2017 Kaiser Permanente Federal Employees Health Benefit

FEHB Drug Formulary

Northern California Region Member Service Contact Center

24 hours a day, 7 days a week. Closed holidays.
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60558913
2017 Kaiser Permanente Federal Employees
Health Benefit (FEHB) Drug Formulary
Northern California Region
This document contains information about the drugs we cover when you participate in a Federal Employees
Health Benefits (FEHB) plan offered by Kaiser Permanente.
This formulary is effective October 3, 2017.
What is the Kaiser Permanente FEHB Drug 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 formulary drugs enables Kaiser Permanente to provide high quality 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.
How much will I pay for covered drugs?
The cost-sharing you will pay for most drugs depends on:
• the tier in which your drug is categorized, and
• whether your drug is included in our formulary. Preferred drugs are included in our formulary. Non-
preferred drugs are not included in our formulary.
We categorize prescription drugs into four tiers:

Drug Type Description

Tier
Tier 1 Generic drugs Generic drugs are produced and sold under their generic names
after the patent on the brand-name drug expires. Although the price
is usually lower, the quality of generic drugs is the same as brand-
name drugs. Generic drugs are also just as effective as brand-name
drugs. The U.S. Food and Drug Administration (FDA) requires that a
generic drug contain the same active drug ingredient in the same
amount as the brand-name drug.
Tier 2 Preferred brand- Brand-name drugs are produced and sold under the original
name drugs manufacturer's brand name. Preferred brand-name drugs are listed
on our drug formulary.
Tier 3 Non-preferred Non-preferred brand-name drugs are not listed on our drug
brand-name drugs formulary and are not covered unless approved through the
exception process.

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 Drug Type Description
Tier
Tier 4 Specialty drugs Specialty drugs are high-cost drugs that are on our specialty drug
list. Kaiser Permanente adopts the model used by most Medicare
plans to determine which drugs are in the specialty tier.

The amount you pay and other coverage information is determined by the outpatient prescription drug
benefit in your FEHB brochure (RI 73-003, See Section 5(f) Prescription drug benefits).
Some drugs may be covered at no cost or a different cost-sharing amount. Examples of these include tobacco
cessation medications, women’s contraceptive drugs and devices at no cost; fertility drugs and sexual
dysfunction drugs have different cost-sharing amounts. Cost-sharing for these drugs is listed in your FEHB
brochure.
All benefits are subject to the definitions, limitations, and exclusions set forth in the Federal brochure. To get a
copy of your FEHB brochure or if you have questions, please visit our website at kp.org/feds or call Member
Services at 1-800-464-4000, 24 hours a day, 7 days a week (closed holidays). For TTY for the hearing/speech
impaired, call 711.
How do I use the FEHB Drug Formulary?
Our formulary drugs are listed in this formulary by medical condition and alphabetically. We consider drugs
not listed on our formulary to be “non-preferred drugs”. You may pay higher cost-sharing for non-formulary
drugs that are medically necessary.
The cost-sharing you pay and other coverage information is determined by the outpatient prescription drug
benefit in your FEHB brochure (RI 73-003, See Section 5(f) Prescription drug benefits).
Formulary Drugs by Medical Condition
The formulary begins on page 4. The drugs in 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 Agents.” If you know the medical condition your drug is
used for, simply look for the category name in the list. Then look under the category name for your drug.
Formulary Drugs by Alphabetical Listing
If you are not sure what category to look under, the Index starting on page 24, provides an alphabetical
list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed.
Look in the Index to find the drug name and the page number where you can locate coverage information.
Turn to the page listed in the Index and find the name of the drug on the list. If you are using a computer
to view this document, you also use the search function (Ctrl F) to find the medication by name.

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Columns on Medical Condition and Alphabetical Listings
There are three columns in the attached chart.
• The first column lists the drug name. Brand-name drugs are capitalized (e.g. ALBENZA) and generic drugs
are listed in lower-case italics (e.g. amoxicillin). Some drugs include different dosage forms and strengths.
All dosage forms and strengths for a particular drug listed may not be on the Formulary. Some drugs have
multiple dosage forms. In such cases, some dosages may be on the Formulary and others not. Some of
these drugs may be available only in a clinic setting.
• The second column indicates drug tier. Some drugs may have more than one tier listed in this column. This
means that the amount you pay may vary based on the dosage or the way the drug is administered. You
will find cost-sharing for your drug in your FEHB brochure. To get a copy of your FEHB brochure or if you
have questions, please visit our website at kp.org/feds or call Member Services at 1-800-464-4000 (TTY
711), 24 hours a day, 7 days a week (closed holidays).
• The third column indicates additional requirements or limits on coverage. These requirements and limits may
include:

QL = Quantity Limit. For certain drugs, we may limit the amount of the drug you can receive.
Additionally, when there is a national shortage of a drug, we may limit the quantity of
the drug dispensed.

Does the FEHB Drug Formulary ever change?

Yes, Kaiser Permanente continually 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.
Our online formulary at kp.org/formulary is updated on a regular basis. To get updated information about the
drugs covered by Kaiser Permanente or if you have questions, please visit our website at kp.org/feds or call
Member Services at 1-800-464-4000, 24 hours a day, 7 days a week (closed holidays). For TTY for the
hearing/speech impaired, call 711.

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Formulary Drugs by Medical Condition
Drug Requirement Drug Requirement
Name of drug Name of drug
Tier / Limits Tier / Limits
ANTI-INFECTIVE AGENTS CEFTRIAXONE SODIUM
1
ANTHELMINTICS IN DEXTROSE
ALBENZA 2 CEFTRIAXONE SODIUM-
2
BILTRICIDE 2 DEXTROSE
ANTIBACTERIALS cefuroxime axetil 1
amikacin sulfate 1 cefuroxime sodium 1, 2
amoxicillin 1 CEFUROXIME-
2
amoxicillin & pot DEXTROSE
1, 2 cephalexin 1
clavulanate
ampicillin & sulbactam CHLORAMPHENICOL
1 1
sodium SOD SUCCINATE
ampicillin sodium 1 ciprofloxacin 1
AVELOX 2 ciprofloxacin hcl 1
AZACTAM IN DEXTROSE 2 ciprofloxacin in d5w 1
azithromycin 1, 2 clarithromycin 1
aztreonam 1 CLEOCIN IN D5W 2
BACTOCILL IN clindamycin hcl 1
2
DEXTROSE clindamycin palmitate
1
BICILLIN L-A 2 hydrochloride
CAYSTON 4 clindamycin phosphate 1
cefaclor 1 CUBICIN 4
cefadroxil 1 demeclocycline hcl 1
CEFAZOLIN IN D5W 1 dicloxacillin sodium 1
cefazolin sodium 1 doxycycline (monohydrate) 1
cefdinir 1 doxycycline hyclate 1
cefepime hcl 1 ERYTHROCIN
1, 2
CEFEPIME-DEXTROSE 2 LACTOBIONATE
cefixime 1 FLUCONAZOLE IN
1
CEFOTAXIME SODIUM 1 SODIUM CHLORIDE
cefotetan disodium 1 gentamicin in saline 1
CEFOTETAN DISODIUM- gentamicin sulfate 1
2 INVANZ 2
DEXTROSE
cefoxitin sodium 1 levofloxacin 1
CEFOXITIN SODIUM- levofloxacin in d5w 1
2 linezolid 1
DEXTROSE
cefpodoxime proxetil 1 meropenem 1
ceftazidime 1 minocycline hcl 1
ceftriaxone sodium 1 moxifloxacin hcl 1
nafcillin sodium 1

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 Drug Requirement Drug Requirement
Name of drug Name of drug
Tier / Limits Tier / Limits
NAFCILLIN SODIUM IN ANTIMYCOBACTERIALS
2
DEXTROSE CAPASTAT SULFATE 2
neomycin sulfate 1 CYCLOSERINE 1
PENICILLIN G POT IN dapsone 1
2
DEXTROSE ethambutol hcl 1
penicillin g potassium 1 isoniazid 1
PENICILLIN G PRIFTIN 2
1
PROCAINE pyrazinamide 1
PENICILLIN G SODIUM 1 rifabutin 1
penicillin v potassium 1 rifampin 1
piperacillin sodium- TRECATOR 2
1
tazobactam sodium ANTIPROTOZOALS
PRIMAXIN IV 2 ALINIA 2
STREPTOMYCIN atovaquone 1
1
SULFATE atovaquone-proguanil hcl 1
SULFADIAZINE 1 chloroquine phosphate 1
sulfamethoxazole- COARTEM 2
1
trimethoprim DARAPRIM 2
sulfasalazine 1 hydroxychloroquine sulfate 1
SYNERCID 2 mefloquine hcl 1
tobramycin 1, 4 metronidazole 1
tobramycin sulfate 1 metronidazole in nacl 1, 2
vancomycin hcl 1 NEBUPENT 2
VANCOMYCIN HCL IN paromomycin sulfate 1
2
DEXTROSE PRIMAQUINE
XIFAXAN 2 QL 2
PHOSPHATE
ZINACEF IN STERILE YODOXIN 2
2
WATER ANTIVIRALS
ZOSYN 2 abacavir sulfate 1, 2
ANTIFUNGALS abacavir sulfate-
ABELCET 2 1
lamivudine
AMPHOTERICIN B 1 abacavir sulfate-
CANCIDAS 4 1
lamivudine-zidovudine
fluconazole 1 acyclovir 1
fluconazole in dextrose 1 acyclovir sodium 1
fluconazole in nacl 1 adefovir dipivoxil 1
flucytosine 1 APTIVUS 2
griseofulvin microsize 1 ATRIPLA 2
griseofulvin ultramicrosize 1 cidofovir 1
ketoconazole 1 COMPLERA 2
nystatin 1 CRIXIVAN 2
nystatin (mouth-throat) 1 DAKLINZA 4 QL
terbinafine hcl 1 DESCOVY 2
voriconazole 1, 2 didanosine 1, 2

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 Drug Requirement Drug Requirement
Name of drug Name of drug
Tier / Limits Tier / Limits
EDURANT 2 VIREAD 2
EMTRIVA 2 voriconazole 1
entecavir 1, 2 zidovudine 1, 2
EPCLUSA 4 QL URINARY ANTI-INFECTIVES
EVOTAZ 2 methenamine hippurate 1
famciclovir 1 nitrofurantoin 1
FOSCAVIR 2 nitrofurantoin macrocrystal 1, 2
FUZEON 2 QL nitrofurantoin monohyd
1
ganciclovir sodium 1 macro
GENVOYA 2 trimethoprim 1
HARVONI 4 QL ANTIHISTAMINE DRUGS
INTELENCE 2 FIRST GENERATION ANTIHISTAMINES
INVIRASE 2 chlorpheniramine &
1
ISENTRESS 2 phenylephrine
KALETRA 2 cyproheptadine hcl 1
lamivudine 1 diphenhydramine hcl 1
lamivudine (hbv) 1 promethazine hcl 1
lamivudine-zidovudine 1 ANTINEOPLASTIC AGENTS
LEXIVA 2 ANTINEOPLASTIC AGENTS
nevirapine 1 ABRAXANE 2
NORVIR 2 ADCETRIS 2
ODEFSEY 2 AFINITOR 4 QL
oseltamivir phosphate 1, 2 ALECENSA 4 QL
PEGASYS 4 QL ALIMTA 2
PREZCOBIX 2 ALKERAN 2
PREZISTA 2 ALUNBRIG 4 QL
RELENZA DISKHALER 2 anastrozole 1
RESCRIPTOR 2 ARRANON 2
REYATAZ 2 AVASTIN 2
ribavirin (hepatitis c) 1 azacitidine 1
rimantadine hydrochloride 1 BENDEKA 2, 4
SELZENTRY 2 bicalutamide 1
SOVALDI 4 QL BICNU 2
stavudine 1 bleomycin sulfate 1
STRIBILD 2 BLINCYTO 4
SUSTIVA 2 CABOMETYX 4 QL
SYNAGIS 4 CAMPTOSAR 1
TIVICAY 2 capecitabine 1 QL
TRIUMEQ 2 CAPRELSA 2 QL
TRUVADA 2 cisplatin 1
valacyclovir hcl 1 cladribine 1
valganciclovir hcl 1, 2 QL COTELLIC 4 QL
VIRACEPT 2 cyclophosphamide 1
VIRAZOLE 2 CYRAMZA 4

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 Drug Requirement Drug Requirement
Name of drug Name of drug
Tier / Limits Tier / Limits
cytarabine 1 LENVIMA 10 MG DAILY
4 QL
dacarbazine 1 DOSE
DACOGEN 2 letrozole 1
dactinomycin 1, 2 LEUKERAN 2
daunorubicin hcl 1 leuprolide acetate 1, 2
DAUNOXOME 2 LONSURF 4 QL
DEPOCYT 2 LUPRON DEPOT (3-
2
1, MONTH)
DOCETAXEL
2, 4 LUPRON DEPOT (4-
2
doxorubicin hcl 1 MONTH)
doxorubicin hcl liposomal 1, 2 LUPRON DEPOT (6-
2
EMCYT 2 QL MONTH)
ERBITUX 2 LUPRON DEPOT-PED (1-
2
ERIVEDGE 4 QL MONTH)
ERWINAZE 2 LUPRON DEPOT-PED (3-
2
etoposide 1 MONTH)
exemestane 1 LYNPARZA 4 QL
FASLODEX 4 QL LYSODREN 2 QL
fludarabine phosphate 1 MARQIBO 4
fluorouracil 1 MATULANE 4 QL
flutamide 1 megestrol acetate 1
GAZYVA 4 MEKINIST 4 QL
gemcitabine hcl 1, 2 melphalan hcl 1
GLEOSTINE 2 mercaptopurine 1, 4 QL
HALAVEN 2 methotrexate sodium 1
HERCEPTIN 2, 4 QL mitomycin 1
HEXALEN 4 mitoxantrone hcl 1
hydroxyurea 1 MUSTARGEN 2
IBRANCE 4 QL MYLERAN 2
idarubicin hcl 1 NEXAVAR 4 QL
ifosfamide 1 NINLARO 4 QL
IFOSFAMIDE-MESNA 2 ODOMZO 4 QL
imatinib mesylate 1 QL OPDIVO 4
IMBRUVICA 4 QL oxaliplatin 1
INTRON A 4 QL paclitaxel 1
IRESSA 4 QL pentostatin 1
ISTODAX 2 PERJETA 4
IXEMPRA KIT 2, 4 POMALYST 4 QL
JAKAFI 4 QL REVLIMID 4 QL, LD
JEVTANA 2 RITUXAN 2
KADCYLA 4 RYDAPT 4 QL
KEYTRUDA 4 SPRYCEL 4 QL
KYPROLIS 4 QL STIVARGA 4 QL
SUTENT 4 QL

