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Last Updated 03/20/2020
2020 Northwest Commercial Formulary
(List of Covered Drugs)
Please Read: This document contains information about the drugs
we cover when you participate in a Kaiser Permanente Commercial
(non-Medicare) plan.
What is the Kaiser Permanente Northwest Commercial Formulary? A
formulary is a list of covered drugs chosen by a group of Kaiser
Permanente physicians and pharmacists known as the Formulary and
Therapeutics Committee. This committee meets regularly to evaluate
and select the safest, most effective medications for our members.
What is a generic drug? Our plan covers both brand-name drugs and
generic drugs. A generic drug is approved by the FDA as having the
same active ingredient as the brand-name drug. Generally, generic
drugs cost less than brand-name drugs. What is a 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 manufacture and sell an FDA-approved generic version of the
drug with the same active ingredient(s) at lower prices. What are
specialty-tier drugs? Specialty-tier drugs are very high-cost
drugs. Kaiser Permanente Formulary The formulary list that begins
on the next page provides coverage information about some of the
drugs covered by our plan.
The first column of the chart lists the drug name. Brand-name
drugs are capitalized (e.g. ALBENZA) and generic drugs are listed
in lower-case italics (e.g. amoxicillin).
The second column will indicate what tier the drug is in. Drugs
on our formulary are categorized as Generic, Preferred Brand or
Specialty.
The third column of the chart will indicate any requirements or
limits for that drug.
DS = A drug that is limited to no more than a 30-day supply per
dispense.
PA = A drug that requires specific medical criteria be met and
requires approval by the plan prior to being dispensed for
benefit.
QL = A drug that is limited to no more than a specific quantity
within a certain period of days.
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Drug Name Drug Tier Requirements/Limits Analgesics No USP Class
(Combination Product) acetaminophen-codeine #2 tabs 300-15 mg
Generic acetaminophen-codeine #3 tabs 300-30 mg Generic
acetaminophen-codeine soln 120-12 mg/5ml Generic
hydrocodone-acetaminophen soln 7.5-325 mg/15ml Generic DS
hydrocodone-acetaminophen tabs 10-325 mg Generic DS
hydrocodone-acetaminophen tabs 5-325 mg Generic DS
oxycodone-acetaminophen tabs 5-325 mg Generic DS Nonsteroidal
Anti-Inflammatory Drugs etodolac caps 300 mg Generic etodolac tabs
400 mg Generic ibuprofen tabs 800 mg Generic indomethacin caps 25
mg Generic indomethacin caps 50 mg Generic ketorolac tromethamine
soln 30 mg/ml Generic meloxicam tabs 15 mg Generic meloxicam tabs
7.5 mg Generic nabumetone tabs 500 mg Generic nabumetone tabs 750
mg Generic naproxen tabs 250 mg Generic naproxen tabs 375 mg
Generic naproxen tabs 500 mg Generic sulindac tabs 150 mg Generic
sulindac tabs 200 mg Generic Opioid Analgesics, Long-Acting
fentanyl pt72 100 mcg/hr Generic DS fentanyl pt72 12 mcg/hr Generic
DS fentanyl pt72 25 mcg/hr Generic DS fentanyl pt72 50 mcg/hr
Generic DS fentanyl pt72 75 mcg/hr Generic DS methadone hcl conc 10
mg/ml Generic DS methadone hcl tabs 10 mg Generic DS methadone hcl
tabs 5 mg Generic DS morphine sulfate (concentrate) soln 100 mg/5ml
Generic DS morphine sulfate er tbcr 100 mg Generic DS morphine
sulfate er tbcr 15 mg Generic DS morphine sulfate er tbcr 200 mg
Generic DS morphine sulfate er tbcr 30 mg Generic DS morphine
sulfate er tbcr 60 mg Generic DS morphine sulfate soln 10 mg/5ml
Generic DS MORPHINE SULFATE TABS 15 MG Preferred Brand DS MORPHINE
SULFATE TABS 30 MG Preferred Brand DS Opioid Analgesics,
Short-Acting codeine sulfate tabs 30 mg Generic DS codeine sulfate
tabs 60 mg Generic DS
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hydromorphone hcl supp 3 mg Generic DS hydromorphone hcl tabs 2
mg Generic DS hydromorphone hcl tabs 4 mg Generic DS morphine
sulfate supp 10 mg Generic DS morphine sulfate supp 20 mg Generic
DS morphine sulfate supp 30 mg Generic DS oxycodone hcl soln 5 mg/5
ml Generic DS oxycodone hcl tabs 5 mg Generic DS oxycodone hcl tabs
10 mg Generic PA, DS oxycodone hcl tabs 15 mg Generic PA, DS
tramadol hcl tabs 50 mg Generic Anesthetics Local Anesthetics
lidocaine hcl gel 2 % Generic lidocaine hcl soln 4 % Generic
lidocaine viscous soln 2 % Generic Anti-Addiction/Substance Abuse
Treatment Agents Alcohol Deterrents/Anti-Craving acamprosate
calcium tbec 333 mg Generic disulfiram tabs 250 mg Generic No USP
Class (Combination Product) buprenorphine hcl-naloxone hcl subl
2-0.5 mg Generic DS buprenorphine hcl-naloxone hcl subl 8-2 mg
Generic DS Opioid Antagonists buprenorphine hcl subl 2 mg Generic
DS buprenorphine hcl subl 8 mg Generic DS naloxone hcl sosy 2
mg/2ml Generic naltrexone hcl tabs 50 mg Generic NARCAN LIQD 4
MG/0.1ML Preferred Brand Smoking Cessation Agents bupropion hcl er
(smoking det) tb12 150 mg Generic CHANTIX STARTING MONTH PAK TABS
0.5 MG X 11 & 1 MG X 42 Preferred Brand PA
CHANTIX TABS 0.5 MG Preferred Brand PA CHANTIX TABS 1 MG
Preferred Brand PA gnp nicotine polacrilex lozg 2 mg Generic gnp
nicotine polacrilex lozg 4 mg Generic nicotine kit 21-14-7 mg/24hr
Generic nicotine polacrilex gum 2 mg Generic nicotine polacrilex
gum 4 mg Generic nicotine pt24 14 mg/24hr Generic nicotine pt24 21
mg/24hr Generic nicotine pt24 7 mg/24hr Generic Antibacterials
Aminoglycosides gentak oint 0.3 % Generic gentamicin sulfate crea
0.1 % Generic gentamicin sulfate oint 0.1 % Generic
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Last Updated 03/20/2020
gentamicin sulfate soln 0.3 % Generic neomycin sulfate tabs 500
mg Generic paromomycin sulfate caps 250 mg Generic TOBI PODHALER
CAPS 28 MG Specialty tobramycin nebu 300 mg/5ml Generic tobramycin
soln 0.3 % Generic Antibacterials, Other acetic acid soln 2 %
Generic bacitracin oint 500 unit/gm Generic clindamycin hcl caps
150 mg Generic clindamycin hcl caps 300 mg Generic clindamycin
palmitate hcl solr 75 mg/5ml Generic clindamycin phosphate gel 1 %
Generic clindamycin phosphate lotn 1 % Generic clindamycin
phosphate soln 1 % Generic FIRVANQ SOLR 50 MG/ML Preferred Brand
linezolid susr 100 mg/5ml Generic linezolid tabs 600 mg Generic
MACRODANTIN CAPS 25 MG Preferred Brand metronidazole crea 0.75 %
Generic metronidazole gel 0.75 % Generic metronidazole tabs 250 mg
Generic metronidazole tabs 500 mg Generic MONUROL PACK 3 GM
Preferred Brand mupirocin oint 2 % Generic nitrofurantoin
macrocrystal caps 100 mg Generic nitrofurantoin macrocrystal caps
50 mg Generic nitrofurantoin monohyd macro caps 100 mg Generic
trimethoprim tabs 100 mg Generic vancomycin hcl caps 125 mg Generic
vancomycin hcl caps 250 mg Generic vancomycin hcl solr 250 mg/5ml
Generic Beta-Lactam, Cephalosporins cefadroxil caps 500 mg Generic
cefdinir caps 300 mg Generic cefdinir susr 125 mg/5ml Generic
cefdinir susr 250 mg/5ml Generic cefixime caps 400 mg Generic
cefpodoxime proxetil susr 100 mg/5ml Generic cefpodoxime proxetil
