Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014) - 1 - Southern Colorado Commercial HMO Formulary The following is a listing of the drugs on the Kaiser Permanente Southern Colorado Commercial HMO formulary. This Formulary applies only to outpatient drugs provided to members for self administration, and does not apply to medications used in inpatient settings or medications administered in a doctor’s office or infusion center. The formulary does not provide information regarding the specific coverage, limitations or quotas an individual member may have. Many members have specific exclusions, copays, or coinsurances that are not reflected in the Drug Formulary. Kaiser Permanente has many brand and generic medications on the formulary. In most cases, a generic equivalent is used. If a member requests a brand name when a generic equivalent is routinely used, the member will pay the difference in price between the generic equivalent and the requested brand plus the appropriate copay. How to use this Formulary document Products available in a generic form are listed by their generic name in italics. With the exception of drugs where multiple branded products exist, medications only available as a brand name product are listed in all CAPITAL letters. Please remember that this list is subject to change and will be updated at least quarterly. Any product not found in this listing or in subsequent updates, will be considered a non-formulary drug. You can search the Formulary by using the index, by using the “Find” function in Adobe Reader, or by therapeutic drug category. All dosage forms and strengths for a particular drug listed may not be formulary. Not all dosage forms of formulary drugs are covered under the prescription drug benefit. Some drugs are available in more than one dosage form (example: tablet and injectable). Restrictions on medication coverage: Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Restricted to specialty: A drug that needs to be written by a physician specialized in the treatment of certain conditions for the drug to be covered under the patient’s pharmacy benefit. For example, budesonide (oral), a drug used for colitis, is restricted to physicians specialized in Gastroenterology. Prior authorization: Some drugs require specific medical criteria be met prior to dispensing the drug for the patient’s pharmacy benefit. Quantity Limits or Quotas: For certain drugs, Kaiser Permanente limits the amount of medication dispensed to a certain quantity per copay. For example, the migraine medication Zomig ® is limited to 12 tablets per 30-day copay. Similar quantity limits exist for most migraine medications. In addition, other drugs are limited to a specific days supply. For example, Tarceva ® is limited to a 30-day supply. In addition, when there is a national shortage of a drug, we may limit the quantity of the drug dispensed per prescription per copayment. Restricted to Benefit: Some drugs are not covered unless the patient’s benefits specifically cover such medications. For example, Viagra ® and other drugs for sexual dysfunction are not covered unless the patient’s benefits specifically cover them. Step therapy: Some medications require a similar therapy be attempted first. For example, before lansoprazole can be dispensed, a drug such as omeprazole must be tried first.
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Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Southern Colorado Commercial HMO Formulary
The following is a listing of the drugs on the Kaiser Permanente Southern Colorado Commercial HMO formulary. This Formulary applies only to outpatient drugs provided to members for self administration, and does not apply to medications used in inpatient settings or medications administered in a doctor’s office or infusion center. The formulary does not provide information regarding the specific coverage, limitations or quotas an individual member may have. Many members have specific exclusions, copays, or coinsurances that are not reflected in the Drug Formulary. Kaiser Permanente has many brand and generic medications on the formulary. In most cases, a generic equivalent is used. If a member requests a brand name when a generic equivalent is routinely used, the member will pay the difference in price between the generic equivalent and the requested brand plus the appropriate copay.
How to use this Formulary document Products available in a generic form are listed by their generic name in italics. With the exception of drugs where multiple branded products exist, medications only available as a brand name product are listed in all CAPITAL letters. Please remember that this list is subject to change and will be updated at least quarterly. Any product not found in this listing or in subsequent updates, will be considered a non-formulary drug. You can search the Formulary by using the index, by using the “Find” function in Adobe Reader, or by therapeutic drug category. All dosage forms and strengths for a particular drug listed may not be formulary. Not all dosage forms of formulary drugs are covered under the prescription drug benefit. Some drugs are available in more than one dosage form (example: tablet and injectable).
Restrictions on medication coverage: Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
Restricted to specialty: A drug that needs to be written by a physician specialized in the treatment of certain conditions for the drug to be covered under the patient’s pharmacy benefit. For example, budesonide (oral), a drug used for colitis, is restricted to physicians specialized in Gastroenterology.
Prior authorization: Some drugs require specific medical criteria be met prior to dispensing the drug for the patient’s pharmacy benefit.
Quantity Limits or Quotas: For certain drugs, Kaiser Permanente limits the amount of medication dispensed to a certain quantity per copay. For example, the migraine medication Zomig
® is limited to
12 tablets per 30-day copay. Similar quantity limits exist for most migraine medications. In addition, other drugs are limited to a specific days supply. For example, Tarceva
® is limited to a 30-day supply.
