2020 kaiser permanente tricare formulary...2020 formulary kaiser permanente, a tricare ® prime...
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2020 Formulary
Kaiser Permanente, a TRICARE® Prime Option
This document includes the formulary for Kaiser Permanente, a TRICARE® Prime option. For the most up-to-date formulary, please visit our website at kp.org/TRICARE or call 1-833-642-
5973, Monday – Friday 7 a.m. to 7 p.m.
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 1
What is the Kaiser Permanente, a TRICARE® Prime Option Formulary? A formulary is a list of drugs determined to be safe and effective for our members by our Pharmacy and Therapeutics committee. Use of the formulary enables Kaiser Permanente to provide optimal care to you and your family at reasonable costs. Kaiser Permanente continually updates the formulary throughout the year based on new medical evidence, considering the recommendations of appropriate physician experts. Our physicians and pharmacists work closely together to ensure that our formulary meets your needs.
Does the formulary ever change? Yes, Kaiser Permanente periodically updates the formulary based on new medical evidence, considering the recommendations of appropriate physician experts and notifies our doctors, pharmacists, and other clinicians about any changes. If a change in the formulary affects any of your prescriptions, your doctor or pharmacist will let you know.
The enclosed formulary is effective as of January 1, 2020 and represents the most commonly prescribed medications.
How do I use the Formulary? There is an easy way to find your drug within the formulary:
To search for a specific medication or condition, press the ‘CTRL’ key and the
‘F’ key on your keyboard at the same time. In the search window that pops up, enter the text you want to search for and press ‘Enter.’ Press ‘Enter’ again to move to the next result.
Medical Condition The drugs on this formulary are grouped into categories depending on the type of medical condition that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Drugs.” If you know what your drug is used for, simply look for the category name in the list. Then look under the category name for your drug.
Alphabetical Listing If you are not sure what category to look under, you can look for the drug in the Index. The Index provides an alphabetical list of all the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to the drug, you will see the page number where you can find coverage information. Go to the page listed in the Index and find the name of your drug on the list.
What are generic drugs? Kaiser Permanente covers both brand-name drugs and generic drugs.
Generic drugs are produced and sold under their chemical names after the patent of the brand name drug expires. Although the price is lower, the
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 2
quality and effectiveness of generic drugs is the same as brand name drugs. The Federal Food and Drug Administration (FDA) requires that generic drugs contain the same active ingredients in the same amount as the brand name drug. Generic drugs are listed in lower-case italics (e.g., amoxicillin) within the formulary. Brand-name drugs are capitalized within the formulary (e.g., FLOVENT).
What are Formulary Brand name drugs? Formulary Brand name drugs are drugs that are produced and sold under the original manufacturer’s name. What are Non-Formulary Brand drugs? Non-Formulary Brand drugs are drugs that are not included on the plan's list of preferred prescription drugs.
Because all drug product strengths and package sizes of a formulary drug will be included in your plan’s benefits, just note the drug cost share coverage amount will be based on the specific tier of the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.
How much will I pay for Covered Drugs? What you pay for covered drugs is determined by the outpatient prescription drug benefit outlined in your Evidence of Coverage. Kaiser Permanente, a TRICARE Prime Option plan has a three-tier open formulary benefit.
Open formulary benefits have a generic cost sharing requirement. This means that if you choose to fill a brand name drug when a generic is available, then in addition to your standard cost share, you will also pay the difference in cost between the brand name and generic drug.
Generics drugs are those covered at the lowest cost share defined as Tier 1 coverage amount. Formulary brand drugs are those brands which will be covered at your formulary brand cost share defined as Tier 2 coverage amount. Non-formulary brands drugs are covered at the non-formulary cost share defined as Tier 3 coverage amount.
Coverage for prescription drugs is limited to drugs for which a prescription is required by law and those that are listed on the Kaiser Permanente, a TRICARE Prime Option drug formulary. Certain diabetic supplies do not require a prescription but must still be listed in our formulary in order to be covered under the benefit.
Each prescription refill is provided on the same basis as the original prescription. Cost shares are applied on a per prescription basis, for up to the lesser of the dispensing amount listed in the “Schedule of Benefits” or the standard prescription amount.
The standard prescription amount for the following items is:
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 3
• Migraine medications ― the smallest package size commercially available
• Ophthalmic and otic medications ― the smallest package size commercially available
• Oral and nasal inhalers ― the smallest standard package size
Are there any other restrictions on coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
• Quantity Limits (QL): For certain drugs, Kaiser Permanente limits the amount of the drug that will be covered.
• Age Restriction (Age): For certain drugs, Kaiser Permanente limits coverage based on a designated age.
• Prior Authorization (PA): For certain drugs, Kaiser Permanente requires review and authorization prior to dispensing. Your Provider must obtain this review and authorization. The list of prescription drugs requiring review and authorization is subject to periodic review and modification by our Pharmacy and Therapeutics Committee.
• Step Therapy (ST): For certain drugs, Kaiser Permanente requires the use of similar, alternative medications prior to coverage.
You can find out if the drug has any additional requirements or limits by looking in the Restrictions Column on the formulary list.
What if my drug is not on the Formulary? Because all drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.
For more information For more detailed information about your Kaiser Permanente, a TRICARE Prime Option prescription drug coverage, please review your Evidence of Coverage and other plan materials.
If you have questions about Kaiser Permanente, please call Member Services at 1-833-642-5973 or 770-291-4430, Monday through Friday 7:00 a.m. to 7 p.m. TTY/TDD users should call 1-800-255-0056.
Or visit kp.org/tricare.
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 4
Restrictions Tier Generic Name Brand Name Coverage Status
Antihistamine Drugs Antihistamine Drugs
ST 1 carbinoxamine maleate ARBINOXA Generic 1 cyproheptadine PERIACTIN Generic
1 chlorpheniramine, phenylephrine & pyrilamine POLY HIST FORTE Generic
1 promethazine & phenylephrine PHENERGAN VC Generic QL 1 promethazine PHENERGAN Generic
Anti-infective Agents Anthelmintics
2 albendazole ALBENZA Formulary Brand
1 ivermectin STROMECTOL Generic
PA, QL 3 ivermectin SOOLANTRA Non-Formulary Brand
ST 1 praziquantel BILTRICIDE Generic Anti-infectives, Miscellaneous
ST 3 bismuth subcitrate & metronidazole PYLERA Non-Formulary Brand
3 metronidazole, tetracycline & bismuth subsalicylate HELIDAC Non-Formulary
Brand
3 benznidazole benznidazole Non-Formulary Brand
Antibacterials
PA 3 amikacin liposomal Inhalation ARIKAYCE Non-Formulary Brand
1 amoxicillin AMOXIL Generic
1 amoxicillin & clavulanate potassium AUGMENTIN Generic
1 amoxicillin & clavulanate potassium extended-release AUGMENTIN XR Generic
1 ampicillin sodium AMPICILLIN Generic 1 azithromycin ZITHROMAX Generic 1 cefaclor CECLOR Generic 1 cefadroxil DURICEF Generic 1 cefdinir OMNICEF Generic
ST 1 cefditoren SPECTRACEF Generic
3 cefixime SUPRAX Non-Formulary Brand
1 cefixime solution SUPRAX Generic
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 5
Restrictions Tier Generic Name Brand Name Coverage Status
1 cefpodoxime VANTIN Generic 1 cefprozil CEFZIL Generic 1 cefuroxime axetil CEFTIN Generic 1 cephalexin KEFLEX Generic 1 ciprofloxacin CIPRO Generic 1 clarithromycin BIAXIN Generic 1 clarithromycin extended-release BIAXIN XL Generic 1 clindamycin hcl CLEOCIN HCL Generic
1 clindamycin palmitate CLEOCIN PEDIATRIC Generic
ST 3 delafloxacin BEXDELA Non-Formulary Brand
1 demeclocycline DECLOMYCIN Generic 1 dicloxacillin DYNAPEN Generic
3 doxycycline ORACEA Non-Formulary Brand
1 doxycycline hyclate PERIOSTAT Generic
3 doxycycline hyclate DORYX Non-Formulary Brand
1 doxycycline monohydrate ADOXA Generic 1 doxycycline monohydrate MONODOX Generic 1 erythromycin & sulfisoxazole E.S.P Generic 1 erythromycin base ERYTHROMYCIN Generic
1 erythromycin base delayed-release ERY-TAB Generic
1 erythromycin ethylsuccinate E.E.S. Generic
3 erythromycin ethylsuccinate ERYPED Non-Formulary Brand
3 erythromycin sterate ERYTHROCIN Non-Formulary Brand
ST 3 fidaxomicin DIFICID Non-Formulary Brand
1 gentamicin sulfate GARAMYCIN Generic 1 levofloxacin LEVAQUIN Generic 1 linezolid ZYVOX Generic 1 minocycline DYNACIN Generic 1 minocycline MINOCIN Generic 1 minocycline SOLODYN Generic
ST 1 moxifloxacin AVELOX Generic 1 neomycin sulfate MYCIFRADIN Generic
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 6
Restrictions Tier Generic Name Brand Name Coverage Status
3 norfloxacin NOROXIN Non-Formulary Brand
1 penicillin v potassium PEN-VEE K Generic
ST 3 omadacycline NUZYRA Non-Formulary Brand
ST, QL (200 mg only) 3 rifaximin XIFAXAN Non-Formulary
Brand 1 sulfadiazine SULFADIAZINE Generic 1 sulfamethoxazole & trimethoprim BACTRIM DS Generic 1 sulfamethoxazole & trimethoprim SEPTRA Generic 1 sulfasalazine AZULFIDINE Generic
ST 3 tedizolid SIVEXTRO Non-Formulary Brand
ST 3 telithromycin KETEK Non-Formulary Brand
1 tetracycline TETRACYCLINE Generic
3 tobramycin inhalation powder TOBI PODHALER Non-Formulary Brand
1 tobramycin inhalation solution TOBI Generic 1 Vancomycin capsule VANCOCIN Generic Antifungals
PA, QL 3 efinaconazole JUBLIA Non-Formulary Brand
QL 1 fluconazole DIFLUCAN Generic 1 flucytosine ANCOBON Generic 1 griseofulvin microsize GRIFULVIN V Generic 1 griseofulvin ultramicrosize GRIS-PEG Generic
3 isavuconazonium CRESEMBA Non-Formulary Brand
1 itraconazole SPORANOX Generic 1 ketoconazole NIZORAL Generic
3 luliconazole LUZU Non-Formulary Brand
1 nystatin MYCOSTATIN Generic
PA 3 posaconazole NOXAFIL Non-Formulary Brand
3 tavaborole KERYDIN Non-Formulary Brand
1 terbinafine LAMISIL Generic 1 voriconazole tablet VFEND Generic
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 7
Restrictions Tier Generic Name Brand Name Coverage Status
ST 3 voriconazole suspension VFEND Non-Formulary Brand
Antimycobacterials 1 cycloserine SEROMYCIN Generic 1 dapsone AVLOSULFON Generic 1 ethambutol MYAMBUTOL Generic
ST 3 ethionamide TRECATOR Non-Formulary Brand
1 isoniazid NYDRAZID Generic 1 pyrazinamide PYRAZINAMIDE Generic 1 rifabutin MYCOBUTIN Generic 1 rifampin RIFADIN Generic 1 rifampin & isoniazid RIFAMATE Generic
ST 3 rifampin, isoniazid, & pryazinamide RIFATER Non-Formulary Brand
3 rifapentine PRIFTIN Non-Formulary Brand
Antiprotozoals
ST 3 artemether & lumefantrine COARTEM Non-Formulary Brand
1 atovaquone MEPRON Generic ST 1 atovaquone & proguanil MALARONE Generic ST 1 chloroquine phosphate ARALEN Generic 1 hydroxychloroquine sulfate PLAQUENIL Generic
ST 1 mefloquine LARIAM Generic 1 metronidazole FLAGYL Generic
3 metronidazoleextended-release FLAGYL ER Non-Formulary Brand
PA 3 miltefosine IMPAVIDO Non-Formulary Brand
3 nitazoxanide ALINIA Non-Formulary Brand
1 paromomycin sulfate HUMATIN Generic
ST 3 pentamidine NEBUPENT Non-Formulary Brand
2 primaquine phosphate PRIMAQUINE Formulary Brand
PA 3 pyrimethamine DARAPRIM Non-Formulary Brand
ST 1 quinine sulfate QUALAQUIN Generic
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 8
Restrictions Tier Generic Name Brand Name Coverage Status
ST 3 secnidazole SOLOSEC Non-Formulary Brand
Antiviral QL 1 abacavir sulfate & lamivudine EPZICOM Generic
QL 2 abacavir sulfate solution ZIAGEN Formulary Brand
QL 1 abacavir sulfate tablet ZIAGEN Generic
3 abacavir, dolutegravir & lamivudine TRIUMEQ Non-Formulary
Brand
QL 1 abacavir, lamivudine & zidovudine TRIZIVIR Generic
1 acyclovir ZOVIRAX Generic QL,ST 1 adefovir dipivoxil HEPSERA Generic
3 atazanavir & cobicistat EVOTAZ Non-Formulary Brand
QL 2 atazanavir sulfate 150 mg REYATAZ Formulary Brand
QL 1 atazanavir sulfate 200 mg, 300 mg REYATAZ Generic
QL 2 bictegravir & emtricitabine & tenofovir BIKTARVY Formulary
Brand
QL 3 boceprevir VICTRELIS Non-Formulary Brand
PA 3 daclatasvir DAKLINZA Non-Formulary Brand
2 darunavir & cobicistat PREZCOBIX Non-Formulary Brand
QL 2 darunavir ethanolate PREZISTA Formulary Brand
QL 3 darunavir/cobicistat/FTC/tenofovir SYMTUZA Non-Formulary Brand
QL 2 delavirdine mesylate RESCRIPTOR Formulary Brand
QL 1 didanosine VIDEX EC Generic
QL 2 didanosine solution VIDEX Formulary Brand
2 dolutegravir TIVICAY Formulary Brand
QL 3 dolutegravir & rilpivirine JULUCA Non-Formulary Brand
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 9
Restrictions Tier Generic Name Brand Name Coverage Status
QL 3 dolutegravir & lamivudine DOVATO Non-Formulary Brand
QL 1 efavirenz 600 mg SUSTIVA Generic
QL 3 efavirenz, emtricitabine & tenofovir ATRIPLA Non-Formulary
Brand
QL 2 efavirenz 600 mg, lamivudine & tenofvir SYMFI Formulary
Brand
QL 3 efavirenz 400 mg, lamivudine & tenofvir SYMFI LO Non-Formulary
Brand
PA 3 elbasvir & grazoprevir ZEPATIER Non-Formulary Brand
QL 3 elvitegravir, cobicistat, emtricitabine, & tenofovir STRIBILD Non-Formulary
Brand
QL 2 elvitegravir, cobicistat, emtricitabine, & tenofovir GENVOYA Formulary
Brand
QL 2 emtricitabine EMTRIVA Formulary Brand
QL 2 emtricitabine & tenofovir TRUVADA Formulary Brand
QL 2 emtricitabine & tenofovir DESCOVY Formulary Brand
QL 3 emtricitabine, rilpivirine, & tenofovir COMPLERA Non-Formulary
Brand
QL 2 emtricitabine, rilpivirine, & tenofovir ODEFSEY Formulary
Brand
QL 2 enfuvirtide FUZEON Formulary Brand
QL 1 entecavir BARACLUDE Generic
QL 2 etravirine INTELENCE Formulary Brand
ST 1 famciclovir FAMVIR Generic
QL 2 fosamprenavir calcium LEXIVA Formulary Brand
1 ganciclovir CYTOVENE Generic
QL, PA 3 glecaprevir & pibrentasvir MAVYRET Non-Formulary Brand
QL 2 indinavir sulfate CRIXIVAN Formulary Brand
3 interferon alfacon-1 INFERGEN Non-Formulary Brand
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 10
Restrictions Tier Generic Name Brand Name Coverage Status
QL, ST 3 lamivudine EPIVIR HBV Non-Formulary Brand
QL 1 lamivudine EPIVIR Generic
QL 2 Lamidudine & tenofovir CIMDUO Formulary Brand
QL 1 lamivudine & zidovudine COMBIVIR Generic
ST 3 letermovir PREVYMIS Non-Formulary Brand
QL, PA 3 ledipasvir & sofosbuvir HARVONI Non-Formulary Brand
QL 2 lopinavir & ritonavir KALETRA Formulary Brand
QL 2 maraviroc SELZENTRY Formulary Brand
QL 2 nelfinavir mesylate VIRACEPT Formulary Brand
QL 1 nevirapine solution VIRAMUNE Generic QL 1 nevirapine tablet VIRAMUNE Generic
PA 3 ombitasvir, paritaprevir & ritonavir TECHNIVIE Non-Formulary Brand
QL, PA 3 ombitasvir, paritaprevir, ritonavir, & dasabuvir VIEKIRA Non-Formulary
Brand
QL, PA 2 sofosbuvir, velpatasvir, voxilaprevir VOSEVI Formulary Brand
QL 1 oseltamivir phosphate TAMIFLU Generic
3 palivizumab SYNAGIS Non-Formulary Brand
QL 2 peginterferon alfa-2a PEGASYS Formulary Brand
2 peginterferon-alfa 2b PEG-INTRON Formulary Brand
QL 2 raltegravir ISENTRESS Formulary Brand
QL 2 raltegravir (600mg) ISENTRESS HD Formulary Brand
1 ribavirin REBETOL Generic
QL 3 rilpivirine EDURANT Non-Formulary Brand
QL 1 rimantadine FLUMADINE Generic QL 1 ritonavir NORVIR Generic
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 11
Restrictions Tier Generic Name Brand Name Coverage Status
QL 2 saquinavir mesylate INVIRASE Formulary Brand
QL, PA 3 simeprevir OLYSIO Non-Formulary Brand
QL, PA 3 sofosbuvir SOVALDI Non-Formulary Brand
QL, PA 2 sofosbuvir & velpatasvir EPCLUSA Formulary Brand
QL 1 stavudine ZERIT Generic
QL 3 telaprevir INCIVEK Non-Formulary Brand
ST 3 telbivudine TYZEKA Non-Formulary Brand
QL 3 tenofovir VIREAD Non-Formulary Brand
QL 1 tenofovir 300 mg VIREAD Generic
QL, PA 3 tenofovir alafenamide VEMLIDY Non-Formulary Brand
QL 2 tipranavir APTIVUS Formulary Brand
ST 1 valacyclovir VALTREX Generic 1 valganciclovir VALCYTE Generic
QL 2 zanamivir RELENZA Formulary Brand
QL 1 zidovudine RETROVIR Generic Urinary Antiinfectives
ST 3 fosfomycin MONUROL Non-Formulary Brand
ST 1 methenamine hippurate HIPREX Generic
3
methenamine, sodium biphosphate, phenyl salicylate, methylene blue, and hyoscyamine
URELLE Non-Formulary Brand
2 nitrofurantoin FURADANTIN Formulary Brand
1 nitrofurantoin macrocrystal MACRODANTIN Generic 1 nitrofurantoin monohydrate MACROBID Generic 1 trimethoprim PROLOPRIM Generic
Antineoplastic Agents Antineoplastic Agents
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 12
Restrictions Tier Generic Name Brand Name Coverage Status
3 abemaciclib VERZENIO Non-Formulary Brand
2 abiraterone ZYTIGA Formulary Brand
3 acalabrutinib CALQUENCE Non-Formulary Brand
QL, PA 3 alpelisib PIQRAY BRAND 1 anastrozole ARIMIDEX Generic
3 axitinib INLYTA Non-Formulary Brand
2 bexarotene TARGRETIN Formulary Brand
1 bicalutamide CASODEX Generic
3 binimetinib MEKTOVI Non-Formulary Brand
3 bosutinib BOSULIF Non-Formulary Brand
2 busulfan MYLERAN Formulary Brand
1 capecitabine XELODA Generic
3 ceritinib ZYKADIA Non-Formulary Brand
2 chlorambucil LEUKERAN Formulary Brand
2 cobimetinib COTELLIC Formulary Brand
2 crizotinib XALKORI Formulary Brand
1 cyclophosphamide CYTOXAN Generic
3 dacomitinib VIZIMPRO Non-Formulary Brand
QL 2 dasatinib SPRYCEL Formulary Brand
QL, PA 3 darolutamide NUBEQA Non-Formulary Brand
3 enasidenib IDHIFA Non-Formulary Brand
3 encorafenib BRAFTOVI Non-Formulary Brand
2 enzalutamide XTANDI Formulary Brand
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 13
Restrictions Tier Generic Name Brand Name Coverage Status
2 erlotinib TARCEVA Formulary Brand
2 estramustine EMCYT Formulary Brand
QL 2 everolimus AFINITOR Formulary Brand
1 exemestane AROMASIN Generic
3 gilteritinib XOSPATA Non-Formulary Brand
3 glasdegib DAURISMO Non-Formulary Brand
1 flutamide EULEXIN Generic 1 hydroxyurea HYDREA Generic
2 hydroxyurea DROXIA Formulary Brand
QL 2 ibrutinib IMBRUVICA Formulary Brand
QL 3 Ibrutinib 140 mg, 280 mg IMBRUVICA Non-Formulary Brand
2 idelalisib ZYDELIG Formulary Brand
1 imatinib mesylate GLEEVEC Generic
3 ivosidenib TIBSOVO Non-Formulary Brand
2 ixazomib NINLARO Formulary Brand
2 lapatinib TYKERB Formulary Brand
QL 2 lenalidomide REVLIMID Formulary Brand
2 lenvatinib LENVIMA Formulary Brand
1 letrozole FEMARA Generic 1 leuprolide acetate LUPRON Generic
ST 1 lomustine GLEOSTINE Generic
3 lorlatinib LORBRENA Non-Formulary Brand
3 mechlorethamine VALCHLOR Non-Formulary Brand
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 14
Restrictions Tier Generic Name Brand Name Coverage Status
2 melphalan ALKERAN Formulary Brand
1 mercaptopurine PURINETHOL Generic
3 methotrexate RASUVO Non-Formulary Brand
3 methotrexate OTREXUP Non-Formulary Brand
ST 1 methotrexate sodium RHEUMATREX Generic
3 methotrexate sodium TREXALL Non-Formulary Brand
2 mitotane LYSODREN Formulary Brand
2 nilotinib TASIGNA Formulary Brand
ST 3 nilutamide NILANDRON Non-Formulary Brand
QL 2 niraparib ZEJULA Formulary Brand
QL 2 palbociclib IBRANCE Formulary Brand
2 pazopanib VOTRIENT Formulary Brand
QL 2 pomalidomide POMALYST Formulary Brand
3 ponatinib ICLUSIG Non-Formulary Brand
2 procarbazine MATULANE Formulary Brand
2 regorafenib STIVARGA Formulary Brand
3 ruxolitinib JAKAFI Non-Formulary Brand
2 sorafenib tosylate NEXAVAR Formulary Brand
2 sunitinib malate SUTENT Formulary Brand
3 talazoparib TALZENNA Non-Formulary Brand
1 tamoxifen citrate NOLVADEX Generic 1 temozolomide TEMODAR Generic
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 15
Restrictions Tier Generic Name Brand Name Coverage Status
2 thioguanine TABLOID Formulary Brand
2 topotecan HYCAMTIN Formulary Brand
ST 1 toremifene FARESTON Generic 1 tretinoin VESANOID Generic
2 trifluidine/tipiracil LONSURF Formulary Brand
2 vandetanib CAPRELSA Formulary Brand
2 vemurafenib ZELBORAF Formulary Brand
2 vorinostat ZOLINZA Formulary Brand
Autonomic Drugs Anticholinergic Agents
1 atropine sulfate ATROPINE SULFATE Generic 1 dicyclomine BENTYL Generic 1 glycopyrrolate ROBINUL Generic 1 glycopyrrolate ROBINULFORTE Generic
3 glycopyrrolate inhalation pow SEEBRI NEOHALER Non-Formulary Brand
ST 3 glycopyrrolate nebulizer soln LONHALA MAGNAIR
Non-Formulary Brand
1 hyoscyamine sulfate LEVBID Generic 1 hyoscyamine sulfate LEVSIN Generic 1 hyoscyamine sulfate SYMAX Generic
3 hyoscyamine sulfate SYMAX DUOTAB Non-Formulary Brand
1 ipratropium bromide ATROVENT Generic
2 ipratropium bromide ATROVENT HFA Formulary Brand
ST 1 methscopolamine PAMINE Generic 1 propantheline bromide PRO-BANTHINE Generic
ST 3 revefenacin YUPELRI Non-Formulary Brand
3 tiotropium SPIRIVA Non-Formulary Brand
2 tiotropium 2.5 mcg SPIRIVA RESPIMAT Formulary Brand
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 16
Restrictions Tier Generic Name Brand Name Coverage Status
3 tiotropium 1.25 mcg SPIRIVA RESPIMAT Non-Formulary Brand
3 umeclidinium INCRUSE ELLIPTA Non-Formulary Brand
Smoking Cessation Agents 1 nicotine gum NICORETTE Generic 1 nicotine lozenge NICORETTE Generic 1 nicotine patch NICODERM Generic
ST 3 nicotine spray NICOTROL Non-Formulary Brand
ST 3 varenicline CHANTIX Non-Formulary Brand
Parasympathomimetic (Cholinergic) Agents 1 bethanechol chloride URECHOLINE Generic 1 cevimeline hcl EVOXAC Generic 1 donepezil ARICEPT Generic 1 donepezil ARICEPT ODT Generic 1 galantamine hydrobromide RAZADYNE Generic 1 galantamine hydrobromide RAZADYNEER Generic 1 neostigmine bromide PROSTIGMIN Generic
ST 1 pilocarpine SALAGEN Generic 1 pyridostigmine MESTION TIMESPAN Generic 1 pyridostigmine MESTION Generic 1 rivastigmine tartrate EXELON Generic
2 rivastigmine tartrate (solution) EXELON Formulary Brand
Skeletal Muscle Relaxants 1 baclofen LIORESAL Generic
ST 1 carisoprodol SOMA Generic
ST 1 carisoprodol & aspirin SOMA COMPOUND Generic
1 chlorzoxazone PARAFON FORTE DSC Generic
1 cyclobenzaprine FLEXERIL Generic
3 cyclobenzaprine extended-release AMRIX Non-Formulary
Brand 1 dantrolene sodium DANTRIUM Generic
ST 1 metaxalone SKELAXIN Generic 1 methocarbamol ROBAXIN Generic 1 orphenadrine citrate NORFLEX Generic
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 17
Restrictions Tier Generic Name Brand Name Coverage Status
1 orphenadrine, aspirin, & caffeine NORGESIC Generic 1 tizanidine ZANAFLEX Generic Sympatholytic (Adrenergic Blocking) Agents
1 alfuzosin UROXATRAL Generic 1 dihydroergotamine mesylate D.H.E.45 Generic
2 dihydroergotamine mesylate MIGRANAL Formulary Brand
1 ergoloid mesylates HYDERGINE Generic 1 ergotamine & caffeine CAFERGOT Generic
ST 1 phenoxybenzamine DIBENZYLINE Generic
ST 3 silodosin RAPAFLO Non-Formulary Brand
1 tamsulosin hcl FLOMAX Generic Sympathomimetic (Adrenergic) Agents
1 albuterol nebulizer solution ACCUNEB Generic
3 albuterol sulfate PROAIR HFA Non-Formulary Brand
3 albuterol sulfate PROVENTIL HFA Non-Formulary Brand
2 albuterol sulfate VENTOLIN HFA Formulary Brand
3 albuterol sulfate & ipratropium COMBIVENT RESPIMAT
Non-Formulary Brand
1 albuterol sulfate & ipratropium DUONEB Generic 1 albuterol sulfate tablet VOSPIRE ER Generic
3 arformoterol BROVANA Non-Formulary Brand
3 droxidopa NORTHERA Non-Formulary Brand
1 epinephrine ADRENACLICK Generic
3 epinephrine AUVI-Q Non-Formulary Brand
3 epinephrine EPIPEN Non-Formulary Brand
3 epinephrine EPIPEN JR Non-Formulary Brand
3 epinephrine TWINJECT Non-Formulary Brand
3 formoterol fumarate FORADIL Non-Formulary Brand
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 18
Restrictions Tier Generic Name Brand Name Coverage Status
ST 1 levalbuterol nebulizer solution XOPENEX NEBULIZER Generic
ST 1 levalbuterol tartrate XOPENEX HFA Generic 1 midodrine hcl PROAMATINE Generic
2 olodaterol STRIVERDI RESPIMAT Formulary Brand
ST 3 pirbuterol acetate MAXAIR AUTOHALER
Non-Formulary Brand
1 terbutaline sulfate BRETHINE Generic
3 umeclidinium & vilanterol ANORO ELLIPTA Non-Formulary Brand
Blood Formation, Coagulation, and Thrombosis Coagulants and Anticoagulants
2 aminocaproic acid AMICAR Formulary Brand
1 anagrelide AGRYLIN Generic
ST 3 apixaban ELIQUIS Non-Formulary Brand
1 aspirin & dipyridamole AGGRENOX Generic
ST 3 betrixaban BEVYXXA Non-Formulary Brand
1 cilostazol PLETAL Generic 2 clopidogrel PLAVIX Generic
QL 2 dabigatran PRADAXA Formulary Brand
ST 3 dalteparin FRAGMIN Non-Formulary Brand
1 dipyridamole PERSANTINE Generic
ST 3 edoxaban SAVAYSA Non-Formulary Brand
1 enoxaparin LOVENOX Generic ST 1 fondaparinux ARIXTRA Generic 1 heparin HEPARIN SODIUM Generic 1 pentoxifylline TRENTAL Generic 1 prasugrel EFFIENT Generic
QL, ST 3 rivaroxaban XARELTO Non-Formulary Brand
2 ticagrelor BRILINTA Formulary Brand
ST 1 tranexamic acid LYSTEDA Generic
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 19
Restrictions Tier Generic Name Brand Name Coverage Status
3 vorapaxar ZONTIVITY Non-Formulary Brand
1 warfarin COUMADIN Generic Hematopoietic Agents
2 darbepoetin alfa ARANESP Formulary Brand
2 eltrombopag PROMACTA Formulary Brand
2 epoetin alfa PROCRIT Formulary Brand
3 epoetin alfa EPOGEN Non-Formulary Brand
3 filgrastim NEUPOGEN Non-Formulary Brand
2 filgrastim ZARXIO Formulary Brand
2 oprelvekin NEUMEGA Formulary Brand
3 pegfilgrastim NEULASTA Non-Formulary Brand
3 pegfilgrastim-jmdb FULPHILA Non-Formulary Brand
2 sargramostim LEUKINE Formulary Brand
Cardiovascular Drugs α-Adrenergic Blocking Agents
1 doxazosin CARDURA Generic
2 prazosin MINIPRESS Non-Formulary Brand
1 terazosin HYTRIN Generic Antilipemic Agents
1 atorvastatin LIPITOR Generic 1 cholestyramine light QUESTRAN LIGHT Generic 1 cholestyramine QUESTRAN Generic
ST 1 colesevelam WELCHOL Generic 1 colestipol COLESTID Generic 1 ezetimibe ZETIA Generic
3 ezetimibe & simvastatin VYTORIN Non-Formulary Brand
1 fenofibrate LOFIBRA TAB Generic
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 20
Restrictions Tier Generic Name Brand Name Coverage Status
1 fenofibrate TRICOR Generic 1 fenofibrate, micronized LOFIBRA CAP Generic 1 fenofibric acid TRILIPIX Generic
ST 1 fluvastatin extended-release LESCOL XL Generic ST 1 fluvastatin LESCOL Generic 1 gemfibrozil LOPID Generic
ST 3 icosapent VASCEPA Non-Formulary Brand
PA 3 lomitapide JUXTAPID Non-Formulary Brand
1 lovastatin MEVACOR Generic
3 lovastatine extended-release ALTOPREV Non-Formulary Brand
PA 3 mipomersen sodium KYNAMRO Non-Formulary Brand
ST 1 niacin NIASPAN Generic
3 niacin & lovastatin ADVICOR Non-Formulary Brand
1 omega-3 acid ethyl esters LOVAZA Generic
3 omega-3-carboxylic acid EPANOVA Non-Formulary Brand
ST 3 pitavastatin LIVALO Non-Formulary Brand
1 pravastatin PRAVACHOL Generic 1 rosuvastatin CRESTOR Generic 1 simvastatin ZOCOR Generic Calcium Channel Blocking Agents
1 amlodipine NORVASC Generic 1 amlodipine & benazepril LOTREL Generic 1 amlodipine & atorvastatin CADUET Generic
3 amlodipine & olmesartan AZOR Non-Formulary Brand
ST 1 amlodipine & telmisartan TWYNSTA Generic ST 1 amlodipine & valsartan EXFORGE Generic
ST 1 amlodipine, valsartan & hydrochlorothiazide EXFORGE HCT Generic
1 amlodipine, olmesartan & hydrochlorothiazide TRIBENZOR Generic
1 diltiazem extended-release CARDIZEM CD Generic 1 diltiazem extended-release TIAZAC Generic
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 21
Restrictions Tier Generic Name Brand Name Coverage Status
1 diltiazem extended-release CARTIA XT Generic 1 diltiazem extended-release CARDIZEM LA Generic 1 diltiazem CARDIZEM Generic 1 felodipine PLENDIL Generic
ST 1 isradipine DYNACIRC Generic 1 nicardipine CARDENE Generic 1 nifedipine PROCARDIA Generic 1 nifedipine extended-release ADALAT CC Generic 1 nifedipine extended-release PROCARDIA XL Generic 1 nimodipine NIMOTOP Generic
ST 1 nisoldipine SULAR Generic 1 trandolapril & verapamil TARKA Generic 1 verapamil sustained-release cap VERELAN Generic
3 verapamil COVERA-HS Non-Formulary Brand
1 verapamil extended-release cap VERELAN PM Generic 1 verapamil sustained-release cap CALAN SR Generic 1 verapamil sustained-release tab ISOPTIN SR Generic Cardiac Drugs
1 amiodarone PACERONE Generic 1 digoxin LANOXIN Generic 1 disopyramide NORPACE Generic
2 disopyramide controlled-release NORPACE CR Formulary Brand
1 dofetilide TIKOSYN Generic
ST 3 dronedarone MULTAQ Non-Formulary Brand
1 flecainide TAMBOCOR Generic
3 Ivabradine CORLANOR Non-Formulary Brand
1 mexiletine MEXITIL Generic 1 propafenone RYTHMOL Generic
3 propafenone RYTHMOL SR Non-Formulary Brand
1 quinidine gluconate QUINAGLUTE Generic 1 quinidine QUINIDINE SULFATE Generic
QL 1 ranolazine RANEXA Generic
3 sacubitril & valsartan ENTRESTO Non-Formulary Brand
Hypotensive Agents
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 22
Restrictions Tier Generic Name Brand Name Coverage Status
ST 1 clonidine extended-release KAPVAY Generic 1 clonidine CATAPRES Generic 1 clonidine transdermal CATAPRES-TTS Generic 1 guanfacine TENEX Generic 1 hydralazine APRESOLINE Generic 1 methyldopa ALDOMET Generic
1 methyldopa & hydrochlorothiazide ALDORIL-25 Generic
1 minoxidil LONITEN Generic
3 reserpine SERPASIL Non-Formulary Brand
Renin-Angiotensin-Aldosterone System Inhibitors
ST 3 aliskiren TEKTURNA Non-Formulary Brand
ST 3 aliskiren, amlodipine & hydrochlorothiazide AMTURNIDE Non-Formulary
Brand
3 aliskiren & amlodipine TEKAMLO Non-Formulary Brand
ST 3 aliskiren & hydrochlorothiazide TEKTURNA HCT Non-Formulary Brand
3 aliskiren & valsartan VALTURNA Non-Formulary Brand
ST 3 azilsartan EDARBI Non-Formulary Brand
1 benazepril LOTENSIN Generic 1 benazepril & hydrochlorothiazide LOTENSIN HCT Generic
ST 1 candesartan ATACAND Generic
ST 1 candesartan & hydrochlorothiazide ATACAND HCT Generic
1 captopril CAPOTEN Generic 1 captopril & hydrochlorothiazide CAPOZIDE Generic 1 enalapril VASOTEC Generic 1 enalapril & hydrochlorothiazide VASERETIC Generic
ST 1 eplerenone INSPRA Generic
ST 3 eprosartan TEVETEN Non-Formulary Brand
3 eprosartan & hydrochlorothiazide TEVETEN Non-Formulary Brand
ST 1 fosinopril MONOPRIL Generic ST 1 fosinopril & hydrochlorothiazide MONOPRIL HCT Generic
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 23
Restrictions Tier Generic Name Brand Name Coverage Status
ST 1 irbesartan AVAPRO Generic ST 1 irbesartan & hydrochlorothiazide AVALIDE Generic 1 lisinopril ZESTRIL Generic 1 lisinopril & hydrochlorothiazide ZESTORETIC Generic 1 losartan COZAAR Generic 1 losartan & hydrochlorothiazide HYZAAR Generic
ST 1 moexipril UNIVASC Generic ST 1 moexipril & hydrochlorothiazide UNIRETIC Generic ST 1 olmesartan BENICAR Generic ST 1 olmesartan & hydrochlorothiazide BENICAR HCT Generic ST 1 perindopril ACEON Generic ST 1 quinapril hcl ACCUPRIL Generic ST 1 quinapril & hydrochlorothiazide ACCURETIC Generic 1 ramipril ALTACE Generic
1 spironolactone & hydrochlorothiazide ALDACTAZIDE Generic
1 spironolactone ALDACTONE Generic ST 1 telmisartan MICARDIS Generic ST 1 telmisartan & hydrochlorothiazide MICARDIS HCT Generic ST 1 trandolapril MAVIK Generic ST 1 valsartan DIOVAN Generic ST 1 valsartan & hydrochlorothiazide DIOVAN HCT Generic
Vasodilating Agents
2 ambrisentan LETAIRIS Formulary Brand
2 bosentan TRACLEER Formulary Brand
3 isosorbide dinitrate & hydralazine BIDIL Non-Formulary Brand
1 isosorbide dinitrate ISORDIL Generic 1 isosorbide mononitrate IMDUR Generic
2 macitentan OPSUMIT Formulary Brand
3 nitroglycerin aerosol NITROMIST Non-Formulary Brand
1 nitroglycerin solution NITROLINGUAL Generic 1 nitroglycerin sublingual NITROSTAT Generic
2 nitroglycerin topical ointment NITRO-BID Formulary Brand
1 nitroglycerin transdermal patch NITRO-DUR Generic
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 24
Restrictions Tier Generic Name Brand Name Coverage Status
2 nitroglycerin transdermal patch 0.8 mg strength NITRO-DUR Formulary
Brand
ST 3 nitroglycerin (intra-anal) RECTIV Non-Formulary Brand
1 papaverine PAVABID Generic
3 riociguat ADEMPAS Non-Formulary Brand
1 sildenafil REVATIO Generic
3 tadalafil ADCIRCA Non-Formulary Brand
3 treprostinil ORENITRAM Non-Formulary Brand
2 treprostinil REMODULIN Formulary Brand
β-Adrenergic Blocking Agents 1 acebutolol SECTRAL Generic 1 atenolol TENORMIN Generic 1 atenolol & chlorthalidone TENORETIC Generic
ST 1 betaxolol KERLONE Generic 1 bisoprol & hydrochlorothiazide ZIAC Generic 1 bisoprolol ZEBETA Generic
1 carvedilol COREG Generic
3 carvedilol phosphate COREG CR Non-Formulary Brand
1 labetalol TRANDATE Generic 1 metoprol & hydrochlorothiazide LOPRESSOR HCT Generic 1 metoprolol succinate TOPROL XL Generic 1 metoprolol tartrate LOPRESSOR Generic 1 nadolol CORGARD Generic 1 nadolol & bendroflumethiazide CORZIDE Generic
ST 3 nebivolol BYSTOLIC Non-Formulary Brand
ST 3 penbutolol LEVATOL Non-Formulary Brand
ST 1 pindolol VISKEN Generic 1 propranolol & hydrochlorothiazide INDERIDE Generic
3 propranolol extended-release INNOPRAN XL Non-Formulary Brand
1 propranolol INDERAL Generic 1 propranolol sustained-release INDERAL LA Generic
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 25
Restrictions Tier Generic Name Brand Name Coverage Status
1 sotalol BETAPACE Generic 1 sotalol BETAPACE AF Generic 1 timolol BLOCADREN Generic
Central Nervous System Agents Analgesics and Antipyretics
1 acetaminophen & codeine TYLENOL W/ CODEINE Generic
1 acetaminophen, caffeine, & dihydrocodine PANLOR SS Generic
1 buprenorphine SUBUTEX Generic QL 1 buprenorphine& naloxone tablet SUBOXONE Generic
QL 3 buprenorphine & naloxone film SUBOXONE Non-Formulary Brand
QL, ST 1 buprenorphine transdermal BUTRANS Generic 1 butalbital & acetaminophen PHRENILIN Generic
3 butalbital & acetaminophen PHRENILIN FORTE Non-Formulary Brand
1 butalbital, acetaminophen, & caffeine FIORICET Generic
1 butalbital, acetaminophen, caffeine, & codeine
FIORICET W/ CODEINE Generic
1 butalbital, aspirin, & caffeine FIORINAL Generic
1 butalbital, aspirin, caffeine, & codeine
FIORINAL W/ CODEINE Generic
1 butorphanol tartrate STADOL Generic
ST 1 carisoprodol, aspirin, & codeine SOMA COMPOUND W/ CODEINE
Generic
ST 1 celecoxib CELEBREX Generic ST 1 codeine CODEINE SULF Generic 1 diclofenac potassium CATAFLAM Generic 1 diclofenac sodium VOLTAREN Generic 1 diclofenac sodium PENNSAID Generic 2 diclofenac sodium & misoprostol ARTHROTEC Generic
1 diclofenac sodium extended release VOLTAREN XR Generic
ST 1 diflunisal DIFLUNISAL Generic 1 etodolac LODINE Generic
ST 3 fenoprofen calcium NALFON Non-Formulary Brand
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 26
Restrictions Tier Generic Name Brand Name Coverage Status
3 fentanyl film ONSOLIS Non-Formulary Brand
3 fentanyl intranasal LAZANDA Non-Formulary Brand
1 fentanyl lozenge ACTIQ Generic
3 fentanyl sublingual ABSTRAL Non-Formulary Brand
3 fentanyl tablet FENTORA Non-Formulary Brand
QL 1 fentanyl transdermal DURAGESIC Generic ST 1 flurbiprofen ANSAID Generic
ST 3 hydrocodone ZOHYDRO ER Non-Formulary Brand
3 hydrocodone er HYSINGLA ER Non-Formulary Brand
1 hydrocodone & acetaminophen NORCO Generic 1 hydrocodone & ibuprofen VICOPROFEN Generic
3 hydromorphone oral suspension DILAUDID Non-Formulary Brand
1 hydromorphone tablet DILAUDID Generic
ST 3 hydromorphone tablet EXALGO Non-Formulary Brand
1 ibuprofen MOTRIN Generic 1 indomethacin INDOCIN Generic 1 ketoprofen KETOPROFEN Generic
QL 1 ketorolac tablet TORADOL Generic ST 1 levorphanol LEVO-DROMORAN Generic ST 1 meclofenamate MECLOMEN Generic
QL, ST 1 mefenamic acid PONSTEL Generic 1 meloxicam MOBIC Generic 1 meperidine tablet DEMEROL Generic 1 methadone DOLOPHINE Generic
2 morphine MORPHINE SULFATE Formulary Brand
1 morphine MSIR Generic
3 morphine beads AVINZA Non-Formulary Brand
3 morphine extended-relase capsule KADIAN Non-Formulary
Brand 1 morphine extended-release tablet MS CONTIN Generic
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 27
Restrictions Tier Generic Name Brand Name Coverage Status
ST 3 morphine & naltrexone EMBEDA Non-Formulary Brand
1 nabumetone RELAFEN Generic 1 nalbuphine NUBAIN Generic 1 naproxen NAPROSYN Generic 1 naproxen sodium ANAPROX Generic
3 naproxen sodium NAPRELAN Non-Formulary Brand
1 opium & belladonna alkaloids B & O SUPPRETTES Generic
3 opium tincture OPIUM Non-Formulary Brand
ST 1 oxaprozin DAYPRO Generic ST 1 oxycodone ROXICODONE Generic 1 oxycodone & acetaminophen PERCOCET Generic
2 oxycodone & acetaminophen ROXICET Formulary Brand
3 oxycodone & acetaminophen er XARTEMIS XR Non-Formulary Brand
1 oxycodone & aspirin PERCODAN Generic
QL 3 oxycodone & ibuprofen COMBUNOX Non-Formulary Brand
QL, ST 1 oxycodone controlled-release OXYCONTIN Generic ST 1 oxymorphone OPANA Generic ST 1 oxymorphone extended-release OPANA ER Generic 1 pentazocine & naloxone TALWIN NX Generic
ST 1 piroxicam FELDENE Generic 1 salsalate DISALCID Generic 1 sulindac CLINORIL Generic
QL, ST 3 tapentadol NUCYNTA Non-Formulary Brand
1 tolmetin sodium TOLECTIN 600 Generic 1 tramadol ULTRAM Generic 1 tramadol & acetaminophen ULTRACET Generic
ST 1 tramadol extended-release ULTRAM ER Generic Anorexigenic Agents and Respiratory and Cerebral Stimulants
ST 3 amphetamine sulfate EVEKEO Non-Formulary Brand
ST 3 amphetamine extended-release ADZENYS ER Non-Formulary Brand
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 28
Restrictions Tier Generic Name Brand Name Coverage Status
1 amphetamine & dextroamphetamine ADDERALL Generic
1 amphetamine & dextroamphetamine extended-release
ADDERALL XR Generic
ST 3 amphetamine & dextroamphetamine extended-release
MYDAYIS Non-Formulary Brand
QL, ST (ST-Brand
only) 1 armodafinil NUVIGIL Generic
QL 1 dexmethylphenidate FOCALIN Generic
ST 1 dexmethylphenidate extended-release FOCALIN XR Generic
QL 1 dextroamphetamine sulfate DEXTROSTAT Generic
QL 1 dextroamphetamine sulfate extended-release DEXEDRINE Generic
QL, ST 3 lisdexamfetamine VYVANSE Non-Formulary Brand
ST 1 methamphetamine DESOXYN Generic 1 methylphenidate METHYLIN Generic 1 methylphenidate RITALIN Generic
QL 1 methylphenidate extended-release METADATE ER Generic
QL 1 methylphenidate extended-release CONCERTA Generic
1 methylphenidate extended-release METADATE CD Generic
QL, ST 1 methylphenidate extended-release RITALIN LA Generic
QL 1 methylphenidate sustained release RITALIN SR Generic
QL, ST 3 methylphenidate transdermal patch DAYTRANA Non-Formulary
Brand
ST Methylphenidate extended-relesase disintegrating tablet COTEMPLA XR-ODT Non-Formulary
Brand QL 1 modafinil PROVIGIL Generic
Anticonvulsants 1 carbamazepine TEGRETOL Generic
1 carbamazepine extended-release cap CARBATROL Generic
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 29
Restrictions Tier Generic Name Brand Name Coverage Status
3 carbamazepine extended-release cap EQUETRO Non-Formulary
Brand
1 carbamazepine extended-release tab TEGRETOL XR Generic
3 clobazam ONFI Non-Formulary Brand
1 clonazepam KLONOPIN Generic 1 diazepam DIASTAT Generic
2 diazepam DIASTAT ACUDIAL Formulary Brand
1 divalproex sodium DEPAKOTE Generic
1 divalproex sodium capsule DEPAKOTE SPRINKLE Generic
1 divalproex sodium extended release DEPAKOTE ER Generic
3 eslicarbazepine APTIOM Non-Formulary Brand
ST 3 ethontoin PEGANONE Non-Formulary Brand
1 ethosuximide ZARONTIN Generic
ST 3 ezogaine POTIGA Non-Formulary Brand
ST 1 felbamate FELBATOL Generic 1 gabapentin NEURONTIN Generic
ST 3 gabapentin HORIZANT Non-Formulary Brand
QL, ST 3 lacosamide VIMPAT Non-Formulary Brand
1 lamotrigine LAMICTAL Generic 1 lamotrigine extended-release LAMICTAL XR Generic 1 levetiracetam KEPPRA Generic 1 levetiracetam extended-release KEPPRA XR Generic
2 methsuximide CELONTIN Formulary Brand
1 oxcarbazepine TRILEPTAL Generic
3 perampanel FYCOMPA Non-Formulary Brand
1 phenytoin sodium extended-release DILANTIN Generic
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 30
Restrictions Tier Generic Name Brand Name Coverage Status
1 phenytoin sodium extended-release PHENYTEK Generic
1 phenytoin suspension DILANTIN Generic ST 1 pregabalin LYRICA Generic 1 primidone MYSOLINE Generic
ST 3 rufinamide BANZEL Non-Formulary Brand
ST 1 tiagabine GABITRIL Generic
1 topiramate capsule TOPAMAX SPRINKLE Generic
1 topiramate tablet TOPAMAX Generic 1 valproate sodium DEPAKENE Generic 1 valproic acid DEPAKENE Generic
PA 3 vigabatrin SABRIL Non-Formulary Brand
1 zonisamide ZONEGRAN Generic Antimigraine Agents
ST 1 almotriptan AXERT Generic 1 ergotamine & caffeine MIGERGOT Generic
ST 1 eletriptan RELPAX Generic ST 1 frovatriptan FROVA Generic 1 naratriptan AMERGE Generic 1 rizatriptan MAXALT Generic 1 rizatriptan orally disintegrating MAXALT MLT Generic 1 sumatriptan IMITREX Generic
ST 1 zolmitriptan ZOMIG Generic 1 zolmitriptan orally disintegrating ZOMIG ZMT Generic Antiparkinsonian Agents
1 amantadine SYMMETREL Generic
ST 3 amantadine ER GOCOVRI Non-Formulary Brand
ST 3 apomorphine APOKYN Non-Formulary Brand
1 benztropine COGENTIN Generic 1 bromocriptine PARLODEL Generic
ST 3 bromocriptine CYCLOSET Non-Formulary Brand
1 cabergoline DOSTINEX Generic
ST 3 carbidopa LODOSYN Non-Formulary Brand
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 31
Restrictions Tier Generic Name Brand Name Coverage Status
1 carbidopa & levodopa SINEMET Generic
3 carbidopa & levodopa PARCOPA Non-Formulary Brand
1 carbidopa & levodopa extended release SINEMET CR Generic
2 carbidopa, levodopa, & entacapone STALEVO Formulary
Brand 1 entacapone COMTAN Generic 1 pramipexole MIRAPEX Generic 1 pramipexole extended-release MIRAPEX ER Generic
ST 3 rasagiline AZILECT Non-Formulary Brand
1 ropinirole REQUIP Generic ST 1 ropinirole extended-release REQUIP XL Generic
ST 3 rotigotine NEUPRO Non-Formulary Brand
1 selegiline ELDEPRYL Generic
ST 3 selegiline ZELAPAR Non-Formulary Brand
ST 3 selegiline transdermal EMSAM Non-Formulary Brand
2 tolcapone TASMAR Formulary Brand
1 trihexyphenidyl ARTANE Generic Anxiolytics, Sedatives, and Hypnotics
1 alprazolam XANAX Generic 1 alprazolam extended-release XANAX XR Generic
3 alprazolam orally disintegrating NIRAVAM Non-Formulary Brand
1 buspirone BUSPAR Generic 1 chlordiazepoxide LIBRIUM Generic 1 clorazepate TRANXENE Generic 1 diazepam VALIUM Generic
ST 3 doxepin (sleep) SILENOR Non-Formulary Brand
1 estazolam PROSOM Generic ST 1 eszopiclone LUNESTA Generic 1 flurazepam DALMANE Generic 1 hydroxyzine hcl ATARAX Generic
ST 1 hydroxyzine pamoate VISTARIL Generic
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 32
Restrictions Tier Generic Name Brand Name Coverage Status
1 lorazepam ATIVAN Generic 1 meprobamate MILTOWN Generic 1 oxazepam SERAX Generic 1 phenobarbital PHENOBARBITAL Generic
ST 1 ramelteon ROZEREM Generic
3 suvorexant BELSOMRA Non-Formulary Brand
PA 3 tasimelteon HETLIOZ Non-Formulary Brand
1 temazepam RESTORIL Generic 1 triazolam HALCION Generic 1 zaleplon SONATA Generic
3 zolipdem sublingual EDLUAR Non-Formulary Brand
1 zolpidem AMBIEN Generic
3 zolpidem extended-release AMBIEN CR Non-Formulary Brand
3 zolpidem oral spray ZOLPIMIST Non-Formulary Brand
Central Nervous System Agents Miscellaneous ST 1 acamprosate CAMPRAL Generic
ST 3 atomoxetine STRATTERA Non-Formulary Brand
PA 3 cannabidiol EPIDIOLEX Non-Formulary Brand
PA 3 deutetrabenazine AUSTEDO Non-Formulary Brand
ST 3 dextromethorphan & quinidine NUEDEXTA Non-Formulary Brand
1 guanfacine extended-release INTUNIV Generic
ST 3 lofexidine LUCEMYRA Non-Formulary Brand
1 memantine NAMENDA Generic
3 memantine er & donepezil NAMZARIC Non-Formulary Brand
QL, ST 3 milnacipran SAVELLA Non-Formulary Brand
1 riluzole RILUTEK Generic
PA solriamfetol SUNOSI Non-Formulary Brand
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 33
Restrictions Tier Generic Name Brand Name Coverage Status
PA 3 sodium oxybate XYREM Non-Formulary Brand
PA 3 tetrabenazine XENAZINE Non-Formulary Brand
PA 3 valbenazine INGREZZA Non-Formulary Brand
Opioid Antagonists 1 naloxone NARCAN Generic
QL 2 naloxone nasal spray NARCAN Formulary Brand
1 naltrexone REVIA Generic Psychotherapeutic Agents
1 amitriptyline ELAVIL Generic 1 amitriptyline & perphenazine TRIAVIL Generic 1 amoxapine ASENDIN Generic 1 aripiprazole tablet ABILIFY Generic
ST 3 aripiprazole solution ABILIFY Non-Formulary Brand
ST 3 aripiprazole ABILIFY DISCMELT Non-Formulary Brand
ST 3 asenapine SAPHRIS Non-Formulary Brand
QL, ST 3 brexpiprazole REXULTI Non-Formulary Brand
1 bupropion WELLBUTRIN Generic 1 bupropion extended-release WELLBUTRIN XL Generic
ST 3 bupropion hydrobromide APLENZIN Non-Formulary Brand
1 bupropion sustained-release WELLBUTRIN SR Generic
ST 3 bupropion (smoking deterrent) ZYBAN Non-Formulary Brand
QL, ST 3 cariprazine VRAYLAR Non-Formulary Brand
1 chlordiazepoxide & amitriptyline LIMBITROL DS Generic 1 chlorpromazine THORAZINE Generic 1 citalopram CELEXA Generic 1 clomipramine ANAFRANIL Generic 1 clozapine CLOZARIL Generic 1 clozapine FAZACLO Generic 1 desipramine NORPRAMIN Generic
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 34
Restrictions Tier Generic Name Brand Name Coverage Status
ST 1 desvenlafaxine succinate extended release PRISTIQ Generic
ST 1 desvenlafaxine extended release KHEDEZLA Generic 1 doxepin SINEQUAN Generic 1 duloxetine CYMBALTA Generic 1 escitalopram LEXAPRO Generic 1 fluoxetine PROZAC Generic
3 fluoxetine PROZAC WEEKLY Non-Formulary Brand
3 fluoxetine SARAFEM Non-Formulary Brand
1 fluphenazine PROLIXIN Generic 1 fluvoxamine LUVOX Generic 1 haloperidol HALDOL Generic
ST 3 iloperidone FANAPT Non-Formulary Brand
1 imipramine TOFRANIL Generic 1 imipramine pamoate TOFRANIL-PM Generic
ST 3 isocarboxazid MARPLAN Non-Formulary Brand
QL 3 levomilnacipran FETZIMA Non-Formulary Brand
1 lithium carbonate capsule LITHIUM CARBONATE Generic 1 lithium carbonate extended release LITHOBID Generic 1 lithium citrate CIBALITH-S Generic
ST 1 loxapine LOXITANE Generic
QL, ST 3 lurasidone LATUDA Non-Formulary Brand
ST 1 maprotiline LUDIOMIL Generic 1 mirtazapine REMERON Generic 1 nefazodone SERZONE Generic 1 nortriptyline PAMELOR Generic 1 olanzapine ZYPREXA Generic 1 olanzapine & fluoxetine hcl SYMBYAX Generic 1 olanzapine orally disintegrating ZYPREXA ZYDIS Generic
ST 1 paliperidone INVEGA Generic 1 paroxetine PAXIL Generic
3 paroxetine extended-release PAXIL CR Non-Formulary Brand
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 35
Restrictions Tier Generic Name Brand Name Coverage Status
3 paroxetine mesylate PEXEVA Non-Formulary Brand
1 perphenazine TRILAFON Generic 1 phenelzine NARDIL Generic
PA 3 pimavanserin NUPLAZID Non-Formulary Brand
ST 1 pimozide ORAP Generic ST 3 protriptyline VIVACTIL Generic 1 quetiapine SEROQUEL Generic 3 quetiapine extended-release SEROQUEL XR Generic 1 risperidone RISPERDAL Generic
3 risperidone orally disintegrating RISPERDALM-TAB Non-Formulary Brand
1 sertraline ZOLOFT Generic 1 thioridazine MELLARIL Generic 1 thiothixene NAVANE Generic 1 tranylcypromine sulfate PARNATE Generic 1 trazodone DESYREL Generic
3 trazodone extended-release OLEPTRO Non-Formulary Brand
1 trifluoperazine STELAZINE Generic ST 3 trimipramine SURMONTIL Generic 1 venlafaxine EFFEXOR Generic 1 venlafaxine extended-release EFFEXOR XR Generic
QL, ST 3 vilazodone VIIBRYD Non-Formulary Brand
QL, ST 3 vortioxetine TRINTELLIX Non-Formulary Brand
1 ziprasidone GEODON Generic Diabetic Supplies
Diabetic Supplies
QL 3 blood sugar diagnostic ONE TOUCH ULTRA TEST STRIPS
Non-Formulary Brand
QL 1 blood sugar diagnostic ONE TOUCH VERIO TEST STRIPS
Formulary Brand
QL 3 blood sugar diagnostic ACCU-CHEK TEST STRIPS
Non-Formulary Brand
QL 3 blood sugar diagnostic ASCENSIA TEST STRIPS
Non-Formulary Brand
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 36
Restrictions Tier Generic Name Brand Name Coverage Status
QL 3 blood sugar diagnostic FREESTYLE TEST STRIPS
Non-Formulary Brand
QL 3 blood sugar diagnostic PRODIGY TEST STRIPS
Non-Formulary Brand
QL 3 blood-glucose meter ONE TOUCH ULTRA 2
Non-Formulary Brand
QL 1 blood-glucose meter ONE TOUCH VERIO FLEX
Formulary Brand
QL 3 blood-glucose meter ACCU-CHEK Non-Formulary Brand
QL 3 blood-glucose meter ASCENSIA BREEZE Non-Formulary Brand
QL 3 blood-glucose meter FREESTYLE SYSTEM Non-Formulary Brand
QL 3 blood-glucose meter ONE TOUCH ULTRA SMART
Non-Formulary Brand
QL 3 blood-glucose meter ONE TOUCH ULTRAMINI
Non-Formulary Brand
QL 3 blood-glucose meter PRODIGY Non-Formulary Brand
QL 1 syringe with needle,disposable BD INSULIN SYRINGE Generic
Electrolytic, Caloric and Water Balance Acidifying and Alkalinizing Agents
3 citric acid, sodium citrate, & potassium citrate CYTRA-3 Non-Formulary
Brand 1 potassium citrate UROCIT-K Generic
2 potassium citrate & citric acid POLYCITRA-K Formulary Brand
3 sodium citrate & citric acid BICITRA Non-Formulary Brand
Ammonia Detoxicants
ST 3 carglumic acid CARBAGLU Non-Formulary Brand
PA 3 glycerol phenylbutyrate RAVICTI Non-Formulary Brand
3 sodium phenylbutyrate BUPHENYL Non-Formulary Brand
3 lactulose CHRONULAC Non-Formulary Brand
1 lactulose ENULOSE Generic
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 37
