KAISER PERMANENTE HMO FORMULARY

HMO Formulary (List of Covered Drugs) Last Update: 9/5/2017 Please Note: This formulary drug list is applicable to the following plan types: Signature HMO, Select HMO, Deductible HMO, and HSA-Qualified Deductible HMO. Please note that this formulary does NOT apply to members who purchased their plans on the District of Columbia, Maryland, or Virginia marketplaces, Federal Employee Health Benefit (FEHB) members, Flexible Choice members, Outof-Area (OOA) members, Maryland HealthChoice members, or Virginia Medicaid and FAMIS members. Formularies for these groups can be found at www.kp.org/formulary and then by selecting ‘Covered drugs in your area, Maryland, Virginia, and Washington, D.C.’

HMO Formulary Drug List The following list contains the formulary, also known as the preferred drug list, approved by the Kaiser Permanente Pharmacy and Therapeutics Committee. This formulary applies only to outpatient drugs and self-administered drugs. It does not apply to medications used in inpatient settings or administered in one of the Kaiser Permanente medical centers. You may have specific exclusions, copays, or coinsurance amounts that are not reflected in the formulary drug list. Please consult your Evidence of Coverage or Membership Agreement, for additional information regarding your pharmacy benefits, including any specific limitations or exclusions. Some plans have a separate specialty drug tier with specialty tier copay. Specialty drugs are high cost, prescription medications used to treat serious or chronic medical conditions and require special handling, administration or monitoring. The details of your outpatient prescription drug benefit, including any specific limitations or exclusions can be found in your Evidence of Coverage or Membership Agreement. A listing of specialty tier drugs can be found at kp.org/formulary and then by selecting ‘Covered drugs in your area, Maryland, Virginia, and Washington, D.C’.

Generic and Brand Name Medications Kaiser Permanente covers generic and brand name drugs. A generic drug is approved by the Food and Drug Administration (FDA) as having the same active ingredient as the brand name drug. Brand name drugs are manufactured and sold by the pharmaceutical company that originally researched and developed the drug. When the patent on a brand name drug expires, other pharmaceutical companies may then manufacture and sell the FDA- approved generic version of the drug at lower prices. In most cases, your doctor will prescribe a generic drug if one is available. Generic drugs generally cost less than brand name drugs.

Non-Formulary Medications The listing only includes drugs on the formulary. Any drug not found on this list is considered nonformulary. A non-formulary medication or non-preferred medication is generally available at a higher cost. Please consult your Evidence of Coverage or Membership Agreement for additional information regarding coverage of non-formulary medications specific to your plan. 140301_HMO Formulary

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Using the Kaiser Permanente Formulary List When you look through the formulary drug listing beginning on page 3, you will see that products available in a generic form are listed by their generic names. Medications that are only available as a brand name product are listed in BOLD AND ALL CAPITAL letters, except where multiple branded products exist. You can search the formulary drug list by using the “FIND” function in Adobe Reader, or by referencing the therapeutic drug category. Some drugs have multiple dosage forms. Not all dosage forms and strengths for a particular drug listed are on the Formulary. Please remember that this list is subject to change and will be updated from time to time during the year. Any product not found on the list will be considered non-formulary or non-preferred. Please also note that this formulary applies only to outpatient drugs and self-administered drugs. It does not apply to medical service drugs or medications used in inpatient settings or administered in one of the Kaiser Permanente medical centers.

Restrictions on medication coverage Some covered drugs may have additional requirements or limits on coverage. Please consult your Evidence of Coverage or Membership Agreement for additional information regarding your pharmacy benefits, including any specific limitations or exclusions. •

Limited distribution: Some drugs may be subject to limited distribution or restricted access. A drug that is a limited distribution drug may only be available at one or a limited number of pharmacies.

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Oral chemotherapy drugs: Drugs that fall under the District of Columbia and State of Maryland Oral Chemotherapy Parity Act.