In addition, when there is a national shortage of a drug, we may limit the quantity of the drug dispensed per prescription per copayment.
Restricted to Benefit: Some drugs are not covered unless the patient’s benefits specifically cover such medications. For example, Viagra
® and other drugs for sexual dysfunction are not covered
unless the patient’s benefits specifically cover them.
Step therapy: Some medications require a similar therapy be attempted first. For example, before lansoprazole can be dispensed, a drug such as omeprazole must be tried first.
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Medication Exception Process: Upon request, Kaiser Permanente may make an exception to our coverage rules. The following are examples of exception requests:
o Request to cover a drug that is not on our formulary o Request to waive coverage restrictions or limitations
Generally Kaiser Permanente will only approve requests for an exception if the alternative drugs included on the plan’s formulary, or existing utilization restrictions, would not be as effective in treating a condition or would cause adverse medical effects.
Key: * (asterisk) = A drug where at least one of the dosage forms is an injectable. Some patients have a specific self-injectable coinsurance. † (dagger) = Certain strengths or forms of the drug (e.g., tablet, gel, liquid) are only available as brand drugs and are subject to the brand cost share. MD = A drug that is required to be written by a physician specialized in the treatment of certain conditions. PA = A drug that requires specific medical criteria be met prior to dispensing for prescription benefit. QL = A drug that has a quantity limit or is limited to a specific day supply. RB = A drug that is restricted to a certain benefit for coverage. ST = A drug that requires another class of medications be attempted prior to dispensing for prescription benefit. This list of drugs should not be used to determine benefit issues such as prescription copay amounts. If you have questions about prescription benefits, please call Customer Service at 1-888-681-7878. The medications on this list are subject to change.
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
ANTIHISTAMINE DRUGS
FIRST GENERATION ANTIHISTAMINES
cyproheptadine hcl Generic
promethazine hcl Generic *
ANTIHISTAMINE DRUGS
SECOND GENERATION ANTIHISTAMINES
None
ANTI-INFECTIVE AGENTS
ANTHELMINTICS
ALBENZA Brand
BILTRICIDE Brand
STROMECTOL Brand
ANTI-INFECTIVE AGENTS
ANTIBACTERIALS
amoxicillin Generic
amoxicillin & potassium
clavulanate Generic/Brand †
ampicillin Generic/Brand †
AVELOX Brand
azithromycin Generic/Brand †
CAYSTON Brand PA
cefaclor Generic
cefadroxil Generic
cefdinir Generic
cefprozil Generic
cefuroxime axetil Generic/Brand †
cephalexin Generic
ciprofloxacin hcl Generic/Brand †
clarithromycin Generic
clindamycin hcl Generic/Brand †
dicloxacillin Generic
doxycycline Generic
erythromycin & sulfisoxazole Generic
erythromycin base Generic/Brand †
erythromycin ethylsuccinate Generic/Brand †
erythromycin stearate Brand
levofloxacin Generic
minocycline Generic
neomycin sulfate Generic/Brand †
NOROXIN Brand
penicillin V potassium Generic
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
SPECTRACEF Brand
sulfadiazine Generic
sulfamethoxazole & trimethoprim Generic
sulfasalazine Generic
SUPRAX Brand
tetracycline Generic/Brand †
TOBI Neb, TOBI Podhaler Brand QL
VANCOCIN Brand QL
ZYVOX Brand * MD, PA, QL
ANTI-INFECTIVE AGENTS
ANTIFUNGALS
fluconazole Generic
griseofulvin ultramicrosize Generic
itraconazole Generic/Brand † PA
ketoconazole Generic
nystatin Generic/Brand †
terbinafine Generic
voriconazole Generic MD
ANTI-INFECTIVE AGENTS
ANTIMYCOBACTERIALS
DAPSONE Brand
