Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Kaiser Permanente NF, Restricted Formulary and Criteria
Document related concepts
no text concepts found
Transcript
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Acanya (Clindamycin/Benzoyl Peroxide) 1.2/2.5% Gel AAA BID Accolate (Zafirlukast) 10, 20mg Tablet BID Accu-Check Glucometer and Test Strips Accupril (Quinapril) 5, 10, 20, 40mg Tablet QD Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy 1) Clindamycin 1% Gel AAA BID AND OTC Benzoyl Peroxide 5% Gel AAA BID 2) Erythromycin/Benzoyl Peroxide 3/5% Gel AAA BID 1) Qvar 40-80mcg 1-2 PUFFS QD-BID 2) Flovent HFA 44mcg 2 PUFFS BID NOTE: Flovent HFA 44mcg for patients 4-11 years of age 3) Asmanex 110-220mcg 1-2 PUFFS QD 4) Budesonide 0.25-0.5mg/2ml QD-BID Comments Dispense Clindamycin as 1 copay and purchase OTC Benzoyl Peroxide Document adequate therapeutic trial or intolerance to an Inhaled Corticosteroid within the past 3 months *Patients should have prescription for a ShortActing Beta 2 Agonist (e.g. Proair) for asthma exacerbations One Touch Ultra 2 Glucometer and One Touch Ultra Test Strips 1) Lisinopril 20-40mg QD 2) Benazepril 20-40mg QD 3) Dose Conversion Enalapril 10-40mg QD 4) Captopril 25-100mg TID 5) Ramipril Quinapril 5mg=Lisinopril 5mg / Quinapril 10mg=Lisinopril 10mg / Quinapril 20mg=Lisinopril 2.5-20mg QD 20mg / Quinapril 40mg=Lisinopril 40mg Accuretic (Quinapril/HCTZ) 20/12.5, 20/25mg 2 Separate Medications Tablet QD HCTZ QD AND 1) Lisinopril 20-40mg QD 2) Benazepril 2040mg QD 3) Enalapril 10-40mg QD 4) Captopril 25-100mg TID 5) Ramipril 2.5-20mg QD Aceon (Perindopril) 4, 8mg Tablet QD 1) Lisinopril 10-40mg QD 2) Benazepril 20-40mg QD 3) Enalapril 10-40mg QD 4) Captopril 25-100mg TID 5) Ramipril 2.5-20mg QD Acetasol HC (Acetic Acid/Hydrocortisone) 1) Neomycin/Polymyxin/Hydrocortisone 1% Suspension 1-2 2/1% 3-5 GTTS Q4-6H GTTS Q4 HOURS 2) Neomycin/Polymyxin/Dexamethasone 0.1% Ophthalmic Suspension 1-2 GTTS Q4 HOURS 3) Acetic Acid 2% Solution 1-2 GTTS Q4-6 HOURS Dose Conversion Quinapril 20mg=Lisinopril 20mg NOTE: Consider Lisinopril/HCTZ 20/12.5, 20/25mg Aciphex (Rabeprazole) 20mg Tablet QD Excluded Medication 1) Pantoprazole 40mg QD 2) OTC Omeprazole 20mg QD 3) OTC Zegerid 20/1100mg QD 4) OTC Prevacid 15mg QD Dose Conversion Aceon 4mg=Lisinopril10mg / Aceon 8mg=Lisinopril 40mg Aclovate (Alclometasone Dipropionate) 0.05% Low Potency Cream, Ointment AAA BID-TID Low Potency 1) Betamethasone Valerate 0.1% Lotion AAA QD-BID 2) Desonide 0.05% Cream, Ointment AAA BID-TID 3) Fluocinolone Acetonide 0.01% Solution AAA QD 4) DermaSmoothe/FS 0.01% Oil AAA QD Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BID-QID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Actemra (Tocilizumab) 80mg/4ml, 1) Humira 40mg QOW 2) Enbrel 50mg QW 200mg/10ml, 400mg/20ml Intravenous Solution 8mg/kg Q4W Actiq (Fentanyl) 0.2, 0.4, 0.6, 0.8, 1.2, 1.6mg 1) Oxycodone/Acetaminophen 5/325mg Q6H 2) Morphine 15- Actiq is contraindicated in the management of acute Buccal Lozenge PRN (Maximum 4 units per 30mg Q4H 3) Hydromorphone 2-8mg Q4-6H 4) Oxycodone 5- or postoperative pain including headache/migrane day) 30mg Q4-6H 5) Morphine Solution 20mg/ml 0.5-1.5ml Q4H 6) Meperidine 50-150mg Q3-4H Activella (Etradiol/Norethindrone Acetate) Dose Conversion 2 Separate Medications 0.5/0.1, 1/0.5mg Tablet QD Norethindrone Acetate 0.5mg=Norethindrone Estradiol QD AND Nora-BE 0.35mg QD 0.35mg Actonel (Risedronate) 5mg Tablet QD, 35mg 1) Alendronate 5, 10mg QD 2) Alendronate 70mg QW 3) Osteoporosis Prophylaxis Tablet QW, 150mg Tablet QM Alendronate 35mg QW or Alendronate 5mg QD Alendronate 35mg QW 4) Fortical 200IU QD Alternate nostrils 5) Ibandronate 150mg QM NF 6) Actonel 5mg QD NF Osteoporosis Treatment Alendronate 70mg QW or Alendronate 10mg QD 7) Actonel 150mg QM NF 8) Evista 60mg QD 9) Actonel 35mg QW NF Actonel (Risedronate) 30mg Tablet QD X2M Alendronate 40mg QD X6M Page 1 Last Updated: 6/20/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Actoplus Met (Metformin/Pioglitazone) 500/15, 850/15mg Tablet QD Actoplus Met XR (Metformin/Pioglitazone) 1000/15, 1000/30mg Extended Release Tablet QD Acuvail (Ketorolac) 0.45% Ophthalmic Solution 1 GTT BID Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Comments Adjust based on patient response American Diabetes Association Recommendations -Patient uncontrolled on maximum Metformin and maximum Sulfonylurea=Do not initiate Actos and initiate Novolin N -Patient on Actos and Insulin=Discontinue Actos and maximize Novolin N Adjust based on patient response 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin 500American Diabetes Association 1000mg (Maximum 2550mg QD) 3) Metformin ER 500Recommendations 750mg (Maximum 2000mg QD) 4) Novolin R (Insulin -Patient uncontrolled on maximum Metformin and Regular) SC 30 minutes AC 5) Novolin N (NPH) SC 15-30 maximum Sulfonylurea=Do not initiate Actos and minutes AC 6) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog (Insulin Aspart) SC 5-10 minutes AC initiate Novolin N -Patient on Actos and Insulin=Discontinue Actos NF 8) Actos 15mg (Maximum 45mg QD) and maximize Novolin N 1) Diclofenac 0.1% 1GTT QID 2) Ketorolac 0.5% 1 GTT QID 3) Prednisolone 1% 1-2 GTTS BID-QID 4) Fluorometholone 0.1% 1-2 GTTS BID-QID 5) Dexamethasone 0.1% 1-2 GTTS BID-QID 6) Ketorolac 0.4% 1 GTT QID 7) Flurbiprofen 0.03% 1 GTT QID NF 8) Vexol 1% 1-2 GTT QID NF 9) Bromfenac 0.09% 1 GTT QD-BID NF 10) Lotemax 0.5% 1-2 GTT QID NF 11) Nevanac 0.1% 1 GTT TID NF 12) Zylet 0.5/0.3% 1-2 GTT Q4-6H NF 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin 5001000mg (Maximum 2550mg QD) 3) Metformin ER 500750mg (Maximum 2000mg QD) 4) Novolin R (Insulin Regular) SC 30 minutes AC 5) Novolin N (NPH) SC 15-30 minutes AC 6) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos 15mg (Maximum 45mg QD) Aczone (Dapsone) 5% Gel AAA BID 1) Clindamycin 1% Gel AAA BID AND OTC Benzoyl Peroxide Dispense Clindamycin or Erythromycin as 1 copay and purchase OTC Benzoyl Peroxide 5% Gel AAA BID 2) Sodium Sulfacetamide/Sulfur 10/5% Lotion AAA BID 3) Erythromycin/Benzoyl Peroxide 3/5% Gel AAA BID Adcirca (Tadalafil) 20mg Tablet 2T QD Pulmonary Hypertension 1) Viagra 50mg 0.5T TID 2) Cialis 20mg 2T QD Adipex-P (Phentermine) 37.5mg Tablet QD Excluded Medication (Exception: Obesity Rider) Adoxa (Doxycycline Monohydrate) 150mg 1) Doxycycline Hyclate 50-100mg BID 2) Minocycline 50Dose Conversion Capsule; 50, 75, 100mg Tablet BID Adoxa 50mg=Doxycycline Hyclate 50mg / Adoxa 100mg BID 3) Tetracycline 250-500mg BID 100mg=Doxycycline Hyclate 100mg Advair Diskus (Fluticasone/Salmeterol) Document adequate trial or intolerance to Qvar 1) Qvar 40-80mcg 1-2 PUFFS QD-BID 2) Flovent HFA 100/50, 250/50, 500/50mcg Inhalation Disk 1 44mcg 2 PUFFS BID NOTE: Flovent HFA 44mcg for patients 80mcg 2 PUFFS BID or Asmanex 220mcg 2 PUFFS PUFF BID 4-11 years of age 3) Asmanex 110-220mcg 1-2 PUFFS QD QD within the past 3 months *Patients should have prescription for a Short4) Dulera 100/5-200/5mcg 2 PUFFS BID NF Acting Beta 2 Agonist (e.g. Proair) for asthma exacerbations Dose Conversion Advair 100/50mcg 1 PUFF BID=Albuterol Q4H PRN + Qvar 80mcg 1PUFF BID =Albuterol Q4H PRN + Flovent 44mcg 2 PUFFS BID / Advair 250/50mcg 1 PUFF BID=Albuterol Q4H PRN + Qvar 80mcg 2 PUFFS BID=Albuterol Q4H PRN + Asmanex 220mcg 2 PUFFS QD=Dulera 100/5mcg 2 PUFFS BID NF / Advair 500/50mcg 1 PUFF BID=Dulera 200/5mcg 2 PUFFS BID NF Page 2 Last Updated: 6/20/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Advair HFA (Fluticasone/Salmeterol) 45/21, 115/21, 230/21mcg/Actuation Inhalation Aerosol Liquid 2 PUFFS BID Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy 1) Qvar 40-80mcg 1-2 PUFFS QD-BID 2) Flovent HFA 44mcg 2 PUFFS BID NOTE: Flovent HFA 44mcg for patients 4-11 years of age 3) Asmanex 110-220mcg 1-2 PUFFS QD 4) Dulera 100/5-200/5mcg 2 PUFFS BID NF Comments Document adequate trial or intolerance to Qvar 80mcg 2 PUFFS BID or Asmanex 220mcg 2 PUFFS QD within the past 3 months *Patients should have prescription for a ShortActing Beta 2 Agonist (e.g. Proair) for asthma exacerbations Dose Conversion Advair HFA 45/21mcg 2 PUFFS BID=Albuterol Q4H PRN + Qvar 80mcg 1PUFF BID=Albuterol Q4H PRN + Flovent 44mcg 2 PUFFS BID / Advair HFA 115/21mcg 2 PUFFS BID=Albuterol Q4H PRN + Qvar 80mcg 2 PUFFS BID=Albuterol Q4H PRN + Asmanex 220mcg 2 PUFFS QD=Dulera 100/5mcg 2 PUFFS BID NF / Advair HFA 230/21mcg 2 PUFFS BID=Dulera 200/5mcg 2 PUFFS BID NF Advicor (Lovastatin/Niacin) 20/500mg, 2 Separate Medications 20/750mg, 20/1000mg, 40/1000mg Extended OTC Slo-Niacin 500mg QD (Titrate to 2000mg/day as Release Tablet QD tolerated using .PITTTSLONIACIN) AND Lovastatin 20-40mg QD Aerobid (Flunisolide) 0.25mg Inhalation Document adequate therapeutic trial or intolerance 1) Qvar 40-80mcg 1-2 PUFFS QD-BID 2) Flovent HFA Aerosol Powder 2 PUFFS BID 44mcg 2 PUFFS BID NOTE: Flovent HFA 44mcg for patients to Qvar 80mcg 2 PUFFS BID or Asmanex 220mcg 2 4-11 years of age 3) Asmanex 110-220mcg 1-2 PUFFS QD PUFFS QD within the past 3 months Dose Conversion Aerobid 0.25mg 2 PUFFS BID=Qvar 80mcg 2 PUFFS BID=Asmanex 220mcg 2 PUFFS QD Afinitor (Everolimus) 2.5, 5, 10mg Tablet QD Alamast (Pemirolast) 0.1% Ophthalmic Solution 1-2 GTTS QID Alesse (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel) Tablet QD 1) Torisel 25mg IV QW 2) Sutent 50mg QD NOTE: 4 weeks Sutent preferred when initiating therapy on then 2 weeks off 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q3-4 HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID 4) Crolom 4% 1-2 GTTS Q4-6 HOURS NF 5) Emadine 0.05% 1 GTT QID NF 6) Alocril 2% 12 GTTS BID NF 7) Optivar 0.05% 1 GTT BID NF 8) Alomide 0.1% 1-2 GTTS QID NF 9) Lastacaft 0.25% 1 GTT QD NF 10) Pataday 0.2% 1 GTT QD NF 11) Alrex 0.2% 1 GTT QID NF 12) Patanol 0.1% 1 GTT BID NF 13) Elestat 0.05 % 1 GTT BID NF 1) Aviane (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel) Equivalent Brand and Generic Products Alesse=Aviane QD 2) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Document adequate therapeutic trial or intolerance Norethindrone) QD 3) Levora (30mcg Ethinyl to at least 3 formulary oral contraceptives Estradiol/0.15mg Levonorgestrel) QD Alinia (Nitazoxanide) 100mg/5ml Powder for Suspension; 500mg Tablet Q12H X3D Cryptosporidiosis No formulary alternative Giardiasis 1) Metronidazole 250mg TID X5-7D 2) Tindamax 2gm Single dose NF Allegra (Fexofenadine) 30, 60, 180mg Tablet 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) OTC Excluded Medication QD-BID Allegra 60mg BID 4) Fluticasone 2 SPRAYS IEN QD 5) Flunisolide 2 SPRAYS IEN BID Allegra D (Fexofenadine/Pseudoephedrine) 1) OTC Claritin D 5/120, 10/240mg QD-BID 2) OTC Zyrtec D Excluded Medication 60/120, 180/240mg Tablet QD-BID 5/120mg BID 3) OTC Allegra D 60/120, 180/240mg QD-BID 4) Fluticasone 2 SPRAYS IEN QD 5) Flunisolide 2 SPRAYS IEN BID Alocril (Nedocromil) 2% Ophthalmic Solution 1- 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q3-4 2 GTTS BID HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID 4) Crolom 4% 1-2 GTTS Q4-6 HOURS NF 5) Emadine 0.05% 1 GTT QID NF Page 3 Last Updated: 6/20/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Alomide (Lodoxamide) 0.1% Ophthalmic Solution 1-2 GTTS QID Comments 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q3-4 HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID 4) Crolom 4% 1-2 GTTS Q4-6 HOURS NF 5) Emadine 0.05% 1 GTT QID NF 6) Alocril 2% 12 GTTS BID NF 7) Optivar 0.05% 1 GTT BID NF Alora (Estradiol) 0.025, 0.05, 0.075, 0.1mg/24 Vasomotor Symtoms Adjust to the lowest dose needed to control hr Transdermal Patch Apply twice weekly symptoms based on patient response 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.0250.1mg/24hr Apply weekly Vaginal/Vulvar Atrophy 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.0250.1mg/24hr Apply weekly 3) Premarin Vaginal 1gm Apply three times a week 4) Vagifem 10mcg Insert twice weekly 5) Estring 2mg Insert for 90 days Alphagan P (Brimonidine) 0.1, 0.15% 1 GTT 1) Brimonidine 0.2% 1 GTT TID 2) Brimonidine 0.15% 1 GTT TID TID Alrex (Loteprednol) 0.2% Ophthalmic 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q3-4 Suspension 1 GTT QID HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID 4) Crolom 4% 1-2 GTTS Q4-6 HOURS NF 5) Emadine 0.05% 1 GTT QID NF 6) Alocril 2% 12 GTTS BID NF 7) Optivar 0.05% 1 GTT BID NF 8) Alomide 0.1% 1-2 GTTS QID NF 9) Lastacaft 0.25% 1 GTT QD NF 10) Pataday 0.2% 1 GTT QD NF Alvesco (Ciclesonide) 80, 160mcg Inhalation 1) Qvar 40-80mcg 1-2 PUFFS QD-BID 2) Flovent HFA Document adequate trial or intolerance to Qvar Aerosol Liquid 1-2 PUFFS BID 44mcg 2 PUFFS BID NOTE: Flovent HFA 44mcg for patients 80mcg 2 PUFFS BID and Asmanex 220mcg 2 4-11 years of age 3) Asmanex 110-220mcg 1-2 PUFFS QD PUFFS QD within the past 3 months 4) Aerobid 0.25mg 2 PUFFS BID NF 5) Pulmicort Flexhaler Dose Conversion 90-180mcg 2 PUFFS BID NF 6) Flovent HFA 110-220mcg 1- Alvesco 80mcg 1 PUFF QD=Qvar 40mcg 1 PUFF QD=Flovent 44mcg 1 PUFF BID / Alvesco 160mcg 2 PUFFS BID NF 1 PUFF QD=Qvar 80mcg 1 PUFF QD=Flovent 44mcg 2 PUFFS BID Amaryl (Glimepiride) 1, 2, 4mg Tablet QD Adjust based on patient response 1) Glipizide 5-15mg QD 2) Glyburide 2.5-10mg QD Glipizide preferred if 65 years of age and older due to prolonged half life of Glyburide Amaryl (Glimepiride) 4mg Tablet BID Adjust based on patient response 1) Glipizide 10-20mg BID 2) Glyburide 7.5-10mg BID Glipizide preferred if 65 years of age and older due to prolonged half life of Glyburide