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 Drug Requirement Drug Requirement
Name of drug Name of drug
Tier / Limits Tier / Limits
SYLVANT 4 ipratropium bromide 1
TABLOID 2 ipratropium bromide
1
TAFINLAR 4 QL (nasal)
TAGRISSO 4 QL PROPANTHELINE
1
tamoxifen citrate 1 BROMIDE
TARCEVA 4 QL SCOPOLAMINE HBR 2
TARGRETIN 4 SPIRIVA RESPIMAT 2
TASIGNA 4 QL AUTONOMIC DRUGS, MISCELLANEOUS
TECENTRIQ 4 QL CHANTIX 2
temozolomide 1 nicotine 1
TENIPOSIDE 2 nicotine polacrilex 1, 2
thiotepa 1 PARASYMPATHOMIMETIC (CHOLINERGIC)
topotecan hcl 1, 2 QL AGENTS
TORISEL 2 bethanechol chloride 1
TRISENOX 2 donepezil hydrochloride 1
TYKERB 4 QL ENLON 1
UNITUXIN 4 galantamine hydrobromide 1
VELCADE 2 neostigmine methylsulfate 1, 2
VENCLEXTA 2, 4 QL PHYSOSTIGMINE
2
VINBLASTINE SULFATE 1 SALICYLATE
vincristine sulfate 1 pilocarpine hcl (oral) 1
vinorelbine tartrate 1 pyridostigmine bromide 1, 2
VOTRIENT 4 QL SKELETAL MUSCLE RELAXANTS
XALKORI 4 QL atracurium besylate 1
XTANDI 4 QL baclofen 1, 2
YONDELIS 4 cisatracurium besylate 1, 2
ZANOSAR 2 cyclobenzaprine hcl 1
ZEJULA 4 QL dantrolene sodium 1, 2
ZELBORAF 4 QL methocarbamol 1
ZYDELIG 4 QL PANCURONIUM
1
ZYKADIA 4 QL BROMIDE
ZYTIGA 4 QL QUELICIN 2
AUTONOMIC DRUGS rocuronium bromide 1
ANTICHOLINERGIC AGENTS tizanidine hcl 1
atropine sulfate 1 vecuronium bromide 1
ATROVENT HFA 2 SYMPATHOLYTIC (ADRENERGIC BLOCKING)
BELLADONNA AGENTS
2 dihydroergotamine
ALKALOIDS-OPIUM 1 QL
chlordiazepoxide hcl- mesylate
1 ERGOMAR 1
clidinium bromide
dicyclomine hcl 1 guanfacine hcl 1
DONNATAL 1, 2 phenoxybenzamine hcl 1
glycopyrrolate 1, 2 PHENTOLAMINE
1
hyoscyamine sulfate 1, 2 MESYLATE

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 Drug Requirement Drug Requirement
Name of drug Name of drug
Tier / Limits Tier / Limits
SYMPATHOMIMETIC (ADRENERGIC) AGENTS HUMATE-P 2 QL
ADVAIR DISKUS 2 IDELVION 2 QL
albuterol sulfate 1 KCENTRA 2
dobutamine hcl 1 NOVOSEVEN RT 2
dobutamine in d5w 1 PRAXBIND 2
dopamine hcl 1 PROFILNINE 2 QL
dopamine in d5w 1 PROTAMINE SULFATE 1
ephedrine sulfate RECOTHROM 2
1
(pressors) tranexamic acid 1
epinephrine 1 XYNTHA 2 QL
ipratropium-albuterol 1 ANTITHROMBOTIC AGENTS
METAPROTERENOL ACTIVASE 2
1
SULFATE anagrelide hcl 1
midodrine hcl 1 ANGIOMAX 2
norepinephrine bitartrate 1 ARGATROBAN 1
phenylephrine hcl aspirin-dipyridamole 1
1
(pressors) BRILINTA 2
SEREVENT DISKUS 2 clopidogrel bisulfate 1
STRIVERDI RESPIMAT 2 EFFIENT 2
terbutaline sulfate 1 heparin (porcine) in
BLOOD DERIVATIVES 1, 2
sodium chloride
BLOOD DERIVATIVES heparin sod (porcine) in
1, 2
albumin, human 1 d5w
PLASMANATE 2 heparin sodium (porcine) 1
BLOOD FORMATION, COAGULATION, AND heparin sodium (porcine)
1
THROMBOSIS lock flush
ANTIANEMIA DRUGS INTEGRILIN 2
INFED 2 LOVENOX 1 QL
polysaccharide iron PRADAXA 2
1
complex PROFILNINE 2
PROFERRIN ES 2 REOPRO 2
PROFERRIN-FORTE 2 THROMBATE III 2
VENOFER 2 TNKASE 2
ANTIHEMORRHAGIC AGENTS warfarin sodium 1
ADVATE 2 QL HEMATOPOIETIC AGENTS
AFSTYLA 2 QL LEUKINE 2 QL
ALPHANINE SD 2 QL NEUMEGA 4
aminocaproic acid 1 NEUPOGEN 4 QL
BENEFIX 2 QL PROCRIT 2 QL
ELOCTATE 2 QL PROMACTA 4 QL
GELFOAM SPONGE SIZE ZARXIO 4 QL
2
100 HEMORRHEOLOGIC AGENTS
HELIXATE FS 2 QL pentoxifylline 1
HEMOFIL M 2 QL CARDIOVASCULAR DRUGS

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 Drug Requirement Drug Requirement
Name of drug Name of drug
Tier / Limits Tier / Limits
ALPHA-ADRENERGIC BLOCKING AGENTS disopyramide phosphate
1, 2
doxazosin mesylate 1 flecainide acetate 1
prazosin hcl 1 ibutilide fumarate 1
tamsulosin hcl 1 lidocaine hcl (cardiac)
1
terazosin hcl 1 lidocaine in d5w 1
ANTILIPEMIC AGENTS mexiletine hcl 1
atorvastatin calcium 1 milrinone lactate 1
cholestyramine 1 milrinone lactate in
1
cholestyramine light 1 dextrose
colestipol hcl 1 PROCAINAMIDE HCL 1
fenofibrate 1 propafenone hcl 1
gemfibrozil 1 quinidine gluconate 1, 2
lovastatin 1 QUINIDINE SULFATE 1
pravastatin sodium 1 TIKOSYN 2
rosuvastatin calcium 1 HYPOTENSIVE AGENTS
simvastatin 1 CARDENE IV 2
BETA-ADRENERGIC BLOCKING AGENTS clonidine hcl 1
atenolol 1 hydralazine hcl 1
atenolol & chlorthalidone 1 hydrochlorothiazide 1
bisoprolol & methyldopa 1
1
hydrochlorothiazide minoxidil 1
bisoprolol fumarate 1 NITROPRESS 1
BREVIBLOC IN NACL 2 RESERPINE 2
carvedilol 1 RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM
esmolol hcl 1 INHIBITORS
labetalol hcl 1 benazepril hcl 1
metoprolol succinate 1 enalaprilat 1
metoprolol tartrate 1 ENTRESTO 2
propranolol hcl 1 lisinopril 1
sotalol hcl 1 lisinopril &
1
sotalol hcl (afib/afl) 1 hydrochlorothiazide
CALCIUM-CHANNEL BLOCKING AGENTS losartan potassium 1
amlodipine besylate 1 losartan potassium &
1
CLEVIPREX 2 hydrochlorothiazide
diltiazem hcl 1 spironolactone 1
diltiazem hcl coated beads 1 spironolactone &
1
nicardipine hcl 1 hydrochlorothiazide
nifedipine 1 valsartan 1
nimodipine 1 valsartan-
1
verapamil hcl 1 hydrochlorothiazide
CARDIAC DRUGS SCLEROSING AGENTS
adenosine 1 ETHAMOLIN 2
amiodarone hcl 1 SOTRADECOL 1
digoxin 1, 2 VARITHENA 2

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 Drug Requirement Drug Requirement
Name of drug Name of drug
Tier / Limits Tier / Limits
VASODILATING AGENTS methadone hcl 1, 2
alprostadil 1 morphine sulfate 1, 2
CAVERJECT 2 nabumetone 1
dipyridamole 1 nalbuphine hcl 1
isosorbide dinitrate 1 naproxen 1
isosorbide mononitrate 1 NEOPROFEN 2
LETAIRIS 4 QL, LD OFIRMEV 2
LEVITRA 2 QL OPANA 2
nitroglycerin 1, 2 oxycodone hcl 1
nitroglycerin in d5w 1, 2 oxycodone w/
1 QL
PAPAVERINE HCL 2 acetaminophen
REMODULIN 4 LD salsalate 1
sildenafil citrate sufentanil citrate 1
1 QL
(pulmonary hypertension) sulindac 1
TRACLEER 4 QL, LD tramadol hcl 1
TYVASO 2 QL tramadol-acetaminophen 1
VENTAVIS 4 QL ULTIVA 2
CENTRAL NERVOUS SYSTEM AGENTS ANOREXIGENIC AGENTS AND RESPIRATORY
ANALGESICS AND ANTIPYRETICS AND CEREBRAL STIMULANTS
acetaminophen w/ codeine 1 amphetamine-
1
alfentanil 1 dextroamphetamine
buprenorphine hcl 1 caffeine citrate 1
buprenorphine hcl- dexmethylphenidate hcl 1
1 QL
naloxone hcl dihydrate dextroamphetamine
1
butorphanol tartrate 1 sulfate
choline & mag salicylate 1 methylphenidate hcl 1, 2
CODEINE SULFATE 1 VYVANSE 2
etodolac 1 ANTICONVULSANTS
fentanyl 1 QL BANZEL 2
fentanyl citrate 1, 2 carbamazepine 1, 2
hydrocodone- CELONTIN 2
1
acetaminophen clonazepam 1
hydromorphone hcl 1, 2 QL divalproex sodium 1
ibuprofen 1 EQUETRO 2
indomethacin 1 ethosuximide 1
INDOMETHACIN felbamate 1
1
SODIUM fosphenytoin sodium 1
INFUMORPH 200 2 gabapentin 1
ketorolac tromethamine 1 lamotrigine 1, 2
MECLOFENAMATE levetiracetam 1
1
SODIUM LEVETIRACETAM IN
2
mefenamic acid 1 NACL
meloxicam 1 magnesium sulfate 1, 2
meperidine hcl 1 oxcarbazepine 1, 2

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 Drug Requirement Drug Requirement
Name of drug Name of drug
Tier / Limits Tier / Limits
phenytoin 1 hydroxyzine hcl 1
phenytoin sodium 1 hydroxyzine pamoate 1
phenytoin sodium lorazepam 1
1
extended midazolam hcl 1
primidone 1 NEMBUTAL 1
SABRIL 4 QL oxazepam 1
topiramate 1 phenobarbital 1
valproate sodium 1 PHENOBARBITAL
2
valproic acid 1 SODIUM
ANTIMANIC AGENTS PRECEDEX 2
LITHIUM 2 temazepam 1
lithium carbonate 1 zolpidem tartrate 1
ANTIMIGRAINE AGENTS CENTRAL NERVOUS SYSTEM AGENTS,
CAFERGOT 1 MISCELLANEOUS
naratriptan hcl 1 acamprosate calcium 1
rizatriptan benzoate 1 flumazenil 1
sumatriptan 1 memantine hcl 1, 2
sumatriptan succinate 1 riluzole 1
ANTIPARKINSONIAN AGENTS selegiline hcl 1
amantadine hcl 1 GENERAL ANESTHETICS
APOKYN 4 QL, LD BREVITAL SODIUM 2
AZILECT 2 etomidate 1
benztropine mesylate 1 FORANE 2
bromocriptine mesylate 1 ketamine hcl 1
cabergoline 1 propofol 1
carbidopa 1, 2 OPIATE ANTAGONISTS
carbidopa-levodopa 1, 2 escitalopram oxalate 1
CARBIDOPA- naloxone hcl 1, 2
LEVODOPA- 1 naltrexone hcl 1, 2
ENTACAPONE PSYCHOTHERAPEUTIC AGENTS
entacapone 1 amitriptyline hcl 1
pramipexole aripiprazole 1
1
dihydrochloride bupropion hcl 1
ropinirole hydrochloride 1 chlorpromazine hcl 1
selegiline hcl 1 citalopram hydrobromide 1
trihexyphenidyl hcl 1 clomipramine hcl 1
ANXIOLYTICS, SEDATIVES, AND HYPNOTICS clozapine 1
alprazolam 1 desipramine hcl 1
buspirone hcl 1 doxepin hcl 1
chlordiazepoxide hcl 1 duloxetine hcl 1
clorazepate dipotassium 1 escitalopram oxalate 1
DIASTAT ACUDIAL 1 fluoxetine hcl 1
diazepam 1 fluphenazine decanoate 1
droperidol 1 fluphenazine hcl 1