tabs 200 mg Generic cefuroxime axetil tabs 250 mg Generic
cefuroxime axetil tabs 500 mg Generic cephalexin caps 250 mg
Generic cephalexin caps 500 mg Generic cephalexin susr 125 mg/5ml
Generic cephalexin susr 250 mg/5ml Generic Beta-Lactam, Penicillins
amoxicillin caps 250 mg Generic
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amoxicillin caps 500 mg Generic amoxicillin susr 125 mg/5ml
Generic amoxicillin susr 250 mg/5ml Generic amoxicillin susr 400
mg/5ml Generic amoxicillin-pot clavulanate chew 200-28.5 mg Generic
amoxicillin-pot clavulanate chew 400-57 mg Generic amoxicillin-pot
clavulanate susr 200-28.5 mg/5ml Generic amoxicillin-pot
clavulanate susr 400-57 mg/5ml Generic amoxicillin-pot clavulanate
susr 600-42.9 mg/5ml Generic amoxicillin-pot clavulanate tabs
500-125 mg Generic amoxicillin-pot clavulanate tabs 875-125 mg
Generic dicloxacillin sodium caps 250 mg Generic dicloxacillin
sodium caps 500 mg Generic penicillin v potassium solr 125 mg/5ml
Generic penicillin v potassium solr 250 mg/5ml Generic penicillin v
potassium tabs 250 mg Generic penicillin v potassium tabs 500 mg
Generic Macrolides azithromycin susr 100 mg/5ml Generic
azithromycin susr 200 mg/5ml Generic azithromycin tabs 250 mg
Generic azithromycin tabs 600 mg Generic clarithromycin tabs 500 mg
Generic ery-tab tbec 250 mg Generic erythromycin ethylsuccinate
susr 400 mg/5ml Generic erythromycin oint 5 mg/gm Generic
erythromycin soln 2 % Generic Quinolones ciprofloxacin hcl soln 0.3
% Generic ciprofloxacin hcl tabs 250 mg Generic ciprofloxacin hcl
tabs 500 mg Generic ciprofloxacin hcl tabs 750 mg Generic
levofloxacin soln 25 mg/ml Generic levofloxacin tabs 250 mg Generic
levofloxacin tabs 500 mg Generic levofloxacin tabs 750 mg Generic
moxifloxacin hcl soln 0.5 % Generic ofloxacin soln 0.3 % Generic
Sulfonamides silver sulfadiazine crea 1 % Generic sulfacetamide
sodium soln 10 % Generic sulfadiazine tabs 500 mg Generic
sulfamethoxazole-trimethoprim susp 200-40 mg/5ml Generic
sulfamethoxazole-trimethoprim tabs 400-80 mg Generic
sulfamethoxazole-trimethoprim tabs 800-160 mg Generic Tetracyclines
doxycycline hyclate caps 100 mg Generic doxycycline hyclate caps 50
mg Generic
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Last Updated 03/20/2020
doxycycline hyclate tabs 20 mg Generic doxycycline monohydrate
tabs 100 mg Generic doxycycline monohydrate tabs 50 mg Generic
minocycline hcl caps 100 mg Generic minocycline hcl caps 50 mg
Generic Anticonvulsants Anticonvulsants, Other levetiracetam er
tb24 500 mg Generic levetiracetam er tb24 750 mg Generic
levetiracetam soln 100 mg/ml Generic levetiracetam tabs 1000 mg
Generic levetiracetam tabs 250 mg Generic levetiracetam tabs 500 mg
Generic levetiracetam tabs 750 mg Generic Calcium Channel Modifying
Agents CELONTIN CAPS 300 MG Preferred Brand ethosuximide caps 250
mg Generic ethosuximide soln 250 mg/5ml Generic zonisamide caps 100
mg Generic zonisamide caps 25 mg Generic zonisamide caps 50 mg
Generic Gamma-Aminobutyric Acid (GABA) Augmenting Agents clonazepam
tabs 0.5 mg Generic clonazepam tabs 1 mg Generic clonazepam tabs 2
mg Generic divalproex sodium csdr 125 mg Generic divalproex sodium
er tb24 250 mg Generic divalproex sodium er tb24 500 mg Generic
divalproex sodium tbec 125 mg Generic divalproex sodium tbec 250 mg
Generic divalproex sodium tbec 500 mg Generic gabapentin caps 100
mg Generic gabapentin caps 300 mg Generic gabapentin caps 400 mg
Generic gabapentin tabs 600 mg Generic gabapentin tabs 800 mg
Generic phenobarbital elix 20 mg/5ml Generic phenobarbital tabs
16.2 mg Generic phenobarbital tabs 32.4 mg Generic phenobarbital
tabs 64.8 mg Generic phenobarbital tabs 97.2 mg Generic primidone
tabs 250 mg Generic primidone tabs 50 mg Generic tiagabine hcl tabs
2 mg Generic tiagabine hcl tabs 4 mg Generic tiagabine hcl tabs 12
mg Generic tiagabine hcl tabs 16 mg Generic valproic acid caps 250
mg Generic
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Last Updated 03/20/2020
valproic acid soln 250 mg/5ml Generic Glutamate Reducing Agents
lamotrigine chew 25 mg Generic lamotrigine chew 5 mg Generic
lamotrigine tabs 100 mg Generic lamotrigine tabs 150 mg Generic
lamotrigine tabs 200 mg Generic lamotrigine tabs 25 mg Generic
topiramate cpsp 15 mg Generic topiramate cpsp 25 mg Generic
topiramate tabs 100 mg Generic topiramate tabs 200 mg Generic
topiramate tabs 25 mg Generic topiramate tabs 50 mg Generic Sodium
Channel Agents carbamazepine chew 100 mg Generic carbamazepine er
cp12 100 mg Generic carbamazepine er cp12 200 mg Generic
carbamazepine er cp12 300 mg Generic carbamazepine er tb12 100 mg
Generic carbamazepine er tb12 200 mg Generic carbamazepine er tb12
400 mg Generic carbamazepine susp 100 mg/5ml Generic carbamazepine
tabs 200 mg Generic dilantin caps 30 mg Generic oxcarbazepine susp
300 mg/5ml Generic oxcarbazepine tabs 150 mg Generic oxcarbazepine
tabs 300 mg Generic oxcarbazepine tabs 600 mg Generic phenytoin
chew 50 mg Generic phenytoin sodium extended caps 100 mg Generic
phenytoin susp 125 mg/5ml Generic Antidementia Agents
Cholinesterase Inhibitors donepezil hcl tabs 10 mg Generic
donepezil hcl tabs 5 mg Generic galantamine hydrobromide er cp24 16
mg Generic galantamine hydrobromide er cp24 24 mg Generic
galantamine hydrobromide er cp24 8 mg Generic galantamine
hydrobromide tabs 12 mg Generic galantamine hydrobromide tabs 4 mg
Generic galantamine hydrobromide tabs 8 mg Generic
N-Methyl-D-Aspartate (NMDA) Receptor Antagonists memantine hcl tabs
10 mg Generic memantine hcl tabs 5 mg Generic Antidepressants
Antidepressants, Other aripiprazole tabs 10 mg Generic
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aripiprazole tabs 15 mg Generic aripiprazole tabs 2 mg Generic
aripiprazole tabs 20 mg Generic aripiprazole tabs 30 mg Generic
aripiprazole tabs 5 mg Generic bupropion hcl er (sr) tb12 100 mg
Generic bupropion hcl er (sr) tb12 150 mg Generic bupropion hcl er
(sr) tb12 200 mg Generic bupropion hcl er (xl) tb24 150 mg Generic
bupropion hcl er (xl) tb24 300 mg Generic bupropion hcl tabs 100 mg
Generic bupropion hcl tabs 75 mg Generic mirtazapine tabs 15 mg
Generic mirtazapine tabs 30 mg Generic mirtazapine tabs 45 mg
Generic trazodone hcl tabs 100 mg Generic trazodone hcl tabs 50 mg
Generic Monoamine Oxidase Inhibitors phenelzine sulfate tabs 15 mg
Generic tranylcypromine sulfate tabs 10 mg Generic
Serotonin/Norepinephrine Reuptake Inhibitors citalopram
hydrobromide soln 10 mg/5ml Generic citalopram hydrobromide tabs 10
mg Generic citalopram hydrobromide tabs 20 mg Generic citalopram
hydrobromide tabs 40 mg Generic desvenlafaxine succinate er tb24 25
mg Generic desvenlafaxine succinate er tb24 50 mg Generic
desvenlafaxine succinate er tb24 100 mg Generic duloxetine hcl cpep
20 mg Generic duloxetine hcl cpep 30 mg Generic duloxetine hcl cpep
60 mg Generic escitalopram oxalate tabs 10 mg Generic escitalopram
oxalate tabs 20 mg Generic escitalopram oxalate tabs 5 mg Generic
fluoxetine hcl caps 10 mg Generic fluoxetine hcl caps 20 mg Generic