Ambien CR (Zolpidem) 6.25, 12.5mg 1) Trazodone 50-100mg QHS 2) Temazepam 15-30mg QHS Document adequate therapeutic trial or intolerance Extended Release Tablet QHS to Trazodone, Zolpidem, and at least 1 3) Zolpidem 5-10mg QHS 4) Zaleplon 5-10mg QHS Benzodiazepine Amevive (Alefacept) 15mg Intramuscular Administered in a healthcare setting by healthcare providers Powder for Solution QW Amitiza (Lubiprostone) 8, 24mcg Liquid Filled 1) OTC Citrucel 1 TBSP in 8oz water QD-TID 2) OTC Capsule BID Benefiber 3T TID 3) OTC Metamucil 1 TBSP in 8oz water QDTID 4) OTC Docusate 50mg QD 5) OTC Dulcolax 5-15mg QD 6) OTC Miralax 1 TBSP in 8oz water 7) Lactulose 1530ml QD Amoxil (Amoxicillin) 875mg Tablet BID 1) Amoxicillin 500mg TID 2) Amoxicillin/Clavulanate 875/125mg BID Ampyra (Dalfampridine) 10mg Tablet BID Ampyra is delivered directly to patient via KP CA Specialty Criteria Restricted Medication Pharmacy QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. KP CA Specialty Pharmacy MD Line 650-301-5799 / Patient Line 1-877-4045777 / Fax Line 650-301-5790 Amrix (Cyclobenzaprine) 15, 30mg Extended 1) Cyclobenzaprine 10mg TID 2) Chlorzoxazone 250-500mg Dose Conversion Release Capsule QD Amrix 15mg QD=Cyclobenzaprine 10mg 0.5T TID / TID 3) Carisoprodol 350mg TID 4) Tizanidine 4mg TID 5) Amrix 30mg QD=Cyclobenzaprine 10mg TID Methocarbamol 500-750mg QID 6) Baclofen 10-20mg TID Page 4 Last Updated: 6/20/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Analpram-HC (Hydrocortisone Acetate/Pramoxine) 1/1% Cream QD-BID AndroGel 1% (Testosterone) 25mg/2.5gm, 50mg/5gm Gel Apply QAM AndroGel Pump 1% (Testosterone) 1.25gm/Actuation Apply 4 pumps QAM AndroGel Pump 1.62% (Testosterone) 20.25mg/Actuation Apply 2 pumps QAM Angeliq (Drospirenone/Estradiol) 0.5/1mg Tablet QD Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Comments 1) OTC Hydrocortisone 0.5-1% Cream, Ointment AAA BIDQID 2) OTC Prax 1% Cream, Lotion AAA BID-QID 3) Hydrocortisone 2.5% Cream, Lotion, Ointment AAA BID-QID 4) Hydrocortisone 25mg Suppository BID 5) Hydrocortisone 100mg/60ml Enema QD-BID 6) Proctofoam-HC 1/1% QDBID 1) Testosterone Cypionate 200mg/ml IM Q2-4W 2) Androderm Patch 2-4mg/24hr Apply QPM 3) AndroGel Pump 1.62% Apply 2 pumps QAM NF 4) AndrogGel Pump 1% Apply 4 pumps QAM NF 1) Testosterone Cypionate 200mg/ml IM Q2-4W 2) Androderm Patch 2-4mg/24hr Apply QPM 3) AndroGel Pump 1.62% Apply 2 pumps QAM NF 1) Testosterone Cypionate 200mg/ml IM Q2-4W 2) Androderm Patch 2-4mg/24hr Apply QPM Adjust to the lowest dose needed to control 2 Separate Medications Estradiol Tablet 1mg QD AND 1) Medroxyprogesterone 2.5- symptoms based on patient response 5mg QD 2) Nora-BE 0.35mg QD 3) Norethindrone 5mg QD Ansaid (Flurbiprofen) 50, 100mg Tablet BIDTID Antara (Fenofibrate Micronized) 43, 130mg Capsule QD 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg BID 3) Ibuprofen 400-800mg TID-QID 1) Gemfibrozil 600mg BID 2) Fenofibrate 54-160mg QD Anzemet (Dolasetron) 50, 100mg Tablet 1 hour prior to chemotherapy 1) Metoclopramide 1-2mg/kg 30 minutes prior to chemotherapy 2) Prochlorperazine 5-10mg Q6H 3) Dexamethasone 20mg 30 minutes prior to chemotherapy 4) Ondansetron 4-8mg 30 minutes prior to chemotherapy 5) Ondansetron 4-8mg ODT 30 minutes prior to chemotherapy 6) Transderm Scop 1.5mg Apply Q72H NF 7) Granisetron 2mg 1 hour prior to chemotherapy NF 1) Novolin R (Insulin Regular) SC 30 minutes AC 2) NovoLog Adjust based on patient response (Insulin Aspart) SC 5-10 minutes AC NF Apidra (Insulin Glulisine) 100U/ml Injection Solution SC 15 minutes AC Aplenzin (Bupropion Hydrobromide) 174, 348, 1) Citalopram 20-40mg QD 2) Fluoxetine 20-40mg QD 3) 522mg Extended Release Tablet QD Sertraline 50-100mg QD 4) Mirtazapine 30mg QHS 5) Bupropion SR/XL 300mg QD 6) Venlafaxine ER 225mg QD 7) Fluvoxamine 50-300mg QD NF 8) Escitalopram 10-20mg QD NF 9) Paxil CR 12.5-37.5mg QD NF 10) Viibryd 10-40mg QD 11) Pristiq 50-100mg QD NF 12) Cymbalta 30-60mg BID NF Apri (30mcg Ethinyl Estradiol/0.15mg 1) Reclipsen (30mcg Ethinyl Estradiol/0.15mg Desogestrel) Desogestrel) Tablet QD QD 2) Microgestin Fe 1.5/30 (30mcg Ethinyl Estradiol/1.5mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD Apriso (Mesalamine) 0.375gm Extended Release Capsule 1.5gm QAM Aromasin (Exemestane) 25mg Tablet QD Aricept ODT (Donepezil) 5, 10mg Orally Disintegrating Tablet QD Arixtra (Fondaparinux) 2.5/0.5, 7.5/0.6, 10/0.8, 5/0.4mg/ml Subcutaneous Solution QD Arthrotec (Diclofenac/Misoprostol) 50/0.2, 75/0.2mg Enteric Coated Tablet BID-TID Dose Conversion Antara 43mg=Fenofibrate 54mg / Antara 130mg=Fenofibrate 160mg Fenofibrate preferred if current statin therapy Gemfibrozil preferred if reduced renal function Dose Conversion Aplenzin 174mg=Bupropion HCL SR/XL 150mg / Aplenzin 348mg=Bupropion HCL SR/XL 300mg Document adequate therapeutic trial or intolerance to 2 SSRIs, Venlafaxine, and Bupropion HCL SR/XL Equivalent Brand and Generic Products Apri=Reclipsen Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives 1) Sulfasalazine 500mg (2-4gm QD) 2) Colazal 750mg (2.25gm TID for 8-12 weeks) 3) Asacol 400mg (800mg TID) 4) Dipentum 550mg BID NF 5) Pentasa 250, 500mg (1gm QID) 1) Anastrozole 1mg QD 2) Letrozole 2.5mg QD 1) Galantamine 4-12mg BID, Galantamine ER 8-24mg QD 2) Document adequate therapeutic trial or intolerance Namenda 5-10mg BID 3) Rivastigmine 6mg BID 4) Aricept 5- to Aricept, Exelon Solution, and Razadyne Solution 10mg QD 5) Exelon 2mg/ml Solution 3ml BID 6) Exelon 4.59.6mg/24hr Patch QD NF 7) Razadyne 4mg/ml 1-3 ml BID NF Enoxaparin 1.5 mg/kg QD or 1mg/kg BID Arixtra preferred if history of Heparin-Induced Thrombocytopenia (HIT) 2 Separate Medications Diclofenac BID-TID AND Misoprostol BID-TID Page 5 Last Updated: 6/20/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Ascensia Breeze Glucometer and Test Strips One Touch Ultra 2 Glucometer and One Touch Ultra Test Strips Comments Document member is unable to accurately use One Touch Ultra 2 Glucometer and One Touch Ultra Test Strips due to impaired dexterity Asendin (Amoxapine) 25, 50, 100, 150mg Tablet BID-TID 1) Nortriptyline 25-150mg QHS 2) Amitriptyline 50-150mg QD 3) Doxepin 25-150mg QD 4) Imipramine 50-150mg QD 5) Desipramine 50-150mg QD Astelin (Azelastine) 137mcg/Actuation Nasal 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) OTC Document adequate therapeutic trial or intolerance to Claritin, Zyrtec, or Allegra and at least 1 Nasal Spray 2 SPRAYS IEN BID Allegra 60mg BID 4) Fluticasone 2 SPRAYS IEN QD 5) Steroid Flunisolide 2 SPRAYS IEN BID Azelastine is indicated for the treatment of vasomotor rhinitis Atacand (Candesartan) 4, 8, 16, 32mg Tablet 1) Lisinopril QD NOTE: If Angiotensin Converting Enzyme Dose Conversion QD Inhibitor allergy or contraindication consider Angiotensin Atacand 4mg=Lisinopril 10mg=Losartan 25mg / Atacand 8mg=Lisinopril 20mg=Losartan 50mg / Receptor Blocker 2) Losartan QD Atacand 16mg=Lisinopril 40mg=Losartan 100mg / Atacand 32mg=No Formulary Alternative Atacand HCT (Candesartan/HCTZ) Tablet 2 Separate Medications Dose Conversion 16/12.5, 32/12.5mg QD Atacand 16mg=Lisinopril 40mg=Losartan 100mg / HCTZ QD AND 1) Lisinopril QD NOTE: If Angiotensin Atacand 32mg=No Formulary Alternative Converting Enzyme Inhibitor allergy or contraindication NOTE: Consider Losartan/HCTZ 100/12.5mg consider Angiotensin Receptor Blocker 2) Losartan QD Atrovent (Ipratropium) 0.03, 0.06% Nasal Document adequate therapeutic trial or intolerance 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) OTC Spray 2 SPRAYS IEN BID-QID to Claritin, Zyrtec, or Allegra and at least 1 Nasal Allegra 60mg BID 4) Fluticasone 2 SPRAYS IEN QD 5) Steroid Flunisolide 2 SPRAYS IEN BID Augmentin (Amoxicillin/Clavulanate) 1) Amoxicillin 125mg/5ml Suspension BID 2) 125mg/31.25mg/5ml Powder for Suspension Amoxicillin/Clavulanate 200mg/28.5mg/5ml Suspension BID BID 3) Amoxicillin 125mg Chew Tablet BID 4) Amoxicillin/Clavulanate 125/31.25mg Chew Tablet BID Augmentin (Amoxicillin/Clavulanate) 1) Amoxicillin 250mg Capsule 2) Amoxicillin 250mg Chew 250mg/62.5mg/5ml Powder for Suspension Tablet BID 3) Amoxicillin 250mg/5ml Suspension BID 4) BID Amoxicillin/Clavulanate 200mg/28.5mg/5ml Suspension BID Augmentin XR (Amoxicillin/Clavulanate) 1000/62.5mg Extended Release Tablet 2T BID Avalide (Irbesartan/HCTZ) Tablet 150/12.5, 300/12.5, 300/25mg QD 2 Separate Medications Amoxicillin/Clavulanate 875/125mg BID AND Amoxicillin 250mg BID 2 Separate Medications HCTZ QD AND 1) Lisinopril QD NOTE: If Angiotensin Converting Enzyme Inhibitor allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan QD Dose Conversion Avapro 150mg=Lisinopril 20mg=Losartan 50mg / Avapro 300mg=Lisinopril 40mg=Losartan 100mg NOTE: Consider Lisinopril/HCTZ 20/12.5mg or Losartan/HCTZ 50/12.5, 100/12.5, 100/25mg Avandamet (Metformin/Rosiglitazone) 500/2, 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin 500Adjust based on patient response 500/4, 1000/2, 1000/4mg Tablet QD-BID American Diabetes Association 1000mg (Maximum 2550mg QD) 3) Metformin ER 500Recommendations 750mg (Maximum 2000mg QD) 4) Novolin R (Insulin -Patient uncontrolled on maximum Metformin and Regular) SC 30 minutes AC 5) Novolin N (NPH) SC 15-30 maximum Sulfonylurea=Do not initiate Actos and minutes AC 6) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog (Insulin Aspart) SC 5-10 minutes AC initiate Novolin N -Patient on Actos and Insulin=Discontinue Actos NF 8) Actos 15mg (Maximum 45mg QD) and maximize Novolin N Dose Conversion Avandia 2mg=Actos 15mg / Avandia 4mg=Actos 30mg / Avandia 8mg=Actos 45mg Avandia (Rosiglitazone) 2, 4, 8mg Tablet QD- 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin 500Adjust based on patient response BID 1000mg (Maximum 2550mg QD) 3) Metformin ER 500American Diabetes Association 750mg (Maximum 2000mg QD) 4) Novolin R (Insulin Recommendations -Patient uncontrolled on maximum Metformin and Regular) SC 30 minutes AC 5) Novolin N (NPH) SC 15-30 maximum Sulfonylurea=Do not initiate Actos and minutes AC 6) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog (Insulin Aspart) SC 5-10 minutes AC initiate Novolin N -Patient on Actos and Insulin=Discontinue Actos NF 8) Actos 15mg (Maximum 45mg QD) and maximize Novolin N Dose Conversion Avandia 2mg=Actos 15mg / Avandia 4mg=Actos 30mg / Avandia 8mg=Actos 45mg Page 6 Last Updated: 6/20/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Avapro (Irbesartan) Tablet 75, 150, 300mg QD 1) Lisinopril QD NOTE: If Angiotensin Converting Enzyme Inhibitor allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan QD AVC Vaginal (Sulfanilamide) 15% Vaginal Cream QD-BID 1) OTC Mycelex (Clotrimazole 1%) QHS 2) OTC Monistat (Miconazole) QHS 3) OTC Vagistat (Tioconazole 6.5%) QHS 4) Fluconazole 150mg QD Community Acquired Pneumonia 1) Levofloxacin 750mg QD X5D 2) Levofloxacin 500mg QD X10D 3) Azithromycin 500mg QD X5D 4) Cefuroxime 500mg BID X10D Sinusitis 1) SMZ-TMP DS BID X7D 2) Doxycycline 100mg BID X7D 3) Amoxicillin 1000mg BID X7D 4) Azithromycin 500mg QD X3D Avelox (Moxifloxacin) 400mg Tablet QD X714D Avinza (Morphine Sulfate) 30, 45, 60, 75, 90, 120mg Extended Release Capsule QD 1) Morphine ER 60-100mg BID 2) Fentanyl 25-100mcg/hr Q72H Avodart (Dutasteride) 0.5mg Capsule QD Finasteride 5mg QD Axert (Almotriptan) 6.25, 12.5mg Tablet PRN 1) Sumatriptan 25-100mg PRN 2) Sumatriptan 20mg Nasal Spray PRN 3) Naratriptan 1-2.5mg PRN 4) Sumatriptan 6mg/ml Subcutaneous Solution PRN 5) Maxalt MLT 5-10mg PRN NF 6) Zomig 5mg PRN NF 7) Zomig 2.5mg PRN NF 8) Relpax 20-40mg PRN NF Comments Dose Conversion Avapro 75mg=Lisinopril 10mg=Losartan 25mg / Avapro 150mg=Lisinopril 20mg=Losartan 50mg / Avapro 300mg=Lisinopril 40mg=Losartan 100mg Dose Conversion Morphine 30mg=Oxycodone 20mg=Oxymorphone 10mg / Morphine 90mg=Fentanyl 25mcg/hr Document adequate therapeutic trial or intolerance to Morphine ER and Fentanyl Quantity Limit Axert 6.25-12.5mg=6 Tablets Maxalt MLT 5-10mg=9 Tablets Naratriptan 1-2.5mg=9 Tablets Relpax 20-40mg=6 Tablets Sumatriptan 25-100mg=9 Tablets Zomig 2.5mg=6 Tablets Zomig 5mg=3 Tablets Axid Pulvules (Nizatidine) 150, 300mg Capsule QD-BID Axiron (Testosterone) 30mg/1.5ml Topical Solution Apply 1 pump to each axilla QAM 1) OTC Famotidine 10-20mg QD-BID 2) OTC Ranitidine 75150mg QD-BID 3) Cimetidine 400-800mg QD-BID 1) Testosterone Cypionate 200mg/ml IM Q2-4W 2) Androderm Patch 2-4mg/24hr Apply QPM 3) AndroGel Pump 1.62% Apply 2 pumps QAM NF 4) AndrogGel Pump 1% Apply 4 pumps QAM NF 5) AndroGel 1% (25mg/2.5gm50mg/5gm) Apply QAM NF 6) Testim 1% Gel Apply QAM NF AzaSite (Azithromycin) 1% Ophthalmic Solution 1 GTT BID Blepharitis 1) Neomycin/Polymyxin/Hydrocortisone 1% Suspension 1-2 GTTS Q4H 2) Neomycin/Polymyxin/Dexamethasone 0.1% Suspension 1-2 GTTS Q4H 3) Sulfacetamide/Prednisolone 10/0.25% Solution 1-2 GTTS Q2-3H 4) Erythromycin 0.5% Ointment APPLY RIBBON Q4H 5) Tobramycin/Dexamethasone 0.3/0.1% 1-2 GTTS Q4-6H 6) Neomycin/Polymyxin/Bacitracin Ointment APPLY RIBBON Q4H 7) Restasis 0.05% 1 GTT BID Conjunctivitis 1) Ofloxacin 0.3% Solution 1-2 GTTS QID 2) Ciprofloxacin 0.3% Solution 1-2 GTTS Q4HS NF 3) Sodium Sulfacetamide 10% Solution 1-3 GTTS Q2-3H 4) Gentamicin 0.3% Solution 1-2 GTTS QID 5) Erythromycin 0.5% Ointment APPLY RIBBON Q4H 6) Vigamox Solution 0.5% 1 GTT BID NF 7) Ciloxan 0.3% Ointment APPLY RIBBON BID-TID NF 8) Zymaxid 0.5% Solution 1 GTT QID 9) Quixin 0.5% Solution 12 GTTS Q4H NF 1) Clindamycin 1% Gel AAA BID AND OTC Benzoyl Peroxide Dispense Clindamycin or Erythromycin as 1 copay and purchase OTC Benzoyl Peroxide 5% Gel