Restrictions Tier Generic Name Brand Name Coverage Status
3 lactulose KRISTALOSE Non-Formulary Brand
Diuretics ST 1 amiloride MIDAMOR Generic 1 amiloride & hydrochlorothiazide MODURETIC Generic 1 bumetanide BUMEX Generic
ST 1 chlorothiazide DIURIL Generic 1 chlorthalidone HYGROTON Generic
ST 3 ethacrynic acid EDECRIN Non-Formulary Brand
1 furosemide LASIX Generic 1 hydrochlorothiazide MICROZIDE Generic 1 indapamide LOZOL Generic
ST 1 methyclothiazide METHYCLOTHIAZIDE Generic 1 metolazone ZAROXOLYN Generic
PA 3 tolvaptan JYNARQUE Non-Formulary Brand
QL 3 tolvaptan SAMSCA Non-Formulary Brand
1 torsemide DEMADEX Generic
ST 3 triamterene DYRENIUM Non-Formulary Brand
1 triamterene & hydrochlorothiazide DYAZIDE Generic 1 triamterene & hydrochlorothiazide MAXZIDE Generic Ion-Removing Agnets
ST 1 sevelamer carbonate RENVELA Generic 1 sodium polystyrene sulfonate SPS Generic
3 sucroferric oxyhydroxide VELPHORO Non-Formulary Brand
ST 3 lanthanum carbonate FOSRENOL Non-Formulary Brand
3 patiromer VELTASSA Non-Formulary Brand
1 sevelamer hcl RENAGEL Generic
ST 3 sodium zirconium cyclosilicate LOKELMA Non-Formulary Brand
Replacement Products
2 calcium acetate ELIPHOS Formulary Brand
1 calcium acetate PHOSLO Generic
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 38
Restrictions Tier Generic Name Brand Name Coverage Status
2 calcium acetate PHOSLYRA Formulary Brand
1 potassium bicarbonate & potassium chloride K-LYTE/CL Generic
1 potassium chloride K-DUR Generic
1 potassium chloride K-TAB 10, KLOR-CON 20 MEQ Generic
3 potassium chrloide powder KLOR-CON 20 MEQ Non-Formulary Brand
1 potassium gluconate KAON Generic
2 potassium phosphate PHOSPHA Formulary Brand
3 potassium phosphate, monobasic K-PHOS NEUTRAL Non-Formulary Brand
2 potassium phosphate, monobasic K-PHOS ORIGINAL Formulary Brand
Uricosuric Agents 1 colchicine & probenecid COL-BENEMID Generic 1 probenecid BENEMID Generic
Enzymes Enzymes
2 dornase alfa PULMOZYME Formulary Brand
Eye, Ear, Nose and Throat (EENT) Anti-infectives
3 azithromycin (ophth) AZASITE Non-Formulary Brand
1 bacitracin & polmyxin B (ophth) POLYSPORIN Generic 1 bacitracin (ophth) AK-TRACIN Generic
ST 3 besilfoxacin BESIVANCE Non-Formulary Brand
1 chlorhexidine (mouth-throat) PERIDEX Generic
3 ciprofloxacin (ophth) ointment CILOXAN Non-Formulary Brand
1 ciprofloxacin (ophth) solution CILOXAN Generic 1 erythromycin (ophth) ROMYCIN Generic
ST 3 ganciclovir (ophth) ZIRGAN Non-Formulary Brand
ST 1 gatifloxacin (ophth) ZYMAXID Generic 1 gentamicin (ophth) GENTAK Generic
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 39
Restrictions Tier Generic Name Brand Name Coverage Status
1 levofloxacin (ophth) QUIXIN Generic 2 moxifloxacin (ophth) VIGAMOX Generic
2 natamycin NATACYN Formulary Brand
1 neomycin, bacitracin & polymyxin b (ophth) NEO-POLYCIN Generic
1 neomycin, polymycin b & gramicidin (ophth) NEOSPORIN Generic
1 ofloxacin (ophth) OCUFLOX Generic 1 ofloxacin (otic) FLOXIN Generic
1 polymyxin b & trimethoprim (ophth) POLYTRIM Generic
1 sulfacetamide sodium (ophth) ointment SULFAC Generic
1 sulfacetamide sodium (ophth) solution BLEPH-10 Generic
2 tobramycin sulfate (ophth) ointment TOBREX Formulary
Brand
1 tobramycin sulfate (ophth) solution TOBREX Generic
1 trifluridine VIROPTIC Generic Anti-Inflammatory Agents
1 bacitracin, neomycin, polymyxin B & hydrocortisone (ophth) NEO-POLYCIN HC Generic
ST 3 bromfenac (ophth) XIBROM Non-Formulary Brand
2 ciprofloxacin & dexamethasone (ophth) CIPRODEX Formulary
Brand
ST 3 ciprofloxacin & hydrocortisone (otic) CIPRO HC Non-Formulary
Brand
QL,ST 3 cyclosporine (ophth) CEQUA Non-Formulary Brand
QL, ST 3 cyclosporine (ophth) RESTASIS Non-Formulary Brand
1 dexamethasone (ophth) solution DECADRON Generic
2 dexamethasone (ophth) suspension MAXIDEX Formulary
Brand 1 diclofenac sodium (ophth) VOLTAREN Generic
ST 3 difluprednate DUREZOL Non-Formulary Brand
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 40
Restrictions Tier Generic Name Brand Name Coverage Status
ST 3 fluocinolone acetonide (otic) DERMOTIC Non-Formulary Brand
1 fluorometholone (ophth) FML Generic
3 fluorometholone (ophth) FML FORTE Non-Formulary Brand
ST 3 fluorometholone (ophth oint) FML OINT Non-Formulary Brand
2 fluorometholone acetate FLAREX Formulary Brand
ST 1 flurbiprofen (ophth) OCUFEN Generic
2 gentamicin & prednisolone PRED-G Formulary Brand
ST 1 hydrocortisone & acetic acid (otic) ACETASOL HC Generic
1 ketorolac (ophth) ACULAR Generic 1 ketorolac (ophth) ACULAR LS Generic
QL, ST 3 lifitegrast XIIDRA Non-preferrred
3 loteprednol ALREX Non-Formulary Brand
ST 3 loteprednol LOTEMAX Non-Formulary Brand
3 loteprednol & tobramycin ZYLET Non-Formulary Brand
3 neomycin, colistin, hydrocortisone & thonzonium (otic) CORTISPORIN-TC Non-Formulary
Brand
1 neomycin, polymyxin B & dexamethasone (ophth) MAXITROL Generic
3 neomycin, polymyxin B & hydrocortisone (ophth) CORTISPORIN Non-Formulary
Brand
1 neomycin, polymyxin B & hydrocortisone (otic) CORTISPORIN Generic
ST 3 nepafenac NEVANAC Non-Formulary Brand
1 prednisolone acetate (ophth) OMNIPRED Generic 1 prednisolone acetate (ophth) PRED FORTE Generic
2 prednisolone acetate (ophth) PRED MILD Formulary Brand
3 prednisolone sodium phosphate (ophth) INFLAMASE FORTE Non-Formulary
Brand
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 41
Restrictions Tier Generic Name Brand Name Coverage Status
1 prednisolone sodium phosphate (ophth) PREDNISOL Generic
ST 3 rimexolone VEXOL Non-Formulary Brand
1 sulfacetamide sodium & prednisolone BLEPHAMIDE Generic
2 tobramycin & dexamethasone ointment TOBRADEX Formulary
Brand
1 tobramycin & dexamethasone suspension TOBRADEX Generic
Antiallergic Agents
ST 3 aflcaftadine LASTACAFT Non-Formulary Brand
1 azelastine ASTELIN Generic 1 azelastine ASTEPRO Generic
3 azelastine & fluticasone DYMISTA Non-Formulary Brand
ST 1 azelastine (ophth) OPTIVAR Generic
ST 3 bepotastine BEPREVE Non-Formulary Brand
1 cromolyn sodium (ophth) OPTICROM Generic
ST 3 emedastine S Non-Formulary Brand
ST 1 epinastine (ophth) ELESTAT Generic
3 grass pollen allergen extract (5 glass extract) ORALAIR Non-Formulary
Brand
ST 3 lodoxamide tromethamine ALOMIDE Non-Formulary Brand
3 house dust mite allergen extract ODACTRA Non-Formulary Brand
ST 3 nedocromil sodium (ophth) ALOCRIL Non-Formulary Brand
ST 3 olopatadine PATADAY Non-Formulary Brand
ST 3 olopatadine (nasal) PATANASE Non-Formulary Brand
ST 1 olopatadine (ophth) PATANOL Generic
3 short ragweed pollen allergen extract RAGWITEK Non-Formulary
Brand
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 42
Restrictions Tier Generic Name Brand Name Coverage Status
3 timothy grass pollen allergen extract GRASTEK Non-Formulary
Brand Antiglaucoma Agents
1 acetazolamide DIAMOX Generic 1 acetazolamide DIAMOX SEQUELS Generic 1 betaxolol hcl BETOPTIC Generic
2 betaxolol hcl BETOPTIC S Formulary Brand
ST 3 bimatoprost LUMIGAN Non-Formulary Brand
1 brimonidine ALPHAGAN Generic 1 brimonidine tartrate ALPHAGAN P Generic
ST 3 brimonidine & timolol COMBIGAN Non-Formulary Brand
ST 3 brinzolamide AZOPT Non-Formulary Brand
2 carbachol ISOPTO CARBACHOL
Formulary Brand
ST 1 carteolol (ophth) OCUPRESS Generic 1 dorzolamide TRUSOPT Generic 1 dorzolamide & timolol COSOPT Generic
2 ecothiophate PHOSPHOLINE IODIDE
Formulary Brand
1 latanoprost XALATAN Generic
PA 3 latanoprostene bunod VYZULTA Non-Formulary Brand
1 levobunolol BETAGAN Generic 1 methazolamide NEPTAZANE Generic 1 metipranolol OPTIPRANOLOL Generic
PA 3 netarsudil RHOPRESSA Non-Formulary Brand
1 pilocarpine ISOPTO CARPINE Generic
3 pilocarpine gel PILOPINE HS Non-Formulary Brand
3 timolol BETIMOL Non-Formulary Brand
3 timolol ISTALOL Non-Formulary Brand
1 timolol TIMOPTIC Generic
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 43
Restrictions Tier Generic Name Brand Name Coverage Status
3 timolol TIMOPTIC-XE Non-Formulary Brand
ST 3 travoprost TRAVATAN Z Non-Formulary Brand
3 unoprostone isopropyl RESCULA Non-Formulary Brand
EENT Drugs, Miscellaneous 1 acetic acid VOSOL Generic
2 apraclonidine IOPIDINE Formulary Brand
ST 3 artificial tear insert LACRISERT Non-Formulary Brand
PA 3 cenegermin-bkbj OXERVATE Non-Formulary Brand
Local Anesthetics 1 antipyrine & benzocaine AURODEX Generic
1 lidocaine (mouth-throat) XYLOCAINE VISCOUS Generic
1 proparacaine OPTHETIC Generic Mydriatics
1 atropine ISOPTO ATROPINE Generic
2 homatropine ISOPTO HOMATROPINE
Formulary Brand
2 scopolamine (ophth) ISOPTO HYOSCINE Formulary Brand
Vasoconstrictors ST 1 tetrahydrozoline TYZINE Generic
Gastrointestinal Drugs Anti-inflammatory Agents 1 alosetron LOTRONEX Generic
1 balsalazide COLAZAL Generic
3 balsalazide GIAZO Non-Formulary Brand
PA 3 eluxadoline VIBERZI Non-Formulary Brand
2 mesalamine controlled-release PENTASA Formulary Brand
2 mesalamine suppository CANASA Formulary Brand
1 mesalamine suspension ROWASA Generic
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 44
Restrictions Tier Generic Name Brand Name Coverage Status
2 mesalamine tablet LIALDA Formulary Brand
ST 3 olsalazine DIPENTUM Non-Formulary Brand
Antidiarrhea Agents
ST 3 difenoxin & atropine MOTOFEN Non-Formulary Brand
1 diphenoxylate & atropine LOMOTIL Generic
3 paregoric PAREGORIC Non-Formulary Brand
Antiemetics
2 aprepitant EMEND Formulary Brand
ST 3 dolasetron ANZEMET Non-Formulary Brand
1 dronabinol MARINOL Generic
ST 3 granisetron KYTRIL Non-Formulary Brand
3 granisetron SANCUSO Non-Formulary Brand
ST 3 nabilone CESAMET Non-Formulary Brand
2 netupitant & palonosetron AKYNZEO Formulary Brand
1 ondansetron ZOFRAN Generic 1 ondansetron (orally disintegrating) ZOFRAN ODT Generic
QL 1 prochlorperazine COMPAZINE Generic
3 rolapitant VARUBI Non-Formulary Brand
ST 1 scopolamine hydrobromide TRANSDERM-SCOP Generic ST 1 trimethobenzamide TIGAN Generic
Antiulcer Agents and Acid Suppressants
3 amoxicillin, clarithromycin, & lansoprazole PREVPAC Non-Formulary
Brand 1 cimetidine TAGAMET Generic
ST 3 dexlansoprazole DEXILANT Non-Formulary Brand
ST 1 esomeprazole NEXIUM Generic 1 famotidine PEPCID Generic lansoprazole PREVACID Generic
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 45
Restrictions Tier Generic Name Brand Name Coverage Status
1 misoprostol CYTOTEC Generic ST 1 nizatidine AXID Generic 1 omeprazole PRILOSEC Generic 1 pantoprazole PROTONIX Generic
ST 1 rabeprazole ACIPHEX Generic 1 ranitidine ZANTAC Generic 1 sucralfate tablets CARAFATE Generic
3 sucralfate suspension CARAFATE Non-Formulary Brand
Cathartics and Laxatives
3 polyethylene glycol-electrolyte solution HALFLYTELY Non-Formulary
Brand
ST 3 polyethylene glycol-electrolyte solution MOVIPREP Non-Formulary
Brand
1 polyethylene glycol-electrolyte solution COLYTE Generic
1 polyethylene glycol-electrolyte solution GOLYTELY Generic
1 polyethylene glycol-electrolyte solution GAVILYTE-C Generic
1 polyethylene glycol-electrolyte solution NULYTELY Generic
ST 3 sodium phosphates OSMOPREP Non-Formulary Brand
3 sodium phosphates VISICOL Non-Formulary Brand
ST 3 sodium picosulfate-mag ox-anhyrous citric acid PREPOPIK Non-Formulary
Brand Digestants
2 pancrelipase (lipase-protease-amylase) CREON Formulary
Brand
2 pancrelipase (lipase-protease-amylase) ZENPEP Formulary
Brand
2 pancrelipase (lipase-protease-amylase) PANCREAZE Formulary
Brand
3 pancrelipase (lipase-protease-amylase) VIOKACE Non-Formulary
Brand
3 pancrelipase (lipase-protease-amylase) PERTZYE Non-Formulary
Brand GI Drugs, Miscellaneous
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 46
Restrictions Tier Generic Name Brand Name Coverage Status
1 clidinium & chlordiazepoxide LIBRAX Generic
QL, ST 3 linaclotide LINZESS Non-Formulary Brand
ST 3 lubiprostone AMITIZA Non-Formulary Brand
ST 3 mepenzolate CANTIL Non-Formulary Brand
1 metoclopramide REGLAN Generic
ST 3 methylnaltrexone RELISTOR Non-Formulary Brand
3 phenobarbital and belladonna alkaloids DONNATAL Non-Formulary
Brand
3 teduglutide GATTEX Non-Formulary Brand
1 ursodiol ACTIGALL Generic 1 ursodiol URSO Generic 1 ursodiol URSO FORTE Generic
Gold Compounds Gold Compounds
2 auranofin RIDAURA Formulary Brand
Heavy Metal Antagonists Heavy Metal Antagonists
2 deferasirox EXJADE Formulary Brand
3 deferiprone FERRIPROX Non-Formulary Brand
2 penicillamine CUPRIMINE Formulary Brand
2 penicillamine DEPEN Formulary Brand
ST 3 succimer CHEMET Non-Formulary Brand
ST 3 trientine SYPRINE Non-Formulary Brand
Hormones and Synthetic Substitutes Adrenals
ST 1 budesonide ENTOCORT EC Generic
3 budesonide UCERIS Non-Formulary Brand
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 47
Restrictions Tier Generic Name Brand Name Coverage Status
ST 1 cortisone acetate CORTONE ACETATE Generic 1 dexamethasone DECADRON Generic 1 fludrocortisone FLORINEF ACETATE Generic 1 hydrocortisone CORTEF Generic 1 methylprednisolone MEDROL Generic 1 prednisolone PRELONE Generic 1 prednisolone acetate PREDNISOLONE Generic 1 prednisolone sodium phosphate ORAPRED Generic 1 prednisolone sodium phosphate ORAPRED ODT Generic 1 prednisolone sodium phosphate PEDIAPRED Generic 1 prednisone PREDNISONE Generic
3 prednisone RAYOS Non-Formulary Brand
Anabolic Steroid
ST 3 oxymetholone ANADROL-50 Non-Formulary Brand
Androgens 1 danazol DANOCRINE Generic
2 fluoxymesterone ANDROXY Formulary Brand
2 methyltestosterone ANDROID 10 Formulary Brand
3 methyltestosterone METHITEST Non-Formulary Brand
1 methyltestosterone TESTRED Generic 1 oxandrolone OXANDRIN Generic
3 testosterone ANDRODERM Non-Formulary Brand
3 testosterone AXIRON Non-Formulary Brand
ST 1 testosterone ANDROGEL Generic 1 testosterone TESTIM Generic
3 testosterone FORTESTA Non-Formulary Brand
1 testosterone cypionate DEPO-TESTOSTERONE Generic
Contraceptives QL 1 desogestrel & ethinyl estradiol APRI Generic
QL 3 desogestrel & ethinyl estradiol DESOGEN Non-Formulary Brand
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 48
Restrictions Tier Generic Name Brand Name Coverage Status
QL 3 desogestrel & ethinyl estradiol ORTHO-CEPT Non-Formulary Brand
QL 1 desogestrel & ethinyl estradiol RECLIPSEN Generic
QL 1 desogestrel & ethinyl estradiol (biphasic) KARIVA Generic
QL 1 desogestrel & ethinyl estradiol (triphasic) CYCLESSA Generic
QL 1 desogestrel & ethinyl estradiol (triphasic) VELIVET Generic
QL 1 drospirenone & ethinyl estradiol GIANVI Generic QL 1 drospirenone & ethinyl estradiol OCELLA Generic QL 1 drospirenone & ethinyl estradiol YASMIN Generic QL 1 drospirenone & ethinyl estradiol YAZ Generic
QL 3 drospirenone & ethinyl estradiol w/ folate BEYAZ Non-Formulary
Brand
QL, ST 3 drospirenone & ethinyl estradiol w/ folate SAFYRAL Non-Formulary
Brand 1 estradiol cypionate DELESTROGEN Generic 1 estradiol valerate DEPO-ESTRADIOL Generic
QL, ST 3 estradiol valerate & dienogest NATAZIA Non-Formulary Brand
QL 1 ethynodiol diacetate & ethinyl estradiol KELNOR Generic
QL 1 ethynodiol diacetate & ethinyl estradiol ZOVIA Generic
QL 2 etonogestrel & ethinyl estradiol NUVARING Formulary Brand
AGE 1 levonorgestrel PLAN B Generic QL 1 levonorgestrel & ethinyl estradiol LUTERA Generic QL 1 levonorgestrel & ethinyl estradiol LESSINA Generic QL 1 levonorgestrel & ethinyl estradiol PORTIA Generic
QL 3 levonorgestrel & ethinyl estradiol NORDETTE-28 Non-Formulary Brand
QL 1 levonorgestrel & ethinyl estradiol (91-day) INTROVALE Generic
QL 3 levonorgestrel & ethinyl estradiol (91-day) LOSEASONIQUE Non-Formulary
Brand
QL 1 levonorgestrel & ethinyl estradiol (91-day) SEASONALE Generic
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 49
Restrictions Tier Generic Name Brand Name Coverage Status
QL 3 levonorgestrel & ethinyl estradiol (91-day) SEASONIQUE Non-Formulary
Brand
QL 1 levonorgestrel & ethinyl estradiol (continuous) AMYTHYST Generic
QL 3 levonorgestrel & ethinyl estradiol (continuous) LYPREL Non-Formulary
Brand
QL 1 levonorgestrel & ethinyl estradiol (triphasic) TRIVORA Generic
QL 3 norelgestromin & ethinyl estradiol ORTHO EVRA Non-Formulary Brand
QL, ST 1 norelgestromin & ethinyl estradiol XULANE Generic QL 1 norethindrone CAMILA Generic QL 1 norethindrone NORA-BE Generic
QL 3 norethindrone NOR-QD Non-Formulary Brand
QL 1 norethindrone & ethinyl estradiol BALZIVA Generic
QL 3 norethindrone & ethinyl estradiol BREVICON Non-Formulary Brand
QL 1 norethindrone & ethinyl estradiol JUNEL Generic QL 1 norethindrone & ethinyl estradiol MICROGESTIN Generic
QL 3 norethindrone & ethinyl estradiol MODICON Non-Formulary Brand
QL 1 norethindrone & ethinyl estradiol NECON Generic
QL 3 norethindrone & ethinyl estradiol NORINYL 1+35 Non-Formulary Brand
QL 1 norethindrone & ethinyl estradiol NORTREL 1/35 Generic QL 1 norethindrone & ethinyl estradiol OVCON-35 Generic
QL 3 norethindrone & ethinyl estradiol OVCON-50 Non-Formulary Brand
QL 1 norethindrone & ethinyl estradiol (biphasic) NECON 10/11 Generic
QL 1 norethindrone & ethinyl estradiol (triphasic) ARANELLE Generic
QL 1 norethindrone & ethinyl estradiol (triphasic) NORTREL 7/7/7 Generic
QL 3 norethindrone & ethinyl estradiol (triphasic) ORTHO-NOVUM Non-Formulary
Brand
QL 3 norethindrone & ethinyl estradiol (triphasic) TRI-NORINYL Non-Formulary
Brand
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 50
Restrictions Tier Generic Name Brand Name Coverage Status
QL 3 norethindrone & ethinyl estradiol w/ ferrous fumarate ESTROSTEP FE Non-Formulary
Brand
QL, ST 3 norethindrone & ethinyl estradiol w/ ferrous fumarate FEMCON FE Non-Formulary
Brand
QL 1 norethindrone & ethinyl estradiol w/ ferrous fumarate GENERESS FE Generic
QL 3 norethindrone & ethinyl estradiol w/ ferrous fumarate JUNEL FE Non-Formulary
Brand
QL 1 norethindrone & ethinyl estradiol w/ ferrous fumarate MICROGESTIN FE Generic
QL, ST 3 norethindrone & ethinyl estradiol w/ ferrous fumarate MINASTRIN 24 FE Non-Formulary
Brand
QL 3 norethindrone acetate & ethinyl estradiol w/ ferrous fumarate LOESTRIN 24 FE Non-Formulary
Brand
QL 3 norethindrone acetate & ethinyl estradiol w/ ferrous fumarate LOESTRIN FE Non-Formulary
Brand
QL 1 norethindrone acetate & ethinyl estradiol w/ ferrous fumarate TILIA Generic
QL, ST 3 norethindrone acetate & ethinyl estradiol w/ ferrous fumarate (biphasic)
LO LOESTRIN FE Non-Formulary Brand
QL 3 norethindrone-mestranol NORINYL 1+50 Non-Formulary Brand
QL 3 norethindrone-mestranol ORTHO-NOVUM Non-Formulary Brand
QL 1 norgestimate & ethinyl estradiol CRYSELLE Generic QL 1 norgestimate & ethinyl estradiol MONONESSA Generic
QL 3 norgestimate & ethinyl estradiol ORTHO-CYCLEN Non-Formulary Brand
QL 1 norgestimate & ethinyl estradiol SPRINTEC Generic QL 1 norgestimate & ethinyl estradiol TRINESSA Generic
QL 3 norgestimate & ethinyl estradiol (triphasic) ORTHO TRI-CYCLEN Non-Formulary
Brand
QL 1 norgestimate & ethinyl estradiol (triphasic) TRI-LO-SPRINTEC Generic
QL 1 norgestimate & ethinyl estradiol (triphasic) TRI-SPRINTEC Generic
QL 3 norgestrel & ethinyl estradiol LO/OVRAL-28 Non-Formulary Brand
QL 1 norgestrel & ethinyl estradiol LOW-OGESTREL Generic QL 1 norgestrel & ethinyl estradiol OGESTREL Generic
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 51
Restrictions Tier Generic Name Brand Name Coverage Status
2 ulipristal ELLA Formulary Brand
Diabetic Agents 1 acarbose PRECOSE Generic
PA 3 albiglutide TANZEUM Non-Formulary Brand
PA 3 alirocumab PRALUENT Non-Formulary Brand
PA 1 alogliptin NESINA Generic PA 1 alogliptin & metformin KAZANO Generic PA 1 alogliptin & pioglitazone OSENI Generic
PA 3 canagliflozin INVOKANA Non-Formulary Brand
PA 3 canagliflozin & metformin INVOKAMET Non-Formulary Brand
ST 1 chlorpropamide CHLORPROPAMIDE Generic
PA 3 dapagliflozin FARXIGA Non-Formulary Brand
PA 3 dapagliflozin & metformin XIGDUO XR Non-Formulary Brand
PA 3 dulaglutide TRULICITY Non-Formulary Brand
PA 3 empagliflozin JARDIANCE Non-Formulary Brand
PA 3 empagliflozin & lingaliptin GLYXAMBI Non-Formulary Brand
PA 3 empagliflozin & metformin SYNJARDY Non-Formulary Brand
PA 3 ertufliglozin STEGLATRO Non-Formulary Brand
PA 3 ertugliflozin & metformin SEGLUROMET Non-Formulary Brand
PA 3 ertugliflozin & sitagliptin STEGLUJAN Non-Formulary Brand
PA 3 evolocumab REPATHA Non-Formulary Brand
PA 3 exenatide BYETTA Non-Formulary Brand
PA 3 exenatide extended-release BYDUREON Non-Formulary Brand
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 52
Restrictions Tier Generic Name Brand Name Coverage Status
1 glimepiride AMARYL Generic 1 glipizide GLUCOTROL Generic 1 glipizide & metformin METAGLIP Generic 1 glipizide extended-release GLUCOTROL XL Generic
2 glucagon GLUCAGON EMERGENCY KIT
Formulary Brand
3 glucagon GLUCAGEN HYPOKIT
Non-Formulary Brand
1 glyburide DIABETA Generic 1 glyburide & metformin GLUCOVANCE Generic 1 glyburide micronized GLYNASE Generic
3 insulin (oral inhalation) AFREZZA Non-Formulary Brand
ST 3 insulin aspart NOVOLOG Non-Formulary Brand
ST 3 insulin aspart FIASP Non-Formulary Brand
ST 3 insulin aspart FIASP FlLEXPEN Non-Formulary Brand
ST 3 insulin aspart protamine & insulin aspart
NOVOLOG MIX 70/30
Non-Formulary Brand
ST 3 insulin aspart protamine & insulin aspart
NOVOLOG MIX 70/30 FLEXPEN
Non-Formulary Brand
ST 3 insulin degludec TRESIBA Non-Formulary Brand
3 insulin degludec/insulin aspart RYZODEG 70/30 Non-Formulary Brand
PA 3 Insulin degludec/ liraglutide XULTOPHY Non-Formulary Brand
ST 3 insulin detemir LEVEMIR Non-Formulary Brand
ST 3 insulin glargine LANTUS Non-Formulary Brand
ST 3 insulin glargine LANTUS SOLOSTAR Non-Formulary Brand
ST 3 insulin glargine BASAGLAR Non-Formulary Brand
PA 3 Insulin glargine/ lixisenatide SOLIQUA Non-Formulary Brand
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 53
Restrictions Tier Generic Name Brand Name Coverage Status
ST 3 insulin glulisine APIDRA Non-Formulary Brand
3 insulin isophane NOVOLIN N Non-Formulary Brand
2 insulin isophane HUMULIN N Formulary Brand
ST 3 insulin isophane HUMULIN N KWIKPEN
Non-Formulary Brand
3 insulin isophane & regular insulin NOVOLIN 70/30 Non-Formulary Brand
3 insulin isophane & regular insulin HUMULIN 50/50 Non-Formulary Brand
2 insulin isophane & regular insulin HUMULIN 70/30 Formulary Brand
ST 3 insulin isophane & regular insulin HUMULIN 70/30 KIWKPEN
Non-Formulary Brand
ST 3 insulin lispro HUMALOG Non-Formulary Brand
ST 3 insulin lispro HUMALOG KWIKPEN
Non-Formulary Brand
ST 3 insulin lispro ADMELOG Non-Formulary Brand
3 insulin lispro protamine & insulin lispro
HUMALOG MIX 50/50
Non-Formulary Brand
ST 3 insulin lispro protamine & insulin lispro
HUMALOG MIX 75/25
Non-Formulary Brand
ST 3 insulin lispro protamine & insulin lispro
HUMALOG MIX 75/25 KWIKPEN
Non-Formulary Brand
3 insulin regular NOVOLIN R Non-Formulary Brand
2 insulin regular HUMULIN R Formulary Brand
ST 2 insulin regular HUMULIN R U-500 Formulary Brand
PA 3 linagliptin TRADJENTA Non-Formulary Brand
PA 3 linagliptin & metformin JENTADUETO Non-Formulary Brand
PA 3 liraglutide VICTOZA Non-Formulary Brand
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 54
Restrictions Tier Generic Name Brand Name Coverage Status
PA 3 lixisenatide ADLYXIN Non-Formulary Brand
1 metformin GLUCOPHAGE Generic PA 1 metformin ER FORTAMET Generic PA 1 metformin ER GLUMETZA Generic
3 metformin RIOMET Non-Formulary Brand
1 metformin extended-release GLUCOPHAGE XR Generic
PA 3 mifepristone KORLYM Non-Formulary Brand
ST 3 miglitol GLYSET Non-Formulary Brand
ST 1 nateglinide STARLIX Generic 1 pioglitazone ACTOS Generic
3 pioglitazone & glimepiride DUETACT Non-Formulary Brand
3 pioglitazone & metformin ACTOPLUS MET Non-Formulary Brand
PA 3 pramlintide acetate SYMLIN Non-Formulary Brand
ST 1 repaglinide PRANDIN Generic ST 1 repaglinide & metformin PRANDIMET Generic
ST 3 rosiglitazone AVANDIA Non-Formulary Brand
ST 3 rosiglitazone & glimepiride AVANDARYL Non-Formulary Brand
ST 3 rosiglitazone & metformin AVANDAMET Non-Formulary Brand
PA 3 saxagliptin ONGLYZA Non-Formulary Brand
PA 3 saxagliptin & metformin extended-release KOMBIGLYZE XR Non-Formulary
Brand
PA 3 sitagliptin & metformin JANUMET Non-Formulary Brand
PA 3 sitagliptin & simvastatin JUVISYNC Non-Formulary Brand
PA 3 sitagliptin phosphate JANUVIA Non-Formulary Brand
ST 1 tolazamide TOLINASE Generic ST 1 tolbutamide ORINASE Generic
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 55
Restrictions Tier Generic Name Brand Name Coverage Status
Estrogens and Antiestrogens
3 conjugated estrogens & bazedoxifene DUAVEE Non-Formulary
Brand
3 conjugated estrogens & medroxyprogesterone acetate PREMPHASE Non-Formulary
Brand
3 conjugated estrogens & medroxyprogesterone acetate PREMPRO Non-Formulary
Brand
3 drospirenone & estradiol ANGELIQ Non-Formulary Brand
ST 3 esterified estrogens MENEST Non-Formulary Brand
1 estradiol ESTRACE TAB Generic 1 estradiol GYNODIOL Generic
ST 3 estradiol & levonorgestrel CLIMARA PRO Non-Formulary Brand
1 estradiol & norethindrone ACTIVELLA Generic
ST 3 estradiol & norethindrone COMBIPATCH Non-Formulary Brand
3 estradiol & norgestimate PREFEST Non-Formulary Brand
3 estradiol acetate FEMTRACE Non-Formulary Brand
ST 3 estradiol acetate vaginal tablets FEMRING Non-Formulary Brand
ST 3 estradiol gel DIVIGEL Non-Formulary Brand
ST 3 estradiol gel ELESTRIN GEL Non-Formulary Brand
ST 3 estradiol transdermal ALORA Non-Formulary Brand
1 estradiol transdermal CLIMARA DIS Generic
3 estradiol transdermal ESTRADERM Non-Formulary Brand
ST 3 estradiol transderomal EVAMIST Non-Formulary Brand
ST 3 estradiol transdermal MENOSTAR Non-Formulary Brand
1 estradiol transdermal MINIVELLE Generic
ST 3 estradiol transdermal VIVELLE-DOT Non-Formulary Brand
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 56
Restrictions Tier Generic Name Brand Name Coverage Status
1 estradiol vaginal ESTRACE CREAM Generic
2 estradiol vaginal ESTRING Formulary Brand
2 estradiol vaginal 10 mg VAGIFEM Formulary Brand
3 estradiol vaginal VAGIFEM Non-Formulary Brand
1 estradiol vaginal YUVAFEM Generic 1 estradiol vaginal ESTRACE Generic 1 estrogen, ester/me-testosterone ESTRATEST Generic
ST 3 estrogens, conjugated PREMARIN Non-Formulary Brand
3 estrogens, conjugated synthetic a CENESTIN Non-Formulary Brand
ST 3 estrogens, conjugated synthetic b ENJUVIA Non-Formulary Brand
ST 2 estrogens, conjugated vaginal PREMARIN CREAM Formulary Brand
1 estropipate ORTHO-EST Generic
1 norethindrone acetate & ethinyl estradiol FEMHRT Generic
3 ospemifene OSPHENA Non-Formulary Brand
1 raloxifene hcl EVISTA Generic Gonadatropins
2 nafarelin SYNAREL Formulary Brand
Parathyroid
PA 3 abaloparatide TYMLOS Non-Formulary Brand
ST 1 calcitonin salmon FORTICAL Generic ST 1 calcitonin salmon MIACALCIN Generic
PA 3 teriparatide FORTEO Non-Formulary Brand
Pitutary
PA 3 corticotropin ACTHAR Non-Formulary Brand
1 desmopressin (non-refrigerated) DDAVP Generic
3 desmopressin acetate STIMATE Non-Formulary Brand
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 57
Restrictions Tier Generic Name Brand Name Coverage Status
Progestins 1 medroxyprogesterone acetate PROVERA Generic 1 megestrol acetate MEGACE Generic 1 norethindrone acetate AYGESTIN Generic 1 progesterone, micronized PROMETRIUM Generic Somatotropin Agonists and Antagonists
PA 3 somatropin GENTROPIN Non-Formulary Brand
PA 3 somatropin HUMATROPE Non-Formulary Brand
PA 3 somatropin NORDITROPIN Non-Formulary Brand
PA 3 somatropin NUTROPIN AQ Non-Formulary Brand
PA 3 somatropin OMNITROPE Non-Formulary Brand
PA 3 somatropin SAIZEN Non-Formulary Brand
PA 3 somatropin SEROSTIM Non-Formulary Brand
PA 3 pegvisomant SOMAVERT Non-Formulary Brand
PA 3 somatropin ZORBTIVE Non-Formulary Brand
Thyroid and Antihyroid Agent 1 levothyroxine LEVOTHROID Generic 1 levothyroxine LEVOXYL Generic 1 levothyroxine SYNTHROID Generic
3 levothyroxine TIROSINT Non-Formulary Brand
1 levothyroxine UNITHROID Generic 1 liothyronine CYTOMEL Generic
ST 3 liotrix THYROLAR Non-Formulary Brand
1 methimazole TAPAZOLE Generic 2 potassium iodide & iodine LUGOL’S SOLUTION Brand 1 propylthiouracil PROPYLTHIOURACIL Generic
3 thyroid ARMOUR THYROID Non-Formulary Brand
Miscellaneous Therapeutic Agents
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 58
Restrictions Tier Generic Name Brand Name Coverage Status
Miscellanous Therapeutic Agents
2 abatacept ORENCIA Formulary Brand
1 acetylcysteine MUCOMYST-10 Generic
2 adalimumab HUMIRA Formulary Brand
ST 3 adalimumab HUMIRA citrate free
Non-Formulary Brand
1 alendronate FOSAMAX Generic
3 alendronate & cholecalciferol FOSAMAX PLUS D Non-Formulary Brand
1 allopurinol ZYLOPRIM Generic
PA 3 amifampridine FIRDAPSE Non-Formulary Brand
3 anakinra KINERET Non-Formulary Brand
2 apremilast OTEZLA Formulary Brand
1 azathioprine AZASAN Generic 1 azathioprine IMURAN Generic
PA 3 baricitnib OLUMIANT Non-Formulary Brand
3 bedaquiline SIRTURO Non-Formulary Brand
ST 3 betaine CYSTADANE POWD Non-Formulary Brand
PA 3 brodalumab SILIQ Non-Formulary Brand
PA 3 c-1 esterase inhibitor HAEGARDA Non-Formulary Brand
PA 3 canakinumab ILARIS Non-Formulary Brand
PA 3 cholic acid CHOLBAM Non-Formulary Brand
2 cinacalcet SENSIPAR Formulary Brand
ST 1 colchicine COLCRYS Generic 1 cyclosporine SANDIMMUNE Generic 1 cyclosporine, modified NEORAL Generic
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 59
Restrictions Tier Generic Name Brand Name Coverage Status
PA 3 cysteamine delayed-release PROCYSBI Non-Formulary Brand
ST 3 cysteamine immediate-release CYSTAGON Non-Formulary Brand
1 dalfampridine AMPYRA Generic
QL, PA 3 dichlorphenamide KEVEYIS Non-Formulary Brand
PA 3 daflazacort EMFLAZA Non-Formulary Brand
PA 3 dimethyl fumarate TECFIDERA Non-Formulary Brand
PA 3 dupilumab DUPIXENT Non-Formulary Brand
1 disulfiram ANTABUSE Generic ST 1 dutasteride AVODART Generic 1 dutasteride & tamsulosin JALYN Generic
PA 3 elagolix ORILISSA Non-Formulary Brand
PA 3 eliglustat CERDELGA Non-Formulary Brand
PA 3 emicizumab-kxwh HEMLIBRA Non-Formulary Brand
PA 3 erenumab-aooe AIMOVIG Non-Formulary Brand
2 etanercept ENBREL Formulary Brand
ST 1 etidronate DIDRONEL Generic
3 everolimus ZORTRESS Non-Formulary Brand
ST 3 febuxostat ULORIC Non-Formulary Brand
PA 3 fingolimod GILENYA Non-Formulary Brand
PA 3 fostamatinib TAVALISSE Non-Formulary Brand
PA 3 galcanezumab EMGALITY Non-Formulary Brand
PA 3 guselkumab TREMFYA Non-Formulary Brand
PA 3 glatiramer acetate COPAXONE 20 mg Non-Formulary Brand
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 60
Restrictions Tier Generic Name Brand Name Coverage Status
1 glatiramer acetate COPAXONE 40 mg Generic 1 glatiramer acetate GLATOPA Generic
3 golimumab SIMPONI Non-Formulary Brand
ST 1 ibandronate BONIVA Generic
PA 3 icatibant FIRAZYR Non-Formulary Brand
PA 3 immune globulin HYQVIA Non-Formulary Brand
PA 3 Immune globulin HIZENTRA Non-Formulary Brand
PA 3 Inotersen TEGSEDI Non-Formulary Brand
PA 3 interferon beta-1a AVONEX Non-Formulary Brand
PA 3 interferon beta-1a PLEGRIDY Non-Formulary Brand
PA 3 interferon beta-1a REBIF Non-Formulary Brand
PA 3 interferon beta-1a REBIF REBIDOSE Non-Formulary Brand
3 interferon beta-1b BETASERON Non-Formulary Brand
2 Interferon beta-1b EXTAVIA Formulary Brand
2 interferon gamma-1b ACTIMMUNE Formulary Brand
PA 3 ixekizumab TALTZ Non-Formulary Brand
PA 3 lanadelumab TAKHZYRO Non-Formulary Brand
3 lanreotide SOMATULINE DEPOT
Non-Formulary Brand
3 lesinurad ZURAMPIC Non-Formulary Brand
1 leflunomide ARAVA Generic 1 leucovorin LEUCOVORIN Generic
PA 3 l-glutamine ENDARI Non-Formulary Brand
2 mesna MESNEX Formulary Brand
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 61
Restrictions Tier Generic Name Brand Name Coverage Status
1
methenamine, sodium biphosphate, phenyl salicylate, methylene blue, and hyoscyamine
URO-MP Generic
1 methylergonovine maleate METHERGINE Generic
3 metreleptin MYALEPT Non-Formulary Brand
3 mifepristone MIFEPREX Non-Formulary Brand
PA 3 migalastat GALAFOLD Non-Formulary Brand
PA 3 miglustat ZAVESCA Non-Formulary Brand
1 mycophenolate mofetil CELLCEPT Generic 1 mycophenolate sodium MYFORTIC Generic
3 nitisinone ORFADIN Non-Formulary Brand
1 octreotide acetate SANDOSTATIN Generic
PA 3 parathyroid hormone NATPARA Non-Formulary Brand
PA 3 pasireotide SIGNIFOR Non-Formulary Brand
1 pediatric multivitamins w/ fluoride POLY-VI-FLOR Generic
1 pediatric multivitamins w/ fluoride & iron
POLY-VI-FLOR W/IRON Generic
1 pediatric vitamins a, c, & d, w/ fluoride TRI-VI-FLOR Generic
1 pediatric vitamins a, c, & d, w/ fluoride & iron TRI-VI-FLOR W/IRON Generic
PA 3 pegvaliase PALYNZIQ Non-Formulary Brand
2 pentosan polysulfate sodium ELMIRON Formulary Brand
PA 3 risankizumab SKYRIZI Non-Formulary Brand
ST 1 risedronate sodium ACTONEL Generic
3 risedronate sodium ATELVIA Non-Formulary Brand
PA 3 sapropterin dihydrochloride KUVAN Non-Formulary Brand
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 62
Restrictions Tier Generic Name Brand Name Coverage Status
PA 3 sarilumab KEVZARA Non-Formulary Brand
2 secukinumab COSENTYX Formulary Brand
3 sirolimus solution RAPAMUNE Non-Formulary Brand
1 sirolimus RAPAMUNE Generic 3 sodium fluoride FLUORABON BASIC Generic 1 sodium fluoride FLUORITAB Generic 1 sodium fluoride LURIDE CHEW Generic 1 sodium fluoride (dental) PREVIDENT Generic
1 sodium fluoride (dental) PREVIDENT 5000 PLUS Generic
1 sodium fluoride drops LURIDE DROPS Generic
2 stannous fluoride GEL-KAM Formulary Brand
1 tacrolimus PROGRAF Generic
PA 3 teriflunomide AUBAGIO Non-Formulary Brand
QL 2 thalidomide THALOMID Formulary Brand
PA 3 tildrakizumab-asmn ILUMYA Non-Formulary Brand
ST 3 tiludronate SKELID Non-Formulary Brand
2 tocilizumab ACTEMRA Formulary Brand
2 tofacitinib XELJANZ Formulary Brand
PA 3 ustekinumab STELARA Non-Formulary Brand
Respiratory Tract Agents Antitussives
1 benzonatate TESSALON PERLES Generic 1 guaifenesin & codeine CHERATUSSIN AC Generic
3 hydrocodone & chlorpheniramine TUSSIONEX Non-Formulary Brand
1 hydrocodone & homatropine HYCODAN Generic
1 promethazine & codeine PHENERGAN W/ CODEINE Generic
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 63
Restrictions Tier Generic Name Brand Name Coverage Status
1 promethazine & dextromethorphan PROMETHAZINE-DM Generic
1 promethazine, phenylephrine & codeine
PHENERGAN VC W/CODEINE Generic
3 pseudoephedrine, brompheniramine & codeine M-END MAX D Non-Formulary
Brand Anti-Inflammatory Agents
3 cromolyn sodium GASTROCROM Non-Formulary Brand
1 cromolyn sodium INTAL Generic 1 montelukast SINGULAIR Generic
ST 3 zafirlukast ACCOLATE Non-Formulary Brand
ST 1 zileuton ZYFLO CR Generic
ST 3 zileuton ZYFO Non-Formulary Brand
Respiratory Agents, Miscellaneous
3 beclomethasone dipropionate QVAR RediHaler Non-Formulary Brand
3 budesonide PULMICORT FLEXHALER
Non-Formulary Brand
1 budesonide PULMICORT RESPULES Generic
ST 3 budesonide & formoterol SYMBICORT Non-Formulary Brand
2 ciclesonide ALVESCO Formulary Brand
ST 3 fluticasone & salmeterol (100/50 mcg) ADVAIR DISKUS Non-Formulary
Brand
ST 2 fluticasone & salmeterol (250/50 mcg and 500/50 mcg) ADVAIR DISKUS Formulary
Brand
ST 3 fluticasone & salmeterol ADVAIR HFA Non-Formulary Brand
ST 3 fluticasone & vilanterol BREO ELLIPTA Non-Formulary Brand
3 fluticasone propionate FLOVENT DISKUS AER
Non-Formulary Brand
3 fluticasone propionate FLOVENT HFA Non-Formulary Brand
ST 3 fluticasone & umeclidinium & vilanterol TRELEGY ELLIPTA Non-Formulary
Brand
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 64
Restrictions Tier Generic Name Brand Name Coverage Status
3 glycopyrrolate & indacaterol UTIBRON NEOHALER Non-Preferrred
ST 3 indacaterol ARCAPTA NEOHALER
Non-Formulary Brand
PA 3 ivacaftor KALYDECO Non-Formulary Brand
PA 3 lumacaftor& ivacaftor ORKAMBI Non-Formulary Brand
ST 3 mometasone & formoterol DULERA Non-Formulary Brand
2 mometasone furoate ASMANEX Formulary Brand
PA 3 mepolizumab NUCALA Non-Formulary Brand
3 nintedanib OFEV Non-Formulary Brand
PA 3 omalizumab XOLAIR Non-Formulary Brand
3 pirfenidone ESBRIET Non-Formulary Brand
ST 3 roflumilast DALIRESP Non-Formulary Brand
3 salmeterol SEREVENT DISKUS Non-Formulary Brand
3 sodium chloride HYPERSAL Non-Formulary Brand
PA 3 tezacaftor & ivacaftor SYMDEKO Non-Formulary Brand
2 tiotropium bromide and olodaterol STIOLTO RESPIMAT Formulary
Brand Skin and Mucous Membrane Agents
Anti-infectives (Skin and Mucous Membranes) ST 1 acyclovir ZOVIRAX Generic
3 benzoyl peroxide & erythromycin BENZAMYCIN Non-Formulary Brand
ST 3 butenafine MENTAX Non-Formulary Brand
3 butoconazole nitrate (vaginal) GYNAZOLE-1 Non-Formulary Brand
1 ciclopirox LOPROX Generic 1 ciclopirox PENLAC Generic
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 65
Restrictions Tier Generic Name Brand Name Coverage Status
ST 1 clindamycin & benzoyl peroxide BENZACLIN Generic 1 clindamycin & benzoyl peroxide DUAC Generic
PA 3 clindamycin & benzoyl peroxide ONEXTON Non-Formulary Brand
1 clindamycin phosphate (topical) CLEOCIN T Generic 1 clindamycin phosphate (topical) CLINDAGEL Generic
3 clindamycin phosphate (topical) EVOCLIN Non-Formulary Brand
1 clindamyinc phosphate (vaginal) CLEOCIN Generic 1 clotrimazole MYCELEX Generic
ST 1 clotrimazole & betametmethasone LOTRISONE Generic
ST 3 crotamiton EURAX Non-Formulary Brand
1 econazole nitrate SPECTAZOLE Generic
3 erythromycin (acne acid) AKNE-MYCIN Non-Formulary Brand
1 erythromycin (acne acid) ERYGEL Generic 1 gentamicin sulfate (topical) GARAMYCIN Generic
3 hexachlorophene PHISOHEX Non-Formulary Brand
1 iodoquinol & hydrocortisone VYTONE Generic 1 ketoconazole (topical) NIZORAL Generic 1 lindane KWELL Generic
ST 3 mafenide acetate SULFAMYLON Non-Formulary Brand
1 malathion OVIDE Generic 1 metronidazole (topical) METROCREAM Generic 1 metronidazole (topical) METROGEL Generic 1 metronidazole (topical) METROLOTION Generic
1 metronidazole (vaginal) METROGEL-VAGINAL Generic
3 miconazole nitrate & zinc oxide VUSION Non-Formulary Brand
1 mupirocin BACTROBAN Generic
3 mupirocin calcium BACTROBAN NASAL
Non-Formulary Brand
3 na sulfacetm/avobenzone/sulfur ROSAC Non-Formulary Brand
ST 1 naftifine cream NAFTIN Generic
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 66
Restrictions Tier Generic Name Brand Name Coverage Status
ST 3 Naftifine gel NAFTIN Non-Formulary Brand
1 nystatin (topical) NYSTATIN Generic
ST 3 oxiconazole nitrate OXISTAT Non-Formulary Brand
ST 3 penciclovir DENAVIR Non-Formulary Brand
1 permethrin ELIMITE Generic
ST 3 retapamulin ALTABAX Non-Formulary Brand
3 selenium sulfide SELSEB Non-Formulary Brand
3 selenium sulfide SELSUN RX Non-Formulary Brand
ST 3 sertaconazole nitrate ERTACZO Non-Formulary Brand
1 silver sulfadiazine SILVADENE Generic
3 spinosad NATROBA Non-Formulary Brand
ST 3 sulconazole nitrate EXELDERM Non-Formulary Brand
1 sulfacetamide sodium (acne) KLARON Generic
3 sulfacetamide sodium (acne) SEB-PREV Non-Formulary Brand
3 sulfanilamide AVC Non-Formulary Brand
ST 1 terconazole TERAZOL 7 Generic ST 1 terconazole (vaginal) TERAZOL 3 Generic
Anti-inflammatory Agents (Skin and Mucous Membranes) 1 alclometasone dipropionate ACLOVATE Generic
ST 1 amcinonide CYCLOCORT Generic
ST 3 bacitracin, polymyxin, neomycin & hydrocortisone CORTISPORIN Non-Formulary
Brand
3 benzoyl peroxide & hydrocortisone VANOXIDE-HC Non-Formulary
Brand
1 betamethasone dipropionate (topical) DIPROSONE Generic
1 betamethasone dipropionate augmented DIPROLENE Generic
1 betamethasone valerate LUXIQ Generic
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 67
Restrictions Tier Generic Name Brand Name Coverage Status
1 betamethasone valerate VALISONE Generic ST 1 calcipotriene & betamethasone TACLONEX Generic 1 clobetasol propionate CLOBEX Generic 1 clobetasol propionate TEMOVATE Generic 1 clobetasol propionate emollient TEMOVATE E Generic
3 clobetasol propionate emulsion OLUX-E Non-Formulary Brand
ST 1 clocortolone pivalate CLODERM Generic
ST 3 crisaborole EUCRISA Non-Formulary Brand
QL 1 desonide DESOWEN Generic ST 1 desoximetasone TOPICORT Generic ST 1 diflorasone diacetate APEXICON Generic
3 fluocinolone acetonide CAPEX SHAMPOO Non-Formulary Brand
1 fluocinolone acetonide DERMA-SMOOTHE/FS OIL Generic
1 fluocinolone acetonide SYNALAR Generic 1 fluocinonide LIDEX Generic
3 fluocinonide VANOS Non-Formulary Brand
1 fluocinonide emollient LIDEX-E Generic
ST 1, 3 flurandrenolide CORDRAN Generic
ST 1 fluticasone propionate (topical) CUTIVATE Generic
ST 3 halcinonide HALOG Non-Formulary Brand
1 halobetasol propionate ULTRAVATE Generic 1 hydrocortisone (intrarectal) CORTENEMA Generic
3 hydrocortisone (rectal) ANUSOL-HC Non-Formulary Brand
1 hydrocortisone (rectal) PROCTOCORT Generic 1 hydrocortisone (topical) HYTONE Generic 1 hydrocortisone acetate & urea CARMOL HC Generic
3 hydrocortisone acetate (intrarectal) CORTIFOAM Non-Formulary
Brand 1 hydrocortisone butyrate LOCOID Generic
3 hydrocortisone butyrate hydrophilic lipo base
LOCOID LIPOCREAM
Non-Formulary Brand
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 68
Restrictions Tier Generic Name Brand Name Coverage Status
3 hydrocortisone probutate PANDEL Non-Formulary Brand
1 hydrocortisone valerate WESTCORT Generic 1 mometasone furoate ELOCON Generic
ST 1 nystatin & triamcinolone MYCOLOG II Generic ST 1 prednicarbate DERMATOP Generic 1 triamcinolone acetonide (topical) KENALOG Generic Antipruritics and Local Anesthetics
ST 3 doxepin (antipuritic) ZONALON Non-Formulary Brand
3 hydrocortisone & pramoxine ANALPRAM HC Non-Formulary Brand
3 hydrocortisone & pramoxine PRAMOSONE Non-Formulary Brand
3 hydrocortisone & pramoxine PRAMOSONE-E Non-Formulary Brand
3 hydrocortisone & pramoxine PROCTOFOAM-HC Non-Formulary Brand
1 lidocaine (jelly, topical) XYLOCAINE Generic
3 lidocaine & hydrocortisone LIDAMANTLE Non-Formulary Brand
1 lidocaine & prilocaine EMLA Generic
ST 3 lidocaine & tetracaine SYNERA PATCH Non-Formulary Brand
1 pramoxine PROCTOFOAM Generic Astringents
2 aluminum chloride hexahydrate HYPERCARE Formulary Brand
Keratolytic Agents
3 sulfacetamide sodium & sulfur AVAR Non-Formulary Brand
1 sulfacetamide sodium & sulfur PLEXION Generic
3 sulfacetamide sodium & sulfur PLEXION SCT Non-Formulary Brand
1 sulfacetamide sodium & sulfur ROSULA Generic 1 urea CARMOL Generic Keratoplastic Agents
ST 3 anthralin DRITHOCREME HP Non-Formulary Brand
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 69
Restrictions Tier Generic Name Brand Name Coverage Status
3 anthralin PSORIATEC Non-Formulary Brand
Cell Stimulants and Proliferants QL, AGE 1 tretinoin RETIN-A Generic
QL, AGE 3 tretinoin microspheres RETIN-A MICRO Non-Formulary Brand
Skin and Mucous Membrane Agents, Miscellaneous ST 1 acitretin SORIATANE Generic
QL, AGE, ST 1 adapalene DIFFERIN Generic
QL, AGE, ST 3 adapalene & benzoyl peroxide EPIDUO Non-Formulary
Brand
QL, AGE 3 alitretinoin PANRETIN Non-Formulary Brand
1 ammonium lactate LAC-HYDRIN Generic
ST 3 azelaic acid FINACEA Non-Formulary Brand
ST 3 azelaic acid (acne) AZELEX Non-Formulary Brand
2 becaplermin REGRANEX Formulary Brand
3 bexarotene (topical) TARGRETIN Non-Formulary Brand
PA, QL 3 brimonidine (topical) MIRVASO Non-Formulary Brand
1 calcipotriene DOVONEX Generic
3 calcipotriene SORILUX Non-Formulary Brand
2 calcitriol (topical) VECTICAL Formulary Brand
AGE, ST 3 clindamycin & tretinoin VELTIN Non-Formulary Brand
AGE, ST 3 clindamycin & tretinoin ZIANA Non-Formulary Brand
2 collagenase SANTYL Formulary Brand
3 dapsone (topical) ACZONE Non-Formulary Brand
3 diclofenac epolamine FLECTOR Non-Formulary Brand
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 70
Restrictions Tier Generic Name Brand Name Coverage Status
1 diclofenac sodium VOLTAREN GEL Generic
3 diclofenac sodium (actinic keratosis) SOLARAZE Non-Formulary
Brand
ST 3 doxepin (antipuritic) PRUDOXIN Non-Formulary Brand
3 doxycycline (rosacea) ORACEA Non-Formulary Brand
3 fluorouracil (topical) CARAC Non-Formulary Brand
1 fluorouracil (topical) EFUDEX Generic
2 fluorouracil (topical) FLUOROPLEX Formulary Brand
1 imiquimod ALDARA Generic
3 imiquimod ZYCLARA Non-Formulary Brand
PA 3 ingenol mebutate PICATO Non-Formulary Brand
1 isotretinoin ACCUTANE Generic 1 isotretinoin CLARAVIS Generic
3 lactic acid (ammonium lactate) LACTINOL Non-Formulary Brand
2 methoxsalen 8-MOP Formulary Brand
1 methoxsalen, rapid OXSORALEN-ULTRA Generic
2 pimecrolimus ELIDEL Formulary Brand
1 podofilox CONDYLOX Generic
ST 3 sinecatechins VEREGEN Non-Formulary Brand
1 tacrolimus (topical) PROTOPIC Generic QL, AGE,
ST 3 tazarotene TAZORAC Non-Formulary Brand
Smooth Muscle Relaxants Smooth Muscle Relaxants
1 darifenacin ENABLEX Generic
ST 3 dyphylline LUFYLLIN Non-Formulary Brand
ST 3 fesoterodine TOVIAZ Non-Formulary Brand
Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
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Restrictions Tier Generic Name Brand Name Coverage Status
ST 3 flavoxate FLAVOXATE Non-Formulary Brand
ST 3 mirabegron MYRBETRIQ Non-Formulary Brand
1 oxybutynin DITROPAN Generic 1 oxybutynin extended-release DITROPAN XL Generic
3 oxybutynin transdermal OXYTROL Non-Formulary Brand
1 solifenacin VESICARE Generic 1 theophylline UNIPHYL Generic
ST 1 tolterodine DETROL Generic ST 1 tolterodine extended-release DETROL LA Generic 1 trospium SANCTURA Generic
3 trospium extended-release SANCTURA XR Non-Formulary Brand
Vitamins Vitamins
1 calcitriol ROCALTROL Generic ST 1 doxercalciferol HECTOROL Generic 1 ergocalciferol DRISDOL Generic 1 niacin NIACOR Generic
ST 1 paricalcitol ZEMPLAR Generic
2 phytonadione MEPHYTON Formulary Brand
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Index of Drugs
8 8-MOP ............................................................................................. 70
A abacavir sulfate & lamivudine ........................................................ 8 abacavir sulfate solution ................................................................. 8 abacavir sulfate tablet ..................................................................... 8 abacavir, dolutegravir & lamivudine .............................................. 8 abacavir, lamivudine & zidovudine ................................................ 8 abaloparatide .................................................................................. 56 abatacept ........................................................................................ 58 abemaciclib ..................................................................................... 12 ABILIFY ........................................................................................... 33 ABILIFY DISCMELT ...................................................................... 33 abiraterone ...................................................................................... 12 ABSTRAL ........................................................................................ 26 acalabrutinib ................................................................................... 12 acamprosate ................................................................................... 32 acarbose ......................................................................................... 51 ACCOLATE .................................................................................... 63 ACCU-CHEK ............................................................................ 35, 36 ACCU-CHEK TEST STRIPS ........................................................ 35 ACCUNEB ...................................................................................... 17 ACCUPRIL ...................................................................................... 23 ACCURETIC ................................................................................... 23 ACCUTANE .................................................................................... 70 acebutolol ........................................................................................ 24 ACEON ............................................................................................ 23 acetaminophen & codeine ............................................................ 25 acetaminophen, caffeine, & dihydrocodine ................................ 25 ACETASOL HC .............................................................................. 40 acetazolamide ................................................................................ 42 acetic acid ................................................................................. 40, 43 acetylcysteine ................................................................................. 58 ACIPHEX ........................................................................................ 45 acitretin ............................................................................................ 69 ACLOVATE ..................................................................................... 66 ACTEMRA ...................................................................................... 62 ACTHAR.......................................................................................... 56 ACTIGALL ....................................................................................... 46 ACTIMMUNE .................................................................................. 60 ACTIQ .............................................................................................. 26 ACTIVELLA .................................................................................... 55 ACTONEL ....................................................................................... 61 ACTOPLUS MET ........................................................................... 54 ACTOS ............................................................................................ 54 ACULAR .......................................................................................... 40 ACULAR LS .................................................................................... 40 acyclovir ...................................................................................... 8, 64