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Quantity limit: For certain drugs, Kaiser Permanente Pharmacy and Therapeutics Committee limit the amount of medication dispensed to a certain quantity per copay.

Key: LD = Limited Distribution Drugs OC = Oral Chemotherapy Drugs QL = A drug that has a quantity limit

For more information about the HMO Formulary Drug List, you may contact Member Services at 301468-6000 or 800-777-7902 (TTY 711). Representatives are available Monday through Friday, 7:30 a.m. until 9 p.m.

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September 2017

DRUG NAME DRUG NAME

REQUIREMENTS AND LIMITS

Antihistamine Drugs Cyproheptadine HCl Promethazine HCL


Sulfadiazine Sulfasalazine Sulfamethoxazole- Trimethoprim Tobramycin Neb Vancomycin HCL

Anti-infective Agents

VIVOTIF BERNA

Anthelmintics

ZYVOX

ALBENZA

Antifungals

YODOXIN

Fluconazole

Antibacterials

Griseofulvin Microsize

Amoxicillin

Griseofulvin Ultramicrosize

Amoxicillin & Pot Clavulanate

Itraconazole

Ampicillin

Ketoconazole

Azithromycin

Nystatin

Cefaclor

Terbinafine

Cefdinir

Voriconazole

Cefixime

Antimycobacterials

Cefuroxime Axetil

Dapsone

Cephalexin

Ethambutol HCL

Ciprofloxacin

Isoniazid

Clarithromycin

Pyrazinamide

Clindamycin

Rifabutin

Clindamycin Palmitate HCL

Rifampin

Dicloxacillin Sodium Doxycycline Monohydrate Erythromycin Base Erythromycin Ethylsuccinate Susp Erythromycin-Sulfisoxazole Levofloxacin Linezolid Minocycline HCL Neomycin Sulfate Penicillin V Potassium

Antiprotozoals Atovaquone Atovaquone-Proguanil HCL COARTEM Chloroquine Phosphate DARAPRIM

LD

Hydroxychloroquine Sulfate Mefloquine HCL Metronidazole NEBUPENT INH

LEGEND • Brand-name drugs are in bold type and all capital letters •For drugs not indicated in bold, generic drugs will be dispensed as the formularyagent

• Limited Distribution-LD • Quantity Limits-QL •Oral Chemo Drugs-OC

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September 2017 DRUG NAME


Primaquine Phosphate

PEG-INTRON

QL

Antivirals

PREZISTA PREZCOBIX

DRUG NAME


Abacavir

RELENZA RESCRIPTOR

Abacavir-Lamivudine Abacavir-Lamivudine-Zidovudine Adefovir Dipivoxil

REYATAZ Ribavirin

Amantadine HCL

Rimantadine HCL

APTIVUS

SELZENTRY

ATRIPLA

SOVALDI

COMPLERA

STRIBILD

CRIXIVAN DAKLINZA

TIVICAY TRIUMEQ

Didanosine

TRUVADA

EDURANT

Valganciclovir

EMTRIVA

VIRACEPT

Entecavir

Zidovudine QL

Urinary Anti-Infectives

GENVOYA

Methenamine Hippurate

INTELENCE

Nitrofurantoin

INVIRASE

Nitrofurantoin Monohydrate Macro

ISENTRESS HARVONI

QL

SUSTIVA QL

DESCOVY

EPCLUSA

QL

QL

Nitrofurantoin Macrocrystals

Lamivudine

Trimethoprim

Lamivudine-Zidovudine LEXIVA

ANTINEOPLASTIC AGENTS Antineoplastic Agents

Lopinavir-Ritonavir

AFINITOR

OC

Nevirapine

ALKERAN

OC

NORVIR

Anastrozole

OC

ODEFSEY

Bicalutamide

OC

Oseltamivir

QL

CABOMETYX

OC

PEGASYS

QL

PEGASYS PROCLICK

QL

Capecitabine CEENU CYTOXAN EMCYT

OC OC OC OC

Etoposide

OC



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DRUG NAME


Exemestane

OC

TASIGNA

OC

Flutamide

OC

HEXALEN

OC

Temozolomide Tretinoin (Chemotherapy)