AAA BID 2) Sodium Sulfacetamide/Sulfur 10/5% Lotion AAA BID 3) Erythromycin/Benzoyl Peroxide 3/5% Gel AAA BID 1) Carbidopa/Levodopa ER 25/100mg BID 2) Bromocriptine 2.5mg QD 3) Amantadine 100mg BID 4) Selegiline 5mg QD Azelex (Azelaic Acid) 20 % Cream AAA BID Azilect (Rasagiline) 0.5, 1mg Tablet QD Page 7 Last Updated: 6/20/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Azopt (Brinzolamide) 1% Ophthalmic Suspension 1 GTT TID Azor (Amlodipine/Olmesartan) 5/20, 5/40, 10/20, 10/40mg Tablet QD Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy 1) Methazolamide 50-100mg BID-TID 2) Dorzolamide 2% 1 GTT TID 3) Dorzolamide/Timolol 2/0.5% 1 GTT BID 4) Acetazolamide 250mg QD-QID 2 Separate Medications Amlodipine QD AND 1) Lisinopril QD NOTE: If Angiotensin Converting Enzyme Inhibitor allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan QD Comments Dose Conversion Benicar 20mg=Lisinopril 20mg=Losartan 50mg / Benicar 40mg=Lisinopril 40mg=Losartan 100mg B12 Vitamins (Cyanocobalamin, Hydroxocobalamin, Metanx) QD Bactroban (Mupirocin) 2% Cream, Ointment AAA TID Bactroban Nasal (Mupirocin) 2% Nasal Ointment Apply 1/2 tube IEN BID OTC Vitamin B12 (Cyanocobalamin) 50, 100, 250, 500, 1000mcg QD Mupirocin 2% Ointment AAA TID Excluded Medication Available OTC Mupirocin 2% Ointment Apply IEN BID Balziva (35mcg Ethinyl Estradiol/0.4mgNorethindrone) Tablet QD 1) Sprintec (35mcg Ethinyl Estradiol/0.25mg Norgestimate) QD 2) Necon 1/35 (35mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Necon 0.5/35 (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD 4) Zovia 1/35 (35mcg Ethinyl Estradiol/1mg Ethynodiol diacetate) QD 5) Brevicon (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD MRSA Colonization Mupirocin 2% Ointment may be administered with a cotton swab to the anterior nares Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Banzel (Rufinamide) 40mg/ml Suspension; 200, 400mg Tablet BID 1) Lamotrigine 100-200mg BID 2) Carbamazepine 8001600mg QD 3) Topiramate 200mg BID 4) Phenytoin 100mg TID 5) Levetiracetam 500-1500mg BID 6) Zonisamide 100mg TID NF 7) Gabapentin 300-600mg TID 8) Levetiracetam ER 1000mg QD 9) Oxcarbazepine 600mg BID NF 10) Divalproex 250-500mg TID 11) Lyrica 50-200mg TID NF 12) Vimpat 100200mg BID NF Beconase (Beclomethasone) 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) OTC 0.042mg/Actuation Nasal Aerosol Powder 1-2 Allegra 60mg BID 4) Fluticasone 2 SPRAYS IEN QD 5) SPRAYS IEN BID Flunisolide 2 SPRAYS IEN BID 6) Triamcinolone 2 SPRAYS IEN QD NF 7) Nasonex 2 SPRAYS IEN QD NF 8) Veramyst 2 SPRAYS IEN QD NF 9) Omnaris 2 SPRAYS IEN QD NF 10) Rhinocort AQ 2 SPRAYS IEN BID NF Benicar (Olmesartan) 5, 20, 40mg Tablet QD 1) Lisinopril QD NOTE: If Angiotensin Converting Enzyme Inhibitor allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan QD Benicar HCT (Olmesartan/HCTZ) 20/12.5, 2 Separate Medications 40/12.5, 40/25mg Tablet QD HCTZ QD AND 1) Lisinopril QD NOTE: If Angiotensin Converting Enzyme Inhibitor allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan QD Age Recommendations Fluticasone=4 years of age and older / Flunisolide=6 years of age and older / Triamcinolone=2 years of age and older / Nasonex=2 years of age and older / Veramyst=2 years of age and older / Omnaris=6 years of age and older / Rhinocort Aqua=6 years of age and older / Beconase=5 years of age and older Dose Conversion Benicar 20mg=Lisinopril 20mg=Losartan 50mg / Benicar 40mg=Lisinopril 40mg= Losartan 100mg Dose Conversion Benicar 20mg=Lisinopril 20mg=Losartan 50mg / Benicar 40mg=Lisinopril 40mg= Losartan 100mg NOTE: Consider Lisinopril/HCTZ 20/12.5mg or Losartan/HCTZ 50/12.5, 100/12.5, 100/25mg Excluded Medication Benzac AC (Benzoyl Peroxide) 5, 10% Liquid OTC Benzoyl Peroxide 5-10% Liquid AAA QD-BID AAA QD-BID BenzaClin (Clindamycin/Benzoyl Peroxide) 1) Clindamycin 1% Gel AAA BID AND OTC Benzoyl Peroxide Dispense Clindamycin as 1 copay and purchase 1/5% Gel AAA BID 5% Gel AAA BID 2) Erythromycin/Benzoyl Peroxide 3/5% Gel OTC Benzoyl Peroxide AAA BID Bepreve (Bepotastine) 1.5% Ophthalmic 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q3-4 Solution 1 GTT BID HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID 4) Crolom 4% 1-2 GTTS Q4-6 HOURS NF 5) Emadine 0.05% 1 GTT QID NF 6) Alocril 2% 12 GTTS BID NF 7) Optivar 0.05% 1 GTT BID NF 8) Alomide 0.1% 1-2 GTTS QID NF 9) Lastacaft 0.25% 1 GTT QD NF 10) Pataday 0.2% 1 GTT QD NF 11) Alrex 0.2% 1 GTT QID NF 12) Patanol 0.1% 1 GTT BID NF 13) Elestat 0.05 % 1 GTT BID NF 14) Alamast 0.1% 1-2 GTTS QID NF Page 8 Last Updated: 6/20/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Berinert (C1 Esterase Inhibitor) 500U Intravenous Powder for Solution 20U/kg Q34D 1) Danazol 200mg BID-TID 2) Oxandrolone 2.5-20mg BIDQID NF Betapace AF (Sotalol AF) 80, 120, 160mg Tablet QD-BID Betaseron (Interferon Beta-1b) 0.3mg Subcutaneous Powder for Solution 0.25mg QOD Beyaz (20mcg Ethinyl Estradiol/3mg Drospirenone) Tablet QD Sotalol 80mg BID Biaxin XL (Clarithromycin) 500mg Extended Release Tablet 2T QD BiDil (Isosorbide Dinitrate/Hydralazine) 20/37.5mg Tablet TID Biltricide (Praziquantel) 600mg Tablet 25mg/kg TID X1D Boniva (Ibandronate) 150mg Tablet QM Botox (Onabotulinumtoxin A) 200U Injection Powder for Solution; 100U Intramuscular Powder for Solution Q12-16W Comments Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Extavia 0.25mg QOD Equivalent Brand and Generic Products Betaseron=Extavia 1) Reclipsen (30mcg Ethinyl Estradiol/0.15 Desogestrel) QD 2) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Aviane (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel) QD 1) Clarithromycin 500mg BID 2) Azithromycin Day 1: 500mg Day 2-5: 250mg QD 3) Erythromycin 333mg EC Q8H 4) Erythromycin 250mg EC Q6H 2 Separate Medications Isosorbide Dinitrate 20mg TID AND Hydralazine 25mg 1.5T TID 1) Paromomycin 250mg 25-35mg/kg/day divided TID X5-10D 2) Albenza 400mg Single dose 1) Alendronate 10mg QD 2) Alendronate 70mg QW 3) Fortical 200IU QD Alternate nostrils 4) Ibandronate 150mg QM NF Administered in a healthcare setting by healthcare providers Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Brilinta (Ticagrelor) 90mg Tablet BID Clopidogrel 75mg QD Bromday (Bromfenac) 0.09% Ophthalmic Solution 1 GTT QD 1) Diclofenac 0.1% 1GTT QID 2) Ketorolac 0.5% 1 GTT QID 3) Prednisolone 1% 1-2 GTTS BID-QID 4) Fluorometholone 0.1% 1-2 GTTS BID-QID 5) Dexamethasone 0.1% 1-2 GTTS BID-QID 6) Ketorolac 0.4% 1 GTT QID 7) Flurbiprofen 0.03% 1 GTT QID NF 8) Vexol 1% 1-2 GTT QID NF 9) Bromfenac 0.09% 1 GTT QD-BID NF Bumex (Bumetanide) 0.5, 1, 2mg Tablet QD 1) Bumetanide 0.5-1mg QD 2) Furosemide 20-80mg QD Biaxin XL to Clarithromycin is a 1:1 Conversion Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Dose Conversion Bumetanide 0.5mg=Furosemide 20mg / Bumetanide 1mg=Furosemide 40mg / Bumetanide 2mg=Furosemide 80mg Butrans (Buprenorphine) 5, 10, 20mcg/hr 1) Morphine ER 60-100mg BID 2) Fentanyl 25-100mcg/hr Dose Conversion Transdermal Patch Apply QW Q72H Morphine 30mg=Butrans 5mcg/hr / Morphine 90mg=Fentanyl 25mcg/hr Document adequate therapeutic trial or intolerance to Morphine ER and Fentanyl Byetta (Exenatide) 250mcg/ml Subcutaneous 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin 500Criteria Restricted Medication Solution BID QRM approval required prior to being dispensed for 1000mg (Maximum 2550mg QD) 3) Metformin ER 500Commercial, Multi-Choice, Self-Funded, and Triple 750mg (Maximum 2000mg QD) 4) Novolin R (Insulin Tier members. Regular) SC 30 minutes AC 5) Novolin N (NPH) SC 15-30 Provider must call 404-364-7320 (Option 2) to minutes AC 6) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog (Insulin Aspart) SC 5-10 minutes AC initiate review by QRM department. NF 8) Actos 15mg (Maximum 45mg QD) Bystolic (Nebivolol) 2.5, 5, 10, 20mg Tablet 1) Atenolol 50-100mg QD 2) Metoprolol 100-450mg QD 3) Dose Conversion QD Bystolic 2.5mg QD=Metoprolol Tartrate 12.5mg BID Acebutolol 400-800mg QD 4) Bisoprolol 2.5-20mg QD 5) / Bystolic 5mg QD=Metoprolol Tartrate 25mg BID / Carvedilol 12.5-25mg BID 6) Labetalol 200-400mg BID Bystolic 10mg=Metoprolol Tartrate 50mg BID / Bystolic 20mg QD=Metoprolol Tartrate 100mg BID Page 9 Last Updated: 6/20/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Caduet (Amlodipine/Atorvastatin) 2.5/10, 2.5/20, 2.5/40, 5/10, 5/20, 5/40, 5/80, 10/10, 10/20, 10/40, 10/80mg Tablet QD 2 Separate Medications Amlodipine 2.5-10mg QD AND Atorvastatin 10-80mg QD Campral (Acamprosate) 333mg Enteric Coated Tablet 2T TID Capex (Fluocinolone Acetonide) 0.01% Shampoo Low Potency 1) Naltrexone 50mg QD 2) Disulfiram 250-500mg QD Carac (Fluorouracil) 0.5% Cream AAA BID Cardene SR (Nicardipine) 30, 45, 60mg Extended Release Capsule BID Carmol HC (Hydrocortisone/Urea) 1/10% Cream AAA BID Catapres TTS-1,TTS-2, TTS-3 Transdermal Patch Apply QW Low Potency 1) Betamethasone Valerate 0.1% Lotion AAA QD-BID 2) Desonide 0.05% Cream, Ointment AAA BID-TID 3) Fluocinolone Acetonide 0.01% Solution AAA QD 4) DermaSmoothe/FS 0.01% Oil AAA QD Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BID-QID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID 1) Fluorouracil 5% Solution AAA BID 2) Efudex 5% Cream AAA BID 3) Fluoroplex 1% Cream AAA BID 1) Amlodipine 5-10mg QD 2) Verapamil SR 180-240mg BID 3) Diltiazem ER 240-360mg QD 4) Nifedipine ER 30-60mg QD 5) Felodipine 2.5-20mg QD 2 Separate Medications OTC Hydrocortisone 1% Cream AAA BID-QID AND OTC Carmol 10 (Urea 10%) Cream AAA BID Clonidine 0.1-0.3mg BID Caverject (Alprostadil) 10, 20, 40mcg Intracavernosal Powder for Solution; 0.02mg/ml Intracavernosal Solution PRN Cayston (Aztreonam) 75mg/vial Inhalation Powder for Solution TID Comments Atorvastatin to minimize drug interactions and risk of myalgias if current therapy with: -Amlodipine (Maximum Simvastatin 20mg) Dose Conversion Cardene SR 30mg BID=Nifedipine ER 30mg QD / Cardene SR 45mg BID=Nifedipine ER 60 QD / Cardene SR 60mg BID=Nifedipine ER 90mg QD Dose Conversion Catapres TTS-1=Clonidine 0.1mg BID / Catapres TTS-2=Clonidine 0.2mg BID / Catapres TTS3=Clonidine 0.3mg BID Excluded Medication (Exception: Sexual Dysfunction Rider) 1) Tobi 300mg/5ml BID NF 2) Colistimethate 150mg/ml BID NF Cayston is delivered directly to patient via Foundation Care Pharmacy Cedax (Ceftibuten) 400mg Capsule; 1) Cefdinir 125mg/5ml-250mg/5ml 7mg/kg BID 3rd 90mg/5ml, 180mg/5ml Powder for Suspension Generation 2) Pediazole (Erythromycin QD 3rd Generation Ethylsuccinate/Sulfisoxazole) 50mg/kg divided TID-QID Ceftin (Cefuroxime) 125mg/5ml, 250mg/5ml 1) Cefuroxime 250-500mg BID 2nd Generation 2) Cefdinir Powder for Suspension BID 2nd Generation 125mg/5ml-250mg/5ml BID 3rd Generation 3) Ceflacor 250500mg BID-TID 2nd Generation Cefzil (Cefprozil) 125mg/5ml, 250mg/5ml 1) Cefuroxime 250-500mg BID 2nd Generation 2) Cefdinir Powder for Suspension; 250, 500mg Tablet 125mg/5ml-250mg/5ml BID 3rd Generation 3) Ceflacor 250BID 2nd Generation 500mg BID-TID 2nd Generation Celebrex (Celecoxib) 50, 100, 200, 400mg Capsule BID Cenestin (Conjugated Estrogen Synthetic A) 0.3, 0.45, 0.625, 0.9, 1.25mg Tablet QD Chantix (Varenicline) 0.5, 1mg Tablet 1mg BID 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg BID 3) Ibuprofen 400-800mg TID-QID 4) Sulindac 150-200mg BID 5) Etodolac 200-500mg BID-TID 6) Nabumetone 500-750mg BID 7) Lidocaine 5% Ointment AAA Q4H 8) Diclofenac 25100mg BID-TID 9) Indomethacin 25-75mg QD-BID 10) Tolmetin 200-600mg TID Vasomotor Symtoms 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.0250.1mg/24hr Apply weekly Vaginal/Vulvar Atrophy 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.0250.1mg/24hr Apply weekly 3) Premarin Vaginal 1gm Apply three times a week 4) Vagifem 10mcg Insert twice weekly 5) Estring 2mg Insert for 90 days 1) OTC Nicoderm 7, 14, 21mg/day Patch Apply QD 2) OTC Nicorette 2, 4mg Gum Chew 3-24 QD 3) Bupropion SR 150mg QD-BID Page 10 Last Updated: 6/20/2012 Document NSAID GI Risk Score > 21 and adequate therapeutic trial or intolerance to Etodolac, Meloxicam, and Nabumetone Adjust to the lowest dose needed to control symptoms based on patient response Dose Conversion Cenestin 0.3mg=Estradiol 0.5mg / Cenestin 0.45mg=Estradiol 0.75mg / Cenestin 0.625mg=Estradiol 1mg / Cenestin 0.9mg=Estradiol 1.5mg / Cenestin 1.25mg=Estradiol 2mg Document adequate therapeutic trial or intolerance to Nicotine Replacement Therapy and/or Bupropion SR Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Cialis (Tadalafil) 2.5, 5mg Tablet QD; 10, 20mg Tablet PRN Ciloxan (Ciprofloxacin) 0.3% Ophthalmic Ointment APPLY RIBBON BID-TID; 0.3% Ophthalmic Solution 1-2 GTTS Q4H Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Comments Excluded Medication (Exception: Sexual Dysfunction Rider) 1) Ofloxacin 0.3% Solution 1-2 GTTS QID 2) Ciprofloxacin 0.3% Solution 1-2 GTTS Q4HS NF 3) Sodium Sulfacetamide 10% Solution 1-3 GTTS Q2-3H 4) Gentamicin 0.3% Solution 1-2 GTTS QID 5) Erythromycin 0.5% Ointment APPLY RIBBON Q4H 6) Vigamox Solution 0.5% 1 GTT BID NF 7) Ciloxan 0.3% Ointment APPLY RIBBON BID-TID NF Cimzia (Certolizumab Pegol) 200mg 1) Humira 40mg QOW (CD/RA) 2) Enbrel 50mg QW (RA) 3) Crohns Disease (CD) Subcutaneous Powder for Solution, 200mg/ml Remicade 5mg/kg Q8W NF (CD/RA) Document adequate therapeutic trial or intolerance Subcutaneous Solution 400mg Q4W (CD/RA) to Humira and Remicade Rheumatoid Arthritis (RA) Document adequate therapeutic trial or intolerance to Humira, Enbrel, and Remicade Remicade Infusion KP GI or Rheumatology Contact CU Infusion Center 770-431-4367 or SW Infusion