ACZONE ......................................................................................... 69 ADALAT CC ................................................................................... 21 adalimumab .................................................................................... 58 adapalene ....................................................................................... 69 adapalene & benzoyl peroxide .................................................... 69 ADCIRCA ........................................................................................ 24 ADDERALL ..................................................................................... 28 ADDERALL XR .............................................................................. 28 adefovir dipivoxil .............................................................................. 8 ADEMPAS ...................................................................................... 24 ADLYXIN......................................................................................... 54 ADMELOG ...................................................................................... 53 ADOXA .............................................................................................. 5 ADRENACLICK ............................................................................. 17 ADVAIR DISKUS ........................................................................... 63 ADVAIR HFA .................................................................................. 63 ADVICOR ....................................................................................... 20 ADZENYS ER ................................................................................ 27 AFINITOR ....................................................................................... 13 aflcaftadine ..................................................................................... 41 AFREZZA ....................................................................................... 52 AGGRENOX ................................................................................... 18 AGRYLIN ........................................................................................ 18 AIMOVIG......................................................................................... 59 AKNE-MYCIN ................................................................................. 65 AK-TRACIN .................................................................................... 38 AKYNZEO ....................................................................................... 44 albendazole ...................................................................................... 4 ALBENZA ......................................................................................... 4 albiglutide ........................................................................................ 51 albuterol nebulizer solution .......................................................... 17 albuterol sulfate.............................................................................. 17 albuterol sulfate & ipratropium ..................................................... 17 albuterol sulfate tablet ................................................................... 17 alclometasone dipropionate ......................................................... 66 ALDACTAZIDE .............................................................................. 23 ALDACTONE ................................................................................. 23 ALDARA .......................................................................................... 70 ALDOMET ...................................................................................... 22 ALDORIL-25 ................................................................................... 22 alendronate ..................................................................................... 58 alendronate & cholecalciferol ....................................................... 58 alfuzosin .......................................................................................... 17 ALINIA ............................................................................................... 7 alirocumab ...................................................................................... 51 aliskiren ........................................................................................... 22 aliskiren & amlodipine ................................................................... 22 aliskiren & hydrochlorothiazide .................................................... 22 aliskiren & valsartan ...................................................................... 22 aliskiren, amlodipine & hydrochlorothiazide ............................... 22 alitretinoin ....................................................................................... 69
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ALKERAN ....................................................................................... 14 allopurinol ........................................................................................ 58 almotriptan ...................................................................................... 30 ALOCRIL ......................................................................................... 41 alogliptin .......................................................................................... 51 alogliptin & metformin .................................................................... 51 alogliptin & pioglitazone ................................................................ 51 ALOMIDE ........................................................................................ 41 ALORA ............................................................................................ 55 alosetron ......................................................................................... 43 alpelisib ........................................................................................... 12 ALPHAGAN .................................................................................... 42 ALPHAGAN P................................................................................. 42 alprazolam ...................................................................................... 31 alprazolam extended-release ....................................................... 31 alprazolam orally disintegrating ................................................... 31 ALREX ............................................................................................. 40 ALTABAX ........................................................................................ 66 ALTACE .......................................................................................... 23 ALTOPREV ..................................................................................... 20 aluminum chloride hexahydrate ................................................... 68 ALVESCO ....................................................................................... 63 amantadine ..................................................................................... 30 amantadine ER............................................................................... 30 AMARYL.......................................................................................... 52 AMBIEN ........................................................................................... 32 AMBIEN CR .................................................................................... 32 ambrisentan .................................................................................... 23 amcinonide...................................................................................... 66 AMERGE ......................................................................................... 30 AMICAR .......................................................................................... 18 amifampridine ................................................................................. 58 amikacin liposomal Inhalation ........................................................ 4 amiloride .......................................................................................... 37 amiloride & hydrochlorothiazide ................................................... 37 aminocaproic acid .......................................................................... 18 amiodarone ..................................................................................... 21 AMITIZA .......................................................................................... 46 amitriptyline ..................................................................................... 33 amitriptyline & perphenazine ........................................................ 33 amlodipine ................................................................................. 20, 22 amlodipine & atorvastatin ............................................................. 20 amlodipine & benazepril ................................................................ 20 amlodipine & olmesartan .............................................................. 20 amlodipine & telmisartan............................................................... 20 amlodipine & valsartan .................................................................. 20 amlodipine, olmesartan & hydrochlorothiazide .......................... 20 amlodipine, valsartan & hydrochlorothiazide ............................. 20 ammonium lactate ................................................................... 69, 70 amoxapine ...................................................................................... 33 amoxicillin................................................................................ 2, 4, 44 amoxicillin & clavulanate potassium .............................................. 4 amoxicillin & clavulanate potassium extended-release .............. 4 amoxicillin, clarithromycin, & lansoprazole ................................. 44
AMOXIL............................................................................................. 4 amphetamine & dextroamphetamine .......................................... 28 amphetamine & dextroamphetamine extended-release .......... 28 amphetamine extended-release .................................................. 27 amphetamine sulfate ..................................................................... 27 AMPICILLIN ..................................................................................... 4 ampicillin sodium ............................................................................. 4 AMPYRA ......................................................................................... 59 AMRIX ............................................................................................. 16 AMTURNIDE .................................................................................. 22 AMYTHYST .................................................................................... 49 ANADROL-50 ................................................................................. 47 ANAFRANIL ................................................................................... 33 anagrelide ....................................................................................... 18 anakinra .......................................................................................... 58 ANALPRAM HC ............................................................................. 68 ANAPROX ...................................................................................... 27 anastrozole ..................................................................................... 12 ANCOBON ....................................................................................... 6 ANDRODERM................................................................................ 47 ANDROGEL ................................................................................... 47 ANDROID 10 .................................................................................. 47 ANDROXY ...................................................................................... 47 ANGELIQ ........................................................................................ 55 ANORO ELLIPTA .......................................................................... 18 ANSAID ........................................................................................... 26 ANTABUSE .................................................................................... 59 anthralin .................................................................................... 68, 69 antipyrine & benzocaine ............................................................... 43 ANUSOL-HC .................................................................................. 67 ANZEMET ....................................................................................... 44 APEXICON ..................................................................................... 67 APIDRA ........................................................................................... 53 apixaban ......................................................................................... 18 APLENZIN ...................................................................................... 33 APOKYN ......................................................................................... 30 apomorphine .................................................................................. 30 apraclonidine .................................................................................. 43 apremilast ....................................................................................... 58 aprepitant ........................................................................................ 44 APRESOLINE ................................................................................ 22 APRI ................................................................................................ 47 APTIOM .......................................................................................... 29 APTIVUS......................................................................................... 11 ARALEN ............................................................................................ 7 ARANELLE ..................................................................................... 49 ARANESP ....................................................................................... 19 ARAVA ............................................................................................ 60 ARBINOXA ....................................................................................... 4 ARCAPTA NEOHALER ................................................................ 64 arformoterol .................................................................................... 17 ARICEPT ........................................................................................ 16 ARICEPT ODT ............................................................................... 16 ARIKAYCE ....................................................................................... 4
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ARIMIDEX ....................................................................................... 12 aripiprazole ..................................................................................... 33 aripiprazole solution ....................................................................... 33 aripiprazole tablet ........................................................................... 33 ARIXTRA ......................................................................................... 18 armodafinil ...................................................................................... 28 ARMOUR THYROID ..................................................................... 57 AROMASIN ..................................................................................... 13 ARTANE .......................................................................................... 31 artemether & lumefantrine .............................................................. 7 ARTHROTEC ................................................................................. 25 artificial tear insert .......................................................................... 43 ASCENSIA BREEZE ..................................................................... 36 ASCENSIA TEST STRIPS ........................................................... 35 asenapine........................................................................................ 33 ASENDIN ........................................................................................ 33 ASMANEX ...................................................................................... 64 aspirin & dipyridamole ................................................................... 18 ASTELIN ......................................................................................... 41 ASTEPRO ....................................................................................... 41 ATACAND ....................................................................................... 22 ATACAND HCT .............................................................................. 22 ATARAX .......................................................................................... 31 atazanavir & cobicistat .................................................................... 8 atazanavir sulfate 150 mg............................................................... 8 atazanavir sulfate 200 mg, 300 mg ............................................... 8 ATELVIA.......................................................................................... 61 atenolol ............................................................................................ 24 atenolol & chlorthalidone............................................................... 24 ATIVAN ........................................................................................... 32 atomoxetine .................................................................................... 32 atorvastatin ............................................................................... 19, 20 atovaquone ....................................................................................... 7 atovaquone & proguanil .................................................................. 7 ATRIPLA ........................................................................................... 9 atropine ............................................................................... 15, 43, 44 atropine sulfate ............................................................................... 15 ATROPINE SULFATE ................................................................... 15 ATROVENT .................................................................................... 15 ATROVENT HFA ........................................................................... 15 ATROVENTHFA ............................................................................ 15 AUBAGIO ........................................................................................ 62 AUGMENTIN .................................................................................... 4 AUGMENTIN XR ............................................................................. 4 auranofin ......................................................................................... 46 AURODEX ...................................................................................... 43 AUSTEDO ....................................................................................... 32 AUVI-Q ............................................................................................ 17 AVALIDE ......................................................................................... 23 AVANDAMET ................................................................................. 54 AVANDARYL .................................................................................. 54 AVANDIA ........................................................................................ 54 AVAPRO ......................................................................................... 23 AVAR ............................................................................................... 68
AVC ................................................................................................. 66 AVELOX ............................................................................................ 5 AVINZA ........................................................................................... 26 AVLOSULFON ................................................................................. 7 AVODART ...................................................................................... 59 AVONEX ......................................................................................... 60 AXERT ............................................................................................ 30 AXID ................................................................................................ 45 AXIRON .......................................................................................... 47 axitinib ............................................................................................. 12 AYGESTIN ..................................................................................... 57 AZASAN .......................................................................................... 58 AZASITE ......................................................................................... 38 azathioprine .................................................................................... 58 azelaic acid ..................................................................................... 69 azelaic acid (acne)......................................................................... 69 azelastine ........................................................................................ 41 azelastine & fluticasone ................................................................ 41 azelastine (ophth) .......................................................................... 41 AZELEX .......................................................................................... 69 AZILECT ......................................................................................... 31 azilsartan......................................................................................... 22 azithromycin ............................................................................... 4, 38 azithromycin (ophth) ...................................................................... 38 AZOPT ............................................................................................ 42 AZOR .............................................................................................. 20 AZULFIDINE .................................................................................... 6
B B & O SUPPRETTES ................................................................... 27 bacitracin & polmyxin B (ophth) ................................................... 38 bacitracin (ophth) ........................................................................... 38 bacitracin, neomycin, polymyxin B & hydrocortisone (ophth) .. 39 bacitracin, polymyxin, neomycin & hydrocortisone ................... 66 baclofen .......................................................................................... 16 BACTRIM DS ................................................................................... 6 BACTROBAN ................................................................................. 65 BACTROBAN NASAL ................................................................... 65 balsalazide ...................................................................................... 43 BALZIVA ......................................................................................... 49 BANZEL .......................................................................................... 30 BARACLUDE ................................................................................... 9 baricitnib .......................................................................................... 58 BASAGLAR .................................................................................... 52 BD INSULIN SYRINGE ................................................................ 36 becaplermin .................................................................................... 69 beclomethasone dipropionate ...................................................... 63 bedaquiline ..................................................................................... 58 BELSOMRA ................................................................................... 32 benazepril ................................................................................. 20, 22 benazepril & hydrochlorothiazide ................................................ 22 BENEMID ....................................................................................... 38 BENICAR ........................................................................................ 23
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BENICAR HCT ............................................................................... 23 BENTYL .......................................................................................... 15 BENZACLIN .................................................................................... 65 BENZAMYCIN ................................................................................ 64 benznidazole .................................................................................... 4 benzonatate .................................................................................... 62 benzoyl peroxide & erythromycin ................................................ 64 benzoyl peroxide & hydrocortisone ............................................. 66 benztropine ..................................................................................... 30 bepotastine ..................................................................................... 41 BEPREVE ....................................................................................... 41 besilfoxacin ..................................................................................... 38 BESIVANCE ................................................................................... 38 BETAGAN ....................................................................................... 42 betaine ............................................................................................. 58 betamethasone dipropionate (topical) ......................................... 66 betamethasone dipropionate augmented ................................... 66 betamethasone valerate ......................................................... 66, 67 BETAPACE ..................................................................................... 25 BETAPACE AF............................................................................... 25 BETASERON ................................................................................. 60 betaxolol .................................................................................... 24, 42 betaxolol hcl .................................................................................... 42 bethanechol chloride ..................................................................... 16 BETIMOL ........................................................................................ 42 BETOPTIC ...................................................................................... 42 BETOPTIC S .................................................................................. 42 betrixaban ....................................................................................... 18 BEVYXXA ....................................................................................... 18 bexarotene ................................................................................ 12, 69 bexarotene (topical) ....................................................................... 69 BEXDELA.......................................................................................... 5 BEYAZ ............................................................................................. 48 BIAXIN ............................................................................................... 5 BIAXIN XL ......................................................................................... 5 bicalutamide .................................................................................... 12 BICITRA .......................................................................................... 36 bictegravir & emtricitabine & tenofovir .......................................... 8 BIDIL ................................................................................................ 23 BIKTARVY ........................................................................................ 8 BILTRICIDE ...................................................................................... 4 bimatoprost ..................................................................................... 42 binimetinib ....................................................................................... 12 bismuth subcitrate & metronidazole .............................................. 4 bisoprol & hydrochlorothiazide ..................................................... 24 bisoprolol ......................................................................................... 24 BLEPH-10 ....................................................................................... 39 BLEPHAMIDE ................................................................................ 41 BLOCADREN ................................................................................. 25 blood sugar diagnostic ............................................................ 35, 36 blood-glucose meter ...................................................................... 36 boceprevir ......................................................................................... 8 BONIVA ........................................................................................... 60 bosentan ......................................................................................... 23
BOSULIF......................................................................................... 12 bosutinib .......................................................................................... 12 BRAFTOVI ...................................................................................... 12 BREO ELLIPTA ............................................................................. 63 BRETHINE ..................................................................................... 18 BREVICON ..................................................................................... 49 brexpiprazole .................................................................................. 33 BRILINTA ........................................................................................ 18 brimonidine ............................................................................... 42, 69 brimonidine & timolol ..................................................................... 42 brimonidine (topical) ...................................................................... 69 brimonidine tartrate ....................................................................... 42 brinzolamide ................................................................................... 42 brodalumab ..................................................................................... 58 bromfenac (ophth) ......................................................................... 39 bromocriptine.................................................................................. 30 BROVANA ...................................................................................... 17 budesonide ............................................................................... 46, 63 budesonide & formoterol .............................................................. 63 bumetanide ..................................................................................... 37 BUMEX ........................................................................................... 37 BUPHENYL .................................................................................... 36 buprenorphine ................................................................................ 25 buprenorphine & naloxone film .................................................... 25 buprenorphine transdermal .......................................................... 25 buprenorphine& naloxone tablet ................................................. 25 bupropion ........................................................................................ 33 bupropion (smoking deterrent)..................................................... 33 bupropion extended-release ........................................................ 33 bupropion hydrobromide ............................................................... 33 bupropion sustained-release ........................................................ 33 BUSPAR ......................................................................................... 31 buspirone ........................................................................................ 31 busulfan .......................................................................................... 12 butalbital & acetaminophen .......................................................... 25 butalbital, acetaminophen, & caffeine ......................................... 25 butalbital, acetaminophen, caffeine, & codeine ......................... 25 butalbital, aspirin, & caffeine ........................................................ 25 butalbital, aspirin, caffeine, & codeine ........................................ 25 butenafine ....................................................................................... 64 butoconazole nitrate (vaginal) ...................................................... 64 butorphanol tartrate ....................................................................... 25 BUTRANS ....................................................................................... 25 BYDUREON ................................................................................... 51 BYETTA .......................................................................................... 51 BYSTOLIC ...................................................................................... 24
C c-1 esterase inhibitor ..................................................................... 58 cabergoline ..................................................................................... 30 CADUET ......................................................................................... 20 CAFERGOT ................................................................................... 17 CALAN SR ...................................................................................... 21
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calcipotriene .............................................................................. 67, 69 calcipotriene & betamethasone.................................................... 67 calcitonin salmon ........................................................................... 56 calcitriol ..................................................................................... 69, 71 calcitriol (topical) ............................................................................ 69 calcium acetate ........................................................................ 37, 38 CALQUENCE ................................................................................. 12 CAMILA ........................................................................................... 49 CAMPRAL ....................................................................................... 32 canagliflozin .................................................................................... 51 canagliflozin & metformin .............................................................. 51 canakinumab .................................................................................. 58 CANASA.......................................................................................... 43 candesartan .................................................................................... 22 candesartan & hydrochlorothiazide ............................................. 22 cannabidiol ...................................................................................... 32 CANTIL ............................................................................................ 46 capecitabine .................................................................................... 12 CAPEX SHAMPOO ....................................................................... 67 CAPOTEN ....................................................................................... 22 CAPOZIDE ...................................................................................... 22 CAPRELSA ..................................................................................... 15 captopril ........................................................................................... 22 captopril & hydrochlorothiazide .................................................... 22 CARAC ............................................................................................ 70 CARAFATE ..................................................................................... 45 carbachol ......................................................................................... 42 CARBAGLU .................................................................................... 36 carbamazepine ......................................................................... 28, 29 carbamazepine extended-release cap .................................. 28, 29 carbamazepine extended-release tab ......................................... 29 CARBATROL .................................................................................. 28 carbidopa .................................................................................. 30, 31 carbidopa & levodopa.................................................................... 31 carbidopa & levodopa extended release .................................... 31 carbidopa, levodopa, & entacapone ............................................ 31 carbinoxamine maleate ................................................................... 4 CARDENE ...................................................................................... 21 CARDIZEM ............................................................................... 20, 21 CARDIZEM CD .............................................................................. 20 CARDIZEM LA ............................................................................... 21 CARDURA ...................................................................................... 19 carglumic acid................................................................................. 36 cariprazine ...................................................................................... 33 carisoprodol .............................................................................. 16, 25 carisoprodol & aspirin .................................................................... 16 carisoprodol, aspirin, & codeine ................................................... 25 CARMOL ................................................................................... 67, 68 CARMOL HC .................................................................................. 67 carteolol (ophth) ............................................................................. 42 CARTIA XT ..................................................................................... 21 carvedilol ......................................................................................... 24 carvedilol phosphate...................................................................... 24 CASODEX ...................................................................................... 12
CATAFLAM .................................................................................... 25 CATAPRES .................................................................................... 22 CATAPRES-TTS ........................................................................... 22 CECLOR ........................................................................................... 4 cefaclor .............................................................................................. 4 cefadroxil........................................................................................... 4 cefdinir ............................................................................................... 4 cefditoren .......................................................................................... 4 cefixime ............................................................................................. 4 cefixime solution .............................................................................. 4 cefpodoxime ..................................................................................... 5 cefprozil ............................................................................................. 5 CEFTIN ............................................................................................. 5 cefuroxime axetil .............................................................................. 5 CEFZIL .............................................................................................. 5 CELEBREX .................................................................................... 25 celecoxib ......................................................................................... 25 CELEXA .......................................................................................... 33 CELLCEPT ..................................................................................... 61 CELONTIN ..................................................................................... 29 cenegermin-bkbj ............................................................................ 43 CENESTIN ..................................................................................... 56 cephalexin......................................................................................... 5 CEQUA ........................................................................................... 39 CERDELGA .................................................................................... 59 ceritinib ............................................................................................ 12 CESAMET ...................................................................................... 44 cevimeline hcl ................................................................................. 16 CHANTIX ........................................................................................ 16 CHEMET ......................................................................................... 46 CHERATUSSIN AC....................................................................... 62 chlorambucil ................................................................................... 12 chlordiazepoxide ................................................................ 31, 33, 46 chlordiazepoxide & amitriptyline .................................................. 33 chlorhexidine (mouth-throat) ........................................................ 38 chloroquine phosphate ................................................................... 7 chlorothiazide ................................................................................. 37 chlorpheniramine, phenylephrine & pyrilamine ........................... 4 chlorphenirmine, phenylephrine & pyrilamine.............................. 4 chlorpromazine .............................................................................. 33 chlorpropamide .............................................................................. 51 CHLORPROPAMIDE .................................................................... 51 chlorthalidone ........................................................................... 24, 37 chlorzoxazone ................................................................................ 16 CHOLBAM ...................................................................................... 58 cholestyramine ............................................................................... 19 cholestyramine light....................................................................... 19 cholic acid ....................................................................................... 58 CHRONULAC ................................................................................ 36 CIBALITH-S .................................................................................... 34 ciclesonide ...................................................................................... 63 ciclopirox ......................................................................................... 64 cilostazol ......................................................................................... 18 CILOXAN ........................................................................................ 38
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CIMDUO .......................................................................................... 10 cimetidine ........................................................................................ 44 cinacalcet ........................................................................................ 58 CIPRO ......................................................................................... 5, 39 CIPRO HC ...................................................................................... 39 CIPRODEX ..................................................................................... 39 ciprofloxacin .......................................................................... 5, 38, 39 ciprofloxacin & dexamethasone (ophth) ..................................... 39 ciprofloxacin & hydrocortisone (otic) ........................................... 39 ciprofloxacin (ophth) ointment ...................................................... 38 ciprofloxacin (ophth) solution ....................................................... 38 citalopram........................................................................................ 33 citric acid, sodium citrate, & potassium citrate ........................... 36 CLARAVIS ...................................................................................... 70 clarithromycin ............................................................................. 5, 44 clarithromycin extended-release .................................................... 5 CLEOCIN .................................................................................... 5, 65 CLEOCIN HCL ................................................................................. 5 CLEOCIN PEDIATRIC .................................................................... 5 CLEOCIN T ..................................................................................... 65 clidinium & chlordiazepoxide ........................................................ 46 CLIMARA DIS................................................................................. 55 CLIMARA PRO............................................................................... 55 CLINDAGEL ................................................................................... 65 clindamycin & benzoyl peroxide .................................................. 65 clindamycin & tretinoin .................................................................. 69 clindamycin hcl ................................................................................. 5 clindamycin palmitate ...................................................................... 5 clindamycin phosphate (topical) .................................................. 65 clindamyinc phosphate (vaginal) ................................................. 65 CLINORIL........................................................................................ 27 clobazam ......................................................................................... 29 clobetasol propionate .................................................................... 67 clobetasol propionate emollient ................................................... 67 clobetasol propionate emulsion ................................................... 67 CLOBEX .......................................................................................... 67 clocortolone pivalate ...................................................................... 67 CLODERM ...................................................................................... 67 clomipramine .................................................................................. 33 clonazepam .................................................................................... 29 clonidine .......................................................................................... 22 clonidine extended-release........................................................... 22 clonidine transdermal .................................................................... 22 clopidogrel ....................................................................................... 18 clorazepate ..................................................................................... 31 clotrimazole ..................................................................................... 65 clotrimazole & betametmethasone .............................................. 65 clozapine ......................................................................................... 33 CLOZARIL ...................................................................................... 33 COARTEM ........................................................................................ 7 cobimetinib ...................................................................................... 12 codeine ................................................................................ 25, 62, 63 CODEINE SULF ............................................................................. 25 COGENTIN ..................................................................................... 30