fluoxetine hcl caps 40 mg Generic fluoxetine hcl soln 20 mg/5ml
Generic fluvoxamine maleate tabs 100 mg Generic fluvoxamine maleate
tabs 25 mg Generic fluvoxamine maleate tabs 50 mg Generic
paroxetine hcl tabs 10 mg Generic paroxetine hcl tabs 20 mg Generic
paroxetine hcl tabs 30 mg Generic paroxetine hcl tabs 40 mg Generic
sertraline hcl tabs 100 mg Generic sertraline hcl tabs 25 mg
Generic sertraline hcl tabs 50 mg Generic
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venlafaxine hcl er cp24 150 mg Generic venlafaxine hcl er cp24
37.5 mg Generic venlafaxine hcl er cp24 75 mg Generic venlafaxine
hcl tabs 100 mg Generic venlafaxine hcl tabs 25 mg Generic
venlafaxine hcl tabs 37.5 mg Generic venlafaxine hcl tabs 50 mg
Generic venlafaxine hcl tabs 75 mg Generic Tricyclics amitriptyline
hcl tabs 10 mg Generic amitriptyline hcl tabs 100 mg Generic
amitriptyline hcl tabs 150 mg Generic amitriptyline hcl tabs 25 mg
Generic amitriptyline hcl tabs 50 mg Generic amitriptyline hcl tabs
75 mg Generic desipramine hcl tabs 10 mg Generic desipramine hcl
tabs 25 mg Generic desipramine hcl tabs 50 mg Generic desipramine
hcl tabs 75 mg Generic desipramine hcl tabs 100 mg Generic
desipramine hcl tabs 150 mg Generic doxepin hcl caps 10 mg Generic
doxepin hcl caps 25 mg Generic doxepin hcl caps 50 mg Generic
doxepin hcl conc 10 mg/ml Generic nortriptyline hcl caps 10 mg
Generic nortriptyline hcl caps 25 mg Generic nortriptyline hcl caps
50 mg Generic nortriptyline hcl caps 75 mg Generic protriptyline
hcl tabs 10 mg Generic protriptyline hcl tabs 5 mg Generic
Antiemetics Antiemetics, Other chlorpromazine hcl tabs 10 mg
Generic chlorpromazine hcl tabs 100 mg Generic chlorpromazine hcl
tabs 200 mg Generic chlorpromazine hcl tabs 25 mg Generic
chlorpromazine hcl tabs 50 mg Generic hydroxyzine hcl soln 10
mg/5ml Generic hydroxyzine hcl soln 50 mg/ml Generic hydroxyzine
hcl tabs 10 mg Generic hydroxyzine hcl tabs 25 mg Generic
hydroxyzine hcl tabs 50 mg Generic hydroxyzine pamoate caps 25 mg
Generic hydroxyzine pamoate caps 50 mg Generic metoclopramide hcl
soln 5 mg/5ml Generic metoclopramide hcl tabs 10 mg Generic
metoclopramide hcl tabs 5 mg Generic
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perphenazine tabs 16 mg Generic perphenazine tabs 2 mg Generic
perphenazine tabs 4 mg Generic perphenazine tabs 8 mg Generic
prochlorperazine maleate tabs 10 mg Generic prochlorperazine
maleate tabs 5 mg Generic prochlorperazine supp 25 mg Generic
promethazine hcl syrp 6.25 mg/5ml Generic promethazine hcl tabs 25
mg Generic promethegan supp 12.5 mg Generic promethegan supp 25 mg
Generic scopolamine pt72 1 mg/3days Generic TRANSDERM-SCOP (1.5 MG)
PT72 1 MG/3DAYS Preferred Brand Emetogenic Therapy Adjuncts AKYNZEO
CAPS 300-0.5 MG Preferred Brand DS ondansetron hcl tabs 4 mg
Generic ondansetron hcl tabs 8 mg Generic ondansetron tbdp 4 mg
Generic ondansetron tbdp 8 mg Generic Antifungals clotrimazole troc
10 mg Generic fluconazole tabs 100 mg Generic fluconazole tabs 150
mg Generic fluconazole tabs 200 mg Generic fluconazole tabs 50 mg
Generic FLUCYTOSINE CAPS 250 MG Specialty FLUCYTOSINE CAPS 500 MG
Specialty griseofulvin microsize susp 125 mg/5ml Generic
griseofulvin ultramicrosize tabs 125 mg Generic griseofulvin
ultramicrosize tabs 250 mg Generic ketoconazole crea 2 % Generic
ketoconazole sham 2 % Generic ketoconazole tabs 200 mg Generic
NATACYN SUSP 5 % Preferred Brand NOXAFIL SUSP 40 MG/ML Specialty
nystatin crea 100000 unit/gm Generic nystatin oint 100000 unit/gm
Generic nystatin susp 100000 unit/ml Generic nystop powd 100000
unit/gm Generic posaconazole tbec 100 mg Specialty terbinafine hcl
tabs 250 mg Generic voriconazole tabs 200 mg Generic voriconazole
tabs 50 mg Generic Antigout Agents allopurinol tabs 100 mg Generic
allopurinol tabs 300 mg Generic probenecid tabs 500 mg Generic
colchicine-probenecid tabs 0.5-500 mg Generic
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Antimigraine Agents Ergot Alkaloids dihydroergotamine mesylate
soln 1 mg/ml Generic DS dihydroergotamine mesylate soln 4 mg/ml
Generic No USP Class (Combination Product) MIGERGOT SUPP 2-100 MG
Preferred Brand Serotonin (5-HT) 1B/1D Receptor Agonists
naratriptan hcl tabs 1 mg Generic naratriptan hcl tabs 2.5 mg
Generic rizatriptan benzoate tabs 10 mg Generic rizatriptan
benzoate tabs 5 mg Generic rizatriptan benzoate tbdp 10 mg Generic
rizatriptan benzoate tbdp 5 mg Generic sumatriptan soln 20 mg/act
Generic sumatriptan succinate refill soct 6 mg/0.5ml Generic
sumatriptan succinate soaj 6 mg/0.5ml Generic sumatriptan succinate
soln 6 mg/0.5ml Generic sumatriptan succinate tabs 100 mg Generic
sumatriptan succinate tabs 25 mg Generic sumatriptan succinate tabs
50 mg Generic Antimyasthenic Agents Parasympathomimetics
pyridostigmine bromide er tbcr 180 mg Generic pyridostigmine
bromide tabs 60 mg Generic Antimycobacterials Antimycobacterials,
Other dapsone tabs 100 mg Generic dapsone tabs 25 mg Generic
rifabutin caps 150 mg Generic Antituberculars ethambutol hcl tabs
100 mg Generic ethambutol hcl tabs 400 mg Generic isoniazid syrp 50
mg/5ml Generic isoniazid tabs 100 mg Generic isoniazid tabs 300 mg
Generic pyrazinamide tabs 500 mg Generic rifamate caps 150-300 mg
Generic rifampin caps 150 mg Generic rifampin caps 300 mg Generic
TRECATOR TABS 250 MG Preferred Brand Antineoplastics Alkylating
Agents cyclophosphamide caps 25 mg Generic cyclophosphamide caps 50
mg Generic GLEOSTINE CAPS 10 MG Preferred Brand GLEOSTINE CAPS 40
MG Specialty GLEOSTINE CAPS 100 MG Specialty HEXALEN CAPS 50 MG
Specialty DS
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LEUKERAN TABS 2 MG Preferred Brand LOMUSTINE CAPS 100 MG
Preferred Brand MATULANE CAPS 50 MG Specialty DS melphalan tabs 2
mg Generic MYLERAN TABS 2 MG Preferred Brand temozolomide caps 100
mg Generic temozolomide caps 140 mg Generic temozolomide caps 180
mg Generic temozolomide caps 20 mg Generic temozolomide caps 250 mg
Generic temozolomide caps 5 mg Generic Antiangiogenic Agents
REVLIMID CAPS 2.5 MG Specialty DS, QL (28 PER 28 DAYS)
REVLIMID CAPS 5 MG Specialty DS, QL (28 PER 28 DAYS)
REVLIMID CAPS 10 MG Specialty DS, QL (28 PER 28 DAYS)
REVLIMID CAPS 15 MG Specialty DS, QL (21 PER 28 DAYS)
REVLIMID CAPS 20 MG Specialty DS, QL (21 PER 28 DAYS)
REVLIMID CAPS 25 MG Specialty DS, QL (21 PER 28 DAYS)
Antiestrogens/Modifiers tamoxifen citrate tabs 10 mg Generic
tamoxifen citrate tabs 20 mg Generic Antimetabolites capecitabine
tabs 150 mg Generic DS capecitabine tabs 500 mg Generic DS
hydroxyurea caps 500 mg Generic LONSURF TABS 15-6.14 MG Specialty
DS LONSURF TABS 20-8.19 MG Specialty DS PURIXAN SUSP 2000 MG/100ML
Specialty DS TABLOID TABS 40 MG Preferred Brand Antineoplastics,
Other etoposide caps 50 mg Generic JAKAFI TABS 10 MG Specialty DS
JAKAFI TABS 15 MG Specialty DS JAKAFI TABS 20 MG Specialty DS
JAKAFI TABS 25 MG Specialty DS JAKAFI TABS 5 MG Specialty DS
leucovorin calcium tabs 25 mg Generic leucovorin calcium tabs 5 mg
Generic
ODOMZO CAPS 200 MG Specialty PA, DS, QL (30 PER 30 DAYS)