Center 770-603-3663 Network GI or Rheumatology Contact Provider Relations 404-364-4934 Cinryze (C1 Esterase Inhibitor) 500 U Administered in a healthcare setting by healthcare providers Criteria Restricted Medication Intravenous Powder for Solution Q3-4D QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Cipro Hc (Ciprofloxacin/Hydrocortisone) Ophthalmic Solution may be administered in the ear 1) Ofloxacin 0.3% Ophthalmic Solution 10 GTTS QD 2) 0.2/1% Otic Suspension 3 GTTS BID Neomycin/Polymyxin/Hydrocortisone 1% Suspension 1-2 GTTS Q4 HOURS 3) Neomycin/Polymyxin/Dexamethasone 0.1% Ophthalmic Suspension 1-2 GTTS Q4 HOURS 4) Acetic Acid 2% Solution 1-2 GTTS Q4-6 HOURS 5) Ciprodex 0.3/0.1% Suspension 4 GTTS BID Clarinex (Desloratadine) 5mg Tablet; 5mg Orally Disintegrating Tablet; 0.5mg/ml Syrup QD Cleocin Vaginal (Clindamycin) 2% Cream; 100mg Suppository QHS Climara Pro (Estradiol/Levonorgestrel) 0.045/0.015mg/24hr Transdermal Patch Apply weekly 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) OTC Excluded Medication Allegra 60mg BID 4) Fluticasone 2 SPRAYS IEN QD 5) Flunisolide 2 SPRAYS IEN BID 1) Clindamycin 300mg BID 2) Metronidazole 500mg BID 3) Metronidazole 0.75% Vaginal Gel QHS NF Adjust to the lowest dose needed to control 2 Separate Medications symptoms based on patient response 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.0250.1mg/24hr Apply weekly AND 1) Medroxyprogesterone 2.55mg QD 2) Nora-BE 0.35mg QD 3) Norethindrone 5mg QD Clobex (Clobetasol) 0.05% Lotion, Shampoo, Very High Potency Spray AAA BID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID Cloderm (Clocortolone Pivalate) 0.1% Cream Medium-High Potency AAA TID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BID-QID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BID-QID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QD-BID Page 11 Last Updated: 6/20/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Coartem (Artemether/Lumefantrine) 20/120mg Tablet Day1: 80/480mg, 80/480mg 8 hours later Day 2: 80/480mg BID Day 3: 80/480mg BID Colcrys (Colchicine) 0.6mg Tablet QD-BID Colestid (Colestipol) 5gm Powder for Suspension 5-30gm QD Combigan (Brimonidine/Timolol) 0.2/0.5% Ophthalmic Solution 1 GTT BID Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Comments 1) Aralen 500mg (Day 1: 1gm, 500mg 6-8 hours later Day 2: 500mg Day 3: 500mg) NF 2) Lariam 1250mg (Single dose) NF Gout Prophylaxis 1) Allopurinol 100-800mg QD 2) Probenecid 250-1000mg BID Gout Treatment 1) Prednisone 40mg X3D decreased by 10mg Q3D to 5mg X3D 2) Ibuprofen 400mg TID-QID 3) Etodolac 400mg BIDTID 4) Indomethacin 25mg QD-BID 1) Cholestyramine 4gm 8-16gm QD 2) Cholestyramine Light 4gm 8-16gm QD 3) Colestipol 1gm 2-16gm QD 2 Separate Medications Brimonidine 0.2% 1 GTT BID AND Timolol 0.5% 1 GTT BID Quantity Limit Gout Prophylaxis (30 Day Supply)=60 Tablets Gout Treatment=9 Tablets Combipatch (Estradiol/Norethindrone Acetate) 2 Separate Medications Adjust to the lowest dose needed to control 0.05/0.14mg/24hr, 0.05/0.25mg/24hr symptoms based on patient response Vasomotor Symtoms Transdermal Patch Apply twice weekly 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.0250.1mg/24hr Apply weekly AND 1) Medroxyprogesterone 2.55mg QD 2) Nora-BE 0.35mg QD 3) Norethindrone 5mg QD Vaginal/Vulvar Atrophy 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.0250.1mg/24hr Apply weekly 3) Premarin Vaginal 1gm Apply three times a week 4) Vagifem 10mcg Insert twice weekly 5) Estring 2mg Insert for 90 days AND 1) Medroxyprogesterone 2.5-5mg QD 2) Nora-BE 0.35mg QD 3) Norethindrone 5mg QD Combunox (Ibuprofen/Oxycodone) 400/5mgTablet QID Condylox (Podofilox) 0.5% Solution BID ConZip (Tramadol) 100, 200, 300mg Variable Release Capsule QD 2 Separate Medications Ibuprofen 400mg QID AND Oxycodone 5mg QID Condylox 0.5% Gel BID 1) Tramadol 50mg Q4-6H PRN 2) Hydrocodone/Acetaminophen 5/325mg Q4-6H 3) Codeine/APAP 15/300, 30/300, 60/300mg Q4H Cordran (Flurandrenolide) 0.05% Lotion AAA BID-TID Medium Potency ConZip 100mg=Tramadol 25mg Immediate Release + Tramadol 75mg Extended Release / ConZip 200mg=Tramadol 50mg Immediate Release + Tramadol 150mg Extended Release / ConZip 300mg=Tramadol 50mg Immediate Release + Tramadol 250mg Extended Release Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BID-QID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BID-QID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID Cordran (Flurandrenolide) 4mcg/cm Tape Medium-High Potency Apply Q12-24H Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BID-QID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BID-QID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QD-BID Coreg CR (Carvedilol Phosphate) 10, 20, 40, 1) Propranolol 120-240mg QD 2) Nadolol 240-320mg QD 3) Dose Conversion 80mg Extended Release Capsule QD Coreg CR 10mg QD=Carvedilol 3.125mg BID / Carvedilol 12.5-25mg BID 4) Labetalol 200-400mg BID Coreg CR 20mg QD=Carvedilol 6.25mg BID / Coreg CR 40mg QD=Carvedilol 12.5mg BID / Coreg CR 80mg QD=Carvedilol 25mg BID Cortisporin (Hydrocortisone 2 Separate Medications Acetate/Neomycin Sulfate/Polymyxin B OTC Hydrocortisone 0.5% Cream AND OTC Neosporin Sulfate) Cream AAA BID-QID Lowest (Neomycin/Polymixin B/Bacitracin) Potency Page 12 Last Updated: 6/20/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Corzide (Nadolol/Bendroflumethiazide) 40/5, 80/5mg Tablet QD Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Comments 2 Separate Medications Nadolol QD AND 1) HCTZ 25mg QD 2) Chlorthalidone 50mg QD 1) Pancrelipase 5 Unit 10000 Lipase Units/kg QD 2) Zenpep 5-20 Unit 10000 Lipase Units/kg QD Creon (Pancrelipase Enzyme) 5, 6, 10, 12, 20, 24 Unit Delayed Release Capsule 10000 Lipase Units/kg QD Crestor (Rosuvastatin) 5, 10, 20, 40mg Tablet 1) Simvastatin 20-40mg QD 2) Pravastatin 40-80mg QD 3) QD Atorvastatin 10-80mg QD Crestor to minimize drug interactions and risk of myalgias if current therapy with: -Clarithromycin, Cyclosporine, Danazol, Erythromycin, Gemfibrozil, HIV Protease Inhibitors, Itraconazole, Ketoconazole, Nefazodone, Posaconazole,Telithromycin -Diltiazem, Verapamil (Maximum Lovastatin 40mg, Pravastatin 40mg, or Simvastatin 10mg) -Amiodarone, Amlodipine, Ranolazine (Maximum Simvastatin 20mg) Dose Conversion Crestor 5mg=Atorvastatin 10mg=Pravastatin 40mg=Simvastatin 20mg / Crestor 10mg=Atorvastatin 20mg=Pravastatin 80mg=Simvastatin 40mg / Crestor 20mg=Atorvastatin 40mg / Crestor 40mg=Atorvastatin 80mg Crinone (Progesterone) 4% Vaginal Gel QOD Medroxyprogesterone 5-10mg QD Crolom (Cromolyn) 4% Ophthalmic Solution 1- 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q3-4 2GTT Q4-6 HOURS HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID Cryselle (30mcg Ethinyl Estradiol/0.3 1) Reclipsen (30mcg Ethinyl Estradiol/0.15mg Desogestrel) Document adequate therapeutic trial or intolerance Norgestrel) Tablet QD QD 2) Microgestin Fe 1.5/30 (30mcg Ethinyl Estradiol/1.5mg to at least 3 formulary oral contraceptives Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD Cutivate (Fluticasone Propionate) 0.005% High Potency Ointment AAA BID High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BID-QID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QD-BID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Cutivate (Fluticasone Propionate) 0.05% Cream, Lotion AAA BID Medium Potency Cuvposa (Glycopyrrolate) 1mg/5ml Oral Solution BID-TID Cyclessa (25 mcg Ethinyl Estradiol/0.1mg Desogestrel x 7days, 25 mcg EE/0.125mg Desogestrel x 7 days, 25 mcg EE/0.15mg Desogestrel x 7 days) Tablet QD Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BID-QID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BID-QID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID 1) Benztropine 2mg TID-QID 2) Trihexphenidyl 2mg TID 3) Trihexphenidyl 0.4mg/ml NF 4) Glycopyrrolate 1mg TID-QID 5) Atrovent 1-2 PUFFS TID 6) Transderm Scop 1.5mg Patch Apply Q72H NF Document adequate therapeutic trial or intolerance 1) Tri-Sprintec (35mcg Ethinyl Estradiol/0.18mg to at least 3 formulary oral contraceptives Norgestimate x 7 days, 35mcg EE/0.215mg NG x 7 days, 35mcg EE/0.25mg NGx 7 days) QD 2) Reclipsen (30mcg Ethinyl Estradiol/0.15 Desogestrel) QD 3) Trivora (30mcg Ethinyl Estradiol/0.05mg Levonorgestrel x 6 days, 40mcg EE/0.075mg LVNGL x 5 days, 30mcg EE/0.125mg LVNGL x 10 days) QD 4) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) QD 5) Leena (35mcg Ethinyl Estradiol/0.5mg Norethindrone x 7 days, 35mcg EE/1mg NE x 9 days, 35mcg EE/0.5mg NE x 5 days) QD Page 13 Last Updated: 6/20/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Cyclocort (Amcinonide) 0.1% Cream, Lotion AAA BID-TID High Potency High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BID-QID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QD-BID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Cyclocort (Amcinonide) 0.1% Ointment AAA BID -TID Very High Potency Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID Comments Cymbalta (Duloxetine) 20, 30, 60mg Delayed Major Depressive Disorder or Generalized Anxiety Major Depressive Disorder or Generalized Release Capsule QD Disorder Anxiety Disorder Document adequate therapeutic trial or intolerance 1) Citalopram 20-40mg QD 2) Fluoxetine 20-40mg QD 3) to 2 SSRIs and Venlafaxine Sertraline 50-100mg QD 4) Mirtazapine 30mg QHS 5) Bupropion SR/XL 300mg QD 6) Venlafaxine ER 225mg QD Diabetic Peripheral Neuropathic Pain 7) Fluvoxamine 50-300mg QD NF 8) Escitalopram 10-20mg Document adequate therapeutic trial or intolerance QD NF 9) Paxil CR 12.5-37.5mg QD NF 10) Viibryd 10-40mg to 1 TCA*, Tramadol*; and Venlafaxine Non-Diabetic Peripheral Neuropathic Pain QD NF 11) Pristiq 50-100mg QD NF Document adequate therapeutic trial or intolerance Diabetic Peripheral Neuropathic Pain to 1 TCA*, Tramadol*, and Cyclobenzaprine 1) Amitriptyline (AMT)* 50mg QHS 2) Nortriptyline (NRT)* (<65 YOA: 25mg/>65 YOA: 10mg) QHS 3) Cyclobenzaprine* Fibromyalgia 10mg TID 4) Tramadol* 50mg BID 5) Venlafaxine ER 225mg Document adequate therapeutic trial or intolerance to 1 TCA*, Tramadol*, and Cyclobenzaprine QD Post Herpetic Neuralgia Non-Diabetic Peripheral Neuropathic Pain Document adequate therapeutic trial or intolerance 1) AMT* 50mg QHS 2) NRT* (<65 YOA: 25mg/>65 YOA: to1 TCA* and Gabapentin 10mg) QHS 3) Cyclobenzaprine* 10mg TID 4) Tramadol* HIV Associated Polyneuropathy 50mg BID Document adequate therapeutic trial or intolerance Fibromyalgia to Lamotrigine 1) AMT* 50mg QHS 2) NRT* (<65 YOA: 25mg/>65 YOA: Trigeminal Neuralgia 10mg) QHS 3) Cyclobenzaprine* 10mg TID 4) Tramadol* Document adequate therapeutic trial or intolerance 50mg BID to Carbamazepine and Oxcarbazepine NF Post Herpetic Neuralgia Migrane Prophylaxis 1) NRT* (<65 YOA: 25mg/>65 YOA: 10mg) QHS 2) Document adequate therapeutic trial or intolerance Gabapentin 600mg TID 3) Lidocaine 5% Ointment AAA to Topiramate, Divalproex, 1 Beta Blocker, and 1 HIV Associated Polyneuropathy TCA* 1) Lamotrigine 200-400mg QD Trigeminal Neuralgia 1) Carbamazepine 200-1200mg QD 2) Oxcarbazepine 600- *Not recommended in the elderly and not a required medication for patients over 65 years old 1800mg QD NF Migrane Prophylaxis 1) AMT* 10-150mg QD 2) Propranolol 80mg BID-TID 3) Topiramate 50mg BID 4) Di alproe 500 1000mg QD Cytovene (Ganciclovir) 250, 500mg Capsule CMV Retinitis Prophylaxis 1000mg TID 1) Valcyte 450mg 2T QD 2) Valcyte 50mg/ml 18ml QD CMV Retinitis Treatment 1) Valcyte 450mg 2T BID 2) Valcyte 50mg/ml 18ml BID Daliresp (Roflumilast) 500mcg Tablet QD 1) Ipratropium 0.02% Inhalation Solution QID 2) Aminophylline 100-200mg BID-TID 3) Proair HFA (Albuterol) 0.09mg Inhalation Aerosol Powder Q4H PRN 4) Theophylline 100-300 TID-QID 5) Albuterol 0.5% Inhalation Solution QID 6) Combivent (Albuterol Sulfate/Ipratropium Bromide) 0.09mg0.018mg Inhalation Aerosol Powder QID 7) Spiriva 18mcg QD Page 14 Last Updated: 6/20/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Comments Dalmane (Flurazepam) 15, 30mg Capsule QHS 1) Temazepam 15mg QHS 2) Lorazepam 0.5mg QHS 3) Oxazepam 10-30mg QHS 4) Trazodone 50-100mg QHS 5) Zolpidem 5-10mg QHS 6) Hydroxyzine 10-25mg QHS Dantrium (Dantrolene) 25, 50, 100mg Capsule 1) Cyclobenzaprine 10mg TID 2) Chlorzoxazone 250-500mg TID TID 3) Carisoprodol 350mg TID 4) Tizanidine 4mg TID 5) Methocarbamol 500-750mg QID 6) Baclofen 10-20mg TID Daytrana (Methylphenidate) 10mg/9hr, 15mg/9hr, 20mg/9hr, 30mg/9hr Transdermal Patch Apply 1 patch up to 9 hours Daypro (Oxaprozin) 600mg Tablet BID-TID Demadex (Torsemide) 5, 10, 20, 100mg Tablet QD 1) Methylin 5-20mg BID-TID 2) Adderall 5-30mg QD-BID 3) Document adequate therapeutic trial or intolerance Methylin ER 10-20mg BID-TID 4) Dextroamphetamine CR 5- to at least 3 formulary alternatives 15mg QD-BID 5) Adderall XR 5-30mg QAM 6) Methylphenidate ER 18-72mg QAM 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg BID 3) Ibuprofen 400-800mg TID-QID 4) Sulindac 150-200mg BID 5) Etodolac 200-500mg BID-TID 6) Nabumetone 500-750mg BID 7) Lidocaine 5% Ointment AAA Q4H 8) Diclofenac 25100mg BID-TID 9) Indomethacin 25-75mg QD-BID 10) Tolmetin 200-600mg TID 1) Bumetanide 0.5-1mg QD 2) Furosemide 20-80mg QD Dose Conversion Torsemide 10mg=Bumetanide 0.5mg=Furosemide 20mg / Torsemide 20mg=Bumetanide 1mg=Furosemide 40mg / Torsemide 40mg=Bumetanide 2mg=Furosemide 80mg Denavir (Penciclovir) 1% Cream AAA Q2H 1) OTC Abreva 10% Cream AAA Q4H 2) Acyclovir 400mg BID Depo-Testosterone (Testosterone Cypionate) 1) Testosterone Cypionate 200mg/ml IM Q2-4W 2) 100mg/ml