OC

HYCAMTIN

OC

Hydroxyurea

OC

IBRANCE

OC

ICLUSIG

OC

Imatinib Mesylate

OC

IMBRUVICA

OC

INLYTA

OC

INTRON-A

QL

IRESSA

OC

JAKAFI

OC

LENVIMA Letrozole

OC OC

LEUKERAN

OC

LUPRON

QL

LUPRON DEPOT

QL

LUPRON DEPOT-PED LYSODREN

QL OC

Megestrol Acetate

TYKERB

OC OC

VANDETANIB

OC

VENCLEXTA

OC

VOTRIENT

OC

XALKORI

OC

XTANDI

OC

ZELBORAF

OC

ZYKADIA

OC

ZYTIGA

OC

ANXIOLYTICS, SEDATIVES, AND HYPNOTICS Barbiturates Phenobarbital

Benzodiazepines Alprazolam

QL

Chlordiazepoxide HCL

QL

OC

Clonazepam

QL

Melphalan

OC

Clorazepate Dipotassium

QL

Mercaptopurine

OC

Diazepam

QL

Lorazepam

QL

Methotrexate Sodium MYLERAN

OC

Oxazepam

QL

NEXAVAR

OC

Temazepam

QL

NINLARO

OC

AUTONOMIC DRUGS

Procarbazine HCL

OC

Anticholinergic Agents

SPRYCEL

OC

ATROVENT HFA

SUTENT

OC

TABLOID

OC

Tamoxifen Citrate

OC

TARCEVA

OC

TARGRETIN

OC


Benztropine Mesylate Dicyclomine HCL Hyoscyamine Ipratropium Bromide (Nasal) Trihexyphenidyl HCL • Limited Distribution-LD • Quantity Limits-QL •Oral Chemo Drugs-OC

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DRUG NAME

SPIRIVA

Aminocaproic Acid

STIOLTO RESPIMAT

Aspirin/Dipyridamole

Autonomic Drugs, Miscellaneous Ergoloid Mesylates Nicotrol Inhaler

HC

Phenoxybenzamine


BRILINTA Cilostazol Clopidogrel Dipyridamole EFFIENT

Parasympathomimetic (Cholinergic)Agents

Fondaparinux

QL

Bethanechol Chloride

LOVENOX

QL

Donepezil HCL

Pentoxifylline

Galantamine Hydrobromide

PRADAXA

Neostigmine Bromide

Prasugrel

Pilocarpine HCL (ORAL)

Warfarin Sodium

Pyridostigmine Bromide

Hematopoietic Agents

Skeletal Muscle Relaxants

NEUPOGEN

QL

Baclofen

PROCRIT/EPOGEN

QL

Cyclobenzaprine HCL

PROMACTA

Dantrolene Sodium

ZARXIO

Methocarbamol

QL

CARDIOVASCULAR DRUGS

Sympathomimetic (Adrenergic) Agents ADVAIR DISKUS

Alpha-Adrenergic Blocking Agents Terazosin HCL

Albuterol Neb

Tamsulosin HCL

COMBIVENT RESPIMAT

Antilipemic Agents

Epinephrine HCL

QL

EPIPEN

QL

SEREVENT DISKUS AER STRIVERDI Terbutaline Sulfate

Atorvastatin Calcium Cholestyramine Cholestyramine Light Colestipol Fenofibrate 54mg, 160mg

VENTOLIN HFA

Gemfibrozil

BLOOD FORM ATION, COAGULATION, AND THROMBOSIS Coagulants And Anticoagulants

Lovastatin

Anagrelide HCL LEGEND • Brand-name drugs are in bold type and all capital letters •For drugs not indicated in bold, generic drugs will be dispensed as the formularyagent