Aromatase Inhibitors, 3rd Generation anastrozole tabs 1 mg
Generic
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letrozole tabs 2.5 mg Generic Enzyme Inhibitors ALECENSA CAPS
150 MG Specialty DS
COTELLIC TABS 20 MG Specialty DS, QL (63 PER 28 DAYS)
IBRANCE CAPS 75 MG Specialty DS, QL (21 PER 28 DAYS)
IBRANCE CAPS 100 MG Specialty DS, QL (21 PER 28 DAYS)
IBRANCE CAPS 125 MG Specialty DS, QL (21 PER 28 DAYS) IRESSA
TABS 250 MG Specialty DS LENVIMA 4 MG DAILY DOSE CPPK 4 MG
Specialty PA, DS LENVIMA 10 MG DAILY DOSE CPPK 10 MG Specialty PA,
DS LENVIMA 12 MG DAILY DOSE CPPK 3 X 4 MG Specialty PA, DS LENVIMA
14 MG DAILY DOSE CPPK 10 & 4 MG Specialty PA, DS LENVIMA 20 MG
DAILY DOSE CPPK 10 (2) MG Specialty PA, DS LENVIMA 24 MG DAILY DOSE
CPPK 10 (2) & 4 MG Specialty PA, DS LORBRENA TABS 25 MG
Specialty PA, DS LORBRENA TABS 100 MG Specialty PA, DS LYNPARZA
TABS 100 MG Specialty DS LYNPARZA TABS 150 MG Specialty DS MEKINIST
TABS 0.5 MG Specialty DS MEKINIST TABS 2 MG Specialty DS NINLARO
CAPS 2.3 MG Specialty DS NINLARO CAPS 3 MG Specialty DS NINLARO
CAPS 4 MG Specialty DS RYDAPT CAPS 25 MG Specialty DS
TAFINLAR CAPS 50 MG Specialty DS, QL (120 PER 30 DAYS)
TAFINLAR CAPS 75 MG Specialty DS, QL (120 PER 30 DAYS) TAGRISSO
TABS 40 MG Specialty DS TAGRISSO TABS 80 MG Specialty DS VELCADE
SOLR 3.5 MG Preferred Brand ZEJULA CAPS 100 MG Specialty DS
Molecular Target Inhibitors AFINITOR TABS 10 MG Specialty DS
AFINITOR TABS 2.5 MG Specialty DS AFINITOR TABS 5 MG Specialty DS
AFINITOR TABS 7.5 MG Specialty DS
erlotinib hcl tabs 25 mg Generic DS, QL (90 PER 30 DAYS)
erlotinib hcl tabs 100 mg Generic DS, QL (30 PER 30 DAYS)
erlotinib hcl tabs 150 mg Generic DS, QL (30 PER 30 DAYS)
everolimus tabs 2.5 mg Specialty DS
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everolimus tabs 5 mg Specialty DS everolimus tabs 7.5 mg
Specialty DS imatinib mesylate tabs 100 mg Generic imatinib
mesylate tabs 400 mg Generic
IMBRUVICA CAPS 140 MG Specialty DS, QL (90 PER 30 DAYS)
IMBRUVICA TABS 140 MG Specialty DS
IMBRUVICA TABS 280 MG Specialty DS, QL (30 PER 30 DAYS)
IMBRUVICA TABS 420 MG Specialty DS, QL (30 PER 30 DAYS)
IMBRUVICA TABS 560 MG Specialty DS, QL (30 PER 30 DAYS)
NEXAVAR TABS 200 MG Specialty DS, QL (30 PER 30 DAYS)
SPRYCEL TABS 100 MG Specialty DS, QL (30 PER 30 DAYS)
SPRYCEL TABS 140 MG Specialty DS, QL (30 PER 30 DAYS)
SPRYCEL TABS 20 MG Specialty DS, QL (60 PER 30 DAYS)
SPRYCEL TABS 50 MG Specialty DS, QL (30 PER 30 DAYS)
SPRYCEL TABS 70 MG Specialty DS, QL (30 PER 30 DAYS) SUTENT CAPS
12.5 MG Specialty DS SUTENT CAPS 25 MG Specialty DS SUTENT CAPS 50
MG Specialty DS
TYKERB TABS 250 MG Specialty DS, QL (180 PER 30 DAYS) VOTRIENT
TABS 200 MG Specialty DS ZELBORAF TABS 240 MG Specialty DS
Monoclonal Antibodies HERCEPTIN SOLR 440 MG Preferred Brand No USP
Class MESNEX TABS 400 MG Preferred Brand DS
XTANDI CAPS 40 MG Specialty DS, QL (120 PER 30 DAYS) Retinoids
RETIN-A CREA 0.025 % Preferred Brand RETIN-A CREA 0.05 % Preferred
Brand RETIN-A CREA 0.1 % Preferred Brand RETIN-A GEL 0.01 %
Preferred Brand RETIN-A GEL 0.025 % Preferred Brand RETIN-A MICRO
GEL 0.1 % Preferred Brand tretinoin caps 10 mg Generic DS
Antiparasitics Anthelmintics
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albendazole tabs 200 mg Generic DS ivermectin tabs 3 mg Generic
praziquantel tabs 600 mg Generic Antiprotozoals ALINIA SUSR 100
MG/5ML Preferred Brand atovaquone susp 750 mg/5ml Generic
atovaquone-proguanil hcl tabs 250-100 mg Generic
atovaquone-proguanil hcl tabs 62.5-25 mg Generic chloroquine
phosphate tabs 500 mg Generic COARTEM TABS 20-120 MG Preferred
Brand DARAPRIM TABS 25 MG Preferred Brand DS hydroxychloroquine
sulfate tabs 200 mg Generic KRINTAFEL TABS 150 MG Preferred Brand
mefloquine hcl tabs 250 mg Generic primaquine phosphate tabs 26.3
mg Generic YODOXIN TABS 650 MG Preferred Brand
Pediculicides/Scabicides permethrin crea 5 % Generic Antiparkinson
Agents Anticholinergics benztropine mesylate tabs 0.5 mg Generic
benztropine mesylate tabs 1 mg Generic benztropine mesylate tabs 2
mg Generic trihexyphenidyl hcl tabs 2 mg Generic trihexyphenidyl
hcl tabs 5 mg Generic Antiparkinson Agents, Other amantadine hcl
caps 100 mg Generic amantadine hcl syrp 50 mg/5ml Generic
amantadine hcl tabs 100 mg Generic entacapone tabs 200 mg Generic
Dopamine Agonists bromocriptine mesylate tabs 2.5 mg Generic
pramipexole dihydrochloride tabs 0.125 mg Generic pramipexole
dihydrochloride tabs 0.25 mg Generic pramipexole dihydrochloride
tabs 0.5 mg Generic pramipexole dihydrochloride tabs 0.75 mg
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Last Updated 03/20/2020
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DS
PROMACTA TABS 25 MG Specialty PA, DS, QL (60 PER 30 DAYS)
PROMACTA TABS 50 MG Specialty PA, DS, QL (90 PER 30 DAYS)
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VENOFER SOLN 20 MG/ML Preferred Brand ZARXIO SOSY 300 MCG/0.5ML
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Last Updated 03/20/2020
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Last Updated 03/20/2020
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Generic DS claravis caps 20 mg Generic DS claravis caps 30 mg
Generic DS claravis caps 40 mg Generic DS
COSENTYX SENSOREADY PEN SOAJ 150 MG/ML Specialty PA, DS, QL (2
PER 28 DAYS)
COSENTYX SOSY 150 MG/ML Specialty PA, DS, QL (2 PER 28 DAYS)
DIFFERIN CREA 0.1 % Preferred Brand DRITHO-CRÈME HP CREA 1 %
Preferred Brand
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Last Updated 03/20/2020
DRYSOL SOLN 20 % Preferred Brand fluocinolone acetonide scalp
oil 0.01% Generic fluorouracil crea 5 % Generic fluorouracil soln 2
% Generic fluorouracil soln 5 % Generic hydrocortisone lotn 2.5 %
Generic imiquimod crea 5 % Generic methoxsalen rapid caps 10 mg
Generic nystatin-triamcinolone crea 100000-0.1 unit/gm-% Generic
nystatin-triamcinolone oint 100000-0.1 unit/gm-% Generic
pimecrolimus crea 1 % Generic podofilox soln 0.5 % Generic RECTIV
OINT 0.4 % Preferred Brand SANTYL OINT 250 UNIT/GM Preferred Brand
selenium sulfide lotn 2.5 % Generic STELARA SOLN 130 MG/26ML
Specialty PA
STELARA SOSY 45 MG/0.5ML Specialty PA, QL (0.5 PER 84 DAYS)
STELARA SOSY 90 MG/ML Specialty PA, QL (1 PER 56 DAYS)
sulfacetamide sodium-sulfur emul 10-5 % Generic tacrolimus oint
0.03 % Generic tacrolimus oint 0.1 % Generic tazarotene crea 0.1 %
Generic TAZORAC CREA 0.05 % Preferred Brand TAZORAC GEL 0.05 %
Preferred Brand TAZORAC GEL 0.1 % Preferred Brand VECTICAL OINT 3
MCG/GM Preferred Brand XERAC AC SOLN 6.25 % Preferred Brand Enzyme
Replacement/Modifiers CERDELGA CAPS 84 MG Specialty DS ZENPEP CPEP
5000-24000 UNIT Preferred Brand ZENPEP CPEP 10000-32000 UNIT
Preferred Brand ZENPEP CPEP 15000-47000 UNIT Preferred Brand ZENPEP
CPEP 20000-63000 UNIT Preferred Brand ZENPEP CPEP 25000-79000 UNIT
Preferred Brand ZENPEP CPEP 40000-126000 UNIT Preferred Brand
Gastrointestinal Agents Antispasmodics, Gastrointestinal
dicyclomine hcl caps 10 mg Generic dicyclomine hcl soln 10 mg/5ml
Generic dicyclomine hcl tabs 20 mg Generic glycopyrrolate tabs 1 mg