COLAZAL ....................................................................................... 43 COL-BENEMID .............................................................................. 38 colchicine .................................................................................. 38, 58 colchicine & probenecid ................................................................ 38 COLCRYS ...................................................................................... 58 colesevelam ................................................................................... 19 COLESTID ...................................................................................... 19 colestipol ......................................................................................... 19 collagenase .................................................................................... 69 COLYTE .......................................................................................... 45 COMBIGAN .................................................................................... 42 COMBIPATCH ............................................................................... 55 COMBIVENT RESPIMAT ............................................................. 17 COMBIVIR ...................................................................................... 10 COMBUNOX .................................................................................. 27 COMPAZINE .................................................................................. 44 COMPLERA ..................................................................................... 9 COMTAN ........................................................................................ 31 CONCERTA ................................................................................... 28 CONDYLOX ................................................................................... 70 conjugated estrogens & bazedoxifene ....................................... 55 conjugated estrogens & medroxyprogesterone acetate .......... 55 COPAXONE 20 mg ....................................................................... 59 COPAXONE 40 mg ....................................................................... 60 CORDRAN ..................................................................................... 67 COREG ........................................................................................... 24 COREG CR .................................................................................... 24 CORGARD ..................................................................................... 24 CORLANOR ................................................................................... 21 CORTEF ......................................................................................... 47 CORTENEMA ................................................................................ 67 corticotropin .................................................................................... 56 CORTIFOAM .................................................................................. 67 cortisone acetate ........................................................................... 47 CORTISPORIN ........................................................................ 40, 66 CORTISPORIN-TC ....................................................................... 40 CORTONE ACETATE .................................................................. 47 CORZIDE ........................................................................................ 24 COSENTYX .................................................................................... 62 COSOPT ......................................................................................... 42 COTELLIC ...................................................................................... 12 COTEMPLA XR-ODT ................................................................... 28 COUMADIN .................................................................................... 19 COVERA-HS .................................................................................. 21 COZAAR ......................................................................................... 23 CREON ........................................................................................... 45 CRESEMBA ..................................................................................... 6 CRESTOR ...................................................................................... 20 crisaborole ...................................................................................... 67 CRIXIVAN ......................................................................................... 9 crizotinib .......................................................................................... 12 cromolyn sodium ...................................................................... 41, 63 cromolyn sodium (ophth) .............................................................. 41 crotamiton ....................................................................................... 65
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CRYSELLE ..................................................................................... 50 CUPRIMINE .................................................................................... 46 CUTIVATE ...................................................................................... 67 CYCLESSA ..................................................................................... 48 cyclobenzaprine ............................................................................. 16 cyclobenzaprine extended-release .............................................. 16 CYCLOCORT ................................................................................. 66 cyclophosphamide ......................................................................... 12 cycloserine ........................................................................................ 7 CYCLOSET .................................................................................... 30 cyclosporine .............................................................................. 39, 58 cyclosporine (ophth) ...................................................................... 39 cyclosporine, modified ................................................................... 58 CYMBALTA .................................................................................... 34 cyproheptadine ................................................................................. 4 CYSTADANE POWD .................................................................... 58 CYSTAGON .................................................................................... 59 cysteamine delayed-release ......................................................... 59 cysteamine immediate-release .................................................... 59 CYTOMEL ....................................................................................... 57 CYTOTEC ....................................................................................... 45 CYTOVENE ...................................................................................... 9 CYTOXAN ....................................................................................... 12 CYTRA-3 ......................................................................................... 36
D D.H.E.45 .......................................................................................... 17 dabigatran ....................................................................................... 18 daclatasvir ......................................................................................... 8 dacomitinib ...................................................................................... 12 daflazacort ...................................................................................... 59 DAKLINZA ........................................................................................ 8 dalfampridine .................................................................................. 59 DALIRESP ...................................................................................... 64 DALMANE ....................................................................................... 31 dalteparin ........................................................................................ 18 danazol ............................................................................................ 47 DANOCRINE .................................................................................. 47 DANTRIUM ..................................................................................... 16 dantrolene sodium ......................................................................... 16 dapagliflozin .................................................................................... 51 dapagliflozin & metformin ............................................................. 51 dapsone ....................................................................................... 7, 69 dapsone (topical) ........................................................................... 69 DARAPRIM ....................................................................................... 7 darbepoetin alfa ............................................................................. 19 darifenacin ...................................................................................... 70 darolutamide ................................................................................... 12 darunavir & cobicistat ...................................................................... 8 darunavir ethanolate ........................................................................ 8 darunavir/cobicistat/FTC/tenofovir ................................................. 8 dasatinib .......................................................................................... 12 DAURISMO .................................................................................... 13
DAYPRO ......................................................................................... 27 DAYTRANA .................................................................................... 28 DDAVP ............................................................................................ 56 DECADRON ............................................................................. 39, 47 DECLOMYCIN ................................................................................. 5 deferasirox ...................................................................................... 46 deferiprone ..................................................................................... 46 delafloxacin ....................................................................................... 5 delavirdine mesylate ....................................................................... 8 DELESTROGEN ............................................................................ 48 DEMADEX ...................................................................................... 37 demeclocycline ................................................................................ 5 DEMEROL ...................................................................................... 26 DENAVIR ........................................................................................ 66 DEPAKENE .................................................................................... 30 DEPAKOTE .................................................................................... 29 DEPAKOTE ER ............................................................................. 29 DEPAKOTE SPRINKLE ............................................................... 29 DEPEN ............................................................................................ 46 DEPO-ESTRADIOL....................................................................... 48 DEPO-TESTOSTERONE ............................................................. 47 DERMA-SMOOTHE/FS OIL ........................................................ 67 DERMATOP ................................................................................... 68 DERMOTIC .................................................................................... 40 DESCOVY ........................................................................................ 9 desipramine .................................................................................... 33 desmopressin (non-refrigerated) ................................................. 56 desmopressin acetate ................................................................... 56 DESOGEN ...................................................................................... 47 desogestrel & ethinyl estradiol ............................................... 47, 48 desogestrel & ethinyl estradiol (biphasic) ................................... 48 desogestrel & ethinyl estradiol (triphasic) .................................. 48 desonide ......................................................................................... 67 DESOWEN ..................................................................................... 67 desoximetasone ............................................................................. 67 DESOXYN ...................................................................................... 28 desvenlafaxine extended release ................................................ 34 desvenlafaxine succinate extended release .............................. 34 DESYREL ....................................................................................... 35 DETROL ......................................................................................... 71 DETROL LA ................................................................................... 71 deutetrabenazine ........................................................................... 32 dexamethasone ........................................................... 39, 40, 41, 47 dexamethasone (ophth) solution ................................................. 39 dexamethasone (ophth) suspension ........................................... 39 DEXEDRINE .................................................................................. 28 DEXILANT ...................................................................................... 44 dexlansoprazole ............................................................................. 44 dexmethylphenidate ...................................................................... 28 dexmethylphenidate extended-release ...................................... 28 dextroamphetamine sulfate .......................................................... 28 dextroamphetamine sulfate extended-release .......................... 28 dextromethorphan & quinidine ..................................................... 32 DEXTROSTAT ............................................................................... 28
Kaiser Permanente, a TRICARE® Prime Option Formulary
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DIABETA ......................................................................................... 52 DIAMOX .......................................................................................... 42 DIAMOX SEQUELS ...................................................................... 42 DIASTAT ......................................................................................... 29 DIASTAT ACUDIAL ....................................................................... 29 diazepam ................................................................................... 29, 31 DIBENZYLINE ................................................................................ 17 dichlorphenamide ........................................................................... 59 diclofenac epolamine ..................................................................... 69 diclofenac potassium ..................................................................... 25 diclofenac sodium .............................................................. 25, 39, 70 diclofenac sodium & misoprostol ................................................. 25 diclofenac sodium (actinic keratosis) .......................................... 70 diclofenac sodium (ophth)............................................................. 39 diclofenac sodium extended release ........................................... 25 dicloxacillin ........................................................................................ 5 dicyclomine ..................................................................................... 15 didanosine ......................................................................................... 8 didanosine solution .......................................................................... 8 DIDRONEL ..................................................................................... 59 difenoxin & atropine ....................................................................... 44 DIFFERIN........................................................................................ 69 DIFICID ............................................................................................. 5 diflorasone diacetate ..................................................................... 67 DIFLUCAN ........................................................................................ 6 diflunisal .......................................................................................... 25 DIFLUNISAL ................................................................................... 25 difluprednate ................................................................................... 39 digoxin ............................................................................................. 21 dihydroergotamine mesylate ........................................................ 17 DILANTIN .................................................................................. 29, 30 DILAUDID ....................................................................................... 26 diltiazem .................................................................................... 20, 21 diltiazem extended-release ..................................................... 20, 21 dimethyl fumarate .......................................................................... 59 DIOVAN ........................................................................................... 23 DIOVAN HCT ................................................................................. 23 DIPENTUM ..................................................................................... 44 diphenoxylate & atropine .............................................................. 44 DIPROLENE ................................................................................... 66 DIPROSONE .................................................................................. 66 dipyridamole ................................................................................... 18 DISALCID........................................................................................ 27 disopyramide .................................................................................. 21 disopyramide controlled-release .................................................. 21 disulfiram ......................................................................................... 59 DITROPAN ..................................................................................... 71 DITROPAN XL ............................................................................... 71 DIURIL ............................................................................................. 37 divalproex sodium .......................................................................... 29 divalproex sodium capsule ........................................................... 29 divalproex sodium extended release........................................... 29 DIVIGEL .......................................................................................... 55 dofetilide .......................................................................................... 21
dolasetron ....................................................................................... 44 DOLOPHINE .................................................................................. 26 dolutegravir ................................................................................... 8, 9 dolutegravir & lamivudine ........................................................... 8, 9 dolutegravir & rilpivirine .................................................................. 8 donepezil................................................................................... 16, 32 DONNATAL .................................................................................... 46 dornase alfa .................................................................................... 38 DORYX ............................................................................................. 5 dorzolamide .................................................................................... 42 dorzolamide & timolol .................................................................... 42 DOSTINEX ..................................................................................... 30 DOVATO ........................................................................................... 9 DOVONEX ...................................................................................... 69 doxazosin ........................................................................................ 19 doxepin .......................................................................... 31, 34, 68, 70 doxepin (antipuritic) ................................................................. 68, 70 doxepin (sleep) .............................................................................. 31 doxercalciferol ................................................................................ 71 doxycycline ................................................................................. 5, 70 doxycycline (rosacea) ................................................................... 70 doxycycline hyclate ......................................................................... 5 doxycycline monohydrate ............................................................... 5 DRISDOL ........................................................................................ 71 DRITHOCREME HP ..................................................................... 68 dronabinol ....................................................................................... 44 dronedarone ................................................................................... 21 drospirenone & estradiol ............................................................... 55 drospirenone & ethinyl estradiol .................................................. 48 drospirenone & ethinyl estradiol w/ folate .................................. 48 DROXIA .......................................................................................... 13 droxidopa ........................................................................................ 17 DUAC .............................................................................................. 65 DUAVEE ......................................................................................... 55 DUETACT ....................................................................................... 54 dulaglutide ...................................................................................... 51 DULERA ......................................................................................... 64 duloxetine ....................................................................................... 34 DUONEB......................................................................................... 17 dupilumab ....................................................................................... 59 DUPIXENT ..................................................................................... 59 DURAGESIC .................................................................................. 26 DUREZOL ....................................................................................... 39 DURICEF .......................................................................................... 4 dutasteride ...................................................................................... 59 dutasteride & tamsulosin .............................................................. 59 DYAZIDE ........................................................................................ 37 DYMISTA ........................................................................................ 41 DYNACIN .......................................................................................... 5 DYNACIRC ..................................................................................... 21 DYNAPEN ........................................................................................ 5 dyphylline ........................................................................................ 70 DYRENIUM .................................................................................... 37
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E E.E.S.................................................................................................. 5 E.S.P .................................................................................................. 5 econazole nitrate ............................................................................ 65 ecothiophate ................................................................................... 42 EDARBI ........................................................................................... 22 EDECRIN ........................................................................................ 37 EDLUAR .......................................................................................... 32 edoxaban ........................................................................................ 18 EDURANT ....................................................................................... 10 efavirenz 400 mg, lamivudine & tenofvir ....................................... 9 efavirenz 600 mg ............................................................................. 9 efavirenz 600 mg, lamivudine & tenofvir ....................................... 9 efavirenz, emtricitabine & tenofovir ............................................... 9 EFFEXOR ....................................................................................... 35 EFFEXOR XR................................................................................. 35 EFFIENT ......................................................................................... 18 efinaconazole ................................................................................... 6 EFUDEX .......................................................................................... 70 elagolix ............................................................................................ 59 ELAVIL ............................................................................................ 33 elbasvir & grazoprevir ...................................................................... 9 ELDEPRYL ..................................................................................... 31 ELESTAT ........................................................................................ 41 ELESTRIN GEL ............................................................................. 55 eletriptan ......................................................................................... 30 ELIDEL ............................................................................................ 70 eliglustat .......................................................................................... 59 ELIMITE .......................................................................................... 66 ELIPHOS ......................................................................................... 37 ELIQUIS .......................................................................................... 18 ELLA ................................................................................................ 51 ELMIRON ........................................................................................ 61 ELOCON ......................................................................................... 68 eltrombopag .................................................................................... 19 eluxadoline ...................................................................................... 43 elvitegravir, cobicistat, emtricitabine, & tenofovir ........................ 9 EMBEDA ......................................................................................... 27 EMCYT ............................................................................................ 13 emedastine ..................................................................................... 41 EMEND ........................................................................................... 44 EMFLAZA........................................................................................ 59 EMGALITY ...................................................................................... 59 emicizumab-kxwh .......................................................................... 59 EMLA ............................................................................................... 68 empagliflozin ................................................................................... 51 empagliflozin & lingaliptin ............................................................. 51 empagliflozin & metformin ............................................................ 51 EMSAM ........................................................................................... 31 emtricitabine ................................................................................. 8, 9 emtricitabine & tenofovir ............................................................. 8, 9 emtricitabine, rilpivirine, & tenofovir............................................... 9 EMTRIVA .......................................................................................... 9
ENABLEX ....................................................................................... 70 enalapril .......................................................................................... 22 enalapril & hydrochlorothiazide ................................................... 22 enasidenib ...................................................................................... 12 ENBREL .......................................................................................... 59 encorafenib ..................................................................................... 12 ENDARI........................................................................................... 60 enfuvirtide ......................................................................................... 9 ENJUVIA ......................................................................................... 56 enoxaparin ...................................................................................... 18 entacapone ..................................................................................... 31 entecavir ........................................................................................... 9 ENTOCORT EC ............................................................................. 46 ENTRESTO .................................................................................... 21 ENULOSE ....................................................................................... 36 enzalutamide .................................................................................. 12 EPANOVA ...................................................................................... 20 EPCLUSA ....................................................................................... 11 EPIDIOLEX ..................................................................................... 32 EPIDUO .......................................................................................... 69 epinastine (ophth) .......................................................................... 41 epinephrine ..................................................................................... 17 EPIPEN ........................................................................................... 17 EPIPEN JR ..................................................................................... 17 EPIVIR ............................................................................................ 10 EPIVIR HBV ................................................................................... 10 eplerenone ...................................................................................... 22 epoetin alfa ..................................................................................... 19 EPOGEN......................................................................................... 19 eprosartan....................................................................................... 22 eprosartan & hydrochlorothiazide................................................ 22 EPZICOM ......................................................................................... 8 EQUETRO ...................................................................................... 29 erenumab-aooe.............................................................................. 59 ergocalciferol .................................................................................. 71 ergoloid mesylates......................................................................... 17 ergotamine & caffeine ............................................................. 17, 30 erlotinib ............................................................................................ 13 ERTACZO ....................................................................................... 66 ertufliglozin ..................................................................................... 51 ertugliflozin & metformin ............................................................... 51 ertugliflozin & sitagliptin ................................................................ 51 ERYGEL ......................................................................................... 65 ERYPED ........................................................................................... 5 ERY-TAB .......................................................................................... 5 ERYTHROCIN ................................................................................. 5 ERYTHROMYCIN ........................................................................... 5 erythromycin & sulfisoxazole ......................................................... 5 erythromycin (acne acid) .............................................................. 65 erythromycin (ophth) ..................................................................... 38 erythromycin base ........................................................................... 5 erythromycin base delayed-release .............................................. 5 erythromycin ethylsuccinate ........................................................... 5 erythromycin sterate ........................................................................ 5
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ESBRIET ......................................................................................... 64 escitalopram ................................................................................... 34 eslicarbazepine .............................................................................. 29 esomeprazole ................................................................................. 44 estazolam ........................................................................................ 31 esterified estrogens ....................................................................... 55 ESTRACE ................................................................................. 55, 56 ESTRACE CREAM ........................................................................ 56 ESTRACE TAB .............................................................................. 55 ESTRADERM ................................................................................. 55 estradiol ............................................................. 47, 48, 49, 50, 55, 56 estradiol & levonorgestrel ............................................................. 55 estradiol & norethindrone .............................................................. 55 estradiol & norgestimate ............................................................... 55 estradiol acetate ............................................................................. 55 estradiol acetate vaginal tablets .................................................. 55 estradiol cypionate ......................................................................... 48 estradiol gel .................................................................................... 55 estradiol transdermal ..................................................................... 55 estradiol transderomal ................................................................... 55 estradiol vaginal ............................................................................. 56 estradiol vaginal 10 mg ................................................................. 56 estradiol valerate ............................................................................ 48 estradiol valerate & dienogest ...................................................... 48 estramustine ................................................................................... 13 ESTRATEST .................................................................................. 56 ESTRING ........................................................................................ 56 estrogen, ester/me-testosterone .................................................. 56 estrogens, conjugated ................................................................... 56 estrogens, conjugated synthetic a ............................................... 56 estrogens, conjugated synthetic b ............................................... 56 estrogens, conjugated vaginal ..................................................... 56 estropipate ...................................................................................... 56 ESTROSTEP FE ............................................................................ 50 eszopiclone ..................................................................................... 31 etanercept ....................................................................................... 59 ethacrynic acid ............................................................................... 37 ethambutol ........................................................................................ 7 ethionamide ...................................................................................... 7 ethontoin ......................................................................................... 29 ethosuximide .................................................................................. 29 ethynodiol diacetate & ethinyl estradiol ...................................... 48 etidronate ........................................................................................ 59 etodolac ........................................................................................... 25 etonogestrel & ethinyl estradiol .................................................... 48 etravirine............................................................................................ 9 EUCRISA ........................................................................................ 67 EULEXIN ......................................................................................... 13 EURAX ............................................................................................ 65 EVAMIST ........................................................................................ 55 EVEKEO.......................................................................................... 27 everolimus ................................................................................. 13, 59 EVISTA ............................................................................................ 56 EVOCLIN ........................................................................................ 65
evolocumab .................................................................................... 51 EVOTAZ ............................................................................................ 8 EVOXAC ......................................................................................... 16 EXALGO ......................................................................................... 26 EXELDERM .................................................................................... 66 EXELON ......................................................................................... 16 exemestane .................................................................................... 13 exenatide ........................................................................................ 51 exenatide extended-release ......................................................... 51 EXFORGE ...................................................................................... 20 EXFORGE HCT ............................................................................. 20 EXJADE .......................................................................................... 46 EXTAVIA ......................................................................................... 60 ezetimibe......................................................................................... 19 ezetimibe & simvastatin ................................................................ 19 ezogaine ......................................................................................... 29
F famciclovir ......................................................................................... 9 famotidine ....................................................................................... 44 FAMVIR............................................................................................. 9 FANAPT .......................................................................................... 34 FARESTON .................................................................................... 15 FARXIGA ........................................................................................ 51 FAZACLO ....................................................................................... 33 febuxostat ....................................................................................... 59 felbamate ........................................................................................ 29 FELBATOL ..................................................................................... 29 FELDENE ....................................................................................... 27 felodipine......................................................................................... 21 FEMARA ......................................................................................... 13 FEMCON FE .................................................................................. 50 FEMHRT ......................................................................................... 56 FEMRING ....................................................................................... 55 FEMTRACE .................................................................................... 55 fenofibrate ................................................................................. 19, 20 fenofibrate, micronized ................................................................. 20 fenofibric acid ................................................................................. 20 fenoprofen calcium ........................................................................ 25 fentanyl film .................................................................................... 26 fentanyl intranasal ......................................................................... 26 fentanyl lozenge ............................................................................. 26 fentanyl sublingual ......................................................................... 26 fentanyl tablet ................................................................................. 26 fentanyl transdermal ...................................................................... 26 FENTORA ....................................................................................... 26 FERRIPROX .................................................................................. 46 fesoterodine .................................................................................... 70 FETZIMA......................................................................................... 34 FIASP .............................................................................................. 52 FIASP FlLEXPEN .......................................................................... 52 fidaxomicin ........................................................................................ 5 filgrastim .......................................................................................... 19