Niacin Pravastatin Sodium 20mg, 40mg, 80mg • Limited Distribution-LD • Quantity Limits-QL •Oral Chemo Drugs-OC

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Rosuvastatin Simvastatin 20mg, 40mg, 80mg

DRUG NAME


Acetazolamide Clonidine HCL

Beta-Adrenergic Blocking Agents

Guanfacine HCL

Atenolol/Chlorthalidone

Hydralazine HCL

Atenolol HCL

Methazolamide

Bisoprolol/ Hydrochlorothiazide

Methyldopa

Bisoprolol Fumarate Carvedilol Labetalol HCL Metoprolol Succinate Metoprolol Tartrate Propranolol HCL Sotalol HCL

Minoxidil Reserpine

Renin-Angiotensin-Aldosterone System Inhibitors Enalapril Maleate ENTRESTO Lisinopril Lisinopril/Hydrochlorothiazide

Calcium-Channel Blocking Agents

Losartan Potassium

Amlodipine Besylate

Losartan Potassium/HCTZ

Diltiazem HCL

Spironolactone

Nifedipine Verapamil HCL

Spironolactone/ Hydrochlorothiazide

Cardiac Drugs

Valsartan

Amiodarone HCL

Valsartan/ Hydrochlorothiazide

Digoxin

Vasodilating Agents

Disopyramide Phosphate

ADEMPAS

Dofetilide

Isosorbide Dinitrate

Flecainide Acetate

Isosorbide Mononitrate

Mexiletine HCL

Nitroglycerin Patch

Propafenone HCL

Nitroglycerin

Quinidine Gluconate

OPSUMIT

Quinidine Sulfate

Papaverine HCL

Quinidine Sulfate ER

Sildenafil Citrate

Hypotensive Agents


LD

LD

CENTRAL NERVOUS SYSTEM AGENTS


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September 2017 REQUIREMENTS AND LIMITS

DRUG NAME

DRUG NAME


Analgesics and Antipyretics Acetaminophen/Codeine

QL

Buprenorphine HCL/ Naloxone HCL SL

QL

Amphetamine/ Detroamphetamine (Mixed) Dextroamphetamine Sulfate Methylphenidate HCL Methylphenidate HCL ER

Butalbital/Acetaminophen/ Caffeine

Anticonvulsants

Butalbital/Aspirin/Caffeine

BANZEL

Codeine Phosphate

QL

Carbamazepine

Codeine Sulfate

QL

Diazepam (Anticonvulsant)

Diclofenac Sodium EMBEDA

QL

Etodolac

Divalproex Sodium Ethosuximide Gabapentin

Fentanyl

QL

Lamotrigine

Hydrocodone/ Acetaminophen

QL

Levetiracetam

Hydromorphone HCL

QL

Ibuprofen

Levetiracetam XR Methsuximide Oxcarbazepine

Indomethacin

Phenobarbital

Meloxicam Meperidine HCL

QL

Methadone HCL

QL

Morphine Sulfate

QL

Nabumetone

Phenytoin Sodium Primidone Topiramate Valproate Sodium Valproic Acid

Naproxen Oxycodone HCL, ER

QL

Antimigraine Agents

Oxycodone/Acetaminophen

QL

Ergotamine/Caffeine

OXYCONTIN

QL

Naratriptan HCL

QL

Rizatriptan Benzoate ODT

QL

Sumatriptan

QL

Sulindac Tramadol HCL

QL

Anorexigenic Agents and Respiratory and Cerebral Stimulants

Anxiolytics, Sedatives, and Hypnotics

ADDERALL XR

Hydroxyzine HCL


Buspirone HCL


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REQUIREMENTS AND LIMITS DRUG NAME

Hydroxyzine Pamoate Zaleplon

QL

Lithium Carbonate

Zolpidem Tartrate

QL

Lithium Citrate

Central Nervous System Agents, Misc.