Generic glycopyrrolate tabs 2 mg Generic Gastrointestinal Agents,
Other diphenoxylate-atropine liqd 2.5-0.025 mg/5ml Generic
diphenoxylate-atropine tabs 2.5-0.025 mg Generic propantheline
bromide tabs 15 mg Generic
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Last Updated 03/20/2020
READI-CAT 2 SUSP 2 % Preferred Brand ursodiol tabs 250 mg
Generic ursodiol tabs 500 mg Generic Histamine-2 (H2) Receptor
Antagonists cimetidine hcl soln 300 mg/5ml Generic ranitidine hcl
syrp 75 mg/5ml Generic ranitidine hcl tabs 300 mg Generic Irritable
Bowel Syndrome Agents mesalamine enem 4 gm Generic salsalate tabs
500 mg Generic salsalate tabs 750 mg Generic Laxatives gavilyte-c
solr 240 gm Generic lactulose soln 10 gm/15ml Generic Protectants
misoprostol tabs 100 mcg Generic misoprostol tabs 200 mcg Generic
sucralfate tabs 1 gm Generic Proton Pump Inhibitors pantoprazole
sodium tbec 20 mg Generic pantoprazole sodium tbec 40 mg Generic
Genitourinary Agents Antispasmodics, Urinary oxybutynin chloride er
tb24 10 mg Generic oxybutynin chloride er tb24 15 mg Generic
oxybutynin chloride er tb24 5 mg Generic oxybutynin chloride syrp 5
mg/5ml Generic oxybutynin chloride tabs 5 mg Generic solifenacin
succinate tabs 5 mg Generic solifenacin succinate tabs 10 mg
Generic tolterodine tartrate tabs 1 mg Generic tolterodine tartrate
tabs 2 mg Generic trospium chloride tabs 20 mg Generic Benign
Prostatic Hypertrophy Agents finasteride tabs 5 mg Generic
tamsulosin hcl caps 0.4 mg Generic Genitourinary Agents, Other
bethanechol chloride tabs 5 mg Generic bethanechol chloride tabs 10
mg Generic bethanechol chloride tabs 25 mg Generic DEPEN TITRATABS
TABS 250 MG Preferred Brand ELMIRON CAPS 100 MG Preferred Brand No
USP Class methylergonovine maleate tabs 0.2 mg Generic Phosphate
Binders calcium acetate (phos binder) caps 667 mg Generic PHOSLYRA
SOLN 667 MG/5ML Preferred Brand sevelamer carbonate pack 0.8 gm
Generic
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Last Updated 03/20/2020
sevelamer carbonate pack 2.4 gm Generic sevelamer carbonate tabs
800 mg Generic sevelamer hcl tabs 800 mg Generic Hormonal Agents,
Stimulant/Replacement/Modifying (Adrenal)
Glucocorticoids/Mineralocorticoids alclometasone dipropionate crea
0.05 % Generic alclometasone dipropionate oint 0.05 % Generic
betamethasone dipropionate aug crea 0.05 % Generic betamethasone
dipropionate aug oint 0.05 % Generic betamethasone dipropionate
crea 0.05 % Generic betamethasone dipropionate lotn 0.05 % Generic
betamethasone dipropionate oint 0.05 % Generic betamethasone
valerate crea 0.1 % Generic betamethasone valerate lotn 0.1 %
Generic betamethasone valerate oint 0.1 % Generic budesonide cpep 3
mg Generic clobetasol propionate e crea 0.05 % Generic clobetasol
propionate lotn 0.05 % Generic clobetasol propionate oint 0.05 %
Generic clobetasol propionate soln 0.05 % Generic CLOBEX SHAM 0.05
% Preferred Brand CLOBEX SPRAY LIQD 0.05 % Preferred Brand colocort
enem 100 mg/60ml Generic CORDRAN TAPE 4 MCG/SQCM Preferred Brand
desoximetasone crea 0.25 % Generic dexamethasone elix 0.5 mg/5ml
Generic dexamethasone intensol conc 1 mg/ml Generic dexamethasone
soln 0.5 mg/5ml Generic dexamethasone tabs 0.5 mg Generic
dexamethasone tabs 0.75 mg Generic dexamethasone tabs 1.5 mg
Generic dexamethasone tabs 4 mg Generic fludrocortisone acetate
tabs 0.1 mg Generic fluocinolone acetonide crea 0.01 % Generic
fluocinolone acetonide crea 0.025 % Generic fluocinolone acetonide
oint 0.025 % Generic fluocinolone acetonide soln 0.01 % Generic
fluocinonide gel 0.05 % Generic fluocinonide oint 0.05 % Generic
fluocinonide soln 0.05 % Generic hydrocortisone butyr lipo base
crea 0.1 % Generic hydrocortisone crea 2.5 % Generic hydrocortisone
enem 100 mg/60ml Generic hydrocortisone oint 2.5 % Generic
hydrocortisone tabs 10 mg Generic hydrocortisone tabs 20 mg Generic
hydrocortisone tabs 5 mg Generic mometasone furoate crea 0.1 %
Generic
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Last Updated 03/20/2020
mometasone furoate oint 0.1 % Generic mometasone furoate soln
0.1 % Generic prednicarbate crea 0.1 % Generic prednisolone sodium
phosphate soln 15 mg/5ml Generic prednisone tabs 1 mg Generic
prednisone tabs 10 mg Generic prednisone tabs 2.5 mg Generic
prednisone tabs 20 mg Generic prednisone tabs 5 mg Generic
prednisone tabs 50 mg Generic prednisone tbpk 5 mg (21) Generic
SOLU-CORTEF SOLR 100 MG Preferred Brand triamcinolone acetonide
aers 0.147 mg/gm Generic triamcinolone acetonide crea 0.025 %
Generic triamcinolone acetonide crea 0.1 % Generic triamcinolone
acetonide crea 0.5 % Generic triamcinolone acetonide oint 0.025 %
Generic triamcinolone acetonide oint 0.1 % Generic triamcinolone
acetonide oint 0.5 % Generic triamcinolone acetonide pste 0.1 %
Generic Hormonal Agents, Stimulant/Replacement/Modifying
(Pituitary) desmopressin ace rhinal tube soln 0.01 % Generic
desmopressin acetate spray soln 0.01 % Generic desmopressin acetate
tabs 0.1 mg Generic desmopressin acetate tabs 0.2 mg Generic
novarel solr 10000 unit Generic OMNITROPE SOLN 10 MG/1.5ML
Preferred Brand DS OMNITROPE SOLN 5 MG/1.5ML Preferred Brand DS
OMNITROPE SOLR 5.8 MG Preferred Brand DS Hormonal Agents,
Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) Androgens
danazol caps 100 mg Generic danazol caps 200 mg Generic danazol
caps 50 mg Generic DEPO-TESTOSTERONE SOLN 100 MG/ML Preferred Brand
PA DEPO-TESTOSTERONE SOLN 200 MG/ML Preferred Brand PA methitest
tabs 10 mg Generic testosterone enanthate soln 200 mg/ml Generic PA
testosterone gel 25 mg/2.5gm (1%) Generic PA testosterone gel 50
mg/5gm (1%) Generic PA Estrogens CLIMARA PTWK 0.025 MG/24HR
Preferred Brand CLIMARA PTWK 0.0375 MG/24HR Preferred Brand CLIMARA
PTWK 0.05 MG/24HR Preferred Brand CLIMARA PTWK 0.06 MG/24HR
Preferred Brand CLIMARA PTWK 0.075 MG/24HR Preferred Brand CLIMARA
PTWK 0.1 MG/24HR Preferred Brand depo-estradiol oil 5 mg/ml
Generic
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Last Updated 03/20/2020
estradiol crea 0.1 mg/gm Generic estradiol tabs 0.5 mg Generic
estradiol tabs 1 mg Generic estradiol tabs 2 mg Generic ESTRING
RING 2 MG Preferred Brand No USP Class (Combination Product)
aranelle tabs 0.5/1/0.5-35 mg-mcg Generic eluryng ring 0.12-0.015
mg/24hr Generic est estrogens-methyltest hs tabs 0.625-1.25 mg
Generic est estrogens-methyltest tabs 1.25-2.5 mg Generic kelnor
1/50 tabs 1-50 mg-mcg Generic levora 0.15/30 (28) tabs 0.15-30
mg-mcg Generic microgestin fe 1.5/30 tabs 1.5-30 mg-mcg Generic
microgestin fe 1/20 tabs 1-20 mg-mcg Generic necon 0.5/35 (28) tabs
0.5-35 mg-mcg Generic nortrel 1/35 (28) tabs 1-35 mg-mcg Generic
NUVARING RING 0.12-0.015 MG/24HR Preferred Brand sprintec 28 tabs
0.25-35 mg-mcg Generic tri-sprintec tabs 0.18/0.215/0.25 mg-35 mcg
Generic trivora (28) tabs Generic XULANE PTWK 150 35 MCG/24HR
Preferred Brand zovia 1/35e (28) tabs 1-35 mg-mcg Generic
Progestins ELLA TABS 30 MG Preferred Brand hydroxyprogesterone
caproate oil 250 mg/ml Generic DS medroxyprogesterone acetate susp
