCL, ER
QL
Valproic Acid
Oxycodone/Acetaminophen
QL
OXYCONTIN
QL
Antimigraine Agents
Sulindac
Tramadol HCL
REQUIREMENTS
AND LIMITS
QL
Anorexigenic Agents and
Respiratory and Cerebral Stimulants
ADDERALL XR
Amphetamine/
Detroamphetamine (Mixed)
LEGEND
• Brand-name drugs are in bold type and all capital letters
•For drugs not indicated in bold, generic drugs
will be dispensed as the formularyagent
Ergotamine/Caffeine
Naratriptan HCL
QL
Rizatriptan Benzoate ODT
QL
Sumatriptan
QL
Anxiolytics, Sedatives, and Hypnotics
Buspirone HCL
Hydroxyzine HCL
• Limited Distribution-LD
• Quantity Limits-QL
•Oral Chemo Drugs-OC
8
March 2016
DRUG NAME
REQUIREMENTS
AND LIMITS
DRUG NAME
Hydroxyzine Pamoate
Zaleplon
QL
Lithium Citrate
Zolpidem Tartrate
QL
Maprotiline HCL
Central Nervous System Agents, Misc.
Carbidopa/Levodopa, ER
Entacapone
LODOSYN
Memantine
Pramipexole Dihydrochloride
Riluzole
Ropinirole HCL
Selegiline
REQUIREMENTS
AND LIMITS
Mirtazapine
Nefazodone HCL
Nortriptyline HCL
Olanzapine
Paroxetine HCL
Pimozide
Perphenazine
Phenelzine Sulfate
Prochlorperazine Maleate
Protriptyline HCL
Opiate Antagonists
Quetiapine
EVZIO
Risperidone
Naltrexone HCL
Sertraline HCL
Psychotherapeutic Agents
Thioridazine HCL
Amitriptyline HCL
Thiothixene
Bupropion HCL, SR, XL
Trazodone HCL
Chlorpromazine HCL
Trifluoperazine HCL
Citalopram HCL
Venlafaxine HCL
Clozapine
Ziprasidone HCL
Desipramine HCL
Doxepine HCL
ELECTROLYTIC, CALORIC,
AND WATER BALANCE
Duloxetine HCL
Acidifying and Alkalinizing Agents
Escitalopram Oxalate
Fluoxetine HCL
Potassium & Sodium Acid
Phosphates
Fluphenazine HCL
Potassium Citrate(Alkalinizer)
Fluvoxamine Maleate
Sodium Citrate & Citric Acid
Haloperidol
Ammonia Detoxicants
Imipramine HCL
Lactulose
Lithium Carbonate
LEGEND
• Brand-name drugs are in bold type and all capital letters
•For drugs not indicated in bold, generic drugs
will be dispensed as the formularyagent
• Limited Distribution—LD
• Quantity Limits—QL
•Oral Chemo Drugs-OC
9
March 2016
DRUG NAME
REQUIREMENTS
AND LIMITS
DRUG NAME
REQUIREMENTS
AND LIMITS
Diuretics
Amiloride HCL
Amiloride/ Hydrochlorothiazide
Chlorothiazide
Furosemide
Hydrochlorothiazide
EYE, EAR, NOSE, AND THROAT (EENT)
PREPARATIONS
Antiallergic Agents
Azelastine HCL
Cromolyn Sodium (OP)
Indapamide
Anti-Infectives
Metolazone
Bacitracin (OP)
Torsemide
Bacitracin/Polymyxin B (OP)
Triamterene/
Hydrochlorothiazide
Ciprofloxacin (OP)
Ion-Removing Agents
Gentamicin Sulfate (OP)
RENVELA
NATACYN
Sodium Polystyrene Sulfonate
Neomycin/Bacitracin/
Polymyxin
Replacement Preparations
Erythromycin (OP)
Calcium Acetate
Neomycin/Polymyxin/
Gramicid
ELIPHOS
Ofloxacin (OP)
PHOSLYRA
Ofloxacin (OTIC)
Potassium Phosphate
Dibasic/Monobasic
Polymyxin B/Trimethoprim
Potassium Bicarbonate
Tobramycin Sulfate (OP)
Potassium Chloride
Trifluridine
Potassium Phosphate
Monobasic
ZYMAXID
Uricosuric Agents
Sulfacetamide
Anti-Inflammatory Agents
Probenecid
Bacitracin/Polymyxin/
Neomycin/HC
ENZYMES
CIPRODEX OTIC
Enzymes
COLY-MYCIN S OTIC
PULMOZYME SOL
VPRIV
LEGEND
• Brand-name drugs are in bold type and all capital letters
•For drugs not indicated in bold, generic drugs
will be dispensed as the formularyagent
Dexamethasone (OP)
Fluorometholone (OP)
• Limited Distribution—LD
• Quantity Limits—QL
•Oral Chemo Drugs-OC
10
March 2016
DRUG NAME
REQUIREMENTS
AND LIMITS
DRUG NAME
Flunisolide
Flurbiprofen (OP)
Proparacaine HCL