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FINACEA ......................................................................................... 69 fingolimod ........................................................................................ 59 FIORICET ....................................................................................... 25 FIORICET W/ CODEINE .............................................................. 25 FIORINAL........................................................................................ 25 FIORINAL W/ CODEINE............................................................... 25 FIRAZYR ......................................................................................... 60 FIRDAPSE ...................................................................................... 58 FLAGYL ............................................................................................. 7 FLAGYL ER ...................................................................................... 7 FLAREX .......................................................................................... 40 flavoxate .......................................................................................... 71 FLAVOXATE .................................................................................. 71 flecainide ......................................................................................... 21 FLECTOR ....................................................................................... 69 FLEXERIL ....................................................................................... 16 FLOMAX.......................................................................................... 17 FLORINEF ACETATE ................................................................... 47 FLOVENT DISKUS AER............................................................... 63 FLOVENT HFA............................................................................... 63 FLOXIN ........................................................................................... 39 fluconazole ........................................................................................ 6 flucytosine ......................................................................................... 6 fludrocortisone ................................................................................ 47 FLUMADINE ................................................................................... 10 fluocinolone acetonide ............................................................ 40, 67 fluocinolone acetonide (otic) ......................................................... 40 fluocinonide ..................................................................................... 67 fluocinonide emollient .................................................................... 67 FLUORABON BASIC .................................................................... 62 FLUORITAB .................................................................................... 62 fluorometholone (ophth oint) ........................................................ 40 fluorometholone (ophth) ................................................................ 40 fluorometholone acetate ............................................................... 40 FLUOROPLEX ............................................................................... 70 fluorouracil (topical) ....................................................................... 70 fluoxetine ......................................................................................... 34 fluoxymesterone ............................................................................. 47 fluphenazine ................................................................................... 34 flurandrenolide ................................................................................ 67 flurazepam ...................................................................................... 31 flurbiprofen ................................................................................ 26, 40 flurbiprofen (ophth) ........................................................................ 40 flutamide .......................................................................................... 13 fluticasone & salmeterol ................................................................ 63 fluticasone & salmeterol (100/50 mcg) ....................................... 63 fluticasone & salmeterol (250/50 mcg and 500/50 mcg) .......... 63 fluticasone & umeclidinium & vilanterol ...................................... 63 fluticasone & vilanterol .................................................................. 63 fluticasone propionate ............................................................. 63, 67 fluticasone propionate (topical) .................................................... 67 fluvastatin ........................................................................................ 20 fluvastatin extended-release ........................................................ 20 fluvoxamine ..................................................................................... 34
FML.................................................................................................. 40 FML FORTE ................................................................................... 40 FML OINT ....................................................................................... 40 FOCALIN ........................................................................................ 28 FOCALIN XR .................................................................................. 28 fondaparinux ................................................................................... 18 FORADIL ........................................................................................ 17 formoterol fumarate ....................................................................... 17 FORTAMET .................................................................................... 54 FORTEO ......................................................................................... 56 FORTESTA .................................................................................... 47 FORTICAL ...................................................................................... 56 FOSAMAX ...................................................................................... 58 FOSAMAX PLUS D ....................................................................... 58 fosamprenavir calcium .................................................................... 9 fosfomycin ....................................................................................... 11 fosinopril .......................................................................................... 22 fosinopril & hydrochlorothiazide................................................... 22 FOSRENOL .................................................................................... 37 fostamatinib .................................................................................... 59 FRAGMIN ....................................................................................... 18 FREESTYLE SYSTEM ................................................................. 36 FREESTYLE TEST STRIPS ........................................................ 36 FROVA ............................................................................................ 30 frovatriptan ...................................................................................... 30 FULPHILA ....................................................................................... 19 FURADANTIN ................................................................................ 11 furosemide ...................................................................................... 37 FUZEON ........................................................................................... 9 FYCOMPA ...................................................................................... 29
G gabapentin ...................................................................................... 29 GABITRIL ....................................................................................... 30 GALAFOLD .................................................................................... 61 galantamine hydrobromide ........................................................... 16 galcanezumab ................................................................................ 59 ganciclovir ................................................................................... 9, 38 ganciclovir (ophth) ......................................................................... 38 GARAMYCIN.............................................................................. 5, 65 GASTROCROM ............................................................................. 63 gatifloxacin (ophth) ........................................................................ 38 GATTEX .......................................................................................... 46 GAVILYTE-C .................................................................................. 45 GEL-KAM ........................................................................................ 62 gemfibrozil ...................................................................................... 20 GENERESS FE ............................................................................. 50 GENTAK ......................................................................................... 38 gentamicin & prednisolone ........................................................... 40 gentamicin (ophth) ......................................................................... 38 gentamicin sulfate ...................................................................... 5, 65 gentamicin sulfate (topical) .......................................................... 65 GENTROPIN .................................................................................. 57
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GENVOYA ........................................................................................ 9 GEODON ........................................................................................ 35 GIANVI ............................................................................................ 48 GIAZO ............................................................................................. 43 GILENYA ......................................................................................... 59 gilteritinib ......................................................................................... 13 glasdegib ......................................................................................... 13 glatiramer acetate ............................................................... 59, 60 GLATOPA ....................................................................................... 60 glecaprevir & pibrentasvir ............................................................... 9 GLEEVEC ....................................................................................... 13 GLEOSTINE ................................................................................... 13 glimepiride ................................................................................. 52, 54 glipizide ........................................................................................... 52 glipizide & metformin ..................................................................... 52 glipizide extended-release ............................................................ 52 GLUCAGEN HYPOKIT ................................................................. 52 glucagon .......................................................................................... 52 GLUCAGON EMERGENCY KIT ................................................. 52 GLUCOPHAGE .............................................................................. 54 GLUCOPHAGE XR ....................................................................... 54 GLUCOTROL ................................................................................. 52 GLUCOTROL XL ........................................................................... 52 GLUCOVANCE .............................................................................. 52 GLUMETZA .................................................................................... 54 glyburide .......................................................................................... 52 glyburide & metformin ................................................................... 52 glyburide micronized...................................................................... 52 glycerol phenylbutyrate ................................................................. 36 glycopyrrolate ........................................................................... 15, 64 glycopyrrolate & indacaterol ......................................................... 64 glycopyrrolate inhalation pow ....................................................... 15 glycopyrrolate nebulizer soln ........................................................ 15 GLYNASE ....................................................................................... 52 GLYSET .......................................................................................... 54 GLYXAMBI ...................................................................................... 51 GOCOVRI ....................................................................................... 30 golimumab ...................................................................................... 60 GOLYTELY ..................................................................................... 45 granisetron ...................................................................................... 44 grass pollen allergen extract (5 glass extract) ........................... 41 GRASTEK ....................................................................................... 42 GRIFULVIN V ................................................................................... 6 griseofulvin microsize ...................................................................... 6 griseofulvin ultramicrosize .............................................................. 6 GRIS-PEG ........................................................................................ 6 guaifenesin & codeine ................................................................... 62 guanfacine ................................................................................ 22, 32 guanfacine extended-release ....................................................... 32 guselkumab .................................................................................. 59 GYNAZOLE-1 ................................................................................. 64 GYNODIOL ..................................................................................... 55
H HAEGARDA ................................................................................... 58 halcinonide ..................................................................................... 67 HALCION ........................................................................................ 32 HALDOL .......................................................................................... 34 HALFLYTELY ................................................................................. 45 halobetasol propionate ................................................................. 67 HALOG ............................................................................................ 67 haloperidol ...................................................................................... 34 HARVONI ....................................................................................... 10 HECTOROL ................................................................................... 71 HELIDAC .......................................................................................... 4 HEMLIBRA ..................................................................................... 59 heparin ............................................................................................ 18 HEPARIN SODIUM ....................................................................... 18 HEPSERA ......................................................................................... 8 HETLIOZ ......................................................................................... 32 hexachlorophene ........................................................................... 65 HIPREX ........................................................................................... 11 HIZENTRA ...................................................................................... 60 homatropine ............................................................................. 43, 62 HORIZANT ..................................................................................... 29 house dust mite allergen extract ................................................. 41 HUMALOG ..................................................................................... 53 HUMALOG KWIKPEN .................................................................. 53 HUMALOG MIX 50/50 .................................................................. 53 HUMALOG MIX 75/25 .................................................................. 53 HUMALOG MIX 75/25 KWIKPEN ............................................... 53 HUMATIN ......................................................................................... 7 HUMATROPE ................................................................................ 57 HUMIRA .......................................................................................... 58 HUMIRA citrate free ...................................................................... 58 HUMULIN 50/50 ............................................................................ 53 HUMULIN 70/30 ............................................................................ 53 HUMULIN 70/30 KIWKPEN ......................................................... 53 HUMULIN N ................................................................................... 53 HUMULIN N KWIKPEN ................................................................ 53 HUMULIN R ................................................................................... 53 HUMULIN R U-500 ........................................................................ 53 HYCAMTIN ..................................................................................... 15 HYCODAN ...................................................................................... 62 HYDERGINE .................................................................................. 17 hydralazine ............................................................................... 22, 23 HYDREA ......................................................................................... 13 hydrochlorothiazide ............................................... 20, 22, 23, 24, 37 hydrocodone ............................................................................. 26, 62 hydrocodone & acetaminophen ................................................... 26 hydrocodone & chlorpheniramine................................................ 62 hydrocodone & homatropine ........................................................ 62 hydrocodone & ibuprofen ............................................................. 26 hydrocodone er .............................................................................. 26 hydrocortisone............................................. 39, 40, 47, 65, 66, 67, 68 hydrocortisone & acetic acid (otic) .............................................. 40
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hydrocortisone & pramoxine ......................................................... 68 hydrocortisone (intrarectal) ........................................................... 67 hydrocortisone (rectal) .................................................................. 67 hydrocortisone (topical) ................................................................. 67 hydrocortisone acetate & urea ..................................................... 67 hydrocortisone acetate (intrarectal) ............................................. 67 hydrocortisone butyrate ................................................................ 67 hydrocortisone butyrate hydrophilic lipo base ............................ 67 hydrocortisone probutate .............................................................. 68 hydrocortisone valerate ................................................................. 68 hydromorphone oral suspension ................................................. 26 hydromorphone tablet ................................................................... 26 hydroxychloroquine sulfate ............................................................. 7 hydroxyurea .................................................................................... 13 hydroxyzine hcl............................................................................... 31 hydroxyzine pamoate .................................................................... 31 HYGROTON ................................................................................... 37 hyoscyamine sulfate ...................................................................... 15 HYPERCARE ................................................................................. 68 HYPERSAL ..................................................................................... 64 HYQVIA ........................................................................................... 60 HYSINGLA ER ............................................................................... 26 HYTONE ......................................................................................... 67 HYTRIN ........................................................................................... 19 HYZAAR .......................................................................................... 23
I ibandronate ..................................................................................... 60 IBRANCE ........................................................................................ 14 ibrutinib ............................................................................................ 13 Ibrutinib 140 mg, 280 mg .............................................................. 13 ibuprofen ................................................................................... 26, 27 icatibant ........................................................................................... 60 ICLUSIG .......................................................................................... 14 icosapent ......................................................................................... 20 idelalisib ........................................................................................... 13 IDHIFA ............................................................................................. 12 ILARIS ............................................................................................. 58 iloperidone ...................................................................................... 34 ILUMYA ........................................................................................... 62 imatinib mesylate ........................................................................... 13 IMBRUVICA .................................................................................... 13 IMDUR ............................................................................................. 23 imipramine ...................................................................................... 34 imipramine pamoate ...................................................................... 34 imiquimod ........................................................................................ 70 IMITREX .......................................................................................... 30 immune globulin ............................................................................. 60 Immune globulin ............................................................................. 60 IMPAVIDO ........................................................................................ 7 IMURAN .......................................................................................... 58 INCIVEK .......................................................................................... 11 INCRUSE ELLIPTA ....................................................................... 16
indacaterol ...................................................................................... 64 indapamide ..................................................................................... 37 INDERAL ........................................................................................ 24 INDERAL LA .................................................................................. 24 INDERIDE ....................................................................................... 24 indinavir sulfate ................................................................................ 9 INDOCIN ......................................................................................... 26 indomethacin .................................................................................. 26 INFERGEN ....................................................................................... 9 INFLAMASE FORTE ..................................................................... 40 ingenol mebutate ........................................................................... 70 INGREZZA ..................................................................................... 33 INLYTA ............................................................................................ 12 INNOPRAN XL ............................................................................... 24 Inotersen ......................................................................................... 60 INSPRA ........................................................................................... 22 insulin (oral inhalation) .................................................................. 52 insulin aspart .................................................................................. 52 insulin aspart protamine & insulin aspart ................................... 52 insulin degludec ............................................................................. 52 Insulin degludec/ liraglutide .......................................................... 52 insulin degludec/insulin aspart ..................................................... 52 insulin detemir ................................................................................ 52 insulin glargine ............................................................................... 52 Insulin glargine/ lixisenatide ......................................................... 52 insulin glulisine ............................................................................... 53 insulin isophane ............................................................................. 53 insulin isophane & regular insulin ................................................ 53 insulin lispro .................................................................................... 53 insulin lispro protamine & insulin lispro....................................... 53 insulin regular ................................................................................. 53 INTAL .............................................................................................. 63 INTELENCE ..................................................................................... 9 interferon alfacon-1 ......................................................................... 9 interferon beta-1a .......................................................................... 60 interferon beta-1b .......................................................................... 60 Interferon beta-1b .......................................................................... 60 interferon gamma-1b ..................................................................... 60 INTROVALE ................................................................................... 48 INTUNIV .......................................................................................... 32 INVEGA........................................................................................... 34 INVIRASE ....................................................................................... 11 INVOKAMET .................................................................................. 51 INVOKANA ..................................................................................... 51 iodoquinol & hydrocortisone ......................................................... 65 IOPIDINE ........................................................................................ 43 ipratropium bromide ...................................................................... 15 irbesartan ........................................................................................ 23 irbesartan & hydrochlorothiazide ................................................. 23 isavuconazonium ............................................................................. 6 ISENTRESS ................................................................................... 10 ISENTRESS HD ............................................................................ 10 isocarboxazid ................................................................................. 34 isoniazid ............................................................................................ 7
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ISOPTIN SR ................................................................................... 21 ISOPTO ATROPINE...................................................................... 43 ISOPTO CARBACHOL ................................................................. 42 ISOPTO CARPINE ........................................................................ 42 ISOPTO HOMATROPINE ............................................................ 43 ISOPTO HYOSCINE ..................................................................... 43 ISORDIL .......................................................................................... 23 isosorbide dinitrate ......................................................................... 23 isosorbide dinitrate & hydralazine ................................................ 23 isosorbide mononitrate .................................................................. 23 isotretinoin ....................................................................................... 70 isradipine ......................................................................................... 21 ISTALOL.......................................................................................... 42 itraconazole ...................................................................................... 6 Ivabradine ....................................................................................... 21 ivacaftor ........................................................................................... 64 ivermectin .......................................................................................... 4 ivosidenib ........................................................................................ 13 ixazomib .......................................................................................... 13 ixekizumab ...................................................................................... 60
J JAKAFI ............................................................................................ 14 JALYN ............................................................................................. 59 JANUMET ....................................................................................... 54 JANUVIA ......................................................................................... 54 JARDIANCE ................................................................................... 51 JENTADUETO ............................................................................... 53 JUBLIA .............................................................................................. 6 JULUCA ............................................................................................ 8 JUNEL ....................................................................................... 49, 50 JUNEL FE ....................................................................................... 50 JUVISYNC ...................................................................................... 54 JUXTAPID ....................................................................................... 20 JYNARQUE .................................................................................... 37
K KADIAN ........................................................................................... 26 KALETRA ........................................................................................ 10 KALYDECO .................................................................................... 64 KAON............................................................................................... 38 KAPVAY .......................................................................................... 22 KARIVA ........................................................................................... 48 KAZANO.......................................................................................... 51 K-DUR ............................................................................................. 38 KEFLEX ............................................................................................. 5 KELNOR.......................................................................................... 48 KENALOG ....................................................................................... 68 KEPPRA .......................................................................................... 29 KEPPRA XR ................................................................................... 29 KERLONE ....................................................................................... 24 KERYDIN .......................................................................................... 6
KETEK .............................................................................................. 6 ketoconazole .............................................................................. 6, 65 ketoconazole (topical) ................................................................... 65 ketoprofen ....................................................................................... 26 KETOPROFEN .............................................................................. 26 ketorolac (ophth) ............................................................................ 40 ketorolac tablet ............................................................................... 26 KEVEYIS......................................................................................... 59 KEVZARA ....................................................................................... 62 KHEDEZLA ..................................................................................... 34 KINERET ........................................................................................ 58 KLARON ......................................................................................... 66 KLONOPIN ..................................................................................... 29 KLOR-CON 20 MEQ ..................................................................... 38 K-LYTE/CL ..................................................................................... 38 KOMBIGLYZE XR ......................................................................... 54 KORLYM ......................................................................................... 54 K-PHOS NEUTRAL ....................................................................... 38 K-PHOS ORIGINAL ...................................................................... 38 KRISTALOSE ................................................................................. 37 K-TAB 10, KLOR-CON 20 MEQ ................................................. 38 K-TAB, KLOR-CON 20 MEQ ...................................................... 38 KUVAN ............................................................................................ 61 KWELL ............................................................................................ 65 KYNAMRO ..................................................................................... 20 KYTRIL ............................................................................................ 44
L labetalol ........................................................................................... 24 LAC-HYDRIN ................................................................................. 69 lacosamide ..................................................................................... 29 LACRISERT ................................................................................... 43 lactic acid (ammonium lactate) .................................................... 70 LACTINOL ...................................................................................... 70 lactulose .................................................................................... 36, 37 LAMICTAL ...................................................................................... 29 LAMICTAL XR................................................................................ 29 Lamidudine & tenofovir ................................................................. 10 LAMISIL ............................................................................................ 6 lamivudine............................................................................... 8, 9, 10 lamivudine & zidovudine ........................................................... 8, 10 lamotrigine ...................................................................................... 29 lamotrigine extended-release....................................................... 29 lanadelumab ................................................................................... 60 LANOXIN ........................................................................................ 21 lanreotide ........................................................................................ 60 lansoprazole ................................................................................... 44 lanthanum carbonate .................................................................... 37 LANTUS .......................................................................................... 52 LANTUS SOLOSTAR ................................................................... 52 lapatinib ........................................................................................... 13 LARIAM ............................................................................................. 7 LASIX .............................................................................................. 37
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LASTACAFT ................................................................................... 41 latanoprost ...................................................................................... 42 latanoprostene bunod.................................................................... 42 LATUDA .......................................................................................... 34 LAZANDA........................................................................................ 26 ledipasvir & sofosbuvir .................................................................. 10 leflunomide...................................................................................... 60 lenalidomide .................................................................................... 13 lenvatinib ......................................................................................... 13 LENVIMA ........................................................................................ 13 LESCOL .......................................................................................... 20 LESCOL XL .................................................................................... 20 lesinurad .......................................................................................... 60 LESSINA ......................................................................................... 48 LETAIRIS ........................................................................................ 23 letermovir ........................................................................................ 10 letrozole ........................................................................................... 13 leucovorin ........................................................................................ 60 LEUCOVORIN ................................................................................ 60 LEUKERAN .................................................................................... 12 LEUKINE ......................................................................................... 19 leuprolide acetate ........................................................................... 13 levalbuterol nebulizer solution ...................................................... 18 levalbuterol tartrate ........................................................................ 18 LEVAQUIN ........................................................................................ 5 LEVATOL ........................................................................................ 24 LEVBID ............................................................................................ 15 LEVEMIR ........................................................................................ 52 levetiracetam .................................................................................. 29 levetiracetam extended-release ................................................... 29 levobunolol ...................................................................................... 42 LEVO-DROMORAN ...................................................................... 26 levofloxacin ................................................................................. 5, 39 levofloxacin (ophth)........................................................................ 39 levomilnacipran .............................................................................. 34 levonorgestrel ..................................................................... 48, 49, 55 levonorgestrel & ethinyl estradiol ........................................... 48, 49 levonorgestrel & ethinyl estradiol (91-day) ........................... 48, 49 levonorgestrel & ethinyl estradiol (continuous) .......................... 49 levonorgestrel & ethinyl estradiol (triphasic) .............................. 49 levorphanol ..................................................................................... 26 LEVOTHROID ................................................................................ 57 levothyroxine .................................................................................. 57 LEVOXYL ........................................................................................ 57 LEVSIN ............................................................................................ 15 LEXAPRO ....................................................................................... 34 LEXIVA .............................................................................................. 9 l-glutamine ...................................................................................... 60 LIALDA ............................................................................................ 44 LIBRAX ............................................................................................ 46 LIBRIUM .......................................................................................... 31 LIDAMANTLE ................................................................................. 68 LIDEX .............................................................................................. 67 LIDEX-E .......................................................................................... 67
lidocaine & hydrocortisone ........................................................... 68 lidocaine & prilocaine .................................................................... 68 lidocaine & tetracaine .................................................................... 68 lidocaine (jelly, topical) .................................................................. 68 lidocaine (mouth-throat) ................................................................ 43 lifitegrast .......................................................................................... 40 LIMBITROL DS .............................................................................. 33 linaclotide ........................................................................................ 46 linagliptin ......................................................................................... 53 linagliptin & metformin ................................................................... 53 lindane ............................................................................................. 65 linezolid ............................................................................................. 5 LINZESS ......................................................................................... 46 LIORESAL ...................................................................................... 16 liothyronine ..................................................................................... 57 liotrix ................................................................................................ 57 LIPITOR .......................................................................................... 19 liraglutide................................................................................... 52, 53 lisdexamfetamine ........................................................................... 28 lisinopril ........................................................................................... 23 lisinopril & hydrochlorothiazide .................................................... 23 LITHIUM CARBONATE ................................................................ 34 lithium carbonate capsule ............................................................. 34 lithium carbonate extended release ............................................ 34 lithium citrate .................................................................................. 34 LITHOBID ....................................................................................... 34 LIVALO ............................................................................................ 20 lixisenatide ................................................................................ 52, 54 LO LOESTRIN FE ......................................................................... 50 LO/OVRAL-28 ................................................................................ 50 LOCOID .......................................................................................... 67 LOCOID LIPOCREAM .................................................................. 67 LODINE ........................................................................................... 25 LODOSYN ...................................................................................... 30 lodoxamide tromethamine ............................................................ 41 LOESTRIN 24 FE .......................................................................... 50 LOESTRIN FE................................................................................ 50 lofexidine ......................................................................................... 32 LOFIBRA CAP ............................................................................... 20 LOFIBRA TAB ................................................................................ 19 LOKELMA ....................................................................................... 37 lomitapide ....................................................................................... 20 LOMOTIL ........................................................................................ 44 lomustine......................................................................................... 13 LONHALA MAGNAIR ................................................................... 15 LONITEN ........................................................................................ 22 LONSURF ....................................................................................... 15 LOPID .............................................................................................. 20 lopinavir & ritonavir ........................................................................ 10 LOPRESSOR ................................................................................. 24 LOPRESSOR HCT ........................................................................ 24 LOPROX ......................................................................................... 64 lorazepam ....................................................................................... 32 LORBRENA .................................................................................... 13