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(Northern California Region)
 Drug Requirement Drug Requirement
Name of drug Name of drug
Tier / Limits Tier / Limits
fluvoxamine maleate 1 BAYER BREEZE 2
2
haloperidol 1 CONTROL
haloperidol decanoate 1 BD CATHETER TIP
2
haloperidol lactate 1 SYRINGE
imipramine hcl 1 BD DISP NEEDLES 2
loxapine succinate 1 BD ECLIPSE SYRINGE 2
mirtazapine 1 BD FILTER NEEDLE/5
2
nefazodone hcl 1 MICRON
nortriptyline hcl 1 BD HYPODERMIC
2
olanzapine 1 NEEDLE
ORAP 2 BD INSULIN SYR
1, 2
paroxetine hcl 1 ULTRAFINE II
perphenazine 1 BD LANCET DEVICE 2
PERPHENAZINE- BD LANCET ULTRAFINE
1 2
AMITRIPTYLINE 33G
phenelzine sulfate 1 BD LUER-LOK SYRINGE 2
prochlorperazine 1 BD PEN NEEDLE MINI
2
prochlorperazine edisylate 1 U/F
prochlorperazine maleate 1 BD SAFETYGLIDE
2
protriptyline hcl 1 SYRINGE/NEEDLE
quetiapine fumarate 1 BD SYRINGE 2
risperidone 1 BLUNT PLASTIC
2
sertraline hcl 1 CANNULA
SURMONTIL 2 DISPOSABLE POWER 2
thioridazine hcl 1 INSUFLON 2
thiothixene 1 OMNITROPE PEN 5 INJ
2
tranylcypromine sulfate 1 DEVICE
trazodone hcl 1 ONETOUCH ULTRA MINI 2
trifluoperazine hcl 1 PEDIATRIC SMALL
2
venlafaxine hcl 1 MASK
ziprasidone hcl 1 PENLET II BLOOD
2
CONTRACEPTIVES (FOAMS, DEVICES) SAMPLER
CONTRACEPTIVES (FOAMS, DEVICES) POLYFIN QR INFUSION
2
SET 42"
WIDE-SEAL DIAPHRAGM
2 YALE DISP NEEDLES 2
60
DEVICES DIAGNOSTIC AGENTS
DEVICES DIAGNOSTIC AGENTS
AEROCHAMBER Z-STAT ACETEST 2
2 adenosine (diagnostic) 1
PLUS
AEROTRACH PLUS 2 ALBUSTIX 2
ALLERGIST SYRINGE 2 CANDIN 2
ASSESS FULL RANGE CHEMSTRIP 9 2
2 CHIRHOSTIM 2
PEAK METER
CLINITEST 2
CONRAY 2

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(Northern California Region)
 Drug Requirement Drug Requirement
Name of drug Name of drug
Tier / Limits Tier / Limits
CORTROSYN 2 CLINIMIX E/DEXTROSE
2
CREON 2 (2.75/5)
CYSTOGRAFIN 2 CLINIMIX E/DEXTROSE
2
DIASTIX 2 (4.25/25)
E-Z-CAT DRY 2 CLINIMIX E/DEXTROSE
2
EOVIST 2 (5/15)
fluorescein sodium CLINIMIX E/DEXTROSE
1 2
injection (5/20)
fluorescein sodium topical 1 CLINIMIX/DEXTROSE
2
fluorescein w/ benoxinate 1 (4.25/10)
GADAVIST 2 CLINIMIX/DEXTROSE
2
GASTROGRAFIN 2 (4.25/25)
INDIGO CARMINE 2 dextrose 1, 2
KETO-DIASTIX 2 fat emulsion 1
LEXISCAN 2 PHENEX-1 2
LUMASON 2 DIURETICS
MAGNEVIST 2 amiloride &
1
METOPIRONE 2 hydrochlorothiazide
MULTIHANCE 2 bumetanide 1
OMNIPAQUE 2 chlorthalidone 1
ONETOUCH ULTRA EDECRIN 1
2 furosemide 1
BLUE
THYROGEN 2 hydrochlorothiazide 1
TUBERSOL 2 indapamide 1
ELECTROLYTIC, CALORIC, AND WATER mannitol 1
BALANCE metolazone 1
ALKALINIZING AGENTS SODIUM EDECRIN 2
potassium citrate torsemide 1
1 triamterene &
(alkalinizer) 1
potassium citrate-citric hydrochlorothiazide
1 ION-REMOVING AGENTS
acid
sodium acetate 1 RENVELA 1
sodium bicarbonate 1 sodium polystyrene
1
sodium citrate & citric acid 1 sulfonate
AMMONIA DETOXICANTS IRRIGATING SOLUTIONS
lactulose 1 acetic acid 1
lactulose (encephalopathy) 1 DIANEAL LOW
2
LITHOSTAT 2 CALCIUM/4.25% DEX
sodium phenylbutyrate 1, 4 QL ringer's irrigation 1
CALORIC AGENTS sodium chloride (gu
1
AMINOSYN II 1, 2 irrigant)
CLINIMIX E/DEXTROSE water for irrigation, sterile 1
2 REPLACEMENT PREPARATIONS
(2.75/10)
calcium acetate
1, 2
(phosphate binder)

2017 Kaiser Permanente Federal Employees Health Benefit Formulary Page 14

(Northern California Region)
 Drug Requirement Drug Requirement
Name of drug Name of drug
Tier / Limits Tier / Limits
calcium chloride probenecid 1
1
(dihydrate) ENZYMES
calcium gluconate 1 ENZYMES
CHROMIC CHLORIDE 2 ALDURAZYME 2
COPPER CHLORIDE 2 CEREZYME 4
COPPER SULFATE 2 ELAPRASE 4
dextrose in lactated ELITEK 2
1
ringers FABRAZYME 4
dextrose in ringers 1 HYLENEX 2
dextrose w/ sodium LUMIZYME 4
1, 2
chloride NAGLAZYME 4
HESPAN 2 PROLASTIN-C 4
HEXTEND 2 PULMOZYME 4
K-PHOS 2 STRENSIQ 4 QL
KCL-LACTATED VIMIZIM 4
2
RINGERS-D5W VORAXAZE 4
lactated ringer's 1 VPRIV 4
LMD IN D5W 2 EYE, EAR, NOSE, AND THROAT (EENT)
LMD IN NACL 2 PREPARATIONS
MAGNESIUM SULFATE ANTI-INFECTIVES
2
IN D5W BACITRACIN 1
potassium acetate 1 bacitracin-polymyxin b
potassium bicarbonate 1 1
(ophth)
potassium chloride 1, 2 chlorhexidine gluconate
potassium chloride in 1
1 (mouth-throat)
dextrose ciprofloxacin hcl (ophth) 1
potassium chloride in erythromycin (ophth) 1
dextrose & sodium 1, 2 gatifloxacin (ophth) 1
chloride gentamicin sulfate (ophth) 1
potassium chloride in nacl 1 neomycin-bacitracin zn-
potassium chloride 1
polymyxin
microencapsulated 1 neomycin-polymyxin-
crystals er 1
gramicidin
potassium phosphates 1 ofloxacin (ophth) 1
ringer's 1 ofloxacin (otic) 1
SELENIUM 2 polymyxin b-trimethoprim 1
sodium chloride 1 sulfacetamide sodium
sodium phosphates 1
(ophth)
(sodium phosphate dibasic 1 tobramycin (ophth) 1, 2
& monobasic) trifluridine 1
trace minerals (cr-cu-mn- ANTI-INFLAMMATORY AGENTS
1, 2
zn) CIPRODEX 2
ZINC TRACE METAL 2 DEXAMETHASONE
URICOSURIC AGENTS 1
SODIUM PHOSPHATE
colchicine w/ probenecid 1

2017 Kaiser Permanente Federal Employees Health Benefit Formulary Page 15

(Northern California Region)
 Drug Requirement Drug Requirement
Name of drug Name of drug
Tier / Limits Tier / Limits
diclofenac sodium (ophth) 1 ACETIC ACID-
1
flunisolide (nasal) 1 ALUMINUM ACETATE
fluorometholone (ophth) 1, 2 apraclonidine hcl 1, 2
FLURBIPROFEN EYLEA 2
1
SODIUM HEALON5 2
fluticasone propionate LUCENTIS 2
1
(nasal) MACUGEN 2
ketorolac tromethamine ophthalmic irrigation
1 1
(ophth) solution - intraocular
neomycin-polymy- VISUDYNE 2
1
dexameth LOCAL ANESTHETICS
neomycin-polymyxin-hc AKTEN 2
1
(otic) COCAINE HCL 2
prednisolone acetate lidocaine hcl (mouth-
1, 2 1
(ophth) throat)
RESTASIS 2 proparacaine hcl 1
RETISERT 2 tetracaine hcl (ophth) 1
sulfacetamide sod- MYDRIATICS
1, 2
prednisolone atropine sulfate
VEXOL 2 1, 2
(ophthalmic)
ANTIALLERGIC AGENTS CYCLOMYDRIL 1
azelastine hcl 1 cyclopentolate hcl 1
cromolyn sodium (ophth) 1 homatropine hbr 1
olopatadine hcl 1 tropicamide 1
ANTIGLAUCOMA AGENTS VASOCONSTRICTORS
acetazolamide 1 phenylephrine hcl (ophth) 1
acetazolamide sodium 1 GASTROINTESTINAL DRUGS
betaxolol hcl (ophth) 1 ANTI-INFLAMMATORY AGENTS
brimonidine tartrate 1 balsalazide disodium 1
dorzolamide hcl 1 mesalamine 1, 2
dorzolamide hcl-timolol ANTIDIARRHEA AGENTS
1
maleate bismuth subsalicylate 1
latanoprost 1 diphenoxylate w/ atropine 1
levobunolol hcl 1 ANTIEMETICS
LUMIGAN 2 AKYNZEO 2 QL
methazolamide 1 dronabinol 1
MIOCHOL-E 2 EMEND TAB 2 QL
MIOSTAT 2 EMEND INJ 2
MITOSOL 2 meclizine hcl 1
PHOSPHOLINE IODIDE 2 ondansetron 1
pilocarpine hcl 1 ondansetron hcl 1
timolol maleate (ophth) 1 TRANSDERM-SCOP (1.5
EENT DRUGS, MISCELLANEOUS 2
MG)
acetic acid (otic) 1

2017 Kaiser Permanente Federal Employees Health Benefit Formulary Page 16

(Northern California Region)
 Drug Requirement Drug Requirement
Name of drug Name of drug
Tier / Limits Tier / Limits
ANTIULCER AGENTS AND ACID dexamethasone 1
SUPPRESSANTS dexamethasone sodium
1
cimetidine hcl 1 phosphate
famotidine 1 FLOVENT HFA 2
FAMOTIDINE PREMIXED 1 fludrocortisone acetate 1
misoprostol 1 hydrocortisone 1
omeprazole 1 KENALOG 2
pantoprazole sodium 1, 2 methylprednisolone 1
ranitidine hcl 1 methylprednisolone
1
sucralfate 1, 2 acetate
CATHARTICS AND LAXATIVES methylprednisolone sod
1, 2
castor oil 1 succ
MINERAL OIL LIGHT 2 prednisolone 1
peg 3350-kcl-sod bicarb- prednisolone sodium
1 1
sod chloride-sod sulfate phosphate
SORBITOL 2 prednisone 1
CHOLELITHOLYTIC AGENTS QVAR 2
ursodiol 1 ANDROGENS
DIGESTANTS ANDRODERM 1, 2
CREON 2 ANDROID 1
PROKINETIC AGENTS ANDROXY 1
metoclopramide hcl 1 danazol 1
GOLD COMPOUNDS testosterone cypionate 1
GOLD COMPOUNDS testosterone enanthate 1
RIDAURA 2 ANTIDIABETIC AGENTS
HEAVY METAL ANTAGONISTS glimepiride 1
HEAVY METAL ANTAGONISTS glipizide 1
BAL IN OIL 2 glipizide-metformin hcl 1
CHEMET 2 glyburide 1
deferoxamine mesylate 1 HUMALOG 2
DEPEN TITRATABS 2 HUMULIN 70/30 2
EXJADE 2, 4 QL HUMULIN N 2
sodium thiosulfate 1 HUMULIN R 2
HORMONES AND SYNTHETIC SUBSTITUTES LANTUS 2
ADRENALS metformin hcl 1
A-HYDROCORT 1, 2 pioglitazone hcl 1
ARISTOSPAN INTRA- TOLBUTAMIDE 1
2
ARTICULAR ANTIHYPOGLYCEMIC AGENTS
ASMANEX 120 GLUCAGEN
2 2
METERED DOSES DIAGNOSTIC
betamethasone sod GLUCAGON
1 2
phosphate & acetate EMERGENCY
budesonide 1 CONTRACEPTIVES
budesonide (inhalation) 1, 2

2017 Kaiser Permanente Federal Employees Health Benefit Formulary Page 17

(Northern California Region)
 Drug Requirement Drug Requirement
Name of drug Name of drug
Tier / Limits Tier / Limits
desogestrel & ethinyl NOVAREL 1
1
estradiol OVIDREL 2
drospirenone-ethinyl SYNAREL 2
1
estradiol PARATHYROID
ELLA 2 calcitonin (salmon) 1, 2
ethynodiol diacet & eth FORTEO 4 QL
1
estrad PITUITARY
levonorgestrel & eth DDAVP RHINAL TUBE 2
1
estradiol desmopressin acetate 1, 2
levonorgestrel (emergency desmopressin acetate
1 1
oc) spray
levonorgestrel-eth desmopressin acetate
1 1
estradiol (triphasic) spray refrigerated
MIRENA (52 MG) 2 HP ACTHAR 4 LD
NECON 1/50 (28) 1 vasopressin 1
NECON 10/11 (28) 1 PROGESTINS
NEXPLANON 2 DEPO-PROVERA 2
norethin acet & estrad-fe 1 ENDOMETRIN 2
norethindrone & eth medroxyprogesterone
1 1
estradiol acetate
norethindrone medroxyprogesterone
1 1
(contraceptive) acetate (contraceptive)
norethindrone-eth estradiol norethindrone acetate 1
1
(triphasic) progesterone 1
norgestimate-ethinyl progesterone micronized 1
1
estradiol SOMATROPIN AGONISTS-ANTAGONISTS
norgestimate-ethinyl NORDITROPIN FLEXPRO 1, 4 QL
1
estradiol (triphasic) SEROSTIM 4 QL
NUVARING 2 THYROID AND ANTITHYROID AGENTS
OGESTREL 1 levothyroxine sodium 1, 2
XULANE 1 liothyronine sodium 1
ESTROGENS AND ESTROGEN AGONISTS- methimazole 1
ANTAGONISTS propylthiouracil 1
clomiphene citrate 1 SSKI 2
DEPO-ESTRADIOL 1 LOCAL ANESTHETICS
esterified estrogens & LOCAL ANESTHETICS
1
methyltestosterone bupivacaine hcl 1
estradiol 1 bupivacaine in dextrose 1
estradiol vaginal 1, 2 bupivacaine w/
PREMARIN 2 1, 2
epinephrine
raloxifene hcl 1 chloroprocaine hcl 1, 2
GONADOTROPINS lidocaine hcl (cardiac) 1
BRAVELLE 2 lidocaine hcl (local
GONAL-F 2 1
anesth.)
MENOPUR 2