Mirtazapine Nefazodone HCL

Carbidopa

Nortriptyline HCL

Carbidopa/Levodopa, ER

Olanzapine

Entacapone

Paroxetine HCL

Memantine

Pimozide

Pramipexole Dihydrochloride

Perphenazine

Riluzole

Phenelzine Sulfate

Ropinirole HCL

Prochlorperazine Maleate

Selegiline

Protriptyline HCL

Opiate Antagonists Naloxone

Quetiapine QL

Risperidone

Naltrexone HCL

Sertraline HCL

Psychotherapeutic Agents

Thioridazine HCL

Amitriptyline HCL

Thiothixene

Aripiprazole

Trazodone HCL

Bupropion HCL, SR, XL

Trifluoperazine HCL

Chlorpromazine HCL

Venlafaxine HCL

Citalopram HCL

Ziprasidone HCL

Clozapine


QL

Desipramine HCL

ELECTROLYTIC, CALORIC, AND WATER BALANCE

Doxepine HCL

Acidifying and Alkalinizing Agents

Duloxetine HCL Escitalopram Oxalate

Potassium & Sodium Acid Phosphates

Fluoxetine HCL

Potassium Citrate(Alkalinizer)

Fluphenazine HCL

Sodium Citrate & Citric Acid

Fluvoxamine Maleate

Ammonia Detoxicants

Haloperidol

Lactulose

Imipramine HCL


• Limited Distribution—LD • Quantity Limits—QL •Oral Chemo Drugs-OC

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Diuretics

DRUG NAME


Amiloride HCL

EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS

Amiloride/ Hydrochlorothiazide

Antiallergic Agents

Chlorothiazide

Azelastine HCL

Furosemide

Cromolyn Sodium (OP)

Hydrochlorothiazide

Olopatadine (OP)

Indapamide

Anti-Infectives

Metolazone

Bacitracin (OP)

Torsemide

Bacitracin/Polymyxin B (OP)

Triamterene/ Hydrochlorothiazide

Ciprofloxacin (OP) Erythromycin (OP)

Ion-Removing Agents RENVELA Sodium Polystyrene Sulfonate

Replacement Preparations Calcium Acetate ELIPHOS PHOSLYRA

Gatifloxacin Gentamicin Sulfate (OP) NATACYN Neomycin/Bacitracin/ Polymyxin Neomycin/Polymyxin/ Gramicid

Potassium Phosphate Dibasic/Monobasic

Ofloxacin (OP)

Potassium Bicarbonate

Polymyxin B/Trimethoprim

Potassium Chloride

Sulfacetamide

Potassium Phosphate Monobasic

Tobramycin Sulfate (OP)

Uricosuric Agents

ZYMAXID

Probenecid

Anti-Inflammatory Agents

ENZYMES

Bacitracin/Polymyxin/ Neomycin/HC

Enzymes PULMOZYME SOL VPRIV


Ofloxacin (OTIC)

Trifluridine

CIPRODEX OTIC COLY-MYCIN S OTIC Dexamethasone (OP)


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September 2017

DRUG NAME


Fluorometholone (OP) Flunisolide Flurbiprofen (OP) Fluticasone Propionate Hydrocortisone/Acetic Acid (OTIC)

DRUG NAME Proparacaine HCL Tetracaine HCL

Mydriatics Atropine Sulfate CYCLOMYDRIL Homatropine HBR

Ketorolac Tromethamine

Tropicamide

Neomycin/Polymyxin/ Dexamethasone

Vasoconstrictors

Neomycin/Polymyxin/HC PRED-G

Phenylephrine HCL (OP)

GASTROINTESTINAL DRUGS

Prednisolone Acetate

Antidiarrhea Agents

Prednisolone Sodium Phosphate

Diphenoxylate/Atropine

Sulfacetamide Sodium/ Prednisolone Tobramycin/Dexamethasone VEXOL

EENT Drugs, Miscellaneous Acetic Acid (OTIC)