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lorlatinib ........................................................................................... 13 losartan ............................................................................................ 23 losartan & hydrochlorothiazide ..................................................... 23 LOSEASONIQUE .......................................................................... 48 LOTEMAX ....................................................................................... 40 LOTENSIN ...................................................................................... 22 LOTENSIN HCT ............................................................................. 22 loteprednol ...................................................................................... 40 loteprednol & tobramycin .............................................................. 40 LOTREL .......................................................................................... 20 LOTRISONE ................................................................................... 65 LOTRONEX .................................................................................... 43 lovastatin ......................................................................................... 20 lovastatine extended-release ....................................................... 20 LOVAZA .......................................................................................... 20 LOVENOX ....................................................................................... 18 LOW-OGESTREL .......................................................................... 50 loxapine ........................................................................................... 34 LOXITANE ...................................................................................... 34 LOZOL ............................................................................................. 37 lubiprostone .................................................................................... 46 LUCEMYRA .................................................................................... 32 LUDIOMIL ....................................................................................... 34 LUFYLLIN ....................................................................................... 70 luliconazole ....................................................................................... 6 lumacaftor& ivacaftor ..................................................................... 64 LUMIGAN ........................................................................................ 42 LUNESTA........................................................................................ 31 LUPRON ......................................................................................... 13 lurasidone........................................................................................ 34 LURIDE CHEW .............................................................................. 62 LURIDE DROPS ............................................................................ 62 LUTERA .......................................................................................... 48 LUVOX ............................................................................................ 34 LUXIQ .............................................................................................. 66 LUZU ................................................................................................. 6 LYPREL ........................................................................................... 49 LYRICA ........................................................................................... 30 LYSODREN .................................................................................... 14 LYSTEDA ........................................................................................ 18
M macitentan ...................................................................................... 23 MACROBID .................................................................................... 11 MACRODANTIN ............................................................................ 11 mafenide acetate ........................................................................... 65 MALARONE ...................................................................................... 7 malathion ......................................................................................... 65 maprotiline ...................................................................................... 34 maraviroc ........................................................................................ 10 MARINOL ........................................................................................ 44 MARPLAN ....................................................................................... 34 MATULANE .................................................................................... 14
MAVIK ............................................................................................. 23 MAVYRET ........................................................................................ 9 MAXAIR AUTOHALER ................................................................. 18 MAXALT .......................................................................................... 30 MAXALT MLT ................................................................................. 30 MAXIDEX ........................................................................................ 39 MAXITROL ..................................................................................... 40 MAXZIDE ........................................................................................ 37 mechlorethamine ........................................................................... 13 meclofenamate .............................................................................. 26 MECLOMEN ................................................................................... 26 MEDROL......................................................................................... 47 medroxyprogesterone acetate ............................................... 55, 57 mefenamic acid .............................................................................. 26 mefloquine ........................................................................................ 7 MEGACE ........................................................................................ 57 megestrol acetate .......................................................................... 57 MEKTOVI ........................................................................................ 12 MELLARIL ...................................................................................... 35 meloxicam ....................................................................................... 26 melphalan ....................................................................................... 14 memantine ...................................................................................... 32 memantine er & donepezil ............................................................ 32 M-END MAX D ............................................................................... 63 MENEST ......................................................................................... 55 MENOSTAR ................................................................................... 55 MENTAX ......................................................................................... 64 mepenzolate ................................................................................... 46 meperidine tablet ........................................................................... 26 MEPHYTON ................................................................................... 71 mepolizumab .................................................................................. 64 meprobamate ................................................................................. 32 MEPRON .......................................................................................... 7 mercaptopurine .............................................................................. 14 mesalamine controlled-release .................................................... 43 mesalamine suppository ............................................................... 43 mesalamine suspension ............................................................... 43 mesalamine tablet ......................................................................... 44 mesna .............................................................................................. 60 MESNEX ......................................................................................... 60 MESTION ....................................................................................... 16 MESTION TIMESPAN .................................................................. 16 METADATE CD ............................................................................. 28 METADATE ER ............................................................................. 28 METAGLIP ..................................................................................... 52 metaxalone ..................................................................................... 16 metformin ...................................................................... 51, 52, 53, 54 metformin ER ................................................................................. 54 metformin extended-release ........................................................ 54 methadone ...................................................................................... 26 methamphetamine ......................................................................... 28 methazolamide ............................................................................... 42 methenamine hippurate ................................................................ 11
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methenamine, sodium biphosphate, phenyl salicylate, methylene blue, and hyoscyamine ................................... 11, 61
METHERGINE ............................................................................... 61 methimazole ................................................................................... 57 METHITEST ................................................................................... 47 methocarbamol............................................................................... 16 methotrexate ................................................................................... 14 methotrexate sodium ..................................................................... 14 methoxsalen ................................................................................... 70 methoxsalen, rapid ........................................................................ 70 methscopolamine ........................................................................... 15 methsuximide ................................................................................. 29 methyclothiazide ............................................................................ 37 METHYCLOTHIAZIDE .................................................................. 37 methyldopa ..................................................................................... 22 methyldopa & hydrochlorothiazide .............................................. 22 methylergonovine maleate ........................................................... 61 METHYLIN ...................................................................................... 28 methylnaltrexone ............................................................................ 46 methylphenidate ............................................................................. 28 methylphenidate extended-release ............................................. 28 Methylphenidate extended-relesase disintegrating tablet ........ 28 methylphenidate sustained release ............................................. 28 methylphenidate transdermal patch ............................................ 28 methylprednisolone........................................................................ 47 methyltestosterone ........................................................................ 47 metipranolol .................................................................................... 42 metoclopramide .............................................................................. 46 metolazone ..................................................................................... 37 metoprol & hydrochlorothiazide ................................................... 24 metoprolol succinate...................................................................... 24 metoprolol tartrate .......................................................................... 24 metreleptin ...................................................................................... 61 METROCREAM ............................................................................. 65 METROGEL .................................................................................... 65 METROGEL-VAGINAL ................................................................. 65 METROLOTION ............................................................................. 65 metronidazole ......................................................................... 4, 7, 65 metronidazole (topical) .................................................................. 65 metronidazole (vaginal) ................................................................. 65 metronidazole, tetracycline & bismuth subsalicylate .................. 4 metronidazoleextended-release .................................................... 7 MEVACOR ...................................................................................... 20 mexiletine ........................................................................................ 21 MEXITIL .......................................................................................... 21 MIACALCIN .................................................................................... 56 MICARDIS ...................................................................................... 23 MICARDIS HCT ............................................................................. 23 miconazole nitrate & zinc oxide ................................................... 65 MICROGESTIN ........................................................................ 49, 50 MICROGESTIN FE ........................................................................ 50 MICROZIDE .................................................................................... 37 MIDAMOR ....................................................................................... 37 midodrine hcl .................................................................................. 18
MIFEPREX ..................................................................................... 61 mifepristone .............................................................................. 54, 61 migalastat ....................................................................................... 61 MIGERGOT .................................................................................... 30 miglitol ............................................................................................. 54 miglustat .......................................................................................... 61 MIGRANAL ..................................................................................... 17 milnacipran ..................................................................................... 32 miltefosine......................................................................................... 7 MILTOWN ....................................................................................... 32 MINASTRIN 24 FE ........................................................................ 50 MINIPRESS .................................................................................... 19 MINIVELLE ..................................................................................... 55 MINOCIN .......................................................................................... 5 minocycline ....................................................................................... 5 minoxidil .......................................................................................... 22 mipomersen sodium ...................................................................... 20 mirabegron ..................................................................................... 71 MIRAPEX ........................................................................................ 31 MIRAPEX ER ................................................................................. 31 mirtazapine ..................................................................................... 34 MIRVASO ....................................................................................... 69 misoprostol ............................................................................... 25, 45 mitotane .......................................................................................... 14 MOBIC ............................................................................................ 26 modafinil .......................................................................................... 28 MODICON ...................................................................................... 49 MODURETIC.................................................................................. 37 moexipril .......................................................................................... 23 moexipril & hydrochlorothiazide................................................... 23 mometasone & formoterol ............................................................ 64 mometasone furoate ............................................................... 64, 68 MONODOX ....................................................................................... 5 MONONESSA ................................................................................ 50 MONOPRIL .................................................................................... 22 MONOPRIL HCT ........................................................................... 22 montelukast .................................................................................... 63 MONUROL ..................................................................................... 11 morphine ................................................................................... 26, 27 morphine & naltrexone .................................................................. 27 morphine beads ............................................................................. 26 morphine extended-relase capsule ............................................. 26 morphine extended-release tablet ............................................... 26 MORPHINE SULFATE ................................................................. 26 MOTOFEN ...................................................................................... 44 MOTRIN .......................................................................................... 26 MOVIPREP ..................................................................................... 45 moxifloxacin ................................................................................ 5, 39 moxifloxacin (ophth) ...................................................................... 39 MS CONTIN ................................................................................... 26 MSIR................................................................................................ 26 MUCOMYST-10 ............................................................................. 58 MULTAQ ......................................................................................... 21 mupirocin ........................................................................................ 65
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mupirocin calcium .......................................................................... 65 MYALEPT ....................................................................................... 61 MYAMBUTOL ................................................................................... 7 MYCELEX ....................................................................................... 65 MYCIFRADIN ................................................................................... 5 MYCOBUTIN .................................................................................... 7 MYCOLOG II .................................................................................. 68 mycophenolate mofetil .................................................................. 61 mycophenolate sodium ................................................................. 61 MYCOSTATIN .................................................................................. 6 MYDAYIS ........................................................................................ 28 MYFORTIC ..................................................................................... 61 MYLERAN ....................................................................................... 12 MYRBETRIQ .................................................................................. 71 MYSOLINE ..................................................................................... 30
N na sulfacetm/avobenzone/sulfur .................................................. 65 nabilone ........................................................................................... 44 nabumetone .................................................................................... 27 nadolol ............................................................................................. 24 nadolol & bendroflumethiazide ..................................................... 24 nafarelin ........................................................................................... 56 naftifine ............................................................................................ 65 naftifine cream ................................................................................ 65 Naftifine gel ..................................................................................... 66 NAFTIN ..................................................................................... 65, 66 nalbuphine ...................................................................................... 27 NALFON .......................................................................................... 25 naloxone .............................................................................. 25, 27, 33 naloxone nasal spray .................................................................... 33 naltrexone ................................................................................. 27, 33 NAMENDA ...................................................................................... 32 NAMZARIC ..................................................................................... 32 NAPRELAN .................................................................................... 27 NAPROSYN .................................................................................... 27 naproxen ......................................................................................... 27 naproxen sodium ........................................................................... 27 naratriptan ....................................................................................... 30 NARCAN ......................................................................................... 33 NARDIL ........................................................................................... 35 NATACYN ....................................................................................... 39 natamycin ........................................................................................ 39 NATAZIA ......................................................................................... 48 nateglinide ....................................................................................... 54 NATPARA ....................................................................................... 61 NATROBA ....................................................................................... 66 NAVANE.......................................................................................... 35 nebivolol .......................................................................................... 24 NEBUPENT ...................................................................................... 7 NECON ........................................................................................... 49 NECON 10/11................................................................................. 49 nedocromil sodium (ophth) ........................................................... 41
nefazodone ..................................................................................... 34 nelfinavir mesylate ......................................................................... 10 neomycin sulfate .............................................................................. 5 neomycin, bacitracin & polymyxin b (ophth) .............................. 39 neomycin, colistin, hydrocortisone & thonzonium (otic) ........... 40 neomycin, polymycin b & gramicidin (ophth) ............................. 39 neomycin, polymyxin B & dexamethasone (ophth)................... 40 neomycin, polymyxin B & hydrocortisone (ophth) ............... 39, 40 neomycin, polymyxin B & hydrocortisone (otic) ........................ 40 NEO-POLYCIN .............................................................................. 39 NEO-POLYCIN HC ....................................................................... 39 NEORAL ......................................................................................... 58 NEOSPORIN .................................................................................. 39 neostigmine bromide ..................................................................... 16 nepafenac ....................................................................................... 40 NEPTAZANE .................................................................................. 42 NESINA ........................................................................................... 51 netarsudil ........................................................................................ 42 netupitant & palonosetron ............................................................ 44 NEULASTA ..................................................................................... 19 NEUMEGA ..................................................................................... 19 NEUPOGEN ................................................................................... 19 NEUPRO......................................................................................... 31 NEURONTIN .................................................................................. 29 NEVANAC ...................................................................................... 40 nevirapine solution......................................................................... 10 nevirapine tablet ............................................................................ 10 NEXAVAR ....................................................................................... 14 NEXIUM .......................................................................................... 44 niacin ......................................................................................... 20, 71 niacin & lovastatin .......................................................................... 20 NIACOR .......................................................................................... 71 NIASPAN ........................................................................................ 20 nicardipine ...................................................................................... 21 NICODERM .................................................................................... 16 NICORETTE ................................................................................... 16 nicotine gum ................................................................................... 16 nicotine lozenge ............................................................................. 16 nicotine patch ................................................................................. 16 nicotine spray ................................................................................. 16 NICOTROL ..................................................................................... 16 nifedipine......................................................................................... 21 nifedipine extended-release ......................................................... 21 NILANDRON .................................................................................. 14 nilotinib ............................................................................................ 14 nilutamide ....................................................................................... 14 nimodipine ...................................................................................... 21 NIMOTOP ....................................................................................... 21 NINLARO ........................................................................................ 13 nintedanib ....................................................................................... 64 niraparib .......................................................................................... 14 NIRAVAM ....................................................................................... 31 nisoldipine ....................................................................................... 21 nitazoxanide ..................................................................................... 7
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nitisinone ......................................................................................... 61 NITRO-BID ...................................................................................... 23 NITRO-DUR .............................................................................. 23, 24 nitrofurantoin ................................................................................... 11 nitrofurantoin macrocrystal ........................................................... 11 nitrofurantoin monohydrate ........................................................... 11 nitroglycerin (intra-anal) ................................................................ 24 nitroglycerin aerosol ...................................................................... 23 nitroglycerin solution ...................................................................... 23 nitroglycerin sublingual .................................................................. 23 nitroglycerin topical ointment ........................................................ 23 nitroglycerin transdermal patch .............................................. 23, 24 nitroglycerin transdermal patch 0.8 mg strength ....................... 24 NITROLINGUAL ............................................................................. 23 NITROMIST .................................................................................... 23 NITROSTAT ................................................................................... 23 nizatidine ......................................................................................... 45 NIZORAL ..................................................................................... 6, 65 NOLVADEX .................................................................................... 14 NORA-BE ........................................................................................ 49 NORCO ........................................................................................... 26 NORDETTE-28 .............................................................................. 48 NORDITROPIN .............................................................................. 57 norelgestromin & ethinyl estradiol ............................................... 49 norethindrone ......................................................... 49, 50, 55, 56, 57 norethindrone & ethinyl estradiol ........................................... 49, 50 norethindrone & ethinyl estradiol (biphasic) ............................... 49 norethindrone & ethinyl estradiol (triphasic) ............................... 49 norethindrone & ethinyl estradiol w/ ferrous fumarate .............. 50 norethindrone acetate ....................................................... 50, 56, 57 norethindrone acetate & ethinyl estradiol ............................. 50, 56 norethindrone acetate & ethinyl estradiol w/ ferrous fumarate 50 norethindrone acetate & ethinyl estradiol w/ ferrous fumarate
(biphasic) .................................................................................... 50 norethindrone-mestranol ............................................................... 50 NORFLEX ....................................................................................... 16 norfloxacin ......................................................................................... 6 NORGESIC ..................................................................................... 17 norgestimate & ethinyl estradiol ................................................... 50 norgestimate & ethinyl estradiol (triphasic) ................................ 50 norgestrel & ethinyl estradiol ........................................................ 50 NORINYL 1+35 .............................................................................. 49 NORINYL 1+50 .............................................................................. 50 NOROXIN ......................................................................................... 6 NORPACE ...................................................................................... 21 NORPACE CR ............................................................................... 21 NORPRAMIN .................................................................................. 33 NOR-QD .......................................................................................... 49 NORTHERA .................................................................................... 17 NORTREL 1/35 ............................................................................. 49 NORTREL 7/7/7 ............................................................................. 49 nortriptyline ..................................................................................... 34 NORVASC ...................................................................................... 20 NORVIR .......................................................................................... 10
NOVOLIN 70/30 ............................................................................. 53 NOVOLIN N .................................................................................... 53 NOVOLIN R .................................................................................... 53 NOVOLOG ..................................................................................... 52 NOVOLOG MIX 70/30 .................................................................. 52 NOVOLOG MIX 70/30 FLEXPEN ............................................... 52 NOXAFIL........................................................................................... 6 NUBAIN........................................................................................... 27 NUBEQA ......................................................................................... 12 NUCALA ......................................................................................... 64 NUCYNTA ...................................................................................... 27 NUEDEXTA .................................................................................... 32 NULYTELY ..................................................................................... 45 NUPLAZID ...................................................................................... 35 NUTROPIN AQ .............................................................................. 57 NUVARING ..................................................................................... 48 NUVIGIL .......................................................................................... 28 NUZYRA ........................................................................................... 6 NYDRAZID ....................................................................................... 7 nystatin .................................................................................. 6, 66, 68 NYSTATIN ...................................................................................... 66 nystatin & triamcinolone................................................................ 68 nystatin (topical) ............................................................................. 66
O OCELLA .......................................................................................... 48 octreotide acetate .......................................................................... 61 OCUFEN ......................................................................................... 40 OCUFLOX ...................................................................................... 39 OCUPRESS ................................................................................... 42 ODACTRA ...................................................................................... 41 ODEFSEY ......................................................................................... 9 OFEV ............................................................................................... 64 ofloxacin (ophth) ............................................................................ 39 ofloxacin (otic) ................................................................................ 39 OGESTREL .................................................................................... 50 olanzapine ...................................................................................... 34 olanzapine & fluoxetine hcl .......................................................... 34 olanzapine orally disintegrating ................................................... 34 OLEPTRO ....................................................................................... 35 olmesartan ................................................................................ 20, 23 olmesartan & hydrochlorothiazide ......................................... 20, 23 olodaterol .................................................................................. 18, 64 olopatadine ..................................................................................... 41 olopatadine (nasal) ........................................................................ 41 olopatadine (ophth) ....................................................................... 41 olsalazine ........................................................................................ 44 OLUMIANT ..................................................................................... 58 OLUX-E ........................................................................................... 67 OLYSIO ........................................................................................... 11 omadacycline ................................................................................... 6 omalizumab .................................................................................... 64 ombitasvir, paritaprevir & ritonavir ............................................... 10
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ombitasvir, paritaprevir, ritonavir, & dasabuvir........................... 10 omega-3 acid ethyl esters............................................................. 20 omega-3-carboxylic acid ............................................................... 20 omeprazole ..................................................................................... 45 OMNICEF.......................................................................................... 4 OMNIPRED .................................................................................... 40 OMNITROPE .................................................................................. 57 ondansetron .................................................................................... 44 ondansetron (orally disintegrating) .............................................. 44 ONE TOUCH ULTRA 2 ................................................................. 36 ONE TOUCH ULTRA SMART ..................................................... 36 ONE TOUCH ULTRA TEST STRIPS ......................................... 35 ONE TOUCH ULTRAMINI ............................................................ 36 ONE TOUCH VERIO FLEX .......................................................... 36 ONE TOUCH VERIO TEST STRIPS .......................................... 35 ONEXTON ...................................................................................... 65 ONFI ................................................................................................ 29 ONGLYZA ....................................................................................... 54 ONSOLIS ........................................................................................ 26 OPANA ............................................................................................ 27 OPANA ER ..................................................................................... 27 OPIUM ............................................................................................. 27 opium & belladonna alkaloids ...................................................... 27 opium tincture ................................................................................. 27 oprelvekin ........................................................................................ 19 OPSUMIT ........................................................................................ 23 OPTHETIC ...................................................................................... 43 OPTICROM .................................................................................... 41 OPTIPRANOLOL ........................................................................... 42 OPTIVAR ........................................................................................ 41 ORACEA ..................................................................................... 5, 70 ORALAIR ........................................................................................ 41 ORAP............................................................................................... 35 ORAPRED ...................................................................................... 47 ORAPRED ODT ............................................................................. 47 ORENCIA ........................................................................................ 58 ORENITRAM .................................................................................. 24 ORFADIN ........................................................................................ 61 ORILISSA........................................................................................ 59 ORINASE ........................................................................................ 54 ORKAMBI........................................................................................ 64 orphenadrine citrate ....................................................................... 16 orphenadrine, aspirin, & caffeine ................................................. 17 ORTHO EVRA ................................................................................ 49 ORTHO TRI-CYCLEN ................................................................... 50 ORTHO-CEPT ................................................................................ 48 ORTHO-CYCLEN .......................................................................... 50 ORTHO-EST .................................................................................. 56 ORTHO-NOVUM ..................................................................... 49, 50 oseltamivir phosphate ................................................................... 10 OSENI ............................................................................................. 51 OSMOPREP ................................................................................... 45 ospemifene ..................................................................................... 56 OSPHENA ...................................................................................... 56
OTEZLA .......................................................................................... 58 OTREXUP ...................................................................................... 14 OVCON-35 ..................................................................................... 49 OVCON-50 ..................................................................................... 49 OVIDE ............................................................................................. 65 OXANDRIN ..................................................................................... 47 oxandrolone .................................................................................... 47 oxaprozin ........................................................................................ 27 oxazepam ....................................................................................... 32 oxcarbazepine ................................................................................ 29 OXERVATE .................................................................................... 43 oxiconazole nitrate......................................................................... 66 OXISTAT......................................................................................... 66 OXSORALEN-ULTRA ................................................................... 70 oxybutynin....................................................................................... 71 oxybutynin extended-release ....................................................... 71 oxybutynin transdermal ................................................................. 71 oxycodone ...................................................................................... 27 oxycodone & acetaminophen....................................................... 27 oxycodone & acetaminophen er .................................................. 27 oxycodone & aspirin ...................................................................... 27 oxycodone & ibuprofen ................................................................. 27 oxycodone controlled-release ...................................................... 27 OXYCONTIN .................................................................................. 27 oxymetholone ................................................................................. 47 oxymorphone.................................................................................. 27 oxymorphone extended-release .................................................. 27 OXYTROL ....................................................................................... 71