2017 Kaiser Permanente Federal Employees Health Benefit Formulary Page 18

(Northern California Region)
 Drug Requirement Drug Requirement
Name of drug Name of drug
Tier / Limits Tier / Limits
lidocaine w/ epinephrine 1, 2 methylene blue (antidote) 1
mepivacaine hcl 1 mycophenolate mofetil 1
NAROPIN 2 MYOBLOC 2
TETRACAINE HCL 2 octreotide acetate 1, 4 QL
MISCELLANEOUS THERAPEUTIC AGENTS OPSUMIT 4 QL
MISCELLANEOUS THERAPEUTIC AGENTS ORENCIA 4 QL
acetylcysteine 1 OTEZLA 4 QL
acetylcysteine (antidote) 1 pamidronate disodium 1
ACTIMMUNE 4 QL RASUVO 2
alendronate sodium 1 REMICADE 4
allopurinol 1 RIMSO-50 2
amifostine 1 SANDIMMUNE 2
AVONEX 4 QL SENSIPAR 2, 4
azathioprine 1 sirolimus 1, 2
BOTOX 2 sodium fluoride 1, 2
BOTOX COSMETIC 2 sodium fluoride (dental) 1, 2
BRIDION 2 SOLIRIS 2
CERDELGA 4 QL tacrolimus 1, 2
CINRYZE 4 QL THALOMID 4 QL
COLCHICINE 1 THIOLA 2
cyclosporine modified (for TYSABRI 4 LD
1, 2
microemulsion) water for injection, sterile 1
CYSTADANE 2 QL XELJANZ 4 QL
CYSTAGON 2 QL zoledronic acid 1
dexrazoxane 1, 2 OXYTOCICS
disulfiram 1 OXYTOCICS
ELMIRON 2 HEMABATE 2
ENBREL 4 QL methylergonovine maleate 1
ETIDRONATE DISODIUM 1 MIFEPREX 2
EXTAVIA 1 QL oxytocin 1
finasteride 1 PREPIDIL 2
FIRAZYR 4 QL PHARMACEUTICAL AIDS
FLUOR-A-DAY 2 PHARMACEUTICAL AIDS
FUSILEV 2 ALOE VERA 2
glatiramer acetate 1 QL ALPROSTADIL 2
GRASTEK 2 ATROPINE SULFATE
2
HUMIRA 4 QL MONOHYDRATE
INFLECTRA 4 BIOTIN-D 2
KINERET 4 QL BORIC ACID 2
leflunomide 1 CANTHARIDIN 2
leucovorin calcium 1 CARBAMAZEPINE 2
levocarnitine (metabolic CHLORPROMAZINE HCL 2
1
modifiers) CHOLESTEROL
2
mesna 1, 2 QL ACETATE

2017 Kaiser Permanente Federal Employees Health Benefit Formulary Page 19

(Northern California Region)
 Drug Requirement Drug Requirement
Name of drug Name of drug
Tier / Limits Tier / Limits
CLINDAMYCIN HCL 2 SORBITOL 2
CLOBETASOL SQUARIC ACID
2 2
PROPIONATE DIBUTYLESTER
CLOTRIMAZOLE 2 SULFUR PRECIPITATED 2
COLLODION FLEXIBLE 2 TESTOSTERONE
2
CYSTEAMINE HCL 2 PROPIONATE
DEXAMETHASONE 2 THYMOL 2
ESTRADIOL 2 TRANEXAMIC ACID 2
GLYCERIN 2 TRIAMCINOLONE
2
GLYCOPYRROLATE 2 ACETONIDE
HALOPERIDOL 2 UREA 2
HYDROCORTISONE 2 ZINC SULFATE 2
HYDROXOCOBALAMIN 2 RESPIRATORY TRACT AGENTS
HYDROXYPROGESTER ANTI-INFLAMMATORY AGENTS
2
ONE CAPROATE ASMANEX HFA 2
INDOMETHACIN 2 COMBIVENT RESPIMAT 2
KETAMINE HCL 2 CROMOLYN SODIUM 1
L-ARGININE 2 DULERA 2
L-CITRULLINE 2 montelukast sodium 1
L-ISOLEUCINE 2 ANTITUSSIVES
L-VALINE 2 benzonatate 1
LACTIC ACID 2 guaifenesin-codeine 1
LACTOSE 2 phenylephrine-chlorphen-
1
LACTOSE dm
2
MONOHYDRATE PHENYLHISTINE DH 2
LIDOCAINE HCL 2 promethazine-dm 1
METHADONE HCL 2 MUCOLYTIC AGENTS
METOCLOPRAMIDE HCL sodium chloride (inhalant) 1
2
MONOHYDRATE PULMONARY SURFACTANTS
MORPHINE SULFATE 2 CUROSURF 2
NEOMYCIN SULFATE 2 SURVANTA 2
PHENOBARBITAL 2 RESPIRATORY AGENTS, MISCELLANEOUS
PLURONIC F127 2 KALYDECO 4 QL
PODOPHYLLUM RESIN 2 ORKAMBI 4 QL
POLYETHYLENE STIOLTO RESPIMAT 2
2
GLYCOL 400 SERUMS, TOXOIDS, AND VACCINES
PROGESTERONE SERUMS
2
MICRONIZED ANTIVENIN
PROGESTERONE LATRODECTUS 2
2
WETTABLE MACTANS
PROPYLENE GLYCOL 2 CARIMUNE NF 2
QUINACRINE HCL 2 CROFAB 2
SALICYLIC ACID 2 DIGIFAB 2
SODIUM BENZOATE 2 FLUVIRIN 2

2017 Kaiser Permanente Federal Employees Health Benefit Formulary Page 20

(Northern California Region)
 Drug Requirement Drug Requirement
Name of drug Name of drug
Tier / Limits Tier / Limits
GAMASTAN S/D 2 PROQUAD 2
GAMMAGARD 2 RABAVERT 2
HIZENTRA 2 QL ROTARIX 2
HYPERRAB S/D 2 ROTATEQ 2
HYPERTET S/D 2 THERACYS 2
MICRHOGAM ULTRA- TWINRIX 2
2
FILTERED PLUS TYPHIM VI 2
NABI-HB 2 VARIVAX 2
VARIZIG 2 VAXCHORA 2
TOXOIDS VIVOTIF 2
ADACEL 2 YF-VAX 2
INFANRIX 2 ZOSTAVAX 2
TETANUS-DIPHTHERIA SKIN AND MUCOUS MEMBRANE AGENTS
2
TOXOIDS TD ANTI-INFECTIVES
VACCINES benzoyl peroxide-
1, 2
ACTHIB 2 erythromycin
AFLURIA 2 clindamycin phosphate
1
AFLURIA (topical)
2
PRESERVATIVE FREE clindamycin phosphate
1
BEXSERO 2 vaginal
ENGERIX-B 2 clindamycin phosphate-
1
FLUAD 2 benzoyl peroxide
FLUARIX clindamycin phosphate-
2
QUADRIVALENT benzoyl peroxide 1
FLUBLOK 2 (refrigerate)
FLUCELVAX 2 clotrimazole 1
FLUMIST dakin's solution 1, 2
2
QUADRIVALENT erythromycin (acne aid) 1, 2
FLUVIRIN 2 gentamicin sulfate (topical) 1
FLUVIRIN GNP GENTIAN VIOLET 2
2
PRESERVATIVE FREE iodoquinol-hc 1
FLUZONE HIGH-DOSE 2 ketoconazole (topical) 1
GARDASIL 2 metronidazole (topical) 1
GARDASIL 9 2 metronidazole vaginal 1
HAVRIX 2 mupirocin 1
IMOVAX RABIES 2 neomycin/polymyxin b gu 1
IPOL 2 nystatin (topical) 1
IXIARO 2 permethrin 1
KINRIX 2 selenium sulfide 1
M-M-R II 2 silver sulfadiazine 1
MENVEO 2 ANTI-INFLAMMATORY AGENTS
PEDIARIX 2 alclometasone
1
PNEUMOVAX 23 2 dipropionate
PREVNAR 13 2

2017 Kaiser Permanente Federal Employees Health Benefit Formulary Page 21

(Northern California Region)
 Drug Requirement Drug Requirement
Name of drug Name of drug
Tier / Limits Tier / Limits
betamethasone acitretin 1
1
dipropionate (topical) adapalene 1
betamethasone AQUAPHOR 2
1
dipropionate augmented BENZOIN 2
betamethasone valerate 1 benzoin compound 1
clobetasol propionate 1 calcipotriene 1
CORDRAN 2 capsaicin 1
CORTISPORIN 2 COSENTYX 300 DOSE 4 QL
desoximetasone 1 DESITIN 2
fluocinolone acetonide 1 diclofenac sodium (topical) 1
fluocinonide 1 DRITHO-CREME HP 2
halobetasol propionate 1 ELIDEL 2
hydrocortisone (intrarectal) 1 EPIDUO 1, 2
hydrocortisone (topical) 1 fluorouracil (topical) 1, 2
hydrocortisone acetate imiquimod 1
1
(rectal) isotretinoin 1 QL
mometasone furoate 1 LEVULAN KERASTICK 2
nystatin-triamcinolone 1 PODOCON 2
PROCTOFOAM HC 1 podofilox 1, 2
triamcinolone acetonide SANTYL 2
1
(mouth) STELARA 4
triamcinolone acetonide tacrolimus (topical) 1
1
(topical) TARGRETIN 2
ANTIPRURITICS AND LOCAL ANESTHETICS TAZORAC 1, 2
lidocaine 1 VECTICAL 1
lidocaine hcl 1 SMOOTH MUSCLE RELAXANTS
lidocaine-prilocaine 1 GENITOURINARY SMOOTH MUSCLE
PHENOL 2 RELAXANTS
ASTRINGENTS oxybutynin chloride 1
DRYSOL 2 OXYTROL 2
XERAC AC 2 trospium chloride 1
CELL STIMULANTS AND PROLIFERANTS RESPIRATORY SMOOTH MUSCLE RELAXANTS
KEPIVANCE 4 aminophylline 1
RETIN-A 1 theophylline 1
RETIN-A MICRO 1 THEOPHYLLINE IN D5W 2
DEPIGMENTING AND PIGMENTING AGENTS VITAMINS
8-MOP 2 MULTIVITAMIN PREPARATIONS
methoxsalen rapid 1 b-complex w/ c & folic acid 1
OXSORALEN 2 INFUVITE 2
KERATOLYTIC AGENTS INFUVITE PEDIATRIC 2
sulfacetamide sodium w/ ped multivitamins w/fl &
1 1
sulfur iron
SKIN AND MUCOUS MEMBRANE AGENTS, pediatric multivitamins w/fl 1
MISCELLANEOUS

2017 Kaiser Permanente Federal Employees Health Benefit Formulary Page 22

(Northern California Region)
 Drug Requirement Drug Requirement
Name of drug Name of drug
Tier / Limits Tier / Limits
pediatric vitamins acd w/ VITAMIN D
1
fluoride calcitriol 1
TRI-VIT/FLUORIDE/IRON 2 ergocalciferol 1
VITAMIN B COMPLEX VITAMIN K ACTIVITY
cyanocobalamin 1 phytonadione 1, 2
FOLIC ACID 1
niacin 1
thiamine hcl 1