ethambutol Generic
isoniazid Generic
MYCOBUTIN Brand
pyrazinamide Generic
rifampin Generic
ANTI-INFECTIVE AGENTS
ANTIVIRALS
Abacavir sulfate Generic
acyclovir Generic
APTIVUS Brand
ATRIPLA Brand
BARACLUDE Brand
COMBIVIR Brand
CRIXIVAN Brand
didanosine Generic/Brand †
EMTRIVA Brand
EPIVIR HBV Brand
EPZICOM Brand
famciclovir Generic
ganciclovir Generic
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
HEPSERA Brand QL
INCIVEK Brand PA, QL
INFERGEN Brand * PA, QL
INTELENCE Brand
INVIRASE Brand
ISENTRESS Brand
KALETRA Brand
lamivudine Generic
LEXIVA Brand
nevirapine Generic
NORVIR Brand
PEGASYS Brand * PA, QL
PEG-INTRON Brand * PA, QL
PREZISTA Brand
RELENZA Brand QL
RESCRIPTOR Brand
REYATAZ Brand
ribavirin Generic/Brand † PA, QL
rimantadine Generic/Brand †
SELZENTRY Brand
stavudine Generic
SUSTIVA Brand
TAMIFLU Brand QL
TRIZIVIR Brand
TRUVADA Brand
TYZEKA Brand
VALCYTE Brand QL
VALTREX Brand
VIRACEPT Brand
VIREAD Brand
zidovudine Generic
ANTI-INFECTIVE AGENTS
ANTIPROTOZOALS
atovaquone/proguanil Generic
chloroquine phosphate Generic
DARAPRIM Brand
hydroxychloroquine sulfate Generic
mefloquine hcl Generic
metronidazole Generic
NEBUPENT Brand
paromomycin sulfate Generic
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
primaquine phosphate Brand
YODOXIN Generic
ANTI-INFECTIVE AGENTS
URINARY ANTI-INFECTIVES
belladonna alkaloids,
methenamine, methylene blue &
phenyl salicylate
Generic
nitrofurantoin macrocrystals Generic/Brand †
nitrofurantoin monohydrate
macrocystals Generic
nitrofurantoin suspension Generic
trimethoprim Generic/Brand †
ANTINEOPLASTIC AGENTS
ANTINEOPLASTIC AGENTS
AFINITOR Brand MD, QL
ALKERAN Brand *
anastrozole Generic
bicalutamide Generic
CEENU Brand
cyclophosphamide Brand
EMCYT Brand QL
etoposide Generic
exemestane Generic
flutamide Generic
GLEEVEC Brand MD, QL
HEXALEN Brand
hydroxyurea Generic
INTRON-A Brand * PA, QL
IRESSA Brand QL
letrozole Generic
LEUKERAN Brand
leuprolide acetate Generic/Brand *† PA, QL
LYSODREN Brand QL
MATULANE Brand QL
megestrol acetate Generic
mercaptopurine Generic
methotrexate Generic/Brand *†
MYLERAN Brand
NEXAVAR Brand MD, QL
NILANDRON Brand
SPRYCEL Brand QL
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
SUTENT Brand MD, QL
TABLOID Brand
tamoxifen citrate Generic
TARCEVA Brand QL
TARGRETIN Brand QL
temozolomide Generic QL
tretinoin Generic QL
TYKERB Brand QL
VOTRIENT Brand QL
XELODA Brand
XTANDI Brand PA, QL
ZELBORAF Brand PA, QL
ZOLINZA Brand QL
ZYTIGA Brand PA, QL
AUTONOMIC DRUGS
PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS
ARICEPT Brand
ARICEPT ODT Brand
bethanechol chloride Generic
EVOXAC Brand
galantamine hbr Generic
galantamine hbr (extended
release) Generic
PROSTIGMIN Brand
pyridostigmine bromide Generic/Brand †
AUTONOMIC DRUGS
ANTICHOLINERGIC AGENTS
belladonna alkaloids &
phenobarbital Generic/Brand †
chlordiazepoxide & clidinium Generic
dicyclomine hcl Generic
DONNATAL EXTENTABS Brand
glycopyrrolate Generic
hyoscyamine sulfate Generic
ipratropium bromide (inhaled) Generic/Brand †
ipratropium bromide (nasal) Generic
SPIRIVA Brand QL
AUTONOMIC DRUGS
SYMPATHOMIMETIC (ADRENERGIC) AGENTS
ADVAIR DISKUS Brand ST
ADVAIR HFA Brand ST
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
albuterol sulfate Generic/Brand †
COMBIVENT RESPIMAT Brand
DULERA Brand
epinephrine hcl Generic/Brand *† QL
levalbuterol hcl solution Generic ST
MAXAIR AUTOHALER Brand
metaproterenol sulfate Generic/Brand †
midodrine hcl Generic
SEREVENT DISKUS Brand
terbutaline sulfate Generic
XOPENEX HFA Brand ST
AUTONOMIC DRUGS
SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS
DIBENZYLINE Brand
dihydroergotamine mesylate Generic/Brand *† QL
ERGOMAR Brand QL
tamsulosin hcl Generic
AUTONOMIC DRUGS
SKELETAL MUSCLE RELAXANTS