P PACERONE ................................................................................... 21 palbociclib ....................................................................................... 14 paliperidone .................................................................................... 34 palivizumab ..................................................................................... 10 PALYNZIQ ...................................................................................... 61 PAMELOR ...................................................................................... 34 PAMINE .......................................................................................... 15 PANCREAZE ................................................................................. 45 pancrelipase (lipase-protease-amylase) .................................... 45 PANDEL .......................................................................................... 68 PANLOR SS ................................................................................... 25 PANRETIN ..................................................................................... 69 pantoprazole ................................................................................... 45 papaverine ...................................................................................... 24 PARAFON FORTE DSC .............................................................. 16 parathyroid hormone ..................................................................... 61 PARCOPA ...................................................................................... 31 paregoric ......................................................................................... 44 PAREGORIC .................................................................................. 44 paricalcitol ....................................................................................... 71 PARLODEL .................................................................................... 30 PARNATE ....................................................................................... 35 paromomycin sulfate ....................................................................... 7
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paroxetine ................................................................................. 34, 35 paroxetine extended-release ........................................................ 34 paroxetine mesylate ...................................................................... 35 pasireotide ...................................................................................... 61 PATADAY ....................................................................................... 41 PATANASE ..................................................................................... 41 PATANOL ....................................................................................... 41 patiromer ......................................................................................... 37 PAVABID ......................................................................................... 24 PAXIL............................................................................................... 34 PAXIL CR ........................................................................................ 34 pazopanib........................................................................................ 14 PEDIAPRED ................................................................................... 47 pediatric multivitamins w/ fluoride ................................................ 61 pediatric multivitamins w/ fluoride & iron .................................... 61 pediatric vitamins a, c, & d, w/ fluoride ....................................... 61 pediatric vitamins a, c, & d, w/ fluoride & iron ............................ 61 PEGANONE ................................................................................... 29 PEGASYS ....................................................................................... 10 pegfilgrastim ................................................................................... 19 pegfilgrastim-jmdb ......................................................................... 19 peginterferon alfa-2a ..................................................................... 10 peginterferon-alfa 2b ..................................................................... 10 PEG-INTRON ................................................................................. 10 pegvaliase ....................................................................................... 61 pegvisomant ................................................................................... 57 penbutolol........................................................................................ 24 penciclovir ....................................................................................... 66 penicillamine ................................................................................... 46 penicillin v potassium ...................................................................... 6 PENLAC .......................................................................................... 64 PENNSAID ...................................................................................... 25 pentamidine ...................................................................................... 7 PENTASA ....................................................................................... 43 pentazocine .................................................................................... 27 pentazocine & naloxone ................................................................ 27 pentosan polysulfate sodium ........................................................ 61 pentoxifylline ................................................................................... 18 PEN-VEE K ....................................................................................... 6 PEPCID ........................................................................................... 44 perampanel ..................................................................................... 29 PERCOCET .................................................................................... 27 PERCODAN ................................................................................... 27 PERIACTIN ....................................................................................... 4 PERIDEX ........................................................................................ 38 perindopril ....................................................................................... 23 PERIOSTAT ..................................................................................... 5 permethrin ....................................................................................... 66 perphenazine ............................................................................ 33, 35 PERSANTINE................................................................................. 18 PERTZYE........................................................................................ 45 PEXEVA .......................................................................................... 35 phenelzine ....................................................................................... 35 PHENERGAN ....................................................................... 4, 62, 63
PHENERGAN VC ...................................................................... 4, 63 PHENERGAN VC W/CODEINE .................................................. 63 PHENERGAN W/ CODEINE ....................................................... 62 phenobarbital ........................................................................... 32, 46 PHENOBARBITAL ........................................................................ 32 phenobarbital and belladonna alkaloids ..................................... 46 phenoxybenzamine ....................................................................... 17 PHENYTEK .................................................................................... 30 phenytoin sodium extended-release ..................................... 29, 30 phenytoin suspension ................................................................... 30 PHISOHEX ..................................................................................... 65 PHOSLO ......................................................................................... 37 PHOSLYRA .................................................................................... 38 PHOSPHA ...................................................................................... 38 PHOSPHOLINE IODIDE .............................................................. 42 PHRENILIN .................................................................................... 25 PHRENILIN FORTE ...................................................................... 25 phytonadione .................................................................................. 71 PICATO ........................................................................................... 70 pilocarpine ................................................................................ 16, 42 pilocarpine gel ................................................................................ 42 PILOPINE HS ................................................................................. 42 pimavanserin .................................................................................. 35 pimecrolimus .................................................................................. 70 pimozide .......................................................................................... 35 pindolol ............................................................................................ 24 pioglitazone .............................................................................. 51, 54 pioglitazone & glimepiride ............................................................ 54 pioglitazone & metformin .............................................................. 54 PIQRAY........................................................................................... 12 pirbuterol acetate ........................................................................... 18 pirfenidone ...................................................................................... 64 piroxicam......................................................................................... 27 pitavastatin ..................................................................................... 20 PLAN B ........................................................................................... 48 PLAQUENIL ..................................................................................... 7 PLAVIX ............................................................................................ 18 PLEGRIDY ..................................................................................... 60 PLENDIL ......................................................................................... 21 PLETAL ........................................................................................... 18 PLEXION ........................................................................................ 68 PLEXION SCT ............................................................................... 68 podofilox .......................................................................................... 70 POLY HIST FORTE ........................................................................ 4 POLYCITRA-K ............................................................................... 36 polyethylene glycol-electrolyte solution ...................................... 45 polymyxin b & trimethoprim (ophth) ............................................ 39 POLYSPORIN ................................................................................ 38 POLYTRIM ..................................................................................... 39 POLY-VI-FLOR .............................................................................. 61 POLY-VI-FLOR W/IRON .............................................................. 61 pomalidomide ................................................................................. 14 POMALYST .................................................................................... 14 ponatinib ......................................................................................... 14
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PONSTEL ....................................................................................... 26 PORTIA ........................................................................................... 48 posaconazole ................................................................................... 6 potassium bicarbonate & potassium chloride ............................ 38 potassium chloride ......................................................................... 38 potassium chrloide powder ........................................................... 38 potassium citrate ............................................................................ 36 potassium citrate & citric acid ....................................................... 36 potassium gluconate...................................................................... 38 potassium iodide & iodine ............................................................. 57 potassium phosphate .................................................................... 38 potassium phosphate, monobasic ............................................... 38 POTIGA ........................................................................................... 29 PRADAXA ....................................................................................... 18 PRALUENT ..................................................................................... 51 pramipexole .................................................................................... 31 pramipexole extended-release ..................................................... 31 pramlintide acetate ........................................................................ 54 PRAMOSONE ................................................................................ 68 PRAMOSONE-E ............................................................................ 68 pramoxine ....................................................................................... 68 PRANDIMET .................................................................................. 54 PRANDIN ........................................................................................ 54 prasugrel ......................................................................................... 18 PRAVACHOL ................................................................................. 20 pravastatin ...................................................................................... 20 praziquantel ...................................................................................... 4 prazosin ........................................................................................... 19 PRECOSE ...................................................................................... 51 PRED FORTE ................................................................................ 40 PRED MILD .................................................................................... 40 PRED-G .......................................................................................... 40 prednicarbate .................................................................................. 68 PREDNISOL ................................................................................... 41 prednisolone ....................................................................... 40, 41, 47 PREDNISOLONE .......................................................................... 47 prednisolone acetate ............................................................... 40, 47 prednisolone acetate (ophth) ....................................................... 40 prednisolone sodium phosphate ...................................... 40, 41, 47 prednisolone sodium phosphate (ophth) .............................. 40, 41 prednisone ...................................................................................... 47 PREDNISONE ................................................................................ 47 PREFEST........................................................................................ 55 pregabalin ....................................................................................... 30 PRELONE ....................................................................................... 47 PREMARIN ..................................................................................... 56 PREMARIN CREAM...................................................................... 56 PREMPHASE ................................................................................. 55 PREMPRO ...................................................................................... 55 PREPOPIK ...................................................................................... 45 PREVACID ...................................................................................... 44 PREVIDENT ................................................................................... 62 PREVIDENT 5000 PLUS ............................................................. 62 PREVPAC ....................................................................................... 44
PREVYMIS ..................................................................................... 10 PREZCOBIX ..................................................................................... 8 PREZISTA ........................................................................................ 8 PRIFTIN ............................................................................................ 7 PRILOSEC ..................................................................................... 45 PRIMAQUINE .................................................................................. 7 primaquine phosphate .................................................................... 7 primidone ........................................................................................ 30 PRISTIQ .......................................................................................... 34 PROAIR HFA ................................................................................. 17 PROAMATINE ............................................................................... 18 PRO-BANTHINE ............................................................................ 15 probenecid ...................................................................................... 38 procarbazine ................................................................................... 14 PROCARDIA .................................................................................. 21 PROCARDIA XL ............................................................................ 21 prochlorperazine ............................................................................ 44 PROCRIT ........................................................................................ 19 PROCTOCORT ............................................................................. 67 PROCTOFOAM ............................................................................. 68 PROCTOFOAM-HC ...................................................................... 68 PROCYSBI ..................................................................................... 59 PRODIGY ....................................................................................... 36 PRODIGY TEST STRIPS ............................................................. 36 progesterone, micronized ............................................................. 57 PROGRAF ...................................................................................... 62 PROLIXIN ....................................................................................... 34 PROLOPRIM .................................................................................. 11 PROMACTA ................................................................................... 19 promethazine........................................................................ 4, 62, 63 promethazine & codeine ............................................................... 62 promethazine & dextromethorphan ............................................. 63 promethazine & phenylephrine ...................................................... 4 promethazine, phenylephrine & codeine .................................... 63 PROMETHAZINE-DM ................................................................... 63 PROMETRIUM .............................................................................. 57 propafenone ................................................................................... 21 propantheline bromide .................................................................. 15 proparacaine .................................................................................. 43 propranolol ...................................................................................... 24 propranolol & hydrochlorothiazide ............................................... 24 propranolol extended-release ...................................................... 24 propranolol sustained-release ..................................................... 24 propylthiouracil ............................................................................... 57 PROPYLTHIOURACIL ................................................................. 57 PROSOM ........................................................................................ 31 PROSTIGMIN ................................................................................ 16 PROTONIX ..................................................................................... 45 PROTOPIC ..................................................................................... 70 protriptyline ..................................................................................... 35 PROVENTIL HFA .......................................................................... 17 PROVERA ...................................................................................... 57 PROVIGIL ....................................................................................... 28 PROZAC ......................................................................................... 34
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PROZAC WEEKLY ........................................................................ 34 PRUDOXIN ..................................................................................... 70 pseudoephedrine, brompheniramine & codeine ........................ 63 PSORIATEC ................................................................................... 69 PULMICORT FLEXHALER .......................................................... 63 PULMICORT RESPULES ............................................................ 63 PULMOZYME ................................................................................. 38 PURINETHOL ................................................................................ 14 PYLERA ............................................................................................ 4 pyrazinamide .................................................................................... 7 PYRAZINAMIDE .............................................................................. 7 pyridostigmine ................................................................................ 16 pyrimethamine .................................................................................. 7
Q QUALAQUIN .................................................................................... 7 QUESTRAN .................................................................................... 19 QUESTRAN LIGHT ....................................................................... 19 quetiapine........................................................................................ 35 quetiapine extended-release ........................................................ 35 QUINAGLUTE ................................................................................ 21 quinapril & hydrochlorothiazide .................................................... 23 quinapril hcl ..................................................................................... 23 quinidine .................................................................................... 21, 32 quinidine gluconate ........................................................................ 21 QUINIDINE SULFATE .................................................................. 21 quinine sulfate .................................................................................. 7 QUIXIN ............................................................................................ 39 QVAR............................................................................................... 63 QVAR RediHaler ............................................................................ 63
R
rabeprazole ..................................................................................... 45 RAGWITEK ..................................................................................... 41 raloxifene hcl .................................................................................. 56 raltegravir ........................................................................................ 10 raltegravir (600mg) ........................................................................ 10 ramelteon ........................................................................................ 32 ramipril ............................................................................................. 23 RANEXA.......................................................................................... 21 ranitidine .......................................................................................... 45 ranolazine........................................................................................ 21 RAPAFLO ....................................................................................... 17 RAPAMUNE ................................................................................... 62 rasagiline ......................................................................................... 31 RASUVO ......................................................................................... 14 RAVICTI .......................................................................................... 36 RAYOS ............................................................................................ 47 RAZADYNE .................................................................................... 16 RAZADYNEER ............................................................................... 16 REBETOL ....................................................................................... 10 REBIF .............................................................................................. 60
REBIF REBIDOSE ........................................................................ 60 RECLIPSEN ................................................................................... 48 RECTIV ........................................................................................... 24 REGLAN ......................................................................................... 46 regorafenib ..................................................................................... 14 REGRANEX ................................................................................... 69 RELAFEN ....................................................................................... 27 RELENZA ....................................................................................... 11 RELISTOR ...................................................................................... 46 RELPAX .......................................................................................... 30 REMERON ..................................................................................... 34 REMODULIN .................................................................................. 24 RENAGEL ....................................................................................... 37 RENVELA ....................................................................................... 37 repaglinide ...................................................................................... 54 repaglinide & metformin ................................................................ 54 REPATHA ....................................................................................... 51 REQUIP .......................................................................................... 31 REQUIP XL .................................................................................... 31 RESCRIPTOR.................................................................................. 8 RESCULA ....................................................................................... 43 reserpine ......................................................................................... 22 RESTASIS ...................................................................................... 39 RESTORIL ...................................................................................... 32 retapamulin ..................................................................................... 66 RETIN-A .......................................................................................... 69 RETIN-A MICRO ........................................................................... 69 RETROVIR ..................................................................................... 11 REVATIO ........................................................................................ 24 revefenacin ..................................................................................... 15 REVIA .............................................................................................. 33 REVLIMID ....................................................................................... 13 REXULTI ......................................................................................... 33 REYATAZ ......................................................................................... 8 RHEUMATREX .............................................................................. 14 RHOPRESSA ................................................................................. 42 ribavirin ............................................................................................ 10 RIDAURA ........................................................................................ 46 rifabutin ............................................................................................. 7 RIFADIN ............................................................................................ 7 RIFAMATE ....................................................................................... 7 rifampin ............................................................................................. 7 rifampin & isoniazid ......................................................................... 7 rifampin, isoniazid, & pryazinamide .............................................. 7 rifapentine ......................................................................................... 7 RIFATER........................................................................................... 7 rifaximin ............................................................................................. 6 rilpivirine .................................................................................. 8, 9, 10 RILUTEK ......................................................................................... 32 riluzole ............................................................................................. 32 rimantadine ..................................................................................... 10 rimexolone ...................................................................................... 41 riociguat .......................................................................................... 24 RIOMET .......................................................................................... 54
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risankizumab .................................................................................. 61 risedronate sodium ........................................................................ 61 RISPERDAL ................................................................................... 35 RISPERDALM-TAB ....................................................................... 35 risperidone ...................................................................................... 35 risperidone orally disintegrating ................................................... 35 RITALIN ........................................................................................... 28 RITALIN LA ..................................................................................... 28 RITALIN SR .................................................................................... 28 ritonavir ............................................................................................ 10 rivaroxaban ..................................................................................... 18 rivastigmine tartrate ....................................................................... 16 rivastigmine tartrate (solution) ...................................................... 16 rizatriptan ........................................................................................ 30 rizatriptan orally disintegrating ..................................................... 30 ROBAXIN ........................................................................................ 16 ROBINUL ........................................................................................ 15 ROBINULFORTE ........................................................................... 15 ROCALTROL .................................................................................. 71 roflumilast ........................................................................................ 64 rolapitant ......................................................................................... 44 ROMYCIN ....................................................................................... 38 ropinirole ......................................................................................... 31 ropinirole extended-release .......................................................... 31 ROSAC ............................................................................................ 65 rosiglitazone .................................................................................... 54 rosiglitazone & glimepiride ............................................................ 54 rosiglitazone & metformin ............................................................. 54 ROSULA.......................................................................................... 68 rosuvastatin .................................................................................... 20 rotigotine ......................................................................................... 31 ROWASA ........................................................................................ 43 ROXICET ........................................................................................ 27 ROXICODONE ............................................................................... 27 ROZEREM ...................................................................................... 32 rufinamide ....................................................................................... 30 ruxolitinib ......................................................................................... 14 RYTHMOL ...................................................................................... 21 RYTHMOL SR ................................................................................ 21 RYZODEG 70/30 ........................................................................... 52
S S 5, 34, 41, 42, 57, 102 SABRIL ............................................................................................ 30 sacubitril & valsartan ..................................................................... 21 SAFYRAL ........................................................................................ 48 SAIZEN ........................................................................................... 57 SALAGEN ....................................................................................... 16 salmeterol.................................................................................. 63, 64 salsalate .......................................................................................... 27 SAMSCA ......................................................................................... 37 SANCTURA .................................................................................... 71 SANCTURA XR ............................................................................. 71
SANCUSO ...................................................................................... 44 SANDIMMUNE .............................................................................. 58 SANDOSTATIN ............................................................................. 61 SANTYL .......................................................................................... 69 SAPHRIS ........................................................................................ 33 sapropterin dihydrochloride .......................................................... 61 saquinavir mesylate....................................................................... 11 SARAFEM ...................................................................................... 34 sargramostim.................................................................................. 19 sarilumab ........................................................................................ 62 SAVAYSA ....................................................................................... 18 SAVELLA ........................................................................................ 32 saxagliptin ....................................................................................... 54 saxagliptin & metformin extended-release ................................. 54 scopolamine (ophth) ...................................................................... 43 scopolamine hydrobromide .......................................................... 44 SEASONALE.................................................................................. 48 SEASONIQUE ............................................................................... 49 SEB-PREV ..................................................................................... 66 secnidazole ....................................................................................... 8 SECTRAL ....................................................................................... 24 secukinumab .................................................................................. 62 SEEBRI NEOHALER .................................................................... 15 SEGLUROMET .............................................................................. 51 selegiline ......................................................................................... 31 selegiline transdermal ................................................................... 31 selenium sulfide ............................................................................. 66 SELSEB .......................................................................................... 66 SELSUN RX ................................................................................... 66 SELZENTRY .................................................................................. 10 SENSIPAR ..................................................................................... 58 SEPTRA ............................................................................................ 6 SERAX ............................................................................................ 32 SEREVENT DISKUS .................................................................... 64 SEROMYCIN.................................................................................... 7 SEROQUEL ................................................................................... 35 SEROQUEL XR ............................................................................. 35 SEROSTIM ..................................................................................... 57 SERPASIL ...................................................................................... 22 sertaconazole nitrate ..................................................................... 66 sertraline ......................................................................................... 35 SERZONE ...................................................................................... 34 sevelamer carbonate ..................................................................... 37 sevelamer hcl ................................................................................. 37 short ragweed pollen allergen extract ......................................... 41 SIGNIFOR ...................................................................................... 61 sildenafil .......................................................................................... 24 SILENOR ........................................................................................ 31 SILIQ ............................................................................................... 58 silodosin .......................................................................................... 17 SILVADENE ................................................................................... 66 silver sulfadiazine .......................................................................... 66 simeprevir ....................................................................................... 11 SIMPONI ......................................................................................... 60
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simvastatin .......................................................................... 19, 20, 54 sinecatechins .................................................................................. 70 SINEMET ........................................................................................ 31 SINEMET CR ................................................................................. 31 SINEQUAN ..................................................................................... 34 SINGULAIR .................................................................................... 63 sirolimus .......................................................................................... 62 sirolimus solution ........................................................................... 62 SIRTURO ........................................................................................ 58 sitagliptin & metformin ................................................................... 54 sitagliptin & simvastatin ................................................................. 54 sitagliptin phosphate ...................................................................... 54 SIVEXTRO ........................................................................................ 6 SKELAXIN ...................................................................................... 16 SKELID ............................................................................................ 62 SKYRIZI .......................................................................................... 61 sodium chloride .............................................................................. 64 sodium citrate & citric acid ............................................................ 36 sodium fluoride ............................................................................... 62 sodium fluoride (dental) ................................................................ 62 sodium fluoride drops .................................................................... 62 sodium oxybate .............................................................................. 33 sodium phenylbutyrate .................................................................. 36 sodium phosphates........................................................................ 45 sodium picosulfate-mag ox-anhyrous citric acid ........................ 45 sodium polystyrene sulfonate ....................................................... 37 sodium zirconium cyclosilicate ..................................................... 37 sofosbuvir .................................................................................. 10, 11 sofosbuvir & velpatasvir ................................................................ 11 sofosbuvir, velpatasvir, voxilaprevir............................................. 10 SOLARAZE ..................................................................................... 70 solifenacin ....................................................................................... 71 SOLIQUA ........................................................................................ 52 SOLODYN ........................................................................................ 5 SOLOSEC ......................................................................................... 8 solriamfetol ...................................................................................... 32 SOMA ........................................................................................ 16, 25 SOMA COMPOUND................................................................ 16, 25 SOMA COMPOUND W/ CODEINE............................................. 25 somatropin ...................................................................................... 57 SOMATULINE DEPOT ................................................................. 60 SOMAVERT .................................................................................... 57 SONATA.......................................................................................... 32 SOOLANTRA ................................................................................... 4 sorafenib tosylate ........................................................................... 14 SORIATANE ................................................................................... 69 SORILUX ........................................................................................ 69 sotalol .............................................................................................. 25 SOVALDI ......................................................................................... 11 SPECTAZOLE ................................................................................ 65 SPECTRACEF ................................................................................. 4 spinosad .......................................................................................... 66 SPIRIVA .................................................................................... 15, 16 SPIRIVA RESPIMAT ............................................................... 15, 16