2017 Kaiser Permanente Federal Employees Health Benefit Formulary Page 23

(Northern California Region)
Formulary Drugs by Alphabetical Listing
Index
8
8-MOP ............................................................. 22
A A-HYDROCORT .............................................. 17
abacavir sulfate.................................................. 5
abacavir sulfate-lamivudine ............................... 5
abacavir sulfate-lamivudine-zidovudine ............. 5
ABELCET .......................................................... 5
ABRAXANE ....................................................... 6
acamprosate calcium ....................................... 12
acetaminophen w/ codeine .............................. 11
acetazolamide.................................................. 16
acetazolamide sodium ..................................... 16
ACETEST ........................................................ 13
acetic acid .................................................. 14, 16
acetic acid (otic) ............................................... 16
ACETIC ACID-ALUMINUM ACETATE ............ 16
acetylcysteine .................................................. 19
acetylcysteine (antidote) .................................. 19
acitretin ............................................................ 22
ACTHIB ........................................................... 21
ACTIMMUNE ................................................... 19
ACTIVASE ......................................................... 9
acyclovir ............................................................. 5
acyclovir sodium ................................................ 5
ADACEL .......................................................... 21
adapalene ........................................................ 22
ADCETRIS ........................................................ 6
adefovir dipivoxil ................................................ 5
adenosine .................................................. 10, 13
adenosine (diagnostic) ..................................... 13
ADVAIR DISKUS ............................................... 9
ADVATE ............................................................ 9
AEROCHAMBER Z-STAT PLUS ..................... 13
AEROTRACH PLUS ........................................ 13
2017 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
AFINITOR .......................................................... 6
AFLURIA.......................................................... 21
AFLURIA PRESERVATIVE FREE ................... 21
AFSTYLA ........................................................... 9
AKTEN ............................................................. 16
AKYNZEO........................................................ 16
ALBENZA .......................................................... 4
albumin, human ................................................. 9
ALBUSTIX ....................................................... 13
albuterol sulfate ................................................. 9
alclometasone dipropionate ............................. 21
ALDURAZYME ................................................ 15
ALECENSA........................................................ 6
alendronate sodium ......................................... 19
alfentanil .......................................................... 11
ALIMTA .............................................................. 6
ALINIA ............................................................... 5
ALKERAN .......................................................... 6
ALLERGIST SYRINGE .................................... 13
allopurinol ........................................................ 19
ALOE VERA .................................................... 19
ALPHANINE SD ................................................ 9
alprazolam ....................................................... 12
alprostadil ........................................................ 11
ALPROSTADIL ................................................ 19
ALUNBRIG ........................................................ 6
amantadine hcl ................................................ 12
amifostine ........................................................ 19
amikacin sulfate ................................................. 4
amiloride & hydrochlorothiazide ....................... 14
aminocaproic acid .............................................. 9
aminophylline ................................................... 22
AMINOSYN II ................................................... 14
amiodarone hcl ................................................ 10
amitriptyline hcl ................................................ 12
Page 24
amlodipine besylate ......................................... 10
amoxicillin .......................................................... 4
amoxicillin & pot clavulanate .............................. 4
amphetamine-dextroamphetamine .................. 11
AMPHOTERICIN B ............................................ 5
ampicillin & sulbactam sodium ........................... 4
ampicillin sodium ............................................... 4
anagrelide hcl .................................................... 9
anastrozole ........................................................ 6
ANDRODERM ................................................. 17
ANDROID ........................................................ 17
ANDROXY ....................................................... 17
ANGIOMAX ....................................................... 9
ANTIVENIN LATRODECTUS MACTANS ........ 20
APOKYN.......................................................... 12
apraclonidine hcl .............................................. 16
APTIVUS ........................................................... 5
AQUAPHOR .................................................... 22
ARGATROBAN.................................................. 9
aripiprazole ...................................................... 12
ARISTOSPAN INTRA-ARTICULAR................. 17
ARRANON ......................................................... 6
ASMANEX 120 METERED DOSES ................ 17
ASMANEX HFA ............................................... 20
aspirin-dipyridamole ........................................... 9
ASSESS FULL RANGE PEAK METER ........... 13
atenolol ............................................................ 10
atenolol & chlorthalidone.................................. 10
atorvastatin calcium ......................................... 10
atovaquone ........................................................ 5
atovaquone-proguanil hcl................................... 5
atracurium besylate ........................................... 8
ATRIPLA............................................................ 5
atropine sulfate ............................................ 8, 16
atropine sulfate (ophthalmic) ............................ 16
ATROPINE SULFATE MONOHYDRATE ........ 19
ATROVENT HFA ............................................... 8
AVASTIN ........................................................... 6
AVELOX ............................................................ 4
AVONEX.......................................................... 19
azacitidine .......................................................... 6
AZACTAM IN DEXTROSE ................................ 4
azathioprine ..................................................... 19
azelastine hcl ................................................... 16
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AZILECT .......................................................... 12
azithromycin....................................................... 4
aztreonam .......................................................... 4
B
BACITRACIN ................................................... 15
bacitracin-polymyxin b (ophth) ......................... 15
baclofen ............................................................. 8
BACTOCILL IN DEXTROSE .............................. 4
BAL IN OIL....................................................... 17
balsalazide disodium........................................ 16
BANZEL ........................................................... 11
BAYER BREEZE 2 CONTROL ........................ 13
b-complex w/ c & folic acid ............................... 22
BD CATHETER TIP SYRINGE ........................ 13
BD DISP NEEDLES ......................................... 13
BD ECLIPSE SYRINGE................................... 13
BD FILTER NEEDLE/5 MICRON ..................... 13
BD HYPODERMIC NEEDLE ........................... 13
BD INSULIN SYR ULTRAFINE II ..................... 13
BD LANCET DEVICE ...................................... 13
BD LANCET ULTRAFINE 33G ........................ 13
BD LUER-LOK SYRINGE ................................ 13
BD PEN NEEDLE MINI U/F ............................. 13
BD SAFETYGLIDE SYRINGE/NEEDLE .......... 13
BD SYRINGE ................................................... 13
BELLADONNA ALKALOIDS-OPIUM ................. 8
benazepril hcl ................................................... 10
BENDEKA.......................................................... 6
BENEFIX ........................................................... 9
BENZOIN ......................................................... 22
benzoin compound........................................... 22
benzonatate ..................................................... 20
benzoyl peroxide-erythromycin ........................ 21
benztropine mesylate ....................................... 12
betamethasone dipropionate (topical) .............. 22
betamethasone dipropionate augmented ......... 22
betamethasone sod phosphate & acetate ........ 17
betamethasone valerate .................................. 22
betaxolol hcl (ophth)......................................... 16
bethanechol chloride .......................................... 8
BEXSERO ....................................................... 21
bicalutamide....................................................... 6
BICILLIN L-A...................................................... 4
Page 25
BICNU ............................................................... 6
BILTRICIDE ....................................................... 4
BIOTIN-D ......................................................... 19
bismuth subsalicylate ....................................... 16
bisoprolol & hydrochlorothiazide ...................... 10
bisoprolol fumarate .......................................... 10
bleomycin sulfate ............................................... 6
BLINCYTO ......................................................... 6
BLUNT PLASTIC CANNULA ........................... 13
BORIC ACID .................................................... 19
BOTOX ............................................................ 19
BOTOX COSMETIC ........................................ 19
BRAVELLE ...................................................... 18
BREVIBLOC IN NACL ..................................... 10
BREVITAL SODIUM ........................................ 12
BRIDION.......................................................... 19
BRILINTA .......................................................... 9
brimonidine tartrate .......................................... 16
bromocriptine mesylate .................................... 12
budesonide ...................................................... 17
budesonide (inhalation).................................... 17
bumetanide ...................................................... 14
bupivacaine hcl ................................................ 18
bupivacaine in dextrose ................................... 18
bupivacaine w/ epinephrine ............................. 18
buprenorphine hcl ............................................ 11
buprenorphine hcl-naloxone hcl dihydrate ....... 11
bupropion hcl ................................................... 12
buspirone hcl ................................................... 12
butorphanol tartrate ......................................... 11
C ceftazidime......................................................... 4
cabergoline ...................................................... 12
CABOMETYX .................................................... 6
CAFERGOT ..................................................... 12
caffeine citrate ................................................. 11
calcipotriene .................................................... 22
calcitonin (salmon) ........................................... 18
calcitriol............................................................ 23
calcium acetate (phosphate binder) ................. 14
calcium chloride (dihydrate) ............................. 15
calcium gluconate ............................................ 15
CAMPTOSAR .................................................... 6
CANCIDAS ........................................................ 5
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CANDIN ........................................................... 13
CANTHARIDIN ................................................ 19
CAPASTAT SULFATE ....................................... 5
capecitabine....................................................... 6
CAPRELSA........................................................ 6
capsaicin .......................................................... 22
carbamazepine ................................................ 11
CARBAMAZEPINE .......................................... 19
carbidopa ......................................................... 12
carbidopa-levodopa ......................................... 12
CARBIDOPA-LEVODOPA-ENTACAPONE ..... 12
CARDENE IV ................................................... 10
CARIMUNE NF ................................................ 20
carvedilol.......................................................... 10
castor oil .......................................................... 17
CAVERJECT ................................................... 11
CAYSTON ......................................................... 4
cefaclor .............................................................. 4
cefadroxil ........................................................... 4
CEFAZOLIN IN D5W ......................................... 4
cefazolin sodium ................................................ 4
cefdinir ............................................................... 4
cefepime hcl....................................................... 4
CEFEPIME-DEXTROSE .................................... 4
cefixime.............................................................. 4
CEFOTAXIME SODIUM .................................... 4
cefotetan disodium ............................................. 4
CEFOTETAN DISODIUM-DEXTROSE.............. 4
cefoxitin sodium ................................................. 4
CEFOXITIN SODIUM-DEXTROSE .................... 4
cefpodoxime proxetil .......................................... 4
ceftriaxone sodium ............................................. 4
CEFTRIAXONE SODIUM IN DEXTROSE ......... 4
CEFTRIAXONE SODIUM-DEXTROSE ............. 4
cefuroxime axetil ................................................ 4
cefuroxime sodium ............................................. 4
CEFUROXIME-DEXTROSE .............................. 4
CELONTIN....................................................... 11
cephalexin.......................................................... 4
CERDELGA ..................................................... 19
CEREZYME ..................................................... 15
CHANTIX ........................................................... 8
CHEMET.......................................................... 17
Page 26
CHEMSTRIP 9................................................. 13
CHIRHOSTIM .................................................. 13
CHLORAMPHENICOL SOD SUCCINATE ........ 4
chlordiazepoxide hcl .................................... 8, 12
chlordiazepoxide hcl-clidinium bromide ............. 8
chlorhexidine gluconate (mouth-throat) ............ 15
chloroprocaine hcl............................................ 18
chloroquine phosphate ...................................... 5
chlorpheniramine & phenylephrine..................... 6
chlorpromazine hcl ........................................... 12
CHLORPROMAZINE HCL ............................... 19
chlorthalidone .................................................. 14
CHOLESTEROL ACETATE............................. 19
cholestyramine................................................. 10
cholestyramine light ......................................... 10
choline & mag salicylate .................................. 11
CHROMIC CHLORIDE .................................... 15
cidofovir ............................................................. 5
cimetidine hcl ................................................... 17
CINRYZE ......................................................... 19
CIPRODEX ...................................................... 15
ciprofloxacin ................................................. 4, 15
ciprofloxacin hcl ........................................... 4, 15
ciprofloxacin hcl (ophth) ................................... 15
ciprofloxacin in d5w ........................................... 4
cisatracurium besylate ....................................... 8
cisplatin.............................................................. 6
citalopram hydrobromide ................................. 12
cladribine ........................................................... 6
clarithromycin..................................................... 4
CLEOCIN IN D5W ............................................. 4
CLEVIPREX .................................................... 10
clindamycin hcl .................................................. 4
CLINDAMYCIN HCL ........................................ 20
clindamycin palmitate hydrochloride .................. 4
clindamycin phosphate ................................ 4, 21
clindamycin phosphate (topical) ....................... 21
clindamycin phosphate vaginal ........................ 21
clindamycin phosphate-benzoyl peroxide ........ 21
clindamycin phosphate-benzoyl peroxide
(refrigerate) .................................................. 21
CLINIMIX E/DEXTROSE (2.75/10) .................. 14
CLINIMIX E/DEXTROSE (2.75/5) .................... 14
CLINIMIX E/DEXTROSE (4.25/25) .................. 14
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CLINIMIX E/DEXTROSE (5/15) ....................... 14
CLINIMIX E/DEXTROSE (5/20) ....................... 14
CLINIMIX/DEXTROSE (4.25/10) ..................... 14
CLINIMIX/DEXTROSE (4.25/25) ..................... 14
CLINITEST ...................................................... 13
clobetasol propionate ....................................... 22
CLOBETASOL PROPIONATE......................... 20
clomiphene citrate ............................................ 18
clomipramine hcl .............................................. 12
clonazepam ..................................................... 11
clonidine hcl ..................................................... 10
clopidogrel bisulfate ........................................... 9
clorazepate dipotassium .................................. 12
clotrimazole...................................................... 21
CLOTRIMAZOLE ............................................. 20
clozapine.......................................................... 12
COARTEM ......................................................... 5
COCAINE HCL ................................................ 16
CODEINE SULFATE ....................................... 11
COLCHICINE................................................... 19
colchicine w/ probenecid .................................. 15
colestipol hcl .................................................... 10
COLLODION FLEXIBLE .................................. 20
COMBIVENT RESPIMAT ................................ 20
COMPLERA ....................................................... 5
CONRAY ......................................................... 13
COPPER CHLORIDE ...................................... 15
COPPER SULFATE......................................... 15
CORDRAN....................................................... 22
CORTISPORIN ................................................ 22
CORTROSYN .................................................. 14
COSENTYX 300 DOSE ................................... 22
COTELLIC ......................................................... 6
CREON ...................................................... 14, 17
CRIXIVAN .......................................................... 5
CROFAB .......................................................... 20
CROMOLYN SODIUM ..................................... 20
cromolyn sodium (ophth) ................................. 16
CUBICIN ............................................................ 4
CUROSURF .................................................... 20
cyanocobalamin ............................................... 23
cyclobenzaprine hcl ........................................... 8
CYCLOMYDRIL ............................................... 16
cyclopentolate hcl ............................................ 16
Page 27
cyclophosphamide ............................................. 6
CYCLOSERINE ................................................. 5
cyclosporine modified (for microemulsion) ....... 19
cyproheptadine hcl............................................. 6
CYRAMZA ......................................................... 6
CYSTADANE ................................................... 19
CYSTAGON .................................................... 19
CYSTEAMINE HCL ......................................... 20
CYSTOGRAFIN ............................................... 14
cytarabine .......................................................... 7
D dicyclomine hcl .................................................. 8
dacarbazine ....................................................... 7
DACOGEN ........................................................ 7
dactinomycin ...................................................... 7
DAKLINZA ......................................................... 5
danazol ............................................................ 17
dantrolene sodium ............................................. 8
dapsone ............................................................. 5
DARAPRIM ........................................................ 5
daunorubicin hcl................................................. 7
DAUNOXOME ................................................... 7
DDAVP RHINAL TUBE .................................... 18
deferoxamine mesylate .................................... 17
demeclocycline hcl ............................................. 4
DEPEN TITRATABS........................................ 17
DEPOCYT ......................................................... 7
DEPO-ESTRADIOL ......................................... 18
DEPO-PROVERA ............................................ 18
DESCOVY ......................................................... 5
desipramine hcl................................................ 12
DESITIN .......................................................... 22
desmopressin acetate ...................................... 18
desmopressin acetate spray ............................ 18
desmopressin acetate spray refrigerated ......... 18
desogestrel & ethinyl estradiol ......................... 18
desoximetasone............................................... 22
dexamethasone ............................................... 17
DEXAMETHASONE .................................. 15, 20