Intramuscular Suspension Q2-4W Androderm Patch 2-4mg/24hr Apply QPM Dermatop (Prednicarbate) 0.1% Cream, Ointment AAA BID Medium Potency Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BID-QID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BID-QID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID Desonate (Desonide) 0.05% Gel AAA BID Low Potency Low Potency 1) Betamethasone Valerate 0.1% Lotion AAA QD-BID 2) Desonide 0.05% Cream, Ointment AAA BID-TID 3) Fluocinolone Acetonide 0.01% Solution AAA QD 4) DermaSmoothe/FS 0.01% Oil AAA QD Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BID-QID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Detrol (Tolterodine) 1, 2mg Tablet BID 1) Oxybutinin 5mg BID-TID 2) Oxybutynin XL 5-15mg QD 3) Oxytrol 3.9mg/day Patch Apply twice weekly 4) Trospium 20mg BID NF 5) Detrol LA 2-4mg QD NF 6) Toviaz 4-8mg QD NF 7) Enablex 7.5-15mg QD NF 8) Vesicare 5-10mg QD NF Detrol LA (Tolterodine) 2, 4mg Extended 1) Oxybutinin 5mg BID-TID 2) Oxybutynin XL 5-15mg QD 3) Release Capsule QD Oxytrol 3.9mg/day Patch Apply twice weekly 4) Trospium 20mg BID NF Dexilant (Dexlansoprazole) 30, 60mg Capsule 1) Pantoprazole 40mg QD 2) OTC Omeprazole 20mg QD 3) Excluded Medication QD OTC Zegerid 20/1100mg QD 4) OTC Prevacid 15mg QD Didrex (Benzphetamine) 50mg Tablet QD-TID Differin (Adapalene) 0.1% Cream, Gel, Lotion Retin-A 0.025-0.1% Cream, Gel AAA QHS AAA QHS Dificid (Fidaxomicin) 200mg Tablet BID X10D 1) Metronidazole 500mg TID X10-14D 2) Vancomycin 50mg/ml Solution 125mg QID X10-14D Diflucan (Fluconazole) 10, 40mg/ml Oral 1) Nystatin 100000 Suspension 4-6ml QID 2) Clotrimazole Powder for Suspension QD 10mg Troche QID Page 15 Last Updated: 6/20/2012 Excluded Medication (Exception: Obesity Rider) Excluded Medication for patients > 36 YOA KPGA Approved Compound Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Diovan (Valsartan) 80, 160, 320mg Tablet QD 1) Lisinopril QD NOTE: If Angiotensin Converting Enzyme Inhibitor allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan QD Diovan HCT (Valsartan/HCTZ) 80/12.5, 2 Separate Medications 160/12.5, 320/12.5, 160/25, 320/25mg Tablet HCTZ QD AND 1) Lisinopril QD NOTE: If Angiotensin QD Converting Enzyme Inhibitor allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan QD Comments Dose Conversion Diovan 80mg=Lisinopril 10mg=Losartan 25mg / Diovan 160mg=Lisinopril 20mg=Losartan 50mg / Diovan 320mg=Lisinopril 40mg=Losartan 100mg Dose Conversion Diovan 80mg=Lisinopril 10mg=Losartan 25mg / Diovan 160mg=Lisinopril 20mg=Losartan 50mg / Diovan 320mg=Lisinopril 40mg=Losartan 100mg NOTE: Consider Lisinopril/HCTZ 10/12.5, 20/12.5, 20/25mg or Losartan/HCTZ 50/12.5, 100/12.5, 100/25mg Dipentum (Olsalazine) 250mg Capsule 2T BID 1) Sulfasalazine 500mg (2-4gm QD) 2) Colazal 750mg (2.25gm TID for 8-12 weeks) 3) Asacol 400mg (800mg TID) 4) Dipentum 550mg BID NF 5) Pentasa 250, 500mg (1gm QID) Diprolene (Betamethasone Dipropionate Very High Potency Augmented) 0.05% Lotion, Ointment AAA QD- 1) Betamethasone Dipropionate Augmented 0.05% Cream BID Ultra High Potency AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID Diprolene AF (Betamethasone Dipropionate Augmented) 0.05% Cream AAA QD- BID Ultra High Potency Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID Diprosone (Betamethasone Dipropionate) 0.05% Ointment AAA QD-BID Very High Potency High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BID-QID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QD-BID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Divigel (Estradiol) 0.25, 0.5, 1mg Transdermal Gel/Jelly Apply QD alternating right or left upper thigh Dolobid (Diflunisal) 250, 500mg Tablet BIDTID 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.0250.1mg/24hr Apply weekly Doral (Quazepam) 15mg Tablet QHS Doryx (Doxycycline Hyclate) 75, 100, 150mg Delayed Release Tablet QD-BID Duac (Clindamycin/Benzoyl Peroxide) 1/5% Gel AAA BID Adjust to the lowest dose needed to control symptoms based on patient response 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg BID 3) Ibuprofen 400-800mg TID-QID 4) Sulindac 150-200mg BID 5) Etodolac 200-500mg BID-TID 6) Nabumetone 500-750mg BID 7) Lidocaine 5% Ointment AAA Q4H 8) Diclofenac 25100mg BID-TID 1) Temazepam 15mg QHS 2) Lorazepam 0.5mg QHS 3) Oxazepam 10-30mg QHS 4)Trazodone 50-100mg QHS 5) Zolpidem 5-10mg QHS 6) Hydroxyzine 10-25mg QHS 1) Doxycycline Hyclate 50-100mg BID Dose Conversion 2) Minocycline 50-100mg BID 3) Tetracycline 250-500mg BID Doryx 100mg QD=Doxycycline 50mg BID 1) Clindamycin 1% Gel AAA BID AND OTC Benzoyl Peroxide Dispense Clindamycin as 1 copay and purchase 5% Gel AAA BID 2) Erythromycin/Benzoyl Peroxide 3/5% Gel OTC Benzoyl Peroxide AAA BID Page 16 Last Updated: 6/20/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Duetact (Glimepiride/Pioglitazone) 2/30, 4/30mg Tablet QD 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin 5001000mg (Maximum 2550mg QD) 3) Metformin ER 500750mg (Maximum 2000mg QD) 4) Novolin R (Insulin Regular) SC 30 minutes AC 5) Novolin N (NPH) SC 15-30 minutes AC 6) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos 15mg (Maximum 45mg QD) Duexis (Ibuprofen/Famotidine) 800/26.6mg Tablet TID Dulera (Mometasone/Formoterol) 100/5, 200/5mcg Inhalation Aerosol Powder 2 PUFFS BID 2 Separate Medications Ibuprofen 800mg TID AND OTC Famotidine 20mg TID 1) Qvar 40-80mcg 1-2 PUFFS QD-BID 2) Asmanex 110220mcg 1-2 PUFFS QD DuoNeb (Albuterol Sulfate/Ipratropium Bromide) 3mg/3 ml-0.5mg/3ml Inhalation Solution QID 1) Albuterol 0.5% Inhalation Solution QID AND Ipratropium 0.02% Inhalation Solution QID 2) Combivent (Albuterol Sulfate/Ipratropium Bromide) 0.09mg0.018mg Inhalation Aerosol Powder QID 1) Prednisolone 1% 1-2 GTTS BID-QID 2) Fluorometholone 0.1% 1-2 GTTS BID-QID 3) Dexamethasone 0.1% 1-2 GTTS BID-QID 1) Cephalexin 250-500mg BID 1st Generation 2)Cefuroxime 250-500mg BID 2nd Generation 3) Cefdinir 125mg/5ml250mg/5ml BID 3rd Generation 4) Ceflacor 250-500mg BIDTID 2nd Generation 1) Doxycycline 50-100mg BID 2) Minocycline 50-100mg BID 3)Tetracycline 250-500mg BID 1) Amlodipine 5-10mg QD 2) Verapamil SR 180-240mg BID 3) Diltiazem ER 240-360mg QD 4) Nifedipine ER 30-60mg QD 5) Felodipine 2.5-20mg QD 1) Lisinopril QD NOTE: If Angiotensin Converting Enzyme Inhibitor allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan QD Durezol (Difluprednate) 0.05% Ophthalmic Emulsion 1GTT BID-QID Duricef (Cefadroxil) 500mg Capsule; 250mg/5ml, 500mg/5ml Powder for Suspension; 1gm Tablet QD-BID 1st Generation Dynacin (Minocycline) 75mg Tablet BID DynaCirc CR (Isradipine) 5, 10mg Extended Release Tablet QD Edarbi (Azilsartan Medoxomil) 40, 80mg Tablet QD Edecrin (Ethacrynic acid) 25mg Tablet QD Edluar (Zolpidem) 5, 10mg Sublingual Tablet QHS Edurant (Rilpivirine) 25mg Tablet QD Effient (Prasugrel) 5, 10mg Tablet QD Efudex (Fluorouracil) 2% Solution AAA BID Egrifta (Tesamorelin) 1mg Subcutaneous Powder for Solution 2mg SQ QD Comments Adjust based on patient response American Diabetes Association Recommendations -Patient uncontrolled on maximum Metformin and maximum Sulfonylurea=Do not initiate Actos and initiate Novolin N -Patient on Actos and Insulin=Discontinue Actos and maximize Novolin N Glipizide preferred if 65 years of age and older due to prolonged half life of Glyburide Document adequate trial or intolerance to Qvar 80mcg 2 PUFFS BID or Asmanex 220mcg 2 PUFFS QD within the past 3 months *Patients should have prescription for a ShortActing Beta 2 Agonist (e.g. Proair) for asthma exacerbations Dose Conversion Dulera 100/5mcg 2 PUFFS BID=Albuterol Q4H PRN + Qvar 80mcg 2 PUFFS BID=Albuterol Q4H PRN + Asmanex 220mcg 2 PUFFS QD / Dulera 200/5 2 PUFFS BID=No formulary alternative Dose Conversion DynaCirc CR 5mg=Nifedipine ER 30mg QD / DynaCirc CR 10mg=Nifedipine ER 60mg QD Dose Conversion Edarbi 40mg=Lisinopril 40mg=Losartan 100mg / Edarbi 80mg=No formulary alternative (Consider combination therapy)=Lisinopril/HCTZ 20/12.5mg 2T QD=Losartan/HCTZ 100/25mg 1) Bumetanide 0.5-1mg QD 2) Furosemide 20-80mg QD Dose Conversion Ethacrynic Acid 25mg=Bumetanide 0.5mg=Furosemide 20mg 1) Trazodone 50-100mg QHS 2) Temazepam 15-30mg QHS Document adequate therapeutic trial or intolerance to Trazodone, Zolpidem, and at least 1 3) Zolpidem 5-10mg QHS 4) Zaleplon 5-10mg QHS 5) Benzodiazepine Ambien CR 6.25-12.5mg QHS NF Intelence 200mg BID Clopidogrel 75mg QD 1) Fluorouracil 5% Solution AAA BID 2) Efudex 5% Cream AAA BID 3) Carac 0.5% Cream AAA BID NF 4) Fluoroplex 1% Cream AAA BID Egrifta is delivered directly to patient via KP CA Specialty Excluded Medication Pharmacy KP CA Specialty Pharmacy MD Line 650-301-5799 / Patient Line 1-877-4045777 / Fax Line 650-301-5790 Page 17 Last Updated: 6/20/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Elestat (Epinastine) 0.05 % Ophthalmic Solution 1 GTT BID Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Comments 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q3-4 HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID 4) Crolom 4% 1-2 GTTS Q4-6 HOURS NF 5) Emadine 0.05% 1 GTT QID NF 6) Alocril 2% 12 GTTS BID NF 7) Optivar 0.05% 1 GTT BID NF 8) Alomide 0.1% 1-2 GTTS QID NF 9) Lastacaft 0.25% 1 GTT QD NF 10) Pataday 0.2% 1 GTT QD NF 11) Alrex 0.2% 1 GTT QID NF 12) Patanol 0.1% 1 GTT BID NF Eldoquin Forte (Hydroquinone) 4% Cream Excluded Medication AAA BID Eligard (Leuprolide Acetate) 7.5 (1 Month), Administered in a healthcare setting by healthcare providers 22.5 (3 Month), 30 (4 Month), 45mg (6 Month) Lupron Depot available via KP Oncology Floorstock Subcutaneous Powder for Suspension UAD Elocon (Mometasone Furoate ) 0.1% Solution High Potency AAA QD High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BID-QID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QD-BID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Emadine (Emedastine) 0.05% Ophthalmic Solution 1 GTT QID 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q3-4 HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID 4) Crolom 4% 1-2 GTTS Q4-6 HOURS NF Emend (Aprepitant) 80, 125mg Capsule Day 1) Metoclopramide 1-2mg/kg 30 minutes prior to 1: 125mg 1 hour prior to chemotherapy Day 2- chemotherapy 2) Prochlorperazine 5-10mg Q6H 3) 3: 80mg QAM Dexamethasone 20mg 30 minutes prior to chemotherapy 4) Ondansetron 4-8mg 30 minutes prior to chemotherapy 5) Ondansetron 4-8mg ODT 30 minutes prior to chemotherapy Document current treatment with a) Cisplatin > 50mg/m2 b) AC (Doxorubicin/Cyclophosphamide) c) other highly emetogenic chemotherapy Enablex (Darifenacin) 7.5, 15mg Extended Release Tablet QD 1) Oxybutinin 5mg BID-TID 2) Oxybutynin XL 5-15mg QD 3) Oxytrol 3.9mg/day Patch Apply twice weekly 4) Trospium 20mg BID NF 5) Detrol LA 2-4mg QD NF 6) Toviaz 4-8mg QD NF Enjuvia (Conjugated Estrogen Synthetic B) Vasomotor Symtoms 0.3, 0.45, 0.625, 0.9, 1.25mg Tablet QD 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.0250.1mg/24hr Apply weekly Vaginal/Vulvar Atrophy 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.0250.1mg/24hr Apply weekly 3) Premarin Vaginal 1gm Apply three times a week 4) Vagifem 10mcg Insert twice weekly 5) Estring 2mg Insert for 90 days Enpresse (30mcg Ethinyl Estradiol/0.05mg 1) Tri-Sprintec (35mcg Ethinyl Estradiol/0.18mg Levonorgestrel x 6 days, 40 mcg EE/0.075mg Norgestimate x 7 days, 35mcg EE/0.215mg NG x 7 days, LVNGL x 5 days, 30mcg EE/0.125mg LVNGL 35mcg EE/0.25mg NGx 7 days) QD 2) Trivora (30mcg x 10 days) Tablet QD Ethinyl Estradiol/0.05mg Levonorgestrel x 6 days, 40mcg EE/0.075mg LVNGL x 5 days, 30mcg EE/0.125mg LVNGL x 10 days) QD 3) Leena (35mcg Ethinyl Estradiol/0.5mg Norethindrone x 7 days, 35mcg EE/1mg NE x 9 days, 35mcg EE/0.5mg NE x 5 days) QD Entocort (Budesonide) 3mg Delayed Release 1) Prednisone 5-60mg QD 2) Sulfasalazine 500mg (2-4gm Capsule 2-3T QD QD) 3) Hydrocortisone 100mg Enema QHS 4) Mesalamine 4gm Enema QHS 5) Colazal 750mg (2.25gm TID for 8-12 weeks) 6) Asacol 400mg (800mg TID) 7) Dipentum 550mg BID NF 8) Pentasa 250, 500mg (1gm QID) Page 18 Last Updated: 6/20/2012 Adjust to the lowest dose needed to control symptoms based on patient response Dose Conversion Enjuvia 0.3mg=Estradiol 0.5mg / Enjuvia 0.45mg=Estradiol 0.75mg / Enjuvia 0.625mg=Estradiol 1mg / Enjuvia 0.9mg=Estradiol 1.5mg / Enjuvia 1.25mg=Estradiol 2mg Equivalent Brand and Generic Products Enpresse=Trivora Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Entocort is a non-systemic steroid released in the intestine Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Comments Enzone (Hydrocortisone Acetate/Pramoxine) 1/1% Cream QD-BID 1) OTC Hydrocortisone 0.5-1% Cream, Ointment AAA BIDQID 2) OTC Prax 1% Cream, Lotion AAA BID-QID 3) Hydrocortisone 2.5% Cream, Lotion, Ointment AAA BID-QID 4) Hydrocortisone 25mg Suppository BID 5) Hydrocortisone 100mg/60ml Enema QD-BID 6) Proctofoam-HC 1/1% QDBID Epiduo (Adapalene/Benzoyl Peroxide) 2 Separate Medications 0.1/2.5% Gel AAA QD OTC Benzoyl Peroxide 2.5% AAA QD AND 1) Retin-A 0.0250.1% Cream, Gel AAA QHS 2) Differin 0.1% Cream AAA QD NF Epifoam (Hydrocortisone Acetate/Pramoxine) 1) OTC Hydrocortisone 0.5-1% Cream, Ointment AAA BID1/1% Foam QD-BID QID 2) OTC ProctoFoam 1% QD-BID 3) Hydrocortisone 2.5% Cream, Lotion, Ointment AAA BID-QID 4) Hydrocortisone 25mg Suppository BID 5) Hydrocortisone 100mg/60ml Enema QD-BID 6) Proctofoam-HC 1/1% QDBID EpiPen (Epinephrine) 0.3mg/0.3ml Injection Epinephrine 0.3mg/0.3ml Injection Device PRN Device PRN EpiPen Jr (Epinephrine) 0.15mg/0.3ml Epinephrine 0.15mg/0.3ml Injection Device PRN