Antiemetics AKYNZEO Aprepitant Ondansetron HCL Prochlorperazine TRANSDERM-SCOP

Anti-Inflammatory Agents

Acetic Acid/Aluminum Acetate

Balsalazide Disodium

Brimonidine Tartrate

CANASA

Carbachol (OP)

LIALDA

Dorzolamide

Mesalamine Enema

Dorzolamide/Timolol

PENTASA

Latanoprost

Antiulcer Agents and Acid Suppressants

Levobunolol HCL

Famotidine

Metipranolol

Misoprostol

Timolol (OP)

Omeprazole

Local Anesthetics

Pantoprazole

Lidocaine HCL

Ranitidine HCL Sucralfate



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DRUG NAME

Digestants

Androgens

CREON Pancrelipase

Danocrine DEPO-TESTOSTERONE

ZENPEP

Contraceptives

GI Drugs, Miscellaneous

Desogestrel/Ethinyl Estradiol

Librax

Drospirenone/Ethinyl Estradiol

Metoclopramide HCL

ELLA

PEG3350-KCL-Sodium Bicarb Sodium Chl- Sodium

Ursodiol

HEAVY METAL ANTAGONISTS

Ethynodiol Diacetate/Ethinyl Estradiol Levonorgestrel/Ethinyl Estradiol

Heavy Metal Antagonists

Levonorgestrel/Ethinyl Estradiol (Triphasic)

EXJADE

NEXPLANON

JADENU

Norethindrone

HORMONES AND SYNTHETIC SUBSTITUTES

Norethindrone/Ethinyl Estradiol Norethindrone Acetate/ Ethinyl Estradiol

Adrenals ASMANEX Budesonide

Norethindrone/Ethinyl Estradiol (Triphasic)

Dexamethasone

Norgestimate/Ethinyl Estradiol (Triphasic) NUVARING

FLOVENT HFA

PLAN B ONE-STEP

Fludrocortisone Acetate

Xulane patch

Cortisone Acetate

Hydrocortisone Methlyprednisolone MILLIPRED Prednisolone Prednisolone Sodium Phosphate


Diabetic Agents Acarbose Glipizide GLUCAGON EMERGENCY KIT HUMALOG VIAL

Prednisone

HUMULIN N 70/30

QVAR

HUMULIN N HUMULIN R VIAL LANTUS VIAL



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DRUG NAME


Metformin HCL Metformin ER

Somatotropin Agonist and Antagonist

Pioglitazone HCL

OMNITROPE

Estrogens and Antiestrogens

Thyroid and Antithyroid Agents

CLIMARA

Levothyroxine Sodium

Estradiol

Liothyronine Sodium

Esterified Estrogens/Methyl Testosterone

Methimazole

PREMARIN VAGINAL CREAM Raloxifene

Thyroid

Gonadotropins

Miscellaneous Therapeutic Agents

QL

Propylthiouracil

MISCELLANEOUS THERAPEUTIC AGENTS

BRAVELLE

HC, QL

Acamprosate Calcium

Chorionic Gonadotropin

HC, QL

ACTIMMUNE

Clomiphene Citrate

HC

Alendronate Sodium

FOLLISTIM

HC, QL

Allopurinol

Ganirelix Acetate

HC, QL

AVONEX

GONAL-F

HC, QL

Azathioprine

MENOPUR

HC, QL

Bromocriptine Mesylate

IUD

CERDELGA

MIRENA

Colchicine

Parathyroid

Cromolyn Sodium

FORTICAL

Disulfiram

Pituitary Desmopressin Acetate

QL LD

ELMIRON ENBREL

QL

Etidronate Disodium

Progestins

EXTAVIA

Hydroxyprogesterone caproate

Finasteride

Medroxyprogesterone Acetate Norethindrone Acetate

GENGRAF

Progesterone Micronized

QL, LD

FIRAZYR Glatiramer 20mg/ml

QL QL QL

GRASTEK HUMIRA

QL

Leflunomide LEGEND • Brand-name drugs are in bold type and all capital letters •For drugs not indicated in bold, generic drugs will be dispensed as the formularyagent