dexamethasone sodium phosphate ................. 17
DEXAMETHASONE SODIUM PHOSPHATE .. 15
dexmethylphenidate hcl ................................... 11
dexrazoxane .................................................... 19
dextroamphetamine sulfate.............................. 11
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dextrose ..................................................... 14, 15
dextrose in lactated ringers .............................. 15
dextrose in ringers ........................................... 15
dextrose w/ sodium chloride............................. 15
DIANEAL LOW CALCIUM/4.25% DEX ............ 14
DIASTAT ACUDIAL ......................................... 12
DIASTIX ........................................................... 14
diazepam ......................................................... 12
diclofenac sodium (ophth) ................................ 16
diclofenac sodium (topical)............................... 22
dicloxacillin sodium ............................................ 4
didanosine ......................................................... 5
DIGIFAB .......................................................... 20
digoxin ............................................................. 10
dihydroergotamine mesylate .............................. 8
diltiazem hcl ..................................................... 10
diltiazem hcl coated beads ............................... 10
diphenhydramine hcl .......................................... 6
diphenoxylate w/ atropine ................................ 16
dipyridamole .................................................... 11
disopyramide phosphate .................................. 10
DISPOSABLE POWER.................................... 13
disulfiram ......................................................... 19
divalproex sodium ............................................ 11
dobutamine hcl .................................................. 9
dobutamine in d5w ............................................. 9
DOCETAXEL ..................................................... 7
donepezil hydrochloride ..................................... 8
DONNATAL ....................................................... 8
dopamine hcl ..................................................... 9
dopamine in d5w ................................................ 9
dorzolamide hcl ................................................ 16
dorzolamide hcl-timolol maleate....................... 16
doxazosin mesylate ......................................... 10
doxepin hcl....................................................... 12
doxorubicin hcl ................................................... 7
doxorubicin hcl liposomal ................................... 7
doxycycline (monohydrate) ................................ 4
doxycycline hyclate ............................................ 4
DRITHO-CREME HP ....................................... 22
dronabinol ........................................................ 16
droperidol ......................................................... 12
drospirenone-ethinyl estradiol .......................... 18
Page 28
DRYSOL .......................................................... 22
DULERA .......................................................... 20
duloxetine hcl ................................................... 12
E ethosuximide.................................................... 11
EDECRIN ........................................................ 14
EDURANT ......................................................... 6
EFFIENT............................................................ 9
ELAPRASE ...................................................... 15
ELIDEL ............................................................ 22
ELITEK ............................................................ 15
ELLA ................................................................ 18
ELMIRON ........................................................ 19
ELOCTATE ........................................................ 9
EMCYT .............................................................. 7
EMEND INJ ..................................................... 16
EMEND TAB .................................................... 16
EMTRIVA ........................................................... 6
enalaprilat ........................................................ 10
ENBREL .......................................................... 19
ENDOMETRIN................................................. 18
ENGERIX-B ..................................................... 21
ENLON .............................................................. 8
entacapone ...................................................... 12
entecavir ............................................................ 6
ENTRESTO ..................................................... 10
EOVIST ........................................................... 14
EPCLUSA .......................................................... 6
ephedrine sulfate (pressors) .............................. 9
EPIDUO ........................................................... 22
epinephrine ........................................................ 9
EQUETRO ....................................................... 11
ERBITUX ........................................................... 7
ergocalciferol ................................................... 23
ERGOMAR ........................................................ 8
ERIVEDGE ........................................................ 7
ERWINAZE ........................................................ 7
ERYTHROCIN LACTOBIONATE....................... 4
erythromycin (acne aid) ................................... 21
erythromycin (ophth) ........................................ 15
escitalopram oxalate ........................................ 12
esmolol hcl ....................................................... 10
esterified estrogens & methyltestosterone ....... 18
estradiol ........................................................... 18
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ESTRADIOL .................................................... 20
estradiol vaginal ............................................... 18
ethambutol hcl ................................................... 5
ETHAMOLIN .................................................... 10
ethynodiol diacet & eth estrad .......................... 18
ETIDRONATE DISODIUM ............................... 19
etodolac ........................................................... 11
etomidate ......................................................... 12
etoposide ........................................................... 7
EVOTAZ ............................................................ 6
exemestane ....................................................... 7
EXJADE ........................................................... 17
EXTAVIA.......................................................... 19
EYLEA ............................................................. 16
E-Z-CAT DRY .................................................. 14
F
FABRAZYME ................................................... 15
famciclovir .......................................................... 6
famotidine ........................................................ 17
FAMOTIDINE PREMIXED ............................... 17
FASLODEX........................................................ 7
fat emulsion ..................................................... 14
felbamate ......................................................... 11
fenofibrate ........................................................ 10
fentanyl ............................................................ 11
fentanyl citrate ................................................. 11
finasteride ........................................................ 19
FIRAZYR ......................................................... 19
flecainide acetate ............................................. 10
FLOVENT HFA ................................................ 17
FLUAD ............................................................. 21
FLUARIX QUADRIVALENT ............................. 21
FLUBLOK ........................................................ 21
FLUCELVAX .................................................... 21
fluconazole......................................................... 5
fluconazole in dextrose ...................................... 5
fluconazole in nacl ............................................. 5
FLUCONAZOLE IN SODIUM CHLORIDE ......... 4
flucytosine .......................................................... 5
fludarabine phosphate ....................................... 7
fludrocortisone acetate..................................... 17
flumazenil......................................................... 12
Page 29
FLUMIST QUADRIVALENT............................. 21
flunisolide (nasal) ............................................. 16
fluocinolone acetonide ..................................... 22
fluocinonide ..................................................... 22
FLUOR-A-DAY ................................................ 19
fluorescein sodium injection ............................. 14
fluorescein sodium topical................................ 14
fluorescein w/ benoxinate ................................ 14
fluorometholone (ophth) ................................... 16
fluorouracil ................................................... 7, 22
fluorouracil (topical) ......................................... 22
fluoxetine hcl .................................................... 12
fluphenazine decanoate ................................... 12
fluphenazine hcl ............................................... 12
FLURBIPROFEN SODIUM .............................. 16
flutamide ............................................................ 7
fluticasone propionate (nasal) .......................... 16
FLUVIRIN .................................................. 20, 21
FLUVIRIN PRESERVATIVE FREE.................. 21
fluvoxamine maleate ........................................ 13
FLUZONE HIGH-DOSE ................................... 21
FOLIC ACID .................................................... 23
FORANE.......................................................... 12
FORTEO.......................................................... 18
FOSCAVIR ........................................................ 6
fosphenytoin sodium ........................................ 11
furosemide ....................................................... 14
FUSILEV.......................................................... 19
FUZEON ............................................................ 6
G
gabapentin ....................................................... 11
GADAVIST ...................................................... 14
galantamine hydrobromide ................................ 8
GAMASTAN S/D.............................................. 21
GAMMAGARD ................................................. 21
ganciclovir sodium ............................................. 6
GARDASIL ...................................................... 21
GARDASIL 9 ................................................... 21
GASTROGRAFIN ............................................ 14
gatifloxacin (ophth) .......................................... 15
GAZYVA ............................................................ 7
GELFOAM SPONGE SIZE 100 ......................... 9
gemcitabine hcl .................................................. 7
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gemfibrozil ....................................................... 10
gentamicin in saline ........................................... 4
gentamicin sulfate .................................. 4, 15, 21
gentamicin sulfate (ophth) ................................ 15
gentamicin sulfate (topical) .............................. 21
GENVOYA ......................................................... 6
glatiramer acetate ............................................ 19
GLEOSTINE ...................................................... 7
glimepiride ....................................................... 17
glipizide ............................................................ 17
glipizide-metformin hcl ..................................... 17
GLUCAGEN DIAGNOSTIC.............................. 17
GLUCAGON EMERGENCY ............................ 17
glyburide .......................................................... 17
GLYCERIN ...................................................... 20
glycopyrrolate .................................................... 8
GLYCOPYRROLATE....................................... 20
GNP GENTIAN VIOLET .................................. 21
GONAL-F ......................................................... 18
GRASTEK........................................................ 19
griseofulvin microsize......................................... 5
griseofulvin ultramicrosize .................................. 5
guaifenesin-codeine ......................................... 20
guanfacine hcl .................................................... 8
H
HALAVEN .......................................................... 7
halobetasol propionate..................................... 22
haloperidol ....................................................... 13
HALOPERIDOL ............................................... 20
haloperidol decanoate...................................... 13
haloperidol lactate ............................................ 13
HARVONI .......................................................... 6
HAVRIX ........................................................... 21
HEALON5 ........................................................ 16
HELIXATE FS .................................................... 9
HEMABATE ..................................................... 19
HEMOFIL M ....................................................... 9
heparin (porcine) in sodium chloride .................. 9
heparin sod (porcine) in d5w .............................. 9
heparin sodium (porcine) ................................... 9
heparin sodium (porcine) lock flush ................... 9
HERCEPTIN ...................................................... 7
HESPAN .......................................................... 15
Page 30
HEXALEN .......................................................... 7
HEXTEND ....................................................... 15
HIZENTRA ....................................................... 21
homatropine hbr............................................... 16
HP ACTHAR .................................................... 18
HUMALOG ...................................................... 17
HUMATE-P ........................................................ 9
HUMIRA .......................................................... 19
HUMULIN 70/30 .............................................. 17
HUMULIN N ..................................................... 17
HUMULIN R ..................................................... 17
hydralazine hcl ................................................. 10
hydrochlorothiazide .................................... 10, 14
hydrocodone-acetaminophen .......................... 11
hydrocortisone ........................................... 17, 22
HYDROCORTISONE ...................................... 20
hydrocortisone (intrarectal) .............................. 22
hydrocortisone (topical).................................... 22
hydrocortisone acetate (rectal) ........................ 22
hydromorphone hcl .......................................... 11
HYDROXOCOBALAMIN.................................. 20
hydroxychloroquine sulfate ................................ 5
HYDROXYPROGESTERONE CAPROATE .... 20
hydroxyurea ....................................................... 7
hydroxyzine hcl ................................................ 12
hydroxyzine pamoate ....................................... 12
HYLENEX ........................................................ 15
hyoscyamine sulfate .......................................... 8
HYPERRAB S/D .............................................. 21
HYPERTET S/D............................................... 21
I
IBRANCE........................................................... 7
ibuprofen.......................................................... 11
ibutilide fumarate ............................................. 10
idarubicin hcl ...................................................... 7
IDELVION .......................................................... 9
ifosfamide .......................................................... 7
IFOSFAMIDE-MESNA ....................................... 7
imatinib mesylate ............................................... 7
IMBRUVICA ....................................................... 7
imipramine hcl.................................................. 13
imiquimod ........................................................ 22
IMOVAX RABIES............................................. 21
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indapamide ...................................................... 14
INDIGO CARMINE........................................... 14
indomethacin ................................................... 11
INDOMETHACIN ....................................... 11, 20
INDOMETHACIN SODIUM .............................. 11
INFANRIX ........................................................ 21
INFED ................................................................ 9
INFLECTRA ..................................................... 19
INFUMORPH 200 ............................................ 11
INFUVITE ........................................................ 22
INFUVITE PEDIATRIC .................................... 22
INSUFLON....................................................... 13
INTEGRILIN....................................................... 9
INTELENCE....................................................... 6
INTRON A.......................................................... 7
INVANZ.............................................................. 4
INVIRASE .......................................................... 6
iodoquinol-hc ................................................... 21
IPOL ................................................................ 21
ipratropium bromide ........................................... 8
ipratropium bromide (nasal) ............................... 8
ipratropium-albuterol .......................................... 9
IRESSA ............................................................. 7
ISENTRESS ...................................................... 6
isoniazid ............................................................. 5
isosorbide dinitrate ........................................... 11
isosorbide mononitrate..................................... 11
isotretinoin ....................................................... 22
ISTODAX ........................................................... 7
IXEMPRA KIT .................................................... 7
IXIARO ............................................................ 21
J
JAKAFI .............................................................. 7
JEVTANA........................................................... 7
K
KADCYLA .......................................................... 7
KALETRA .......................................................... 6
KALYDECO ..................................................... 20
KCENTRA.......................................................... 9
KCL-LACTATED RINGERS-D5W .................... 15
KENALOG ....................................................... 17
KEPIVANCE .................................................... 22
Page 31
ketamine hcl .................................................... 12
KETAMINE HCL .............................................. 20
ketoconazole ............................................... 5, 21
ketoconazole (topical) ...................................... 21
KETO-DIASTIX ................................................ 14
ketorolac tromethamine ............................. 11, 16
ketorolac tromethamine (ophth) ....................... 16
KEYTRUDA ....................................................... 7
KINERET ......................................................... 19
KINRIX............................................................. 21
K-PHOS ........................................................... 15
KYPROLIS ......................................................... 7
L lidocaine in d5w ............................................... 10
labetalol hcl ...................................................... 10
lactated ringer's ............................................... 15
LACTIC ACID .................................................. 20
LACTOSE ........................................................ 20
LACTOSE MONOHYDRATE ........................... 20
lactulose .......................................................... 14
lactulose (encephalopathy) .............................. 14
lamivudine ......................................................... 6
lamivudine (hbv) ................................................ 6
lamivudine-zidovudine ....................................... 6
lamotrigine ....................................................... 11
LANTUS .......................................................... 17
L-ARGININE .................................................... 20
latanoprost ....................................................... 16
L-CITRULLINE................................................. 20
leflunomide ...................................................... 19
LENVIMA 10 MG DAILY DOSE ......................... 7
LETAIRIS......................................................... 11
letrozole ............................................................. 7
leucovorin calcium ........................................... 19
LEUKERAN ....................................................... 7
LEUKINE ........................................................... 9
leuprolide acetate .............................................. 7
levetiracetam ................................................... 11
LEVETIRACETAM IN NACL ............................ 11
LEVITRA.......................................................... 11
levobunolol hcl ................................................. 16
levocarnitine (metabolic modifiers)................... 19
levofloxacin ........................................................ 4
levofloxacin in d5w ............................................. 4
2017 Kaiser Permanente Federal Employees Health Benefit Formulary
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levonorgestrel & eth estradiol........................... 18
levonorgestrel (emergency oc)......................... 18
levonorgestrel-eth estradiol (triphasic) ............. 18
levothyroxine sodium ....................................... 18
LEVULAN KERASTICK ................................... 22
LEXISCAN ....................................................... 14
LEXIVA .............................................................. 6
lidocaine....................................10, 16, 18, 19, 22
lidocaine hcl ................................... 10, 16, 18, 22
LIDOCAINE HCL ............................................. 20
lidocaine hcl (cardiac) ................................ 10, 18
lidocaine hcl (local anesth.) .............................. 18
lidocaine hcl (mouth-throat).............................. 16
lidocaine w/ epinephrine .................................. 19
lidocaine-prilocaine .......................................... 22
linezolid .............................................................. 4