baclofen Generic
carisoprodol Generic
carisoprodol & aspirin Generic
cyclobenzaprine hcl Generic
dantrolene sodium Generic
methocarbamol Generic/Brand *†
tizanidine hcl Generic
AUTONOMIC DRUGS
AUTONOMIC DRUGS, MISCELLANEOUS
NICOTROL Brand PA, QL
BLOOD FORMATION, COAGULATION, AND THROMBOSIS
ANTITHROMBOTIC AGENTS
anagrelide hcl Generic
BRILINTA Brand
cilostazol Generic
clopidogrel Generic
EFFIENT Brand * QL
fondaparinux Generic* QL
FRAGMIN Brand * QL
heparin sodium Generic/Brand *†
INNOHEP Brand * PA, QL
LOVENOX Brand * QL
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
warfarin sodium Generic
BLOOD FORMATION, COAGULATION AND THROMBOSIS
HEMATOPOIETIC AGENTS
EPOGEN Brand * PA, QL
LEUKINE Brand * PA, QL
NEULASTA Brand * PA, QL
PROCRIT Brand * PA, QL
BLOOD FORMATION, COAGULATION, AND THROMBOSIS
HEMORRHEOLOGIC AGENTS
pentoxifylline Generic
BLOOD FORMATION, COAGULATION, AND THROMBOSIS
ANTIHEMORRHAGIC AGENTS
aminocaproic acid Generic/Brand †
CARDIOVASCULAR DRUGS
CARDIAC DRUGS
amiodarone hcl Generic/Brand †
digoxin Generic/Brand †
disopyramide phosphate Generic/Brand †
flecainide acetate Generic
mexiletine hcl Generic
propafenone hcl Generic
quinidine gluconate Generic
quinidine sulfate Generic
TIKOSYN Brand
CARDIOVASCULAR DRUGS
ANTILIPEMIC AGENTS
cholestyramine Generic
CRESTOR Brand
fenofibrate Generic
fenofibrate (micronized) Generic
gemfibrozil Generic
lovastatin Generic
NIASPAN Brand PA
pravastatin Generic
simvastatin Generic
CARDIOVASCULAR DRUGS
HYPOTENSIVE AGENTS
clonidine hcl Generic
guanfacine hcl Generic
hydralazine hcl Generic
methyldopa Generic
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
reserpine Generic
CARDIOVASCULAR DRUGS
VASODILATING AGENTS
ADCIRCA Brand MD, QL
CAVERJECT Brand * QL, RB
CIALIS Brand QL, RB
dipyridamole Generic
EDEX Brand * QL, RB
isosorbide dinitrate Generic/Brand †
isosorbide mononitrate Generic
LETAIRIS Brand MD, QL
LEVITRA Brand QL, RB
MUSE Brand QL, RB
nitroglycerin Generic/Brand †
sildenafil citrate (REVATIO) Generic MD, QL
TRACLEER Brand MD, QL
VIAGRA Brand QL, RB
CARDIOVASCULAR DRUGS
ALPHA-ADRENERGIC BLOCKING AGENTS
doxazosin mesylate Generic
prazosin hcl Generic
terazosin hcl Generic
CARDIOVASCULAR DRUGS
BETA-ADRENERGIC BLOCKING AGENTS
acebutolol hcl Generic
atenolol Generic
atenolol & chlorthalidone Generic
bisoprolol fumarate Generic
bisoprolol fumarate &
hydrochlorothiazide Generic
BYSTOLIC Brand
carvedilol Generic
COREG CR Brand
labetalol hcl Generic
metoprolol succinate Generic
metoprolol tartrate Generic
nadolol Generic
pindolol Generic
propranolol hcl Generic
sotalol hcl Generic
CARDIOVASCULAR DRUGS
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
CALCIUM-CHANNEL BLOCKING AGENTS
amlodipine besylate Generic
amlodipine besylate & benazepril
hcl Generic/Brand †
CARDENE SR Brand
diltiazem hcl Generic/Brand †
EXFORGE Brand ST
EXFORGE HCT Brand ST
felodipine Generic
isradipine Generic/Brand †
nifedipine Generic
TARKA Brand
verapamil hcl Generic
CARDIOVASCULAR DRUGS
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS
benazepril & hydrochlorothiazide Generic
benazepril hcl Generic
captopril Generic
captopril & hydrochlorothiazide Generic
DIOVAN Brand ST
enalapril maleate Generic
fosinopril sodium Generic
fosinopril sodium &
hydrochlorothiazide Generic
lisinopril Generic
lisinopril & hydrochlorothiazide Generic
losartan potassium Generic
losartan potassium &
hydrochlorothiazide Generic
moexipril & hydrochlorothiazide Generic
moexipril hcl Generic
quinapril & hydrochlorothiazide Generic
quinapril hcl Generic
ramipril Generic
spironolactone Generic
spironolactone &
hydrochlorothiazide Generic
valsartan & hydrochlorothiazide Generic ST
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)