Injection Device PRN Epivir HBV (Lamivudine) 5mg/ml Solution; 1) Epivir 10mg/ml 10ml QD 2) Epivir 150mg QD 100mg Tablet QD Epogen (Epoetin Alfa) 2000, 3000, 4000, Procrit (Epoetin Alfa) 2000, 3000, 4000, 10000, 20000, 10000, 20000U/ml Injection Solution QW 40000U/ml QW Estrace (Estradiol) 0.1mg/gm Vaginal Cream 1) Estradiol QD 2) Climara Patch 0.025-0.1mg/24hr Apply 1gm Apply three times a week weekly 3) Premarin Vaginal 1gm Apply three times a week 4) Vagifem 10mcg Insert twice weekly 5) Estring 2mg Insert for 90 days Estraderm (Estradiol) 0.05, 0.1mg/24hr Vasomotor Symtoms Transdermal Patch Apply twice weekly 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.0250.1mg/24hr Apply weekly Vaginal/Vulvar Atrophy 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.0250.1mg/24hr Apply weekly 3) Premarin Vaginal 1gm Apply three times a week 4) Vagifem 10mcg Insert twice weekly 5) Estring 2mg Insert for 90 days Estrasorb (Estradiol) 2.5mg/gm Transdermal 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.025Emulsion Apply QD to each thigh 0.1mg/24hr Apply weekly EstroGel (Estradiol) 0.06% Transdermal Gel/Jelly Apply 1.25gm QD on the arm from wrist to shoulder Excluded Medication for patients > 36 YOA Dispense Retin-A or Differin as 1 copay and purchase OTC Benzoyl Peroxide EpiPen to Epinephrine 0.3mg/0.3ml is a 1:1 Conversion EpiPen Jr to Epinephrine 0.15mg/0.3ml is a 1:1 Conversion Epogen to Procrit is a 1:1 Conversion Adjust to the lowest dose needed to control symptoms based on patient response Adjust to the lowest dose needed to control symptoms based on patient response Adjust to the lowest dose needed to control symptoms based on patient response Vasomotor Symtoms 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.0250.1mg/24hr Apply weekly Vaginal/Vulvar Atrophy 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.0250.1mg/24hr Apply weekly 3) Premarin Vaginal 1gm Apply three times a week 4) Vagifem 10mcg Insert twice weekly 5) Estring 2mg Insert for 90 days EstroStep Fe (20 mcg Ethinyl Estradiol/1mg 1) Tri-Sprintec (35mcg Ethinyl Estradiol/0.18mg Norethindrone x 5 days, 30mcg EE/1mg NE x Norgestimate x 7 days, 35mcg EE/0.215mg NG x 7 days, 7 days, 35mcg EE/1mg NE x 9 days) Tablet 35mcg EE/0.25mg NGx 7 days) QD 2) Trivora (30mcg QD Ethinyl Estradiol/0.05mg Levonorgestrel x 6 days, 40mcg EE/0.075mg LVNGL x 5 days, 30mcg EE/0.125mg LVNGL x 10 days) QD 3) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) QD 4) Necon 1/35 (35mcg Ethinyl Estradiol/1mg Norethindrone) QD 5) Leena (35mcg Ethinyl Estradiol/0.5mg Norethindrone x 7 days, 35mcg EE/1mg NE x 9 days, 35mcg EE/0.5mg NE x 5 days) QD Adjust to the lowest dose needed to control symptoms based on patient response Evamist (Estradiol) 1.53mg/Actuation Transdermal Spray Apply 1-3 sprays to adjacent, non-overlapping area on the inner surface of the forearm Adjust to the lowest dose needed to control symptoms based on patient response 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.0250.1mg/24hr Apply weekly Page 19 Last Updated: 6/20/2012 Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Evoclin (Clindamycin) 1% Foam AAA QD Evoxac (Cevimeline) 30mg Capsule TID Exalgo (Hydromorphone) 8, 12, 16mg Extended Release Tablet QD Exelderm (Sulconazole) 1% Cream, Solution QD-BID Exelon (Rivastigmine) 4.6mg/24hr, 9.5mg/24 hr Patch QD Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy 1) Clindamycin 1% Solution AAA BID 2) Clindamycin 1% Gel AAA BID 3) Clindamycin 1% Lotion AAA BID 1) Pilocarpine 0.5, 1, 2, 3, 4, 6% Ophthalmic Solution 5-10 GTTS PO TID 2) Pilocarpine 5mg TID-QID NF 1) Morphine ER 60-100mg BID 2) Fentanyl 25-100mcg/hr Q72H 3) Avinza 30-120mg QD NF 4) Opana ER 5-40mg BID NF 5) Kadian 10-200mg QD NF Comments Ophthalmic Solution may be administered orally Dose Conversion Hydromorphone 7.5mg=Morphine 30mg=Oxycodone 20mg=Oxymorphone 10mg / Morphine 90mg=Fentanyl 25mcg/hr Document adequate therapeutic trial or intolerance to Morphine ER and Fentanyl 1) OTC Lamisil Ultra (Butenafine 1%) QD-BID 2) OTC Lotrimin AF (Clotrimazole 1%) BID 3) OTC Micatin (Miconazole 1%) BID 4) Ketoconazole 2% Cream QD 1) Galantamine 4-12mg BID, Galantamine ER 8-24mg QD 2) Document adequate therapeutic trial or intolerance Aricept 5-10mg QD 3) Namenda 5-10mg QD-BID 4) Exelon to Galantamine, Aricept, Namenda, and Exelon Capsule or Solution Capsule 1.5-6mg BID 5) Exelon Solution 2mg/ml 3ml BID Exforge (Amlodipine/Valsartan) 5/160, 5/320, 2 Separate Medications 10/160, 10/320mg Tablet QD Amlodipine QD AND 1) Lisinopril QD NOTE: If Angiotensin Converting Enzyme Inhibitor allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan QD Dose Conversion Diovan 80mg=Lisinopril 10mg=Losartan 25mg / Diovan 160mg=Lisinopril 20mg=Losartan 50mg / Diovan 320mg=Lisinopril 40mg=Losartan 100mg Exforge HCT (Amlodipine/Valsartan/HCTZ) 3 Separate Medications 5/160/12.5, 5/160/25, 10/160/12.5, 10/160/25, Amlodipine QD AND HCTZ QD AND 1) Lisinopril QD NOTE: 10/320/25mg Tablet QD If Angiotensin Converting Enzyme Inhibitor allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan QD Famvir (Famcyclovir) 125, 250, 500mg Tablet Genital Herpes Episodic Treatment BID-TID 1) Acyclovir 200mg Q4H 2) Acyclovir 400mg TID 3) Acyclovir 800mg BID 4) Valacyclovir 1gm BID X7D NF Genital Herpes Suppressive Treatment 1) Acyclovir 400mg BID 2) Valacyclovir 500mg QD NF Herpes Zoster Treatment 1) Acyclovir 800mg Q4H 2) Valacyclovir 1gm TID X7D NF Fanapt (Iloperidone) 1, 2, 4, 6, 8, 10, 12mg 1) Risperidone 4mg QD 2) Haloperidol 0.5-5mg BID-TID 3) Tablet BID Thiothixene 2mg TID 4) Quetiapine 400-800mg QD 5) Ziprasidone 20-80mg BID 6) Olanzapine 10mg QD 7) Olanzapine ODT 10mg QD 8) Latuda 40-80mg QD NF 9) Abilify 10-15mg QD 10) Saphris 5-10mg BID NF Fareston (Toremifene Citrate) 60mg Tablet 1) Tamoxifen 20-40mg QD 2) Faslodex 50mg/ml IM QM QD Felbatol (Felbamate) 600mg/5mL 1) Lamotrigine 100-200mg BID 2) Carbamazepine 800Suspension; 400, 600mg Tablet TID-QID 1600mg QD 3) Topiramate 200mg BID 4) Phenytoin 100mg TID 5) Levetiracetam 500-1500mg BID 6) Zonisamide 100mg TID NF 7) Gabapentin 300-600mg TID 8) Levetiracetam ER 1000mg QD 9) Oxcarbazepine 600mg BID NF 10) Divalproex 250-500mg TID 11) Lyrica 50-200mg TID NF 12) Vimpat 100200mg BID NF 13) Banzel 400mg BID NF 14) Gabitril 16 mg BID-TID NF Feldene (Piroxicam) 10, 20mg Capsule QD Meloxicam 7.5-15mg QD Femcon Fe (35mcg Ethinyl Estradiol/0.4mg 1) Sprintec (35mcg Ethinyl Estradiol/0.25mg Norgestimate) Norethindrone) Tablet QD QD 2) Necon 1/35 (35mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Necon 0.5/35 (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD 4) Zovia 1/35 (35mcg Ethinyl Estradiol/1mg Ethynodiol diacetate) QD 5) Brevicon (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD Dose Conversion Diovan 160mg=Lisinopril 20mg=Losartan 50mg / Diovan 320mg=Lisinopril 40mg=Losartan 100mg NOTE: Consider Lisinopril/HCTZ 20/12.5mg or Losartan/HCTZ 50/12.5, 100/25mg Femhrt 1/5 (Ethinyl Estradiol/Norethindrone Acetate) 5mcg/1mg Tablet QD Adjust to the lowest dose needed to control symptoms based on patient response Dose Conversion Ethinyl Estradiol 5mcg=Estradiol 1mg 2 Separate Medications 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.0250.1mg/24hr Apply weekly AND 1) Medroxyprogesterone 2.55mg QD 2) Nora-BE 0.35mg QD 3) Norethindrone 5mg QD Page 20 Last Updated: 6/20/2012 Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Comments Femring (Estradiol Acetate) 0.05, 0.1mg/24hr Vasomotor Symtoms Adjust to the lowest dose needed to control Vaginal Insert Insert for 90 days symptoms based on patient response 1) Estradiol QD 2) Climara Patch 0.025-0.1mg/24hr Apply weekly Vaginal/Vulvar Atrophy 1) Estradiol QD 2) Climara Patch 0.025-0.1mg/24hr Apply weekly 3) Premarin Vaginal 1gm Apply three times a week 4) Vagifem 10mcg Insert twice weekly 5) Estring 2mg Insert for 90 days Fentora (Fentanyl) 100, 200, 300, 400, 600, 1) Oxycodone/Acetaminophen 5/325mg Q6H 2) Morphine 15- Fentora is only approved for management of 800mg Buccal Tablet PRN 30mg Q4H 3) Hydromorphone 2-8mg Q4-6H 4) Oxycodone 5- breakthrough cancer pain in patients tolerant to 30mg Q4-6H 5) Morphine Solution 20mg/ml 0.5-1.5ml Q4H opioid therapy 6) Meperidine 50-150mg Q3-4H Finacea (Azelaic Acid) 15% Gel AAA BID 1) Tetracycline 250ā1000mg QD 2) Doxycycline 50ā200mg QD 3) Minocycline 50ā200mg QD 4) Metronidazole 0.75% Cream, Gel AAA BID Firazyr (Icatibant Acetate) 10mg/ml Criteria Restricted Medication Subcutaneous Solution 3ml SC QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Flector (Diclofenac Epolamine) 1.3% Topical 1) OTC Aspercreme AAA BID-QID 2) LidoPatch (Lidocaine Patch AAA BID 3.99%/Menthol 1%) Apply 1 patch up to 12 hours 3) Meloxicam 7.5-15mg QD 4) Naproxen 250-550mg BID 5) Ibuprofen 400-800mg TID-QID 6) Sulindac 150-200mg BID 7) Etodolac 200-500mg BID-TID 8) Nabumetone 500-750mg BID 9) Lidocaine 5% Ointment AAA Q4H 10) Diclofenac 25100mg BID-TID 11) Indomethacin 25-75mg QD-BID 12) Tolmetin 200-600mg TID Flovent HFA (Fluticasone) 110, 220mcg Inhalation Aerosol Powder 1-2 PUFFS BID 1) Qvar 40-80mcg 1-2 PUFFS QD-BID 2) Flovent HFA 44mcg 2 PUFFS BID NOTE: Flovent HFA 44mcg for patients 4-11 years of age 3) Asmanex 110-220mcg 1-2 PUFFS QD 4) Aerobid 0.25mg 2 PUFFS BID NF 5) Pulmicort Flexhaler 90-180mcg 2 PUFFS BID NF Florone (Diflorasone Diacetate) 0.05% Ointment AAA QD-QID High Potency High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BID-QID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QD-BID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Floxin (Ofloxacin) 0.3% Otic Solution 10 GTTS QD FML Forte (Fluorometholone) 0.25% Ophthalmic Suspension 1 GTT BID-QID Ofloxacin 0.3% Ophthalmic Solution 10 GTTS QID Focalin (Dexmethylphenidate) 2.5, 5, 10mg Tablet BID Document adequate therapeutic trial or intolerance to Qvar 80mcg 2 PUFFS BID and Asmanex 220mcg 2 PUFFS QD within the past 3 months Flovent is swallowed for the treatment of eosinophilic esophagitis Dose Conversion Flovent 110mcg 1-2 PUFFS BID=Qvar 80mcg 2 PUFFS BID=Asmanex 110mcg 1-2 PUFFS BID / Flovent 220mcg 1-2 PUFFS BID=Asmanex 220mcg 1-2 PUFFS BID Ophthalmic Solution may be administered in the ear 1) Prednisolone 1% 1-2 GTTS BID-QID 2) Fluorometholone 0.1% 1-2 GTTS BID-QID 3) Dexamethasone 0.1% 1-2 GTTS BID-QID 1) Methylin 5-20mg BID-TID 2) Adderall 5-30mg QD-BID 3) Document adequate therapeutic trial or intolerance Methylin ER 10-20mg BID-TID 4) Dextroamphetamine CR 5- to at least 3 formulary alternatives Focalin to Methylphenidate is a 1:2 Conversion 15mg QD-BID 5) Adderall XR 5-30mg QAM 6) Methylphenidate ER 18-72mg QAM Page 21 Last Updated: 6/20/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Focalin XR (Dexmethylphenidate) 5, 10, 15, 20, 30mg Extended Release Capsule QD Folic Acid Vitamins (Deplin, Folvite, Folacin800, FA-8) QD Foradil Aerolizer (Formoterol) 12mcg Inhalation Capsule BID Fortamet (Metformin) 500, 1000mg Extended Release Tablet QD Forteo (Teriparatide) 250mcg/ml Subcutaneous Solution 20mcg QD Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy 1) Methylin 5-20mg BID-TID 2) Adderall 5-30mg QD-BID 3) Methylin ER 10-20mg BID-TID 4) Dextroamphetamine CR 515mg QD-BID 5) Adderall XR 5-30mg QAM 6) Methylphenidate ER 18-72mg QAM OTC Folic Acid 0.4, 0.8,1mg QD 1) Albuterol Q4H PRN 2) Serevent 50mcg 1 PUFF BID 1) Metformin 500-1000mg (Maximum 2550mg QD) 2) Metformin ER 500-750mg (Maximum 2000mg QD) 1) Alendronate 10mg QD 2) Alendronate 70mg QW 3) Fortical 200IU QD Alternate nostrils 4) Ibandronate 150mg QM NF 5) Actonel 5mg QD NF 6) Actonel 150mg QM NF 7) Evista 60mg QD 8) Actonel 35mg QW NF Comments Document adequate therapeutic trial or intolerance to at least 3 formulary alternatives Focalin to Methylphenidate is a 1:2 Conversion Excluded Medication Available OTC Dose Conversion Foradil 12mcg 1 PUFF BID=Albuterol 1 PUFF BID=Serevent 50mcg 1 PUFF BID Adjust based on patient response Document a) diagnosis of osteoporosis (T-Score ā¤ 2.5) b) adequate therapeutic trial or intolerance to Bisphosphonate or SERM c) vertebral or fragility fracture prior to approval of Forteo for a total of 24 months with no renewal Fosamax Plus D (Alendronate/Cholecalciferol) Alendronate 70 mg Tablet QW 70mg/2800 IU, 70mg/5600 IU Tablet QW Fosrenol (Lanthanum Carbonate) 500, 750, 1000mg Chewable Tablet 1T with meals Fragmin (Dalteparin) 10000/1, 2500/0.2, 15000/0.6, 5000/0.2, 7500/0.3, 18000/0.72, 12500/0.5, 25000IU/ml Subcutaneous Solution QD Freestyle Glucometer and Test Strips Frova (Frovatriptan) 2.5mg Tablet PRN 1) Phoslyra 667mg/5ml 15ml with meals 2) Eliphos 667mg 3C with meals 3) Renvela 800mg 3T with meals Enoxaparin 1.5 mg/kg QD or 1mg/kg BID One Touch Ultra 2 Glucometer and One Touch Ultra Test Strips 1) Sumatriptan 25-100mg PRN 2) Sumatriptan 20mg Nasal Spray PRN 3) Naratriptan 1-2.5mg PRN 4) Sumatriptan 6mg/ml Subcutaneous Solution PRN 5) Maxalt MLT 5-10mg PRN NF 6) Zomig 5mg PRN NF 7) Zomig 2.5mg PRN NF 8) Relpax 20-40mg PRN NF 9) Axert 6.25-12.5mg PRN NF 10) Treximet 500/85mg PRN NF Quantity Limit Axert 6.25-12.5mg=6 Tablets Frova 2.5mg=9 Tablets Maxalt MLT 5-10mg=9 Tablets Naratriptan 1-2.5mg=9 Tablets Relpax 20-40mg=6 Tablets Sumatriptan 25-100mg=9 Tablets Treximet 500/85mg=9 Tablets Zomig 2.5mg=6 Tablets Zomig 5mg=3 Tablets Gabitril (Tiagabine) 2, 4, 12, 16mg Tablets QD 1) Lamotrigine 100-200mg BID 2) Carbamazepine 8001600mg QD 3) Topiramate 200mg BID 4) Phenytoin 100mg TID 5) Levetiracetam 500-1500mg BID 6) Zonisamide 100mg TID NF 7) Gabapentin 300-600mg TID 8) Levetiracetam