150 mg/ml Generic medroxyprogesterone acetate tabs 10 mg Generic
medroxyprogesterone acetate tabs 2.5 mg Generic medroxyprogesterone
acetate tabs 5 mg Generic megestrol acetate susp 40 mg/ml Generic
megestrol acetate tabs 20 mg Generic megestrol acetate tabs 40 mg
Generic MIRENA (52 MG) IUD 20 MCG/24HR Preferred Brand NEXPLANON
IMPL 68 MG Preferred Brand nora-be tabs 0.35 mg Generic
norethindrone acetate tabs 5 mg Generic plan b one-step tabs 1.5 mg
Generic Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
levothyroxine sodium tabs 100 mcg Generic levothyroxine sodium tabs
112 mcg Generic levothyroxine sodium tabs 125 mcg Generic
levothyroxine sodium tabs 137 mcg Generic levothyroxine sodium tabs
150 mcg Generic levothyroxine sodium tabs 175 mcg Generic
levothyroxine sodium tabs 200 mcg Generic levothyroxine sodium tabs
25 mcg Generic levothyroxine sodium tabs 300 mcg Generic
levothyroxine sodium tabs 50 mcg Generic
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Last Updated 03/20/2020
levothyroxine sodium tabs 75 mcg Generic levothyroxine sodium
tabs 88 mcg Generic liothyronine sodium tabs 25 mcg Generic
liothyronine sodium tabs 5 mcg Generic liothyronine sodium tabs 50
mcg Generic Hormonal Agents, Suppressant (Adrenal) LYSODREN TABS
500 MG Preferred Brand DS Hormonal Agents, Suppressant (Pituitary)
cabergoline tabs 0.5 mg Generic octreotide acetate soln 100 mcg/ml
Generic octreotide acetate soln 1000 mcg/ml Generic octreotide
acetate soln 200 mcg/ml Generic octreotide acetate soln 500 mcg/ml
Generic SYNAREL SOLN 2 MG/ML Preferred Brand Hormonal Agents,
Suppressant (Sex Hormones/Modifiers) Antiandrogens
abiraterone acetate tabs 250 mg Specialty DS, QL (120 PER 30
DAYS) bicalutamide tabs 50 mg Generic flutamide caps 125 mg Generic
ZYTIGA TABS 500 MG Specialty DS Hormonal Agents, Suppressant
(Thyroid) Antithyroid Agents methimazole tabs 10 mg Generic
methimazole tabs 5 mg Generic propylthiouracil tabs 50 mg Generic
Immunological Agents Immune Suppressants azathioprine tabs 50 mg
Generic
ENBREL SOLR 25 MG Preferred Brand PA, DS, QL (8 PER 28 DAYS)
ENBREL SOSY 25 MG/0.5ML Preferred Brand PA, DS, QL (4.08 PER 28
DAYS)
ENBREL SOSY 50 MG/ML Preferred Brand PA, DS, QL (4 PER 28
DAYS)
ENBREL SURECLICK SOAJ 50 MG/ML Preferred Brand PA, DS, QL (4 PER
28 DAYS) gengraf caps 100 mg Generic gengraf caps 25 mg Generic
HUMIRA PEDIATRIC CROHNS START PSKT 80 MG/0.8ML Preferred Brand
PA, DS, QL (3 PER 365 DAYS) HUMIRA PEDIATRIC CROHNS START PSKT 80
MG/0.8ML & 40MG/0.4ML Preferred Brand
PA, DS, QL (2 PER 365 DAYS)
HUMIRA PEN PNKT 40 MG/0.4ML Preferred Brand PA, DS, QL (2 PER 28
DAYS)
HUMIRA PEN PNKT 40 MG/0.8ML Preferred Brand PA, DS, QL (2 PER 28
DAYS)
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Last Updated 03/20/2020
HUMIRA PSKT 10 MG/0.1ML Preferred Brand DS, QL (2 PER 28
DAYS)
HUMIRA PSKT 20 MG/0.2ML Preferred Brand DS, QL (2 PER 28
DAYS)
HUMIRA PSKT 20 MG/0.4ML Preferred Brand DS, QL (2 PER 28
DAYS)
HUMIRA PSKT 40 MG/0.4ML Preferred Brand PA, DS, QL (2 PER 28
DAYS)
HUMIRA PSKT 40 MG/0.8ML Preferred Brand PA, DS, QL (2 PER 28
DAYS) mercaptopurine tabs 50 mg Generic methotrexate sodium (pf)
soln 50 mg/2ml Generic methotrexate sodium soln 50 mg/2ml Generic
methotrexate tabs 2.5 mg Generic mycophenolate mofetil caps 250 mg
Generic mycophenolate mofetil tabs 500 mg Generic NEORAL SOLN 100
MG/ML Preferred Brand
ORENCIA CLICKJECT SOAJ 125 MG/ML Preferred Brand PA, DS, QL (4
PER 28 DAYS) ORENCIA SOLR 250 MG Preferred Brand DS
ORENCIA SOSY 125 MG/ML Preferred Brand PA, DS, QL (4 PER 28
DAYS) RASUVO SOAJ 10 MG/0.2ML Preferred Brand RASUVO SOAJ 12.5
MG/0.25ML Preferred Brand RASUVO SOAJ 15 MG/0.3ML Preferred Brand
RASUVO SOAJ 17.5 MG/0.35ML Preferred Brand RASUVO SOAJ 20 MG/0.4ML
Preferred Brand RASUVO SOAJ 22.5 MG/0.45ML Preferred Brand RASUVO
SOAJ 25 MG/0.5ML Preferred Brand RASUVO SOAJ 27.5 MG/0.55ML
Preferred Brand RASUVO SOAJ 30 MG/0.6ML Preferred Brand RASUVO SOAJ
7.5 MG/0.15ML Preferred Brand SANDIMMUNE CAPS 100 MG Preferred
Brand SANDIMMUNE CAPS 25 MG Preferred Brand sirolimus tabs 0.5 mg
Generic sirolimus tabs 1 mg Generic sirolimus tabs 2 mg Generic
sirolimus soln 1 mg/ml Generic tacrolimus caps 0.5 mg Generic
tacrolimus caps 1 mg Generic tacrolimus caps 5 mg Generic
XELJANZ TABS 10 MG Preferred Brand PA, DS, QL (60 PER 30 DAYS)
ZORTRESS TABS 0.25 MG Preferred Brand ZORTRESS TABS 0.5 MG
Specialty ZORTRESS TABS 0.75 MG Specialty Immunizing Agents,
Passive VIVOTIF CPDR Preferred Brand
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Last Updated 03/20/2020
Immunomodulators leflunomide tabs 10 mg Generic leflunomide tabs
20 mg Generic
OTEZLA TABS 30 MG Specialty PA, DS, QL (60 PER 30 DAYS)
OTEZLA TBPK 10 & 20 & 30 MG Specialty PA, DS, QL (55 PER
365 DAYS) RIDAURA CAPS 3 MG Preferred Brand No USP Class HAEGARDA
SOLR 2000 UNIT Specialty DS HAEGARDA SOLR 3000 UNIT Specialty DS
TAKHZYRO SOLN 300 MG/2ML Specialty PA, DS Inflammatory Bowel
Disease Agents Aminosalicylates ASACOL TBEC 400 MG Preferred Brand
balsalazide disodium caps 750 mg Generic mesalamine-cleanser kit 4
gm Generic mesalamine supp 1000 mg Generic mesalamine tbec 1.2 gm
Generic Sulfonamides sulfasalazine tabs 500 mg Generic
sulfasalazine tbec 500 mg Generic Metabolic Bone Disease Agents
alendronate sodium tabs 10 mg Generic alendronate sodium tabs 40 mg
Generic alendronate sodium tabs 70 mg Generic calcitonin (salmon)
soln 200 unit/act Generic calcitriol caps 0.25 mcg Generic
calcitriol caps 0.5 mcg Generic calcitriol soln 1 mcg/ml Generic
etidronate disodium tabs 200 mg Generic etidronate disodium tabs
400 mg Generic MIACALCIN SOLN 200 UNIT/ML Preferred Brand No
Designated Placement on USP Model Guidelines V5.0 acetic acid soln
0.25 % Generic BD INSULIN SYRINGE ULTRAFINE MISC 31G X 15/64" 0.3
ML Preferred Brand
BD INSULIN SYRINGE ULTRAFINE MISC 31G X 15/64" 0.5 ML Preferred
Brand
BD INSULIN SYRINGE ULTRAFINE MISC 31G X 15/64" 1 ML Preferred
Brand
BD INSULIN SYRINGE U-500 MISC 31G X 6MM 0.5 ML Preferred Brand
bd magni-guide magnifier misc Generic bd pen needle mini u/f misc
31g x 5 mm Generic bd safetyglide insulin syringe misc 29g x 1/2"
0.5 ml Generic CERDELGA CAPS 84 MG Specialty DS fluoridex pste 1.1
% Generic KETOSTIX STRP Preferred Brand
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Last Updated 03/20/2020
ONETOUCH ULTRA BLUE STRP Preferred Brand PARAGARD INTRAUTERINE
COPPER IUD Preferred Brand PRECISION XTRA KETONE STRP Preferred
Brand proctozone-hc crea 2.5 % Generic sodium benzoate powd Generic
WIDE-SEAL DIAPHRAGM 60 DPRH 2 % Preferred Brand WIDE-SEAL DIAPHRAGM
65 DPRH 2 % Preferred Brand WIDE-SEAL DIAPHRAGM 70 DPRH 2 %
Preferred Brand WIDE-SEAL DIAPHRAGM 75 DPRH 2 % Preferred Brand
WIDE-SEAL DIAPHRAGM 80 DPRH 2 % Preferred Brand WIDE-SEAL DIAPHRAGM
85 DPRH 2 % Preferred Brand WIDE-SEAL DIAPHRAGM 90 DPRH 2 %
Preferred Brand WIDE-SEAL DIAPHRAGM 95 DPRH 2 % Preferred Brand
Ophthalmic Agents No USP Class (Combination Product)
bacitracin-polymyxin b oint 500-10000 unit/gm Generic
bacitra-neomycin-polymyxin-hc oint 1 % Generic blephamide s.o.p.