Fluticasone Propionate
Mydriatics
Hydrocortisone/Acetic Acid
(OTIC)
Atropine Sulfate
Ketorolac Tromethamine
Neomycin/Polymyxin/
Dexamethasone
REQUIREMENTS
AND LIMITS
Tetracaine HCL
CYCLOMYDRIL
Homatropine HBR
Tropicamide
Neomycin/Polymyxin/HC
Vasoconstrictors
PRED-G
Phenylephrine HCL (OP)
Prednisolone Acetate
GASTROINTESTINAL DRUGS
Prednisolone Sodium
Phosphate
Antidiarrhea Agents
Sulfacetamide Sodium/
Prednisolone
Tobramycin/Dexamethasone
VEXOL
Diphenoxylate/Atropine
Antiemetics
EMEND
Ondansetron HCL
EENT Drugs, Miscellaneous
Prochlorperazine
Acetic Acid (OTIC)
TRANSDERM-SCOP
Acetic Acid/Aluminum
Acetate
Anti-Inflammatory Agents
Brimonidine Tartrate
Carbachol (OP)
Dorzolamide
Dorzolamide/Timolol
Latanoprost
Balsalazide Disodium
CANASA
LIALDA
Mesalamine Enema
PENTASA
Levobunolol HCL
Antiulcer Agents and Acid Suppressants
Metipranolol
Famotidine
Timolol (OP)
Misoprostol
Local Anesthetics
Omeprazole
Lidocaine HCL
Pantoprazole
Ranitidine HCL
Sucralfate
LEGEND
• Brand-name drugs are in bold type and all capital letters
•For drugs not indicated in bold, generic drugs
will be dispensed as the formularyagent
• Limited Distribution—LD
• Quantity Limits—QL
•Oral Chemo Drugs-OC
11
March 2016
DRUG NAME
REQUIREMENTS
AND LIMITS
Digestants
CREON
Pancrelipase
ZENPEP
GI Drugs, Miscellaneous
DRUG NAME
Androgens
Danocrine
DEPO-TESTOSTERONE
Contraceptives
Desogestrel/Ethinyl Estradiol
Metoclopramide HCL
Drospirenone/Ethinyl Estradiol
PEG3350-KCL-Sodium
Bicarb-Sodium ChlorideSodium Sulfate
ELLA
Ursodiol
HEAVY METAL ANTAGONISTS
Heavy Metal Antagonists
Ethynodiol Diacetate/Ethinyl
Estradiol
Levonorgestrel/Ethinyl
Estradiol
EXJADE
Levonorgestrel/Ethinyl
Estradiol (Triphasic)
JADENU
NEXPLANON
HORMONES AND SYNTHETIC
SUBSTITUTES
Adrenals
ASMANEX
Norethindrone
Norethindrone/Ethinyl
Estradiol
Norethindrone Acetate/
Ethinyl Estradiol
Cortisone Acetate
Norethindrone/Ethinyl
Estradiol (Triphasic)
Dexamethasone
NUVARING
FLOVENT HFA
PLAN B ONE-STEP
Fludrocortisone Acetate
Xulane patch
Hydrocortisone
Diabetic Agents
Methlyprednisolone
Acarbose
MILLIPRED
Glipizide
Prednisolone
GLUCAGON EMERGENCY KIT
Prednisolone Sodium
Phosphate
HUMALOG VIAL
Budesonide
Prednisone
QVAR
REQUIREMENTS
AND LIMITS
HUMULIN N 70/30
HUMULIN N
HUMULIN R VIAL
LANTUS VIAL
LEGEND
• Brand-name drugs are in bold type and all capital letters
•For drugs not indicated in bold, generic drugs
will be dispensed as the formularyagent
• Limited Distribution—LD
• Quantity Limits—QL
•Oral Chemo Drugs-OC
12
March 2016
DRUG NAME
REQUIREMENTS
AND LIMITS
DRUG NAME
REQUIREMENTS
AND LIMITS
Metformin HCL
Metformin ER
Somatotropin Agonist and Antagonist
Pioglitazone HCL
Thyroid and Antithyroid Agents
Estrogens and Antiestrogens
Levothyroxine Sodium
CLIMARA
Liothyronine Sodium
Estradiol
Methimazole
Esterified Estrogens/Methyl
Testosterone
Propylthiouracil
OMNITROPE
QL
Thyroid
PREMARIN VAGINAL
CREAM
MISCELLANEOUS THERAPEUTIC
AGENTS
Raloxifene
Miscellaneous Therapeutic Agents
Gonadotropins
BRAVELLE
HC, QL
Chorionic Gonadotropin
HC, QL
Clomiphene Citrate
HC
FOLLISTIM
HC, QL
Ganirelix Acetate
HC, QL
GONAL-F
HC, QL
MENOPUR
HC, QL
IUD
MIRENA
Acamprosate Calcium
ACTIMMUNE
Alendronate Sodium
Allopurinol
AVONEX
Bromocriptine Mesylate
Colchicine
Cromolyn Sodium
FORTICAL
ELMIRON
Pituitary
ENBREL
Desmopressin Acetate
Etidronate Disodium
Norethindrone Acetate
Progesterone Micronized
LD
CERDELGA