spironolactone ................................................................................ 23 spironolactone & hydrochlorothiazide ......................................... 23 SPORANOX ..................................................................................... 6 SPRINTEC ..................................................................................... 50 SPRYCEL ....................................................................................... 12 SPS.................................................................................................. 37 STADOL .......................................................................................... 25 STALEVO ....................................................................................... 31 stannous fluoride ........................................................................... 62 STARLIX ......................................................................................... 54 stavudine......................................................................................... 11 STEGLATRO.................................................................................. 51 STEGLUJAN .................................................................................. 51 STELARA ....................................................................................... 62 STELAZINE .................................................................................... 35 STIMATE ........................................................................................ 56 STIOLTO RESPIMAT ................................................................... 64 STIVARGA ..................................................................................... 14 STRATTERA .................................................................................. 32 STRIBILD .......................................................................................... 9 STRIVERDI RESPIMAT ............................................................... 18 STROMECTOL ................................................................................ 4 SUBOXONE ................................................................................... 25 SUBUTEX ....................................................................................... 25 succimer .......................................................................................... 46 sucralfate suspension ................................................................... 45 sucralfate tablets ............................................................................ 45 sucroferric oxyhydroxide ............................................................... 37 SULAR ............................................................................................ 21 sulconazole nitrate......................................................................... 66 SULFAC .......................................................................................... 39 sulfacetamide sodium & prednisolone ........................................ 41 sulfacetamide sodium & sulfur ..................................................... 68 sulfacetamide sodium (acne) ....................................................... 66 sulfacetamide sodium (ophth) ointment ..................................... 39 sulfacetamide sodium (ophth) solution ....................................... 39 sulfadiazine ................................................................................. 6, 66 SULFADIAZINE ............................................................................... 6 sulfamethoxazole & trimethoprim .................................................. 6 SULFAMYLON ............................................................................... 65 sulfanilamide .................................................................................. 66 sulfasalazine ..................................................................................... 6 sulindac ........................................................................................... 27 sumatriptan ..................................................................................... 30 sunitinib malate .............................................................................. 14 SUNOSI .......................................................................................... 32 SUPRAX ........................................................................................... 4 SURMONTIL .................................................................................. 35 SUSTIVA........................................................................................... 9 SUTENT .......................................................................................... 14 suvorexant ...................................................................................... 32 SYMAX ............................................................................................ 15 SYMAX DUOTAB .......................................................................... 15 SYMBICORT .................................................................................. 63
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SYMBYAX ....................................................................................... 34 SYMDEKO ...................................................................................... 64 SYMFI ................................................................................................ 9 SYMFI LO ......................................................................................... 9 SYMLIN ........................................................................................... 54 SYMMETREL ................................................................................. 30 SYMTUZA ......................................................................................... 8 SYNAGIS ........................................................................................ 10 SYNALAR ....................................................................................... 67 SYNAREL ....................................................................................... 56 SYNERA PATCH ........................................................................... 68 SYNJARDY ..................................................................................... 51 SYNTHROID .................................................................................. 57 SYPRINE ........................................................................................ 46 syringe with needle,disposable .................................................... 36
T TABLOID ......................................................................................... 15 TACLONEX .................................................................................... 67 tacrolimus .................................................................................. 62, 70 tacrolimus (topical) ......................................................................... 70 tadalafil ............................................................................................ 24 TAGAMET ....................................................................................... 44 TAKHZYRO .................................................................................... 60 talazoparib ...................................................................................... 14 TALTZ .............................................................................................. 60 TALWIN ........................................................................................... 27 TALWIN NX .................................................................................... 27 TALZENNA ..................................................................................... 14 TAMBOCOR ................................................................................... 21 TAMIFLU ......................................................................................... 10 tamoxifen citrate ............................................................................. 14 tamsulosin hcl ................................................................................. 17 TANZEUM ....................................................................................... 51 TAPAZOLE ..................................................................................... 57 tapentadol ....................................................................................... 27 TARCEVA ....................................................................................... 13 TARGRETIN ............................................................................. 12, 69 TARKA ............................................................................................. 21 TASIGNA ........................................................................................ 14 tasimelteon...................................................................................... 32 TASMAR ......................................................................................... 31 tavaborole ......................................................................................... 6 TAVALISSE .................................................................................... 59 tazarotene ....................................................................................... 70 TAZORAC ....................................................................................... 70 TECFIDERA ................................................................................... 59 TECHNIVIE ..................................................................................... 10 tedizolid ............................................................................................. 6 teduglutide ...................................................................................... 46 TEGRETOL .............................................................................. 28, 29 TEGRETOL XR .............................................................................. 29 TEGSEDI ........................................................................................ 60
TEKAMLO ....................................................................................... 22 TEKTURNA .................................................................................... 22 TEKTURNA HCT ........................................................................... 22 telaprevir ......................................................................................... 11 telbivudine....................................................................................... 11 telithromycin ..................................................................................... 6 telmisartan ................................................................................ 20, 23 telmisartan & hydrochlorothiazide ............................................... 23 temazepam ..................................................................................... 32 TEMODAR ...................................................................................... 14 TEMOVATE .................................................................................... 67 TEMOVATE E ................................................................................ 67 temozolomide ................................................................................. 14 TENEX ............................................................................................ 22 tenofovir ............................................................................ 8, 9, 10, 11 tenofovir 300 mg ............................................................................ 11 tenofovir alafenamide .................................................................... 11 TENORETIC ................................................................................... 24 TENORMIN .................................................................................... 24 TERAZOL 3 .................................................................................... 66 TERAZOL 7 .................................................................................... 66 terazosin ......................................................................................... 19 terbinafine ......................................................................................... 6 terbutaline sulfate .......................................................................... 18 terconazole ..................................................................................... 66 terconazole (vaginal) ..................................................................... 66 teriflunomide ................................................................................... 62 teriparatide ...................................................................................... 56 TESSALON PERLES .................................................................... 62 TESTIM ........................................................................................... 47 testosterone .............................................................................. 47, 56 testosterone cypionate .................................................................. 47 TESTRED ....................................................................................... 47 tetrabenazine ................................................................................. 33 tetracycline ................................................................................... 4, 6 TETRACYCLINE ............................................................................. 6 tetrahydrozoline ............................................................................. 43 TEVETEN ....................................................................................... 22 tezacaftor & ivacaftor .................................................................... 64 thalidomide ..................................................................................... 62 THALOMID ..................................................................................... 62 theophylline .................................................................................... 71 thioguanine ..................................................................................... 15 thioridazine ..................................................................................... 35 thiothixene ...................................................................................... 35 THORAZINE ................................................................................... 33 thyroid .............................................................................................. 57 THYROLAR .................................................................................... 57 tiagabine ......................................................................................... 30 TIAZAC ........................................................................................... 20 TIBSOVO ........................................................................................ 13 ticagrelor ......................................................................................... 18 TIGAN ............................................................................................. 44 TIKOSYN ........................................................................................ 21
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tildrakizumab-asmn........................................................................ 62 TILIA ................................................................................................ 50 tiludronate ....................................................................................... 62 timolol .................................................................................. 25, 42, 43 TIMOPTIC ................................................................................. 42, 43 TIMOPTIC-XE ................................................................................ 43 timothy grass pollen allergen extract ........................................... 42 tiotropium ............................................................................ 15, 16, 64 tiotropium 1.25 mcg ....................................................................... 16 tiotropium 2.5 mcg ......................................................................... 15 tiotropium bromide and olodaterol ............................................... 64 tipranavir.......................................................................................... 11 TIROSINT ....................................................................................... 57 TIVICAY ............................................................................................ 8 tizanidine ......................................................................................... 17 TOBI................................................................................................... 6 TOBI PODHALER ............................................................................ 6 TOBRADEX .................................................................................... 41 tobramycin & dexamethasone ointment ..................................... 41 tobramycin & dexamethasone suspension ................................ 41 tobramycin inhalation powder ........................................................ 6 tobramycin inhalation solution ........................................................ 6 tobramycin sulfate (ophth) ointment ............................................ 39 tobramycin sulfate (ophth) solution ............................................. 39 TOBREX.......................................................................................... 39 tocilizumab ...................................................................................... 62 tofacitinib ......................................................................................... 62 TOFRANIL ...................................................................................... 34 TOFRANIL-PM ............................................................................... 34 tolazamide ....................................................................................... 54 tolbutamide ..................................................................................... 54 tolcapone ......................................................................................... 31 TOLECTIN 600............................................................................... 27 TOLINASE ...................................................................................... 54 tolmetin sodium .............................................................................. 27 tolterodine ....................................................................................... 71 tolterodine extended-release ........................................................ 71 tolvaptan .......................................................................................... 37 TOPAMAX ...................................................................................... 30 TOPAMAX SPRINKLE .................................................................. 30 TOPICORT ..................................................................................... 67 topiramate capsule ........................................................................ 30 topiramate tablet ............................................................................ 30 topotecan ........................................................................................ 15 TOPROL XL .................................................................................... 24 TORADOL ....................................................................................... 26 toremifene ....................................................................................... 15 torsemide ........................................................................................ 37 TOVIAZ ........................................................................................... 70 TQYNSTA ....................................................................................... 20 TRACLEER ..................................................................................... 23 TRADJENTA .................................................................................. 53 tramadol .......................................................................................... 27 tramadol & acetaminophen ........................................................... 27
tramadol extended-release .......................................................... 27 TRANDATE .................................................................................... 24 trandolapril ................................................................................ 21, 23 trandolapril & verapamil ................................................................ 21 tranexamic acid .............................................................................. 18 TRANSDERM-SCOP .................................................................... 44 TRANXENE .................................................................................... 31 tranylcypromine sulfate ................................................................. 35 TRAVATAN Z ................................................................................. 43 travoprost ........................................................................................ 43 trazodone ........................................................................................ 35 trazodone extended-release ........................................................ 35 TRECATOR ...................................................................................... 7 TRELEGY ELLIPTA ...................................................................... 63 TREMFYA ....................................................................................... 59 TRENTAL ....................................................................................... 18 treprostinil ....................................................................................... 24 TRESIBA......................................................................................... 52 tretinoin ..................................................................................... 15, 69 tretinoin microspheres ................................................................... 69 TREXALL ........................................................................................ 14 triamcinolone acetonide (topical) ................................................. 68 triamterene ..................................................................................... 37 triamterene & hydrochlorothiazide .............................................. 37 TRIAVIL........................................................................................... 33 triazolam ......................................................................................... 32 TRIBENZOR ................................................................................... 20 TRICOR .......................................................................................... 20 trientine ........................................................................................... 46 trifluidine/tipiracil ............................................................................ 15 trifluoperazine ................................................................................. 35 trifluridine ........................................................................................ 39 trihexyphenidyl ............................................................................... 31 TRILAFON ...................................................................................... 35 TRILEPTAL .................................................................................... 29 TRILIPIX ......................................................................................... 20 TRI-LO-SPRINTEC ....................................................................... 50 trimethobenzamide ........................................................................ 44 trimethoprim ......................................................................... 6, 11, 39 trimipramine .................................................................................... 35 TRINESSA ...................................................................................... 50 TRI-NORINYL ................................................................................ 49 TRINTELLIX ................................................................................... 35 TRI-SPRINTEC .............................................................................. 50 TRIUMEQ ......................................................................................... 8 TRI-VI-FLOR .................................................................................. 61 TRI-VI-FLOR W/IRON .................................................................. 61 TRIVORA ........................................................................................ 49 TRIZIVIR ........................................................................................... 8 trospium .......................................................................................... 71 trospium extended-release ........................................................... 71 TRULICITY ..................................................................................... 51 TRUSOPT ....................................................................................... 42 TRUVADA ......................................................................................... 9
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TUSSIONEX ................................................................................... 62 TWINJECT ...................................................................................... 17 TWYNSTA ...................................................................................... 20 TYKERB .......................................................................................... 13 TYLENOL W/ CODEINE ............................................................... 25 TYMLOS.......................................................................................... 56 TYZEKA .......................................................................................... 11 TYZINE ............................................................................................ 43
U UCERIS ........................................................................................... 46 ulipristal ........................................................................................... 51 ULORIC ........................................................................................... 59 ULTRACET ..................................................................................... 27 ULTRAM.......................................................................................... 27 ULTRAM ER ................................................................................... 27 ULTRAVATE .................................................................................. 67 umeclidinium ....................................................................... 16, 18, 63 umeclidinium & vilanterol ........................................................ 18, 63 UNIPHYL ......................................................................................... 71 UNIRETIC ....................................................................................... 23 UNITHROID .................................................................................... 57 UNIVASC ........................................................................................ 23 unoprostone isopropyl ................................................................... 43 urea ............................................................................................ 67, 68 URECHOLINE ................................................................................ 16 URELLE .......................................................................................... 11 UROCIT-K ....................................................................................... 36 URO-MP .......................................................................................... 61 UROXATRAL .................................................................................. 17 URSO .............................................................................................. 46 URSO FORTE ................................................................................ 46 ursodiol ............................................................................................ 46 ustekinumab ................................................................................... 62 UTIBRON NEOHALER ................................................................. 64
V VAGIFEM ........................................................................................ 56 valacyclovir ..................................................................................... 11 valbenazine ..................................................................................... 33 VALCHLOR .................................................................................... 13 VALCYTE ........................................................................................ 11 valganciclovir .................................................................................. 11 VALISONE ...................................................................................... 67 VALIUM ........................................................................................... 31 valproate sodium ............................................................................ 30 valproic acid .................................................................................... 30 valsartan ........................................................................ 20, 21, 22, 23 valsartan & hydrochlorothiazide ............................................. 20, 23 VALTREX ........................................................................................ 11 VALTURNA ..................................................................................... 22 VANCOCI .......................................................................................... 6
VANCOCIN ....................................................................................... 6 vancomycin ....................................................................................... 6 Vancomycin capsule ....................................................................... 6 vandetanib ...................................................................................... 15 VANOS ............................................................................................ 67 VANOXIDE-HC .............................................................................. 66 VANTIN ............................................................................................. 5 varenicline....................................................................................... 16 VARUBI ........................................................................................... 44 VASCEPA ....................................................................................... 20 VASERETIC ................................................................................... 22 VASOTEC ....................................................................................... 22 VECTICAL ...................................................................................... 69 VELIVET ......................................................................................... 48 VELPHORO ................................................................................... 37 VELTASSA ..................................................................................... 37 VELTIN ............................................................................................ 69 VEMLIDY ........................................................................................ 11 vemurafenib .................................................................................... 15 venlafaxine ..................................................................................... 35 venlafaxine extended-release ...................................................... 35 VENTOLIN HFA ............................................................................. 17 verapamil ........................................................................................ 21 verapamil extended-release cap ................................................. 21 verapamil sustained-release cap ................................................. 21 verapamil sustained-release tab ................................................. 21 VEREGEN ...................................................................................... 70 VERELAN ....................................................................................... 21 VERELAN PM ................................................................................ 21 VERZENIO ..................................................................................... 12 VESANOID ..................................................................................... 15 VESICARE ..................................................................................... 71 VEXOL ............................................................................................ 41 VFEND .......................................................................................... 6, 7 VIBERZI .......................................................................................... 43 VICOPROFEN ............................................................................... 26 VICTOZA ........................................................................................ 53 VICTRELIS ....................................................................................... 8 VIDEX ................................................................................................ 8 VIDEX EC ......................................................................................... 8 VIEKIRA .......................................................................................... 10 vigabatrin ........................................................................................ 30 VIGAMOX ....................................................................................... 39 VIIBRYD .......................................................................................... 35 vilazodone....................................................................................... 35 VIMPAT ........................................................................................... 29 VIOKACE ........................................................................................ 45 VIRACEPT ...................................................................................... 10 VIRAMUNE ..................................................................................... 10 VIREAD ........................................................................................... 11 VIROPTIC ....................................................................................... 39 VISICOL .......................................................................................... 45 VISKEN ........................................................................................... 24 VISTARIL ........................................................................................ 31
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VIVACTIL ........................................................................................ 35 VIVELLE-DOT ................................................................................ 55 VIZIMPRO ....................................................................................... 12 VOLTAREN ........................................................................ 25, 39, 70 VOLTAREN GEL ........................................................................... 70 VOLTAREN XR .............................................................................. 25 vorapaxar ........................................................................................ 19 voriconazole suspension................................................................. 7 voriconazole tablet ........................................................................... 6 vorinostat ......................................................................................... 15 vortioxetine...................................................................................... 35 VOSEVI ........................................................................................... 10 VOSOL ............................................................................................ 43 VOSPIRE ER .................................................................................. 17 VOTRIENT ...................................................................................... 14 VRAYLAR ....................................................................................... 33 VUSION ........................................................................................... 65 VYTONE.......................................................................................... 65 VYTORIN ........................................................................................ 19 VYVANSE ....................................................................................... 28 VYZULTA ........................................................................................ 42
W warfarin ............................................................................................ 19 WELCHOL ...................................................................................... 19 WELLBUTRIN ................................................................................ 33 WELLBUTRIN SR .......................................................................... 33 WELLBUTRIN XL .......................................................................... 33 WESTCORT ................................................................................... 68
X XALATAN ........................................................................................ 42 XALKORI ......................................................................................... 12 XANAX ............................................................................................ 31 XANAX XR ...................................................................................... 31 XARELTO ....................................................................................... 18 XARTEMIS XR ............................................................................... 27 XELJANZ ........................................................................................ 62 XELODA .......................................................................................... 12 XENAZINE ...................................................................................... 33 XIBROM .......................................................................................... 39 XIFAXAN ........................................................................................... 6 XIGDUO XR .................................................................................... 51 XIIDRA ............................................................................................. 40 XOLAIR ........................................................................................... 64 XOPENEX HFA .............................................................................. 18 XOPENEX NEBULIZER ............................................................... 18 XOSPATA ....................................................................................... 13 XTANDI ........................................................................................... 12 XULANE .......................................................................................... 49 XULTOPHY .................................................................................... 52 XYLOCAINE ............................................................................. 43, 68
XYLOCAINE VISCOUS ................................................................ 43 XYREM ........................................................................................... 33
Y YASMIN .......................................................................................... 48 YAZ .................................................................................................. 48 YUPELRI......................................................................................... 15 YUVAFEM ...................................................................................... 56
Z zafirlukast ........................................................................................ 63 zaleplon ........................................................................................... 32 ZANAFLEX ..................................................................................... 17 zanamivir......................................................................................... 11 ZANTAC .......................................................................................... 45 ZARONTIN ..................................................................................... 29 ZAROXOLYN ................................................................................. 37 ZARXIO ........................................................................................... 19 ZAVESCA ....................................................................................... 61 ZEBETA .......................................................................................... 24 ZEJULA ........................................................................................... 14 ZELAPAR ....................................................................................... 31 ZELBORAF ..................................................................................... 15 ZEMPLAR ....................................................................................... 71 ZENPEP .......................................................................................... 45 ZEPATIER ........................................................................................ 9 ZERIT .............................................................................................. 11 ZESTORETIC ................................................................................ 23 ZESTRIL ......................................................................................... 23 ZETIA .............................................................................................. 19 ZIAC ................................................................................................ 24 ZIAGEN ............................................................................................. 8 ZIANA .............................................................................................. 69 zidovudine............................................................................. 8, 10, 11 zileuton ............................................................................................ 63 ziprasidone ..................................................................................... 35 ZIRGAN........................................................................................... 38 ZITHROMAX .................................................................................... 4 ZOCOR ........................................................................................... 20 ZOFRAN ......................................................................................... 44 ZOFRAN ODT ................................................................................ 44 ZOHYDRO ER ............................................................................... 26 ZOLINZA ......................................................................................... 15 zolipdem sublingual ....................................................................... 32 zolmitriptan ..................................................................................... 30 zolmitriptan orally disintegrating .................................................. 30 ZOLOFT .......................................................................................... 35 zolpidem .......................................................................................... 32 zolpidem extended-release .......................................................... 32 zolpidem oral spray ....................................................................... 32 ZOLPIMIST ..................................................................................... 32 ZOMIG ............................................................................................ 30
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ZOMIG ZMT .................................................................................... 30 ZONALON ....................................................................................... 68 ZONEGRAN ................................................................................... 30 zonisamide ...................................................................................... 30 ZONTIVITY ..................................................................................... 19 ZORBTIVE ...................................................................................... 57 ZORTRESS .................................................................................... 59 ZOVIA .............................................................................................. 48 ZOVIRAX .................................................................................... 8, 64 ZURAMPIC ..................................................................................... 60 ZYBAN ............................................................................................. 33 ZYCLARA........................................................................................ 70
ZYDELIG......................................................................................... 13 ZYFLO ............................................................................................. 63 ZYFLO CR ...................................................................................... 63 ZYFO ............................................................................................... 63 ZYKADIA......................................................................................... 12 ZYLET ............................................................................................. 40 ZYLOPRIM ..................................................................................... 58 ZYMAXID ........................................................................................ 38 ZYPREXA ....................................................................................... 34 ZYPREXA ZYDIS .......................................................................... 34 ZYTIGA ........................................................................................... 12 ZYVOX .............................................................................................. 5
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Kaiser Permanente, a TRICARE® Prime Option Formulary
NONDISCRIMINATION NOTICE Kaiser Foundation Health Plan of Georgia, Inc. (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 1-888-865-5813 (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 at: Member Relations Unit (MRU), Attn: Kaiser Civil Rights Coordinator, Nine Piedmont Center, 3495 Piedmont Road, NE Atlanta, GA 30305-1736. Telephone Number: 1-888-865-5813.
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.
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Kaiser Permanente, a TRICARE® Prime Option Formulary
HELP IN YOUR LANGUAGE
ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-888-865-5813 (TTY: 711).
አማርኛ (Amharic) ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-888-865-5813 (TTY: 711).
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.)711 :TTY( 1-888-865-5813 مرقب اتصل
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. گیریدب ماست (711 :TTY) 1-888-865-5813 با . اشدب اھمفر می شما
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Rufnummer: 1-888-865-5813 (TTY: 711).
ગજ◌ુર◌ાત◌ી
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िह�ी (Hindi) �ान द◌े◌ं: यहद आप हि◌ि◌◌ंदी बोलत◌े ि◌◌ै◌ं तो आपक◌े ललए मुफ्त म◌े◌ं भाषा िस◌ायता स◌ेवाएि◌◌ं उपलब◌्ध ि◌◌ै◌ं। 1-888-865-5813 (TTY: 711) पर कॉल कर◌े◌ं। 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。1-888-865-5813(TTY: 711)まで、お電話にてご連絡ください。
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Kaiser Permanente, a TRICARE® Prime Option Formulary
Naabeehó (Navajo) Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bee áká’ánída’áwo’dé̖ é̖ ’, t’áá jiik’eh, éí ná hóló̖ , koji̖ ’ hódíílnih 1-888-865-5813 (TTY: 711).
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Tumawag sa 1-888-865-5813 (TTY: 711).
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