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Leucovorin Calcium MESNEX Mycophenolate Mofetil


Benzonatate Guaifenesin/Codeine

QL

Respiratory Agents, Miscellaneous

ORENCIA

QL

OTEZLA

QL

RAGWITEK RASUVO

DRUG NAME

Acetylcysteine ORKAMBI Sodium Chloride (Inhalant)

QL

READI-CAT REBIF

QL

REVLIMID

OC, LD

SKIN AND MUCOUS MEMBRANE AGENTS Anti-Infectives (Skin & Mucous Membr)

Benzoyl Peroxide/Erythromycin

SANDIMMUNE SENSIPAR

Ciclopirox Olamine

Sodium Fluoride

Clindamycin Phosphate

Tacrolimus

Clioquinol/Hydrocortisone

THALOMID

LD

OC, LD

Clotrimazole Troche

VOLUMEN

Erythromycin

XELJANZ

Gentamicin Sulfate

Vitamins Folic Acid Iron Complex Phytonadione Potassium Aminobenzoate Pyridoxine HCL

Ketoconazole Metronidazole Mupirocin Nystatin Permethrin Salicylic Acid Selenium Sulfide

OXYTOCICS

Silver Nitrate/Potassium Nitrate

Oxytocics

Silver Sulfadiazine

Methylergonovine Maleate

Urea

RESPIRATORY TRACT AGENTS Anti-Inflammatory Agents

Anti-Inflammatory Agents (Skin and Mucous Membrane)

Cromolyn Sodium

Betamethasone Dipropionate

DULERA

Betamethasone Valerate

Montelukast Sodium

Antitussives LEGEND • Brand-name drugs are in bold type and all capital letters •For drugs not indicated in bold, generic drugs will be dispensed as the formularyagent


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DRUG NAME


Clobetasol Propionate CORDRAN Desoximetasone Diflorasone Diacetate

Methoxsalen OXSORALEN LOT PHISOHEX LIQ

Fluocinolone Acetonide

Podofilox

Fluocinonide

Sulfacetamide Sodium

Hydrocortisone (Rectal) Hydrocortisone (Topical)

SANTYL VECTICAL

Hydrocortisone Butyrate

SMOOTHMUSCLERELAXANTS

Hydrocortisone Valerate

Smooth Muscle Relaxants

Mometasone Furoate

Aminophylline

Nystatin/Triamcinolone

Oxybutynin Chloride

PROCTOFORM

Oxybutynin Chloride XL

Tacrolimus

Theophylline

Triamcinolone Acetonide

Trospium ER

Cell Stimulants and Proliferants

Trospium

Tretinion

VASODILATING AGENTS

Skin and Mucous Membrane Agents, Miscellaneous

Miscellaneous Therapeutic Agents

8-MOP Acitretin

Yohimbine HCL

Phosphodiesterase Inhibitors

Aluminum Chloride

CAVERJECT

AZELEX

EDEX

DIFFERIN

MUSE

EPIDUO

VITAMINS

FINACEA

Vitamins

Fluorouracil Imiquimod Isotretinoin

HC, QL

Calcitriol Pediatric Multivitamins/ Fluoride

Lidocaine HCL Lidocaine/Prilocaine



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DRUG NAME


Pediatric Multivitamins/ Fluoride/Iron Pediatric Multivitamins ACD/ Fluoride Pediatric Multivitamins ACD/ Fluoride/Iron Prenatal Vitamins

LEGEND • Brand-name drugs are in bold type and all capital letters •For drugs not indicated in bold, generic drugs will be dispensed as the formulary agent


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