liothyronine sodium .......................................... 18
lisinopril ............................................................ 10
lisinopril & hydrochlorothiazide......................... 10
L-ISOLEUCINE ................................................ 20
LITHIUM .......................................................... 12
lithium carbonate ............................................. 12
LITHOSTAT ..................................................... 14
LMD IN D5W .................................................... 15
LMD IN NACL .................................................. 15
LONSURF.......................................................... 7
lorazepam ........................................................ 12
losartan potassium ........................................... 10
losartan potassium & hydrochlorothiazide........ 10
lovastatin.......................................................... 10
LOVENOX ......................................................... 9
loxapine succinate ........................................... 13
LUCENTIS ....................................................... 16
LUMASON ....................................................... 14
LUMIGAN ........................................................ 16
LUMIZYME ...................................................... 15
LUPRON DEPOT (3-MONTH) ........................... 7
LUPRON DEPOT (4-MONTH) ........................... 7
LUPRON DEPOT (6-MONTH) ........................... 7
LUPRON DEPOT-PED (1-MONTH)................... 7
LUPRON DEPOT-PED (3-MONTH)................... 7
L-VALINE ......................................................... 20
LYNPARZA ........................................................ 7
Page 32
LYSODREN ....................................................... 7
M metoclopramide hcl .......................................... 17
MACUGEN ...................................................... 16
magnesium sulfate........................................... 11
MAGNESIUM SULFATE IN D5W .................... 15
MAGNEVIST.................................................... 14
mannitol ........................................................... 14
MARQIBO .......................................................... 7
MATULANE ....................................................... 7
meclizine hcl .................................................... 16
MECLOFENAMATE SODIUM ......................... 11
medroxyprogesterone acetate ......................... 18
medroxyprogesterone acetate (contraceptive) . 18
mefenamic acid................................................ 11
mefloquine hcl.................................................... 5
megestrol acetate .............................................. 7
MEKINIST .......................................................... 7
meloxicam ....................................................... 11
melphalan hcl..................................................... 7
memantine hcl ................................................. 12
MENOPUR ...................................................... 18
MENVEO ......................................................... 21
meperidine hcl ................................................. 11
mepivacaine hcl ............................................... 19
mercaptopurine .................................................. 7
meropenem ....................................................... 4
mesalamine ..................................................... 16
mesna .............................................................. 19
METAPROTERENOL SULFATE ....................... 9
metformin hcl ................................................... 17
methadone hcl ................................................. 11
METHADONE HCL .......................................... 20
methazolamide ................................................ 16
methenamine hippurate ..................................... 6
methimazole .................................................... 18
methocarbamol .................................................. 8
methotrexate sodium ......................................... 7
methoxsalen rapid ........................................... 22
methyldopa ...................................................... 10
methylene blue (antidote) ................................ 19
methylergonovine maleate ............................... 19
methylphenidate hcl ......................................... 11
methylprednisolone .......................................... 17
2017 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
methylprednisolone acetate ............................. 17
methylprednisolone sod succ ........................... 17
METOCLOPRAMIDE HCL MONOHYDRATE .. 20
metolazone ...................................................... 14
METOPIRONE ................................................. 14
metoprolol succinate ........................................ 10
metoprolol tartrate ............................................ 10
metronidazole .............................................. 5, 21
metronidazole (topical) ..................................... 21
metronidazole in nacl ......................................... 5
metronidazole vaginal ...................................... 21
mexiletine hcl ................................................... 10
MICRHOGAM ULTRA-FILTERED PLUS ......... 21
midazolam hcl .................................................. 12
midodrine hcl ..................................................... 9
MIFEPREX ...................................................... 19
milrinone lactate ............................................... 10
milrinone lactate in dextrose ............................ 10
MINERAL OIL LIGHT....................................... 17
minocycline hcl .................................................. 4
minoxidil ........................................................... 10
MIOCHOL-E .................................................... 16
MIOSTAT ......................................................... 16
MIRENA (52 MG) ............................................. 18
mirtazapine ...................................................... 13
misoprostol ...................................................... 17
mitomycin........................................................... 7
MITOSOL......................................................... 16
mitoxantrone hcl ................................................ 7
M-M-R II ........................................................... 21
mometasone furoate ........................................ 22
montelukast sodium ......................................... 20
morphine sulfate .............................................. 11
MORPHINE SULFATE .................................... 20
moxifloxacin hcl ................................................. 4
MULTIHANCE ................................................. 14
mupirocin ......................................................... 21
MUSTARGEN .................................................... 7
mycophenolate mofetil ..................................... 19
MYLERAN ......................................................... 7
MYOBLOC ....................................................... 19
Page 33
 N NORDITROPIN FLEXPRO .............................. 18
NABI-HB .......................................................... 21
nabumetone ..................................................... 11
nafcillin sodium .................................................. 4
NAFCILLIN SODIUM IN DEXTROSE ................ 5
NAGLAZYME................................................... 15
nalbuphine hcl.................................................. 11
naloxone hcl .................................................... 12
naltrexone hcl .................................................. 12
naproxen.......................................................... 11
naratriptan hcl .................................................. 12
NAROPIN ........................................................ 19
NEBUPENT ....................................................... 5
NECON 1/50 (28) ............................................ 18
NECON 10/11 (28) .......................................... 18
nefazodone hcl ................................................ 13
NEMBUTAL ..................................................... 12
neomycin sulfate ................................................ 5
NEOMYCIN SULFATE .................................... 20
neomycin/polymyxin b gu................................. 21
neomycin-bacitracin zn-polymyxin ................... 15
neomycin-polymy-dexameth ............................ 16
neomycin-polymyxin-gramicidin ....................... 15
neomycin-polymyxin-hc (otic) .......................... 16
NEOPROFEN .................................................. 11
neostigmine methylsulfate ................................. 8
NEUMEGA ........................................................ 9
NEUPOGEN ...................................................... 9
nevirapine .......................................................... 6
NEXAVAR ......................................................... 7
NEXPLANON................................................... 18
niacin ............................................................... 23
nicardipine hcl .................................................. 10
nicotine .............................................................. 8
nicotine polacrilex .............................................. 8
nifedipine ......................................................... 10
nimodipine ....................................................... 10
NINLARO ........................................................... 7
nitrofurantoin ...................................................... 6
nitrofurantoin macrocrystal................................. 6
nitrofurantoin monohyd macro ........................... 6
nitroglycerin ..................................................... 11
nitroglycerin in d5w .......................................... 11
NITROPRESS ................................................. 10
2017 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
norepinephrine bitartrate .................................... 9
norethin acet & estrad-fe .................................. 18
norethindrone & eth estradiol ........................... 18
norethindrone (contraceptive) .......................... 18
norethindrone acetate ...................................... 18
norethindrone-eth estradiol (triphasic).............. 18
norgestimate-ethinyl estradiol .......................... 18
norgestimate-ethinyl estradiol (triphasic) .......... 18
nortriptyline hcl ................................................. 13
NORVIR ............................................................. 6
NOVAREL........................................................ 18
NOVOSEVEN RT .............................................. 9
NUVARING ...................................................... 18
nystatin .................................................. 5, 21, 22
nystatin (mouth-throat) ....................................... 5
nystatin (topical) ............................................... 21
nystatin-triamcinolone ...................................... 22
O
octreotide acetate ............................................ 19
ODEFSEY.......................................................... 6
ODOMZO........................................................... 7
OFIRMEV ........................................................ 11
ofloxacin (ophth) .............................................. 15
ofloxacin (otic) .................................................. 15
OGESTREL ..................................................... 18
olanzapine ....................................................... 13
olopatadine hcl ................................................. 16
omeprazole ...................................................... 17
OMNIPAQUE ................................................... 14
OMNITROPE PEN 5 INJ DEVICE ................... 13
ondansetron ..................................................... 16
ondansetron hcl ............................................... 16
ONETOUCH ULTRA BLUE ............................. 14
ONETOUCH ULTRA MINI ............................... 13
OPANA ............................................................ 11
OPDIVO ............................................................. 7
ophthalmic irrigation solution - intraocular ........ 16
OPSUMIT ........................................................ 19
ORAP .............................................................. 13
ORENCIA ........................................................ 19
ORKAMBI ........................................................ 20
oseltamivir phosphate ........................................ 6
Page 34
OTEZLA........................................................... 19
OVIDREL ......................................................... 18
oxaliplatin ........................................................... 7
oxazepam ........................................................ 12
oxcarbazepine ................................................. 11
OXSORALEN .................................................. 22
oxybutynin chloride .......................................... 22
oxycodone hcl .................................................. 11
oxycodone w/ acetaminophen ......................... 11
oxytocin ........................................................... 19
OXYTROL ....................................................... 22
P PHYSOSTIGMINE SALICYLATE ...................... 8
paclitaxel............................................................ 7
pamidronate disodium ..................................... 19
PANCURONIUM BROMIDE .............................. 8
pantoprazole sodium ....................................... 17
PAPAVERINE HCL.......................................... 11
paromomycin sulfate .......................................... 5
paroxetine hcl .................................................. 13
ped multivitamins w/fl & iron ............................ 22
PEDIARIX ........................................................ 21
pediatric multivitamins w/fl ............................... 22
PEDIATRIC SMALL MASK .............................. 13
pediatric vitamins acd w/ fluoride ..................... 23
peg 3350-kcl-sod bicarb-sod chloride-sod sulfate
..................................................................... 17
PEGASYS ......................................................... 6
PENICILLIN G POT IN DEXTROSE .................. 5
penicillin g potassium ......................................... 5
PENICILLIN G PROCAINE ................................ 5
PENICILLIN G SODIUM .................................... 5
penicillin v potassium ......................................... 5
PENLET II BLOOD SAMPLER ........................ 13
pentostatin ......................................................... 7
pentoxifylline ...................................................... 9
PERJETA .......................................................... 7
permethrin ....................................................... 21
perphenazine ................................................... 13
PERPHENAZINE-AMITRIPTYLINE ................. 13
phenelzine sulfate ............................................ 13
PHENEX-1 ....................................................... 14
phenobarbital ................................................... 12
PHENOBARBITAL..................................... 12, 20
2017 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
PHENOBARBITAL SODIUM............................ 12
PHENOL .......................................................... 22
phenoxybenzamine hcl ...................................... 8
PHENTOLAMINE MESYLATE........................... 8
phenylephrine hcl (ophth) ................................ 16
phenylephrine hcl (pressors) .............................. 9
phenylephrine-chlorphen-dm ........................... 20
PHENYLHISTINE DH ...................................... 20
phenytoin ......................................................... 12
phenytoin sodium ............................................. 12
phenytoin sodium extended ............................. 12
PHOSPHOLINE IODIDE .................................. 16
phytonadione ................................................... 23
pilocarpine hcl .............................................. 8, 16
pilocarpine hcl (oral)........................................... 8
pioglitazone hcl ................................................ 17
piperacillin sodium-tazobactam sodium ............. 5
PLASMANATE ................................................... 9
PLURONIC F127 ............................................. 20
PNEUMOVAX 23 ............................................. 21
PODOCON ...................................................... 22
podofilox .......................................................... 22
PODOPHYLLUM RESIN ................................. 20
POLYETHYLENE GLYCOL 400 ...................... 20
POLYFIN QR INFUSION SET 42 .................... 13
polymyxin b-trimethoprim ................................. 15
polysaccharide iron complex .............................. 9
POMALYST ....................................................... 7
potassium acetate ............................................ 15
potassium bicarbonate ..................................... 15
potassium chloride ........................................... 15
potassium chloride in dextrose......................... 15
potassium chloride in dextrose & sodium chloride
..................................................................... 15
potassium chloride in nacl ................................ 15
potassium chloride microencapsulated crystals er
..................................................................... 15
potassium citrate (alkalinizer)........................... 14
potassium citrate-citric acid .............................. 14
potassium phosphates ..................................... 15
PRADAXA.......................................................... 9
pramipexole dihydrochloride ............................ 12
pravastatin sodium ........................................... 10
Page 35
PRAXBIND ........................................................ 9 PULMOZYME .................................................. 15
prazosin hcl ..................................................... 10 pyrazinamide ..................................................... 5
PRECEDEX ..................................................... 12 pyridostigmine bromide ...................................... 8
prednisolone .............................................. 16, 17
prednisolone acetate (ophth) ........................... 16 Q
prednisolone sodium phosphate ...................... 17 QUELICIN .......................................................... 8
prednisone ....................................................... 17 quetiapine fumarate ......................................... 13
PREMARIN ...................................................... 18 QUINACRINE HCL .......................................... 20
PREPIDIL ........................................................ 19 quinidine gluconate .......................................... 10
PREVNAR 13 .................................................. 21 QUINIDINE SULFATE ..................................... 10
PREZCOBIX ...................................................... 6 QVAR .............................................................. 17
PREZISTA ......................................................... 6
PRIFTIN............................................................. 5 R
PRIMAQUINE PHOSPHATE ............................. 5
RABAVERT ..................................................... 21
PRIMAXIN IV ..................................................... 5
raloxifene hcl.................................................... 18
primidone ......................................................... 12
ranitidine hcl..................................................... 17
probenecid ....................................................... 15
RASUVO.......................................................... 19
PROCAINAMIDE HCL ..................................... 10
RECOTHROM ................................................... 9
prochlorperazine .............................................. 13
RELENZA DISKHALER ..................................... 6
prochlorperazine edisylate ............................... 13
REMICADE ...................................................... 19
prochlorperazine maleate ................................ 13
REMODULIN ................................................... 11
PROCRIT .......................................................... 9
RENVELA ........................................................ 14
PROCTOFOAM HC ......................................... 22
REOPRO ........................................................... 9
PROFERRIN ES ................................................ 9
RESCRIPTOR ................................................... 6
PROFERRIN-FORTE ........................................ 9
RESERPINE .................................................... 10
PROFILNINE ..................................................... 9
RESTASIS ....................................................... 16
progesterone ................................................... 18
RETIN-A .......................................................... 22
progesterone micronized ................................. 18
RETIN-A MICRO.............................................. 22
PROGESTERONE MICRONIZED ................... 20
RETISERT ....................................................... 16
PROGESTERONE WETTABLE ...................... 20
REVLIMID .......................................................... 7
PROLASTIN-C................................................. 15
REYATAZ .......................................................... 6
PROMACTA ...................................................... 9
ribavirin (hepatitis c) ........................................... 6
promethazine hcl ............................................... 6
RIDAURA......................................................... 17
promethazine-dm ............................................. 20
rifabutin .............................................................. 5
propafenone hcl ............................................... 10
rifampin .............................................................. 5
PROPANTHELINE BROMIDE ........................... 8
riluzole ............................................................. 12
proparacaine hcl .............................................. 16
rimantadine hydrochloride .................................. 6
propofol............................................................ 12
RIMSO-50 ........................................................ 19
propranolol hcl ................................................. 10
risperidone ....................................................... 13
PROPYLENE GLYCOL ................................... 20
RITUXAN ........................................................... 7
propylthiouracil................................................. 18
rizatriptan benzoate ......................................... 12
PROQUAD ...................................................... 21
rocuronium bromide ........................................... 8
PROTAMINE SULFATE .................................... 9
ropinirole hydrochloride .................................... 12
protriptyline hcl................................................. 13
rosuvastatin calcium ........................................ 10