ER 1000mg QD 9) Oxcarbazepine 600mg BID NF 10) Divalproex 250-500mg TID 11) Lyrica 50-200mg TID NF 12) Vimpat 100200mg BID NF 13) Banzel 400mg BID NF Gebauer Ethyl Chloride (Ethyl Chloride) 100% OTC Aerofreeze Topical Spray AAA PRN (Trichloromonofluoromethane/Dichlorodifluoromethane) AAA PRN Gilenya (Fingolimod) 0.5mg Capsule QD Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Glucotrol XL (Glipizide) 5, 10, 20mg Extended Glipizide 5-10mg QD-BID Adjust based on patient response Release Tablet QD Glipizide preferred if 65 years of age and older due to prolonged half life of Glyburide Glucovance (Glyburide/Metformin) 1.25/250, 2 Separate Medications 2.5/500, 5/500mg Tablet BID Glyburide BID AND Metformin BID Page 22 Last Updated: 6/20/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Glynase PresTab (Micronized Glyburide) 1.5, 1) Glipizide QD 2) Glyburide QD 3, 6mg Tablet QD Glyset (Miglitol) 25, 50, 100mg Tablet TID 1) Glipizide 5-15mg QD 2) Glyburide 2.5-10mg QD Golytely (Polyethylene Glycol 3350/Potassium Polyethylene Glycol 3350/Potassium Chloride/Sodium Chloride/Sodium Bicarbonate/Sodium Bicarbonate/Sodium Chloride/Sodium Sulfate Powder for Chloride/Sodium Sulfate) Solution 236/2.97/6.74/5.86/22.74gm Powder for Solution Gralise (Gabapentin) 300, 600mg Tablet 1800mg QD Gris-PEG (Griseofulvin) 125mg Tablet QDTID Halcion (Triazolam) 0.125, 0.25mg Tablet QHS Halog (Halcinonide) 0.1% Cream AAA BIDTID High Potency Comments Dose Conversion Glynase 1.5mg=Glipizide 5mg=Glyburide 2.5mg / Glynase 3mg=Glipizide 10mg=Glyburide 5mg / Glynase 6mg=Glipizide 20mg=Glyburide 10mg Adjust based on patient response Glipizide preferred if 65 years of age and older due to prolonged half life of Glyburide Adjust based on patient response Glipizide preferred if 65 years of age and older due to prolonged half life of Glyburide -Fill to 4L mark with water and shake vigorously to dissolve -Chill prior to administration to improve palatability -Refrigerate and use within 48 hours -Drink 240mL every 10 minutes until rectal effluent is clear or 4L are consumed 1) Nortriptyline (<65 YOA: 25mg/>65 YOA: 10mg) QHS 2) Gabapentin 600mg TID 3) Lidocaine 5% Ointment AAA Gris-PEG 250mg TID 1) Temazepam 15mg QHS 2) Lorazepam 0.5mg QHS 3) Oxazepam 10-30mg QHS 4) Trazodone 50-100mg QHS 5) Zolpidem 5-10mg QHS High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BID-QID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QD-BID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Halog (Halcinonide) 0.1% Ointment AAA BID- Very High Potency TID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID Hectorol (Doxercalciferol) 0.5, 1, 2.5mcg Capsule QD Helidac Therapy (Bismuth Subsalicylate, Metronidazole, Tetracycline) 262.4mg 2T QID, 250mg QID, 500mg QID X14D Hizentra (Immune Globulin) 20% Subcutaneous Solution SC QW Horizant (Gabapentin Enacarbil) 600mg Extended Release Tablet QD Calcitriol 0.25-1mcg QD First Line Tetracycline Hydrochloride 500mg QID, Metronidazole 250mg QID, OTC Omeprazole 20mg BID, OTC Bismuth Subsalicylate 262.4mg 2T QID X14D Second Line Clarithromycin 500mg BID or Amoxicillin 500mg 2C BID, Metronidazole 250mg QID, OTC Omeprazole 20mg BID, OTC Bismuth Subsalicylate 262.4mg 2T QID X14D IVIG Q4W 1) Pramipexole 0.125mg QHS 2) Ropinirole 0.25-4mg QHS Page 23 Last Updated: 6/20/2012 Dispense Antibiotics for copays and purchase OTC Bismuth Subsalicylate and OTC Omeprazole IVIG Infusion KP Hematology Contact CU Infusion Center 770-431-4367 or SW Infusion Center 770-603-3663 Network Hematology Contact Provider Relations 404-364-4934 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Humalog (Insulin Lispro) 100U/ml Injection Solution SC 15 minutes AC Humalog Mix 50/50 (Insulin Lispro Protamine/Insulin Lispro) 100U/ml Injection Solution SC 15 minutes AC Humalog Mix 75/25 (Insulin Lispro Protamine/Insulin Lispro) 100U/ml Injection Solution SC 15 minutes AC Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy 1) Novolin R (Insulin Regular) SC 30 minutes AC 2) NovoLog (Insulin Aspart) SC 5-10 minutes AC NF 2 Separate Medications Novolin N (NPH) SC 15-30 minutes AC AND 1) Novolin R (Insulin Regular) SC 30 minutes AC 2) NovoLog (Insulin Aspart) SC 5-10 minutes AC NF Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC OR 2 Separate Medications Novolin N (NPH) SC 15-30 minutes AC AND 1) Novolin R (Insulin Regular) SC 30 minutes AC 2) NovoLog (Insulin Aspart) SC 5-10 minutes AC NF Comments Adjust based on patient response Adjust based on patient response Dose Conversion Humalog Mix 50/50 20U=NPH 10U+Novolin R 10U Adjust based on patient response Dose Conversion Humalog Mix 75/25 20U=Novolin 70/30 20U=NPH 15U+Novolin R 5U Humalog KwikPen (Insulin Lispro) 100U/ml Injection Solution SC 15 minutes AC 1) Novolin R (Insulin Regular) SC 30 minutes AC 2) NovoLog Adjust based on patient response Insulin Administration Device (Insulin Aspart) SC 5-10 minutes AC NF Document a) member is unable to accurately draw up insulin due to upper extremity amputation, visual impairment, young age, Parkinson's Disease, Rheumatoid Arthritis b) member administers doses < 5U c) school or day care requires insulin cartridge device for insulin administration while member is outside of primary caretaker's care Humatrope (Somatropin) 6, 12, 24mg Injection Powder for Solution; 5mg Subcutaneous Powder for Solution QW Omnitrope (Somatropin) 5/1.5, 10/1.5mg/ml QW NF Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Adjust based on patient response Humulin R (Insulin Regular) 500U/ml Injection 1) Novolin R (Insulin Regular) SC 30 minutes AC 2) Novolin Solution SC 15 minutes AC N (NPH) SC 15-30 minutes AC 3) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 4) NovoLog (Insulin Aspart) SC 5-10 minutes AC NF Hycamtin (Topotecan) Capsule 0.25, 1mg 1) Platinum-based Chemotherapy 2) Etoposide 50mg/m2/day FDA approved for treatment of relapsed small cell 2 lung cancer (SCLC) 2.3mg/m /day PO X5D Q21D X5D Q21D 3) Topotecan 1.5 mg/m2/day IV X5D Q21D Hycodan (Hydrocodone Bitartrate/Homatropine Methylbromide) 5mg/1.5mg/5ml Syrup 5ml Q4-6H PRN 1) Cheratussin AC (Codeine/Guaifenesin) 10mg/100mg/5ml Q4-6H PRN 2) Promethazine/Codeine 6.25mg/10mg/5ml Q46H PRN 3) Promethazine VC/Codeine (Promethazine/Codeine/Phenylephrine) 6.25mg/10mg/5mg/5ml Q4-6H PRN 4) Benzonatate 100200mg TID PRN 5) Tussigon (Hydrocodone Bitartrate/Homatropine Methylbromide) 5/1.5mg Q4-6H PRN Hydrocortisone Acetate/Aloe 2% Cream, Gel AAA BID-QID Lowest Potency Lowest Potency 1) OTC Hydrocortisone 0.5-1% Cream, Ointment AAA BIDQID 2) Hydrocortisone 2.5% Cream, Lotion, Ointment AAA BID-QID Low Potency 1) Betamethasone Valerate 0.1% Lotion AAA QD-BID 2) Desonide 0.05% Cream, Ointment AAA BID-TID 3) Fluocinolone Acetonide 0.01% Solution AAA QD 4) DermaSmoothe/FS 0.01% Oil AAA QD 1) OTC Imodium A-D 4mg after first loose stool then 2mg after each subsequent loose stool 2) Dicyclomine 20mg QID 3) Belladonna Alkaloids/Phenobarbital 1-2T TID-QID 4) Diphenoxylate/Atropine 2.5/0.025mg/5ml 10ml QID 5) Diphenoxylate/Atropine 2.5/0.025mg 2T QID 6) Hyoscyamine SL 0.125mg 1-2T Q4H 7) Hyoscyamine 0.125mg 1-2T Q4H 8) Hyoscyamine Solution 0.125mg/ml 5-10ml Q4H HyoMax SR (Hyoscyamine) 0.375mg Extended Release Tablet BID Imitrex (Sumatriptan) 5mg Nasal Spray PRN Sumatriptan 20mg Nasal Spray PRN Page 24 Last Updated: 6/20/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Comments Imitrex (Sumatriptan) 4mg/0.5ml Subcutaneous Solution PRN Incivek (Telaprevir) 375mg Tablet 2T TID Sumatriptan 6mg/0.5ml Subcutaneous Solution PRN 2 Separate Medications Peg-Intron 1.5mcg/kg QW AND Ribavirin 800-1400mg QD No initial fill Document a) chronic Hepatitis C genotype 1 b) prescription from Gastroenterologist or Infectious Disease Specialist c) compensated liver disease d) active prescriptions for Interferon Alfa and Ribavirin Inderal LA (Propranolol) 60, 80, 120, 160mg Extended Release Capsule QD 1) Propranolol 120-240mg QD 2) Nadolol 240-320mg QD 3) Carvedilol 12.5-25mg BID 4) Labetalol 200-400mg BID Dose Conversion Propanolol ER 60mg=Propranolol 20mg 1.5T BID / Propanolol ER 80mg=Propanolol 40mg BID / Propranolol ER 120mg=Propranolol 60mg BID / Propanolol ER 160mg=Propranolol 80mg BID Infergen (Interferon Alfacon-1) 30mcg/ml Subcutaneous Solution QD 1) Pegasys 180mcg QW 2) PEG-Intron 150mcg QW Inspra (Eplerenone) 25, 50mg Tablet QD 1) Amiloride/HCTZ 5/50mg QD 2) Triamterene/HCTZ 37.5/2575/50mg QD 3) Spironolactone 50-100mg Tablet QD Intuniv (Guanfacine ER) 1, 2, 3, 4mg Tablet QD Document adequate therapeutic trial or intolerance 1) Guanfacine 1-4mg QD 2) Methylin 5-20mg BID-TID 3) Adderall 5-30mg QD-BID 4) Methylin ER 10-20mg BID-TID 5) to 2 formulary alternatives and Guanfacine Dextroamphetamine CR 5-15mg QD-BID 6) Adderall XR 530mg QAM 7) Methylphenidate ER 18-72mg QAM Invega (Paliperidone) 1.5, 3, 6, 9mg Extended 1) Risperidone 4mg QD 2) Haloperidol 0.5-5mg BID-TID 3) Release Tablet QD Thiothixene 2mg TID 4) Quetiapine 400-800mg QD 5) Ziprasidone 20-80mg BID 6) Olanzapine 10mg QD 7) Olanzapine ODT 10mg QD 8) Latuda 40-80mg QD NF 9) Abilify 10-15mg QD 10) Saphris 5-10mg BID NF 11) Fanapt 612mg BID NF Iressa (Gefitinib) 250mg Tablet QD 1) Platinum-based Chemotherapy 2) Docetaxel 75mg/m2 IV FDA approved for treatment of locally advanced or metastatic nonsmall cell lung cancer (NSCLC) who Q21D have failed both Platinum and Docetaxel-based Chemotherapy Iron Vitamins (Ferrex Forte, Niferex, Niferex OTC Ferrex 150 QD Excluded Medication Forte) QD Available OTC Ismo (Isosorbide Mononitrate) 10, 20mg Isosorbide Mononitrate ER 30-120mg QD Tablet BID Jalyn (Dutasteride/Tamsulosin) 0.5/0.4mg 2 Separate Medications Finasteride Capsule QD 5mg QD and 1) Terazosin 1-10mg QD 2) Doxazosin 1-8mg QD 3) Tamsulosin 0.4mg QD Januvia (Sitagliptin) 25, 50, 100mg Tablet QD 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin 500Criteria Restricted Medication QRM approval required prior to being dispensed for 1000mg (Maximum 2550mg QD) 3) Metformin ER 500Commercial, Multi-Choice, Self-Funded, and Triple 750mg (Maximum 2000mg QD) 4) Novolin R (Insulin Tier members. Regular) SC 30 minutes AC 5) Novolin N (NPH) SC 15-30 Provider must call 404-364-7320 (Option 2) to minutes AC 6) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog (Insulin Aspart) SC 5-10 minutes AC initiate review by QRM department. NF 8) Actos 15mg (Maximum 45mg QD) Janumet (Metformin/Sitagliptin) 500/50, 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin 500Criteria Restricted Medication 1000/50mg Tablet QD QRM approval required prior to being dispensed for 1000mg (Maximum 2550mg QD) 3) Metformin ER 500Commercial, Multi-Choice, Self-Funded, and Triple 750mg (Maximum 2000mg QD) 4) Novolin R (Insulin Tier members. Regular) SC 30 minutes AC 5) Novolin N (NPH) SC 15-30 Provider must call 404-364-7320 (Option 2) to minutes AC 6) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog (Insulin Aspart) SC 5-10 minutes AC initiate review by QRM department. NF 8) Actos 15mg (Maximum 45mg QD) Junel 1/20 (20mcg Ethinyl Estradiol/1mg Document adequate therapeutic trial or intolerance 1) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) Tablet QD Norethindrone) QD 2) Aviane (20mcg Ethinyl Estradiol/0.1mg to at least 3 formulary oral contraceptives Levonorgestrel) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD Page 25 Last Updated: 6/20/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Juvisync (Simvastatin/Sitagliptin) 10/100, 20/100, 40/100mg Tablet QD Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy 2 Separate Medications Simvastatin 10-40mg QD AND 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin 500-1000mg (Maximum 2550mg QD) 3) Metformin ER 500-750mg (Maximum 2000mg QD) 4) Novolin R (Insulin Regular) SC 30 minutes AC 5) Novolin N (NPH) SC 15-30 minutes AC 6) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos 15mg (Maximum 45mg QD) Comments Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Kadian (Morphine Sulfate) 10, 20, 30, 50, 60, 1) Morphine ER 60-100mg BID 2) Fentanyl 25-100mcg/hr Dose Conversion 80, 100, 200mg Extended Release Capsule Q72H 3) Avinza 30-120mg QD NF 4) Opana ER 5-40mg BID Morphine 30mg=Oxycodone 20mg=Oxymorphone QD 10mg / Morphine 90mg=Fentanyl 25mcg/hr NF Document adequate therapeutic trial or intolerance to Morphine ER and Fentanyl Kalbitor (Ecallantide) 10mg/ml Subcutaneous 1) Danazol 200mg BID-TID 2) Oxandrolone 2.5-20mg BIDSolution 3ml SC QID NF 3) Berinert 20U/kg IV NF Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Kapvay (Clonidine) 0.1mg Extended Release 1) Clonidine 0.1mg QD-TID 2) Methylin 5-20mg BID-TID 3) Document adequate therapeutic trial or intolerance Tablet QHS-BID Adderall 5-30mg QD-BID 4) Methylin ER 10-20mg BID-TID 5) to 2 formulary alternatives and Clonidine Dextroamphetamine CR 5-15mg QD-BID 6) Adderall XR 530mg QAM 7) Concerta 18-72mg QAM 8) Guanfacine 1-4mg QD Kariva (20mcg Ethinyl Estradiol/0.15mg 1) Reclipsen 0.25 (30mcg Ethinyl Estradiol/0.15 Desogestrel) Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Desogestrel x 21 days, 10mcg EE x 5 days) QD 2) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Tablet QD Norethindrone) QD 3) Aviane (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel) QD Kenalog (Triamcinolone Acetonide) 0.5% Very High Potency Cream, Ointment AAA BID-QID Very High 1) Betamethasone Dipropionate Augmented 0.05% Cream Potency AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID Keppra XR 500, 750mg Extended Release Tablet QD-BID Kineret (Anakinra) 