Disulfiram
Medroxyprogesterone
Acetate
QL
Azathioprine
Parathyroid
Progestins
QL, LD
EXTAVIA
QL
QL
Finasteride
FIRAZYR
QL
GENGRAF
Glatiramer 20mg/ml
QL
HUMIRA
QL
Leflunomide
LEGEND
• Brand-name drugs are in bold type and all capital letters
•For drugs not indicated in bold, generic drugs
will be dispensed as the formularyagent
• Limited Distribution—LD
• Quantity Limits—QL
•Oral Chemo Drugs-OC
13
March 2016
DRUG NAME
REQUIREMENTS
AND LIMITS
Leucovorin Calcium
MESNEX
DRUG NAME
REQUIREMENTS
AND LIMITS
Guaifenesin/Codeine
QL
Respiratory Agents, Miscellaneous
ORENCIA
QL
Acetylcysteine
ORKAMBI
OTEZLA
LD
Sodium Chloride (Inhalant)
RASUVO
QL
SKIN AND MUCOUS
MEMBRANE AGENTS
REBIF
QL
REVLIMID
OC, LD
Anti-Infectives(Skin and Mucous
Membrane)
Mycophenolate Mofetil
READI-CAT
SANDIMMUNE
Benzoyl Peroxide/Erythromycin
SENSIPAR
Ciclopirox Olamine
Sodium Fluoride
Clindamycin Phosphate
Tacrolimus
Clioquinol/Hydrocortisone
THALOMID
OC, LD
LD
Clotrimazole Troche
VOLUMEN
Erythromycin
Vitamins
Gentamicin Sulfate
Folic Acid
Ketoconazole
Iron Complex
Metronidazole
Phytonadione
Mupirocin
Potassium Aminobenzoate
Nystatin
Pyridoxine HCL
Permethrin
OXYTOCICS
Salicylic Acid
Selenium Sulfide
Oxytocics
Silver Nitrate/Potassium Nitrate
Methylergonovine Maleate
RESPIRATORY TRACT AGENTS
Silver Sulfadiazine
Anti-Inflammatory Agents
Anti-Inflammatory Agents
(Skin and Mucous Membrane)
Cromolyn Sodium
Betamethasone Dipropionate
DULERA
Betamethasone Valerate
Montelukast Sodium
Clobetasol Propionate
Antitussives
Benzonatate
LEGEND
• Brand-name drugs are in bold type and all capital letters
•For drugs not indicated in bold, generic drugs
will be dispensed as the formularyagent
• Limited Distribution—LD
• Quantity Limits—QL
•Oral Chemo Drugs-OC
14
March 2016
DRUG NAME
REQUIREMENTS
AND LIMITS
DRUG NAME
REQUIREMENTS
AND LIMITS
Desoximetasone
Methoxsalen
OXSORALEN LOT
Diflorasone Diacetate
PHISOHEX LIQ
Fluocinolone Acetonide
Podofilox
Fluocinonide
Sulfacetamide Sodium
Hydrocortisone (Rectal)
SANTYL
Hydrocortisone (Topical)
VECTICAL
Hydrocortisone Butyrate
SMOOTHMUSCLERELAXANTS
CORDRAN
Hydrocortisone Valerate
Mometasone Furoate
Nystatin/Triamcinolone
PROCTOFORM
Tacrolimus
Triamcinolone Acetonide
Cell Stimulants and Proliferants
Tretinion
Smooth Muscle Relaxants
Aminophylline
Oxybutynin Chloride
Oxybutynin Chloride XL
Theophylline
Trospium ER
Trospium
VASODILATING AGENTS
Skin and Mucous Membrane Agents,
Miscellaneous
Miscellaneous Therapeutic Agents
8-MOP
Yohimbine HCL
Acitretin
Phosphodiesterase Inhibitors
Aluminum Chloride
CAVERJECT
HC, RB
AZELEX
EDEX
HC, RB
DIFFERIN
MUSE
HC, RB
EPIDUO
FINACEA
Fluorouracil
Imiquimod
Isotretinoin
HC, QL
VITAMINS
Vitamins
Calcitriol
Pediatric Multivitamins/
Fluoride
Lidocaine HCL
Lidocaine/Prilocaine
LEGEND
• Brand-name drugs are in bold type and all capital letters
•For drugs not indicated in bold, generic drugs
will be dispensed as the formularyagent
• Limited Distribution—LD
• Quantity Limits—QL
•Oral Chemo Drugs-OC
15
DRUG NAME
REQUIREMENTS
AND LIMITS
Pediatric Multivitamins/
Fluoride/Iron
Pediatric Multivitamins ACD/
Fluoride
Pediatric Multivitamins ACD/
Fluoride/Iron
Prenatal Vitamins
LEGEND
• Brand-name drugs are in bold type and all capital letters
•For drugs not indicated in bold, generic drugs will
be dispensed as the formulary agent
• Limited Distribution-LD
• Quantity Limits-QL
•Oral Chemo Drugs-OC
16