oint 10-0.2 % Generic neomycin-bacitracin zn-polymyx oint
5-400-10000 Generic neomycin-polymyxin-dexameth oint 3.5-10000-0.1
Generic neomycin-polymyxin-dexameth susp 3.5-10000-0.1 Generic
polymyxin b-trimethoprim soln 10000-0.1 unit/ml-% Generic PRED-G
SUSP 0.3-1 % Preferred Brand sulfacetamide-prednisolone soln
10-0.23 % Generic Ophthalmic Agents, Other ATROPINE SULFATE OINT 1
% Preferred Brand ATROPINE SULFATE SOLN 1 % Preferred Brand
cyclopentolate hcl soln 0.5 % Generic cyclopentolate hcl soln 1 %
Generic cyclopentolate hcl soln 2 % Generic homatropaire soln 5 %
Generic ISOPTO CARBACHOL SOLN 1.5 % Preferred Brand ISOPTO
CARBACHOL SOLN 3 % Preferred Brand tropicamide soln 0.5 % Generic
tropicamide soln 1 % Generic VISUDYNE SOLR 15 MG Preferred Brand
Ophthalmic Anti-Allergy Agents cromolyn sodium soln 4 % Generic
olopatadine hcl soln 0.1 % Generic Ophthalmic Antiglaucoma Agents
betaxolol hcl soln 0.5 % Generic brimonidine tartrate soln 0.2 %
Generic dorzolamide hcl soln 2 % Generic dorzolamide hcl-timolol
mal soln 22.3-6.8 mg/ml Generic levobunolol hcl soln 0.5 % Generic
phenylephrine hcl soln 2.5 % Generic PHOSPHOLINE IODIDE SOLR 0.125
% Preferred Brand timolol maleate soln 0.25 % Generic
-
Last Updated 03/20/2020
timolol maleate soln 0.5 % Generic Ophthalmic
Anti-Inflammatories dexamethasone sodium phosphate soln 0.1 %
Generic diclofenac sodium soln 0.1 % Generic fluorometholone susp
0.1 % Generic flurbiprofen sodium soln 0.03 % Generic FML OINT 0.1
% Preferred Brand PRED MILD SUSP 0.12 % Preferred Brand
prednisolone acetate susp 1 % Generic Ophthalmic Prostaglandin and
Prostamide Analogs latanoprost soln 0.005 % Generic Otic Agents
acetic acid-aluminum acetate soln 2 % Generic CIPRODEX SUSP 0.3-0.1
% Preferred Brand neomycin-polymyxin-hc soln 1 % Generic
Respiratory Tract Agents Antihistamines azelastine hcl soln 0.1 %
Generic cyproheptadine hcl syrp 2 mg/5ml Generic cyproheptadine hcl
tabs 4 mg Generic Anti-Inflammatories, Inhaled Corticosteroids
ALVESCO AERS 80 MCG/ACT Preferred Brand ALVESCO AERS 160 MCG/ACT
Preferred Brand ASMANEX 120 METERED DOSES AEPB 220 MCG/INH
Preferred Brand ASMANEX 30 METERED DOSES AEPB 110 MCG/INH Preferred
Brand ASMANEX 60 METERED DOSES AEPB 220 MCG/INH Preferred Brand
ASMANEX HFA AERO 100 MCG/ACT Preferred Brand ASMANEX HFA AERO 200
MCG/ACT Preferred Brand FLOVENT HFA AERO 44 MCG/ACT Preferred Brand
flunisolide soln 25 mcg/act (0.025%) Generic Antileukotrienes
montelukast sodium chew 4 mg Generic montelukast sodium chew 5 mg
Generic montelukast sodium tabs 10 mg Generic Bronchodilators,
Anticholinergic ATROVENT HFA AERS 17 MCG/ACT Preferred Brand
ipratropium bromide soln 0.02 % Generic ipratropium bromide soln
0.03 % Generic ipratropium bromide soln 0.06 % Generic SPIRIVA
RESPIMAT AERS 2.5 MCG/ACT Preferred Brand Bronchodilators,
Phosphodiesterase Inhibitors (Xanthines) theophylline er tb12 300
mg Generic theophylline er tb24 400 mg Generic Bronchodilators,
Sympathomimetic albuterol sulfate nebu (2.5 mg/3ml) 0.083% Generic
albuterol sulfate nebu (5 mg/ml) 0.5% Generic epinephrine soaj 0.15
mg/0.15ml Generic DS epinephrine soaj 0.3 mg/0.3ml Generic DS
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Last Updated 03/20/2020
SEREVENT DISKUS AEPB 50 MCG/DOSE Preferred Brand STRIVERDI
RESPIMAT AERS 2.5 MCG/ACT Preferred Brand terbutaline sulfate tabs
2.5 mg Generic terbutaline sulfate tabs 5 mg Generic VENTOLIN HFA
AERS 108 (90 Base) MCG/ACT Preferred Brand No USP Class benzonatate
caps 100 mg Generic HYPERSAL NEBU 7 % Preferred Brand PULMOZYME
SOLN 1 MG/ML Specialty sodium chloride nebu 0.9 % Generic sodium
chloride nebu 10 % Generic No USP Class (Combination Product)
ADVAIR DISKUS AEPB 100-50 MCG/DOSE Preferred Brand ADVAIR DISKUS
AEPB 250-50 MCG/DOSE Preferred Brand ADVAIR DISKUS AEPB 500-50
MCG/DOSE Preferred Brand ADVAIR HFA AERO 45-21 MCG/ACT Preferred
Brand PA ADVAIR HFA AERO 115-21 MCG/ACT Preferred Brand PA ADVAIR
HFA AERO 230-21 MCG/ACT Preferred Brand PA COMBIVENT RESPIMAT AERS
20-100 MCG/ACT Preferred Brand fluticasone-salmeterol aepb 55-14
mcg/act Generic fluticasone-salmeterol aepb 113-14 mcg/act Generic
fluticasone-salmeterol aepb 232-14 mcg/act Generic
hydrocodone-homatropine syrp 5-1.5 mg/5ml Generic DS
ipratropium-albuterol soln 0.5-2.5 (3) mg/3ml Generic promethazine
vc plain syrp 6.25-5 mg/5ml Generic promethazine vc/codeine syrp
6.25-5-10 mg/5ml Generic promethazine-codeine syrp 6.25-10 mg/5ml
Generic promethazine-dm syrp 6.25-15 mg/5ml Generic STIOLTO
RESPIMAT AERS 2.5-2.5 MCG/ACT Preferred Brand Pulmonary
Antihypertensives LETAIRIS TABS 10 MG Specialty PA, DS LETAIRIS
TABS 5 MG Specialty PA, DS TRACLEER TABS 125 MG Specialty PA, DS
TRACLEER TABS 62.5 MG Specialty PA, DS VELETRI SOLR 1.5 MG
Preferred Brand Respiratory Tract Agents, Other acetylcysteine soln
10 % Generic acetylcysteine soln 20 % Generic cheratussin dac soln
30-10-100 mg/5ml Generic FASENRA PEN SOAJ 30 MG/ML Specialty PA, DS
FASENRA SOSY 30 MG/ML Specialty PA, DS guaifenesin-codeine soln
100-10 mg/5ml Generic TRIKAFTA TBPK 100-50-75 & 150 MG
Specialty PA, DS Skeletal Muscle Relaxants cyclobenzaprine hcl tabs
10 mg Generic cyclobenzaprine hcl tabs 5 mg Generic methocarbamol
tabs 500 mg Generic methocarbamol tabs 750 mg Generic
-
Last Updated 03/20/2020
Sleep Disorder Agents GABA Receptor Modulators eszopiclone tabs
1 mg Generic eszopiclone tabs 2 mg Generic eszopiclone tabs 3 mg
Generic zolpidem tartrate tabs 10 mg Generic zolpidem tartrate tabs
5 mg Generic Sleep Disorders, Other armodafinil tabs 50 mg Generic
armodafinil tabs 150 mg Generic armodafinil tabs 200 mg Generic
armodafinil tabs 250 mg Generic modafinil tabs 100 mg Generic
modafinil tabs 200 mg Generic temazepam caps 15 mg Generic
temazepam caps 30 mg Generic Therapeutic
Nutrients/Minerals/Electrolytes Electrolyte/Mineral Modifiers
deferasirox tabs 90 mg Specialty DS deferasirox tabs 360 mg
Specialty DS deferoxamine mesylate solr 500 mg Generic deferoxamine
mesylate solr 2 gm Generic JADENU TABS 180 MG Specialty DS JADENU