2017 Kaiser Permanente Federal Employees Health Benefit Formulary Page 36

(Northern California Region)
ROTARIX......................................................... 21
ROTATEQ ....................................................... 21
RYDAPT ............................................................ 7
S SQUARIC ACID DIBUTYLESTER ................... 20
SABRIL ............................................................ 12
SALICYLIC ACID ............................................. 20
salsalate .......................................................... 11
SANDIMMUNE ................................................ 19
SANTYL........................................................... 22
SCOPOLAMINE HBR ........................................ 8
selegiline hcl .................................................... 12
SELENIUM ...................................................... 15
selenium sulfide ............................................... 21
SELZENTRY ..................................................... 6
SENSIPAR ...................................................... 19
SEREVENT DISKUS ......................................... 9
SEROSTIM ...................................................... 18
sertraline hcl .................................................... 13
sildenafil citrate (pulmonary hypertension) ....... 11
silver sulfadiazine ............................................ 21
simvastatin ....................................................... 10
sirolimus .......................................................... 19
sodium acetate ................................................ 14
SODIUM BENZOATE ...................................... 20
sodium bicarbonate ......................................... 14
sodium chloride.................................... 14, 15, 20
sodium chloride (gu irrigant) ............................ 14
sodium chloride (inhalant) ................................ 20
sodium citrate & citric acid ............................... 14
SODIUM EDECRIN ......................................... 14
sodium fluoride ................................................ 19
sodium fluoride (dental) ................................... 19
sodium phenylbutyrate ..................................... 14
sodium phosphates (sodium phosphate dibasic &
monobasic) .................................................. 15
sodium polystyrene sulfonate .......................... 14
sodium thiosulfate ............................................ 17
SOLIRIS .......................................................... 19
SORBITOL ................................................ 17, 20
sotalol hcl ......................................................... 10
sotalol hcl (afib/afl) ........................................... 10
SOTRADECOL ................................................ 10
SOVALDI ........................................................... 6
2017 Kaiser Permanente Federal Employees Health Benefit Formulary
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SPIRIVA RESPIMAT ......................................... 8
spironolactone ................................................. 10
spironolactone & hydrochlorothiazide .............. 10
SPRYCEL .......................................................... 7
SSKI ................................................................ 18
stavudine ........................................................... 6
STELARA ........................................................ 22
STIOLTO RESPIMAT ...................................... 20
STIVARGA......................................................... 7
STRENSIQ ...................................................... 15
STREPTOMYCIN SULFATE ............................. 5
STRIBILD........................................................... 6
STRIVERDI RESPIMAT .................................... 9
sucralfate ......................................................... 17
sufentanil citrate ............................................... 11
sulfacetamide sodium (ophth) .......................... 15
sulfacetamide sodium w/ sulfur ........................ 22
sulfacetamide sod-prednisolone ...................... 16
SULFADIAZINE ................................................. 5
sulfamethoxazole-trimethoprim .......................... 5
sulfasalazine ...................................................... 5
SULFUR PRECIPITATED ............................... 20
sulindac ........................................................... 11
sumatriptan ...................................................... 12
sumatriptan succinate ...................................... 12
SURMONTIL.................................................... 13
SURVANTA ..................................................... 20
SUSTIVA ........................................................... 6
SUTENT ............................................................ 7
SYLVANT .......................................................... 8
SYNAGIS ........................................................... 6
SYNAREL ........................................................ 18
SYNERCID ........................................................ 5
T
TABLOID ........................................................... 8
tacrolimus .................................................. 19, 22
tacrolimus (topical) ........................................... 22
TAFINLAR ......................................................... 8
TAGRISSO ........................................................ 8
tamoxifen citrate ................................................ 8
tamsulosin hcl .................................................. 10
TARCEVA .......................................................... 8
Page 37
TARGRETIN ................................................ 8, 22
TASIGNA ........................................................... 8
TAZORAC ....................................................... 22
TECENTRIQ ...................................................... 8
temazepam ...................................................... 12
temozolomide .................................................... 8
TENIPOSIDE ..................................................... 8
terazosin hcl .................................................... 10
terbinafine hcl .................................................... 5
terbutaline sulfate .............................................. 9
testosterone cypionate ..................................... 17
testosterone enanthate .................................... 17
TESTOSTERONE PROPIONATE ................... 20
TETANUS-DIPHTHERIA TOXOIDS TD .......... 21
TETRACAINE HCL .......................................... 19
tetracaine hcl (ophth) ....................................... 16
THALOMID ...................................................... 19
theophylline ..................................................... 22
THEOPHYLLINE IN D5W ................................ 22
THERACYS ..................................................... 21
thiamine hcl ..................................................... 23
THIOLA............................................................ 19
thioridazine hcl ................................................. 13
thiotepa .............................................................. 8
thiothixene ....................................................... 13
THROMBATE III ................................................ 9
THYMOL.......................................................... 20
THYROGEN .................................................... 14
TIKOSYN ......................................................... 10
timolol maleate (ophth) .................................... 16
TIVICAY............................................................. 6
tizanidine hcl ...................................................... 8
TNKASE ............................................................ 9
tobramycin ................................................... 5, 15
tobramycin (ophth) ........................................... 15
tobramycin sulfate.............................................. 5
TOLBUTAMIDE ............................................... 17
topiramate ........................................................ 12
topotecan hcl ..................................................... 8
TORISEL ........................................................... 8
torsemide ......................................................... 14
trace minerals (cr-cu-mn-zn) ............................ 15
TRACLEER ..................................................... 11
tramadol hcl ..................................................... 11
2017 Kaiser Permanente Federal Employees Health Benefit Formulary
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tramadol-acetaminophen ................................. 11
tranexamic acid .................................................. 9
TRANEXAMIC ACID ........................................ 20
TRANSDERM-SCOP (1.5 MG) ........................ 16
tranylcypromine sulfate .................................... 13
trazodone hcl ................................................... 13
TRECATOR ....................................................... 5
TRIAMCINOLONE ACETONIDE ..................... 20
triamcinolone acetonide (mouth) ...................... 22
triamcinolone acetonide (topical) ..................... 22
triamterene & hydrochlorothiazide ................... 14
trifluoperazine hcl ............................................. 13
trifluridine ......................................................... 15
trihexyphenidyl hcl ........................................... 12
trimethoprim ....................................................... 6
TRISENOX ........................................................ 8
TRIUMEQ .......................................................... 6
TRI-VIT/FLUORIDE/IRON ............................... 23
tropicamide ...................................................... 16
trospium chloride ............................................. 22
TRUVADA.......................................................... 6
TUBERSOL ..................................................... 14
TWINRIX.......................................................... 21
TYKERB ............................................................ 8
TYPHIM VI ....................................................... 21
TYSABRI ......................................................... 19
TYVASO .......................................................... 11
U
ULTIVA ............................................................ 11
UNITUXIN .......................................................... 8
UREA ............................................................... 20
ursodiol ............................................................ 17
V
valacyclovir hcl ................................................... 6
valganciclovir hcl ................................................ 6
valproate sodium ............................................. 12
valproic acid ..................................................... 12
valsartan .......................................................... 10
valsartan-hydrochlorothiazide .......................... 10
vancomycin hcl .................................................. 5
VANCOMYCIN HCL IN DEXTROSE ................. 5
VARITHENA .................................................... 10
Page 38
VARIVAX ......................................................... 21
VARIZIG .......................................................... 21
vasopressin ..................................................... 18
VAXCHORA .................................................... 21
VECTICAL ....................................................... 22
vecuronium bromide .......................................... 8
VELCADE .......................................................... 8
VENCLEXTA ..................................................... 8
venlafaxine hcl ................................................. 13
VENOFER ......................................................... 9
VENTAVIS ....................................................... 11
verapamil hcl ................................................... 10
VEXOL............................................................. 16
VIMIZIM ........................................................... 15
VINBLASTINE SULFATE .................................. 8
vincristine sulfate ............................................... 8
vinorelbine tartrate ............................................. 8
VIRACEPT ......................................................... 6
VIRAZOLE ......................................................... 6
VIREAD ............................................................. 6
VISUDYNE ...................................................... 16
VIVOTIF........................................................... 21
VORAXAZE ..................................................... 15
voriconazole .................................................. 5, 6
VOTRIENT ........................................................ 8
VPRIV .............................................................. 15
VYVANSE ........................................................ 11
W ZOSTAVAX...................................................... 21
warfarin sodium ................................................. 9
water for injection, sterile ................................. 19
water for irrigation, sterile................................. 14
WIDE-SEAL DIAPHRAGM 60 ......................... 13
2017 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
X
XALKORI ........................................................... 8
XELJANZ ......................................................... 19
XERAC AC ...................................................... 22
XIFAXAN ........................................................... 5
XTANDI.............................................................. 8
XULANE .......................................................... 18
XYNTHA ............................................................ 9
Y
YALE DISP NEEDLES..................................... 13
YF-VAX ............................................................ 21
YODOXIN .......................................................... 5
YONDELIS......................................................... 8
Z
ZANOSAR ......................................................... 8
ZARXIO ............................................................. 9
ZEJULA ............................................................. 8
ZELBORAF ........................................................ 8
zidovudine.......................................................... 6
ZINACEF IN STERILE WATER ......................... 5
ZINC SULFATE ............................................... 20
ZINC TRACE METAL ...................................... 15
ziprasidone hcl ................................................. 13
zoledronic acid ................................................. 19
zolpidem tartrate .............................................. 12
ZOSYN .............................................................. 5
ZYDELIG ........................................................... 8
ZYKADIA ........................................................... 8
ZYTIGA .............................................................. 8
Page 39
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（TTY：711）。

Vietnamese
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn.
Gọi số 1-800-443-0815 (TTY: 711).

Tagalog
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong
sa wika nang walang bayad. Tumawag sa 1-800-443-0815 (TTY: 711).

Korean
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.
1-800-443-0815 (TTY: 711)번으로 전화해 주십시오.

Armenian
ՈՒՇԱԴՐՈՒԹՅՈՒՆ՝ Եթե խոսում եք հայերեն, ապա ձեզ անվճար կարող են տրամադրվել
լեզվական աջակցության ծառայություններ: Զանգահարեք 1-800-443-0815 (TTY (հեռատիպ)՝
711):

Russian
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги
перевода. Звоните 1-800-443-0815 (телетайп: 711).

Japanese
注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-443-0815
（TTY:711）まで、お電話にてご連絡ください。

H0524_H6050_H6052_17MLI accepted
60503713 CA
‫‪Hmong‬‬
‫‪LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj.‬‬
‫‪Hu rau 1-800-443-0815 (TTY: 711).‬‬

‫‪Thai‬‬
‫‪เรียน: ถ้าคุณพูดภาษาไทยคุณสามารถใช้บริการช่วยเหลือทางภาษาได้ฟรี โทร 1-800-443-0815‬‬
‫‪(TTY: 711).‬‬

‫‪Farsi‬‬
‫ﺗﻮﺟﮫ‪ :‬اﮔﺮ ﺑﮫ زﺑﺎن ﻓﺎرﺳﯽ ﮔﻔﺘﮕﻮ ﻣﯽ ﮐﻨﯿﺪ‪ ،‬ﺗﺴﮭﯿﻼت زﺑﺎﻧﯽ ﺑﺼﻮرت راﯾﮕﺎن ﺑﺮای ﺷﻤﺎ ﻓﺮاھﻢ ﻣﯽ‬
‫ﺑﺎﺷﺪ‪ .‬ﺑﺎ )‪ 1-800-443-0815 (TTY: 711‬ﺗﻤﺎس ﺑﮕﯿﺮﯾﺪ‪.‬‬

‫‪Arabic‬‬
‫ﺑﺮﻗﻢ ‪-‬‬ ‫ﻣﻠﺤﻮظﺔ‪ :‬إذا ﻛﻨﺖ ﺗﺘﺤﺪث اذﻛﺮ اﻟﻠﻐﺔ‪ ،‬ﻓﺈن ﺧﺪﻣﺎت اﻟﻤﺴﺎﻋﺪة اﻟﻠﻐﻮﯾﺔ ﺗﺘﻮاﻓﺮ ﻟﻚ ﺑﺎﻟﻤﺠﺎن‪ .‬اﺗﺼﻞ‬
‫‪) 5180-344-008-1‬رﻗﻢ ھﺎﺗﻒ اﻟﺼﻢ واﻟﺒﻜﻢ‪.(117- :‬‬