TABS 360 MG Specialty DS JADENU TABS 90 MG Specialty DS kionex susp
15 gm/60ml Generic sodium polystyrene sulfonate powd Generic sodium
polystyrene sulfonate susp 15 gm/60ml Generic sps susp 15 gm/60ml
Generic SSKI SOLN 1 GM/ML Preferred Brand Electrolyte/Mineral
Replacement citric acid-sodium citrate soln 334-500 mg/5ml Generic
klor-con m20 tbcr 20 meq Generic K-PHOS TABS 500 MG Preferred Brand
K-TAB TBCR 10 MEQ Preferred Brand PHOSPHA 250 NEUTRAL TABS
155-852-130 MG Preferred Brand potassium chloride soln 20 meq/15ml
(10%) Generic PA potassium citrate er tbcr 5 meq (540 mg) Generic
potassium citrate er tbcr 10 meq (1080 mg) Generic potassium
citrate er tbcr 15 meq (1620 mg) Generic potassium citrate-citric
acid soln 1100-334 mg/5ml Generic sodium fluoride chew 0.55 (0.25
f) mg Generic sodium fluoride chew 1.1 (0.5 f) mg Generic sodium
fluoride chew 2.2 (1 f) mg Generic sodium fluoride soln 1.1 (0.5 f)
mg/ml Generic No USP Class cyanocobalamin soln 1000 mcg/ml Generic
multi-vit/fluoride soln 0.25 mg/ml Generic
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Last Updated 03/20/2020
multi-vit/fluoride soln 0.5 mg/ml Generic
multi-vit/fluoride/iron soln 0.25-10 mg/ml Generic
multivitamin/fluoride chew 0.25 mg Generic multivitamin/fluoride
chew 1 mg Generic polyvitamin/fluoride dro 0.5mg/ml Generic
poly-vit drops w/fluoride dro 0.25mg Generic
poly-vitamin/iron/fluoride dro /fl 0.25 Generic tri-vit/fluoride
soln 0.25 mg/ml Generic tri-vit/fluoride soln 0.5 mg/ml Generic
tri-vit/fluoride/iron soln 0.25-10 mg/ml Generic vitamin d
(ergocalciferol) caps 50000 unit Generic
-
Last Updated 03/20/2020
NONDISCRIMINATION NOTICE Kaiser Foundation Health Plan of the
Northwest (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: • Provide
no cost aids and services to people with disabilities to
communicate effectively with us,
such as: • Qualified sign language interpreters • Written
information in other formats, such as large print, audio, and
accessible electronic
formats
• Provide no cost language services to people whose primary
language is not English, such as: • Qualified interpreters •
Information written in other languages
If you need these services, call 1-800-813-2000 (TTY: 711) If
you believe that Kaiser Health Plan has failed to provide these
services or discriminated in another way on the basis of race,
color, national origin, age, disability, or sex, you can file a
grievance by mail or phone at: Member Relations, Attention: Kaiser
Civil Rights Coordinator, 500 NE Multnomah St. Ste 100, Portland,
OR 97232, telephone number: 1-800-813-2000. You can also file a
civil rights complaint with the U.S. Department of Health and Human
Services, Office for Civil Rights electronically through the Office
for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone
at: U.S. Department of Health and Human Services, 200 Independence
Avenue SW., Room 509F, HHH Building, Washington, DC 20201,
1-800-368-1019, 1-800-537-7697 (TDD). Complaint forms are available
at http://www.hhs.gov/ocr/office/file/index.html.
____________________________________________________________________
HELP IN YOUR LANGUAGE ATTENTION: If you speak English, language
assistance services, free of charge, are available to you. Call
1-800-813-2000 (TTY: 711).
አማርኛ (Amharic) ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ
ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-800-813-2000 (TTY: 711).
-1 ، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل
برقمالعربیةإذا كنت تتحدث : ملحوظة (Arabic) العربیة800-813-2000 )TTY
:711.(
中文 (Chinese)
注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電1-800-813-2000(TTY:711)。
اگر بھ زبان فارسی گفتگو می کنید، تسھیالت زبانی بصورت رایگان برای
شما فراھم می توجھ: (Farsi) فارسی تماس بگیرید. TTY) 1-800-813-2000:
711) باشد. با
Français (French) ATTENTION: Si vous parlez français, des
services d'aide linguistique vous sont proposés gratuitement.
Appelez le 1-800-813-2000 (TTY: 711).
Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen
Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung.
Rufnummer: 1-800-813-2000 (TTY: 711).
日本語 (Japanese)
注意事項:日本語を話される場合、無料の言語支援をご利用いただけます。1-800-813-2000(TTY:
711)まで、お電話にてご連絡ください。
-
Last Updated 03/20/2020
ែខ�រ (Khmer) ្របយ័ត�៖ េបើសិន�អ�កនិ�យ ��ែខ�រ, េស�ជំនួយែផ�ក��
េ�យមិនគិតឈ� �ល គឺ�ច�នសំ�ប់បំេរ �អ�ក។ ចូរ ទូរស័ព� 1-800-813-2000
(TTY: 711)។
한국어 (Korean) 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.
1-800-813-2000 (TTY: 711) 번으로 전화해 주십시오.
ລາວ (Laotian) ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ້ົາພາສາ ລາວ,
ການບໍລິການຊ່ວຍເຫືຼອດ້ານພາສາ, ໂດຍບ່ໍເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ
1-800-813-2000 (TTY: 711).
Naabeehó (Navajo) Díí baa akó nínízin: Díí saad bee yáníłti’go
Diné Bizaad, saad bee áká’ánída’áwo’dé̖é̖’, t’áá jiik’eh, éí ná
hóló̖, koji̖’ hódíílnih 1-800-813-2000 (TTY: 711).
Afaan Oromoo (Oromo) XIYYEEFFANNAA: Afaan dubbattu Oroomiffa,
tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama.
Bilbilaa 1-800-813-2000 (TTY: 711).
ਪੰਜਾਬੀ (Punjabi) ਿਧਆਨ ਿਦਓ: ਜੇ ਤਸੁ� ਪੰਜਾਬੀ ਬੋਲਦੇ ਹੋ, ਤ� ਭਾਸ਼ਾ ਿਵੱਚ
ਸਹਾਇਤਾ ਸਵੇਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਧ ਹੈ। 1-800-813-2000 (TTY: 711) 'ਤੇ
ਕਾਲ ਕਰੋ।
Română (Romanian) ATENȚIE: Dacă vorbiți limba română, vă stau la
dispoziție servicii de asistență lingvistică, gratuit. Sunați la
1-800-813-2000 (TTY: 711).
Pусский (Russian) ВНИМАНИЕ: если вы говорите на русском языке,
то вам доступны бесплатные услуги перевода. Звоните 1-800-813-2000
(TTY: 711).
Español (Spanish) ATENCIÓN: si habla español, tiene a su
disposición servicios gratuitos de asistencia lingüística. Llame al
1-800-813-2000 (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 1-800-813-2000 (TTY: 711).
ไทย (Thai) เรยีน: ถา้คณุพูดภาษาไทย
คณุสามารถใชบ้รกิารชว่ยเหลอืทางภาษาไดฟ้ร ีโทร 1-800-813-2000 (TTY:
711).
Українська (Ukrainian) УВАГА! Якщо ви розмовляєте українською
мовою, ви можете звернутися до безкоштовної служби мовної
підтримки. Телефонуйте за номером 1-800-813-2000 (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
1-800-813-2000 (TTY: 711).