100mg/0.67ml Subcutaneous Solution QD 1) Lamotrigine 100-200mg BID 2) Carbamazepine 8001600mg QD 3) Topiramate 200mg BID 4) Phenytoin 100mg TID 5) Levetiracetam 500-1500mg BID 6) Zonisamide 100mg TID NF 7) Gabapentin 300-600mg TID 8) Levetiracetam ER 1000mg QD 1) Atenolol 50-100mg QD 2) Metoprolol 100-450mg QD 3) Acebutolol 400-800mg QD 4) Bisoprolol 2.5-20mg QD 5) Carvedilol 12.5-25mg BID 6) Labetalol 200-400mg BID Community Acquired Pneumonia 1) Levofloxacin 750mg QD X5D 2) Levofloxacin 500mg QD X10D 3) Azithromycin 500mg QD X5D 4) Cefuroxime 500mg BID X10D 1) Humira 40mg QOW 2) Enbrel 50mg QW 3) Remicade 5mg/kg Q8W NF Klaron (Sodium Sulfacetamide) 10% Lotion AAA BID Klor-Con 25 (Potassium Chloride) 25mEq Powder for Solution QD 1) Sodium Sulfacetamide/Sulfur 10/5% Lotion AAA BID 2) Sodium Sulfacetamide/Sulfur 10/5% Solution AAA BID 1) K-Tab 10mEq Extended Release 2T QD 2) Klor-Con 20mEq Powder for Solution QD Kerlone (Betaxolol) 10, 20mg Tablet QD Ketek (Telithromycin) 300, 400mg Tablet 2T QD Page 26 Last Updated: 6/20/2012 Dose Conversion Betaxolol 10mg QD=Atenolol 50mg QD / Betaxolol 20mg QD=Atenolol 100mg QD Remicade Infusion KP Rheumatology Contact CU Infusion Center 770-431-4367 or SW Infusion Center 770-603-3663 Network Rheumatology Contact Provider Relations 404-364-4934 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Klor-Con M20 (Potassium Chloride) 20mEq Extended Release Tablet QD Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Comments 1) K-Tab 10mEq Extended Release 2T QD 2) Klor-Con 20mEq Powder for Solution QD Kombiglyze (Metformin/Saxagliptin) 500/5, 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin 5001000/2.5, 1000/5mg Extended Release Tablet 1000mg (Maximum 2550mg QD) 3) Metformin ER 500QD 750mg (Maximum 2000mg QD) 4) Novolin R (Insulin Regular) SC 30 minutes AC 5) Novolin N (NPH) SC 15-30 minutes AC 6) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos 15mg (Maximum 45mg QD) Kytril (Granisetron) 1mg Tablet 2T 1 hour prior 1) Metoclopramide 1-2mg/kg 30 minutes prior to to chemotherapy chemotherapy 2) Prochlorperazine 5-10mg Q6H 3) Dexamethasone 20mg 30 minutes prior to chemotherapy 4) Ondansetron 4-8mg 30 minutes prior to chemotherapy 5) Ondansetron 4-8mg ODT 30 minutes prior to chemotherapy 6) Transderm Scop 1.5mg Apply Q72H NF Lac-Hydrin (Ammonium Lactate) 12% Cream OTC AmLactin (Ammonium Lactate) 12% Cream AAA BID AAA BID Lacrisert (Hydroxypropyl Cellulose) 5mg 1) OTC GenTeal, Tears Again, Tears Naturale Free Artificial Tear Insert Insert QD-BID (Hydroxypropyl Methylcelluclose 0.3%) 1-2 GTT TID-QID 2) OTC Isopto Plain (Hydroxypropyl Methylcelluclose 0.5%) 1-2 GTT TID-QID 3) OTC Murocel (Methylcellulose 3%) 1-2 GTT TID-QID Lamisil (Terbinafine) 250mg Tablet QD-BID Thymol/Isopropyl Alcohol 4/99% Solution QD Lantus (Insulin Glargine) 100U/ml Injection Solution SC QD 1) Novolin N (NPH) SC 15-30 minutes AC 2) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC Lantus Solostar (Insulin Glargine) 100U/ml Injection Solution SC QD 1) Novolin N (NPH) SC 15-30 minutes AC 2) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC Lastacaft (Alcaftadine) 0.25% Ophthalmic Solution 1 GTT QD 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q3-4 HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID 4) Crolom 4% 1-2 GTTS Q4-6 HOURS NF 5) Emadine 0.05% 1 GTT QID NF 6) Alocril 2% 12 GTTS BID NF 7) Optivar 0.05% 1 GTT BID NF 8) Alomide 0.1% 1-2 GTTS QID NF Latisse (Bimatoprost) 0.03% Ophthalmic Solution Apply QHS to upper eyelid margin Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Excluded Medication Available OTC KPGA Approved Compound Finger Onychomycosis Document positive fungal culture prior to approval of one 6 week treatment Toe Onychomycosis Document a) positive fungal culture b) DM or Vascular Disease prior to approval one 12 week treatment -Lantus (< 30U QD) to Novolin N (QD dosing) is a 1:1 Conversion -Lantus (>30U QD) to Novlin N (BID dosing) is a 0.8:1 Conversion Document a) member with DM1 b) member undergoing dialysis c) adequate therapeutic trial or intolerance (Hypoglycemia) to NPH -Lantus (< 30U QD) to Novolin N (QD dosing) is a 1:1 Conversion -Lantus (>30U QD) to Novlin N (BID dosing) is a 0.8:1 Conversion Document a) member with DM1 b) member undergoing dialysis c) adequate therapeutic trial or intolerance (Hypoglycemia) to NPH Insulin Administration Device Document a) member is unable to accurately draw up insulin due to upper extremity amputation, visual impairment, young age, Parkinson's Disease, Rheumatoid Arthritis b) member is administers doses < 5U Excluded Medication Page 27 Last Updated: 6/20/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Latuda (Lurasidone) 40, 80mg Tablet QD Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Lescol (Fluvastatin) 20, 40mg Capsule QHS 1) Risperidone 4mg QD 2) Haloperidol 0.5-5mg BID-TID 3) Thiothixene 2mg TID 4) Quetiapine 400-800mg QD 5) Ziprasidone 20-80mg BID 6) Olanzapine 10mg QD 7) Olanzapine ODT 10mg QD 1) Simvastatin 5-10mg QD 2) Pravastatin 10-20mg QD Lescol XL (Fluvastatin) 80mg Extended Release Tablet QHS 1) Simvastatin 20mg QD 2) Pravastatin 40mg QD 3) Atorvastatin 10mg QD Lessina (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel) Tablet QD 1) Aviane (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel) QD 2) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD Comments Dose Conversion Fluvastatin 20mg=Pravastatin 10mg=Simvastatin 5mg / Fluvastatin 40mg=Pravastatin 20mg=Simvastatin 10mg Dose Conversion Fluvastatin 80mg=Atorvastatin 10mg=Pravastatin 40mg=Simvastatin 20mg Equivalent Brand and Generic Products Lessina=Aviane Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Letairis (Ambrisentan) 5, 10mg Tablet QD 1) Tracleer 62.5-125mg BID 2) Flolan 2ng/kg/min 3) KP CA Specialty Pharmacy Remodulin 1.25-2.5ng/kg/min QW MD Line 650-301-5799 / Patient Line 1-877-404Prescribing Physician must call Letairis Education Access 5777 / Fax Line 650-301-5790 Program 866-664-LEAP Letairis is delivered directly to patient via KP CA Specialty Pharmacy Levaquin (Levofloxacin) 25mg/ml Solution QD Community Acquired Pneumonia 1) Levofloxacin 750mg QD X5D 2) Levofloxacin 500mg QD X10D 3) Azithromycin 500mg QD X5D 4) Cefuroxime 500mg BID X10D Sinusitis 1) SMZ-TMP DS BID X7D 2) Doxycycline 100mg BID X7D 3) Amoxicillin 1000mg BID X7D 4) Azithromycin 500mg QD X3D Urinary Tract Infection 1) SMZ-TMP DS BID X3D 2) Ciprofloxacin 250mg BID X3D 3) Levofloxacin 250mg QD X3D 4) Nitrofurantoin Monohydrate 100mg BID X7D Levemir (Insulin Detemir) 100U/ml Injection Solution SC QD-BID Levitra (Vardenafil) 2.5, 5, 10, 20mg Tablet PRN Lexapro (Escitalopram) 5mg/5ml Solution; 5, 10, 20mg Tablet QD 1) Novolin N (NPH) SC 15-30 minutes AC 2) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 1) Citalopram 20-40mg QD 2) Fluoxetine 20-40mg QD 3) Sertraline 50-100mg QD 4) Mirtazapine 30mg QHS 5) Bupropion SR/XL 300mg QD 6) Venlafaxine ER 225mg QD 7) Fluvoxamine 50-300mg QD NF Lialda (Mesalamine) 1.2gm Delayed Release 1) Sulfasalazine 500mg (2-4gm QD) 2) Colazal 750mg Tablet 2.4-4.8gm QD (2.25gm TID for 8-12 weeks) 3) Asacol 400mg (800mg TID) 4) Dipentum 550mg BID NF 5) Pentasa 250, 500mg (1gm QID) Lidoderm (Lidocaine) 5% Topical Patch Apply 1) OTC LMX 4 (Lidocaine 4% Cream) AAA QID 2) OTC 1-3 patches up to 12 hours Axsain cream (Lidocaine 4%/Capsaicin 0.25% Cream) AAA QID 3) LidoPatch (Lidocaine 3.99%/Menthol 1%) Apply 1 patch up to 12 hours 4) Lidocaine 2% Gel AAA QID 5) Lidocaine 5% Ointment AAA 5G QID Lipofen (Fenofibrate) 50, 150mg Capsule QD 1) Gemfibrozil 600mg BID 2) Fenofibrate 54-160mg QD Livalo (Pitavastatin) 1, 2, 4mg Tablet QD 1) Simvastatin 10-40mg QD 2) Pravastatin 20-80mg QD 3) Atorvastatin 10-20mg QD Page 28 Last Updated: 6/20/2012 Document adequate therapeutic trial or intolerance (Hypoglycemia) to NPH Excluded Medication (Exception: Sexual Dysfunction Rider) Document adequate trial or intolerance to all formulary SSRIs Lidoderm is only indicated for postherpetic neuralgia Dose Conversion Lipofen 50mg=Fenofibrate 54mg / Lipofen 150mg=Fenofibrate 160mg Fenofibrate preferred if current statin therapy Gemfibrozil preferred if reduced renal function Dose Conversion Pitavastatin 1mg=Pravastatin 20mg=Simvastatin 10mg / Pitavastatin 2mg=Atorvastatin 10mg=Pravastatin 40mg=Simvastatin 20mg / Pitavastatin 4mg=Atorvastatin 20mg=Pravastatin 80mg=Simvastatin 40mg Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Locoid (Hydrocortisone Butyrate) 0.1% Cream, Ointment, Solution AAA BID-TID Medium Potency Locoid Lipocream (Hydrocortisone Butyrate) 0.1% Cream AAA BID-TID Medium Potency Lodine XL (Etodolac) 400, 500, 600mg Extended Release Tablet QD Loestrin 21 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) Tablet QD Loestrin 24 Fe (20mcg Ethinyl Estradiol/1mg Norethindrone x 24 days) Tablet QD Lo Loestrin Fe (10mcg Ethinyl Estradiol/1mg Norethindrone x 24 days, 10mcg EE x 2 days) Tablet QD Lo/Ovral (30mcg Ethinyl Estradiol/0.3 Norgestrel) Tablet QD Loprox (Ciclopirox) 0.77% Cream; 0.77% Gel; 1% Shampoo BID LoSeasonique (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel x 84 days, 10mcg EE x 7 days) Tablet QD Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BID-QID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BID-QID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BID-QID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BID-QID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg BID 3) Ibuprofen 400-800mg TID-QID 4) Sulindac 150-200mg BID 5) Etodolac 200-500mg BID-TID 6) Nabumetone 500-750mg BID 1) Aviane (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel) QD 2) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD 1) Aviane (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel) QD 2) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD 1) Aviane (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel) QD 2) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD 1) Reclipsen (30mcg Ethinyl Estradiol/0.15mg Desogestrel) QD 2) Microgestin Fe 1.5/30 (30mcg Ethinyl Estradiol/1.5mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD 1) OTC Lamisil Ultra (Butenafine 1%) QD-BID 2) OTC Lotrimin AF (Clotrimazole 1%) BID 3) OTC Micatin (Miconazole 1%) BID 4) Ketoconazole 2% Cream QD 1) Aviane (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel) QD 2) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD Comments Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Equivalent Brand and Generic Products Lo/Ovral=Cryselle Levora Dose Recommendation Day 1-84: Take 1 active tablet QD (Discard placebo tablets from first 3 packets) Day 85-91: Take 1 placebo tablet QD Lotemax (Loteprednol) 0.5% Ophthalmic Suspension 1-2 GTT QID 1) Diclofenac 0.1% 1GTT QID 2) Ketorolac 0.5% 1 GTT QID 3) Prednisolone 1% 1-2 GTTS BID-QID 4) Fluorometholone 0.1% 1-2 GTTS BID-QID 5) Dexamethasone 0.1% 1-2 GTTS BID-QID 6) Ketorolac 0.4% 1 GTT QID 7) Flurbiprofen 0.03% 1 GTT QID NF 8) Vexol 1% 1-2 GTT QID NF 9) Bromfenac 0.09% 1 GTT QD-BID NF Lotrel (Amlodipine/Benazepril) 2.5/10, 5/10, 5/20, 10/20mg Tablet QD Lotrisone (Betamethasone Dipropionate/Clotrimazole) 0.05/1% Cream, Lotion AAA BID Lotronex (Alosetron) 0.5, 1mg Tablet BID 2 Separate Medications Amlodipine QD AND Benazapril QD Dispense Betamethasone Dipropionate as 1 copay 2 Separate Medications and purchase OTC Clotrimazole Betamethasone Dipropionate 0.05% Cream AAA BID AND OTC Clotrimazole 1% Gel AAA BID 1) OTC Imodium A-D 4mg after first loose stool then 2mg after each subsequent loose stool 2) Dicyclomine 20mg QID 3) Belladonna Alkaloids/Phenobarbital 1-2T TID-QID 4) Diphenoxylate/Atropine 2.5/0.025mg/5ml 10ml QID 5) Diphenoxylate/Atropine 2.5/0.025mg 2T QID 6) Hyoscyamine SL 0.125mg 1-2T Q4H 7) Hyoscyamine 0.125mg 1-2T Q4H 8) Hyoscyamine Solution 0.125mg/ml 5-10ml Q4H 9) Hyoscyamine SR 0.375mg BID NF Prescribing Physician must call Prometheus Prescribing 888423-5227 Page 29 Last Updated: 6/20/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Lovaza (Omega-3-Acid Ethyl Esters) 1gm Liquid Filled Capsule QD Low-Ogestrel (30mcg Ethinyl Estradiol/0.3 Norgestrel) Tablet QD Lumigan (Bimatoprost) 0.01, 0.03% Ophthalmic Solution 1 GTT QPM Lunesta (Eszopiclone) 1, 2, 3mg Tablet QHS Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Comments 1) OTC Omega-3 Fish Oil QD 2) Gemfibrozil 600mg BID 3) Fenofibrate 54-160mg QD Dose Conversion Lovaza 1gm= EPA 465mg and DHA 375mg Lovaza is only FDA approved for TG > 500mg/dL Fenofibrate preferred if current statin therapy Gemfibrozil preferred if reduced renal function 1) Reclipsen (30mcg Ethinyl Estradiol/0.15mg Desogestrel) Equivalent Brand and Generic Products QD 2) Microgestin Fe 1.5/30 (30mcg Ethinyl Estradiol/1.5mg Low-Ogestrel=Cryselle Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD 1) Latanoprost 0.005% 1 GTT QPM 1) Trazodone 50-100mg QHS 2) Temazepam 15-30mg QHS Document adequate therapeutic trial or intolerance to Trazodone, Zolpidem, and at least 1 3) Zolpidem 5-10mg QHS 4) Zaleplon 5-10mg QHS 5) Ambien CR 6.25-12.5mg QHS NF 6) Rozerem 8mg QHS NF Benzodiazepine Lustra (Hydroquinone) 4% Cream AAA BID Luvox CR (Fluvoxamine) 100, 150mg Extended Release Capsule 1) Citalopram 20-40mg QD 2) Fluoxetine 20-40mg QD 3) Sertraline 50-100mg QD 4) Mirtazapine 30mg QHS 5) Bupropion SR/XL 300mg QD 6) Venlafaxine ER 225mg QD 7) Fluvoxamine 50-300mg QD NF Luxiq (Betamethasone Valerate) 0.12% Foam Low Potency AAA BID Medium-High Potency Fluocinolone 0.01% Solution Medium-High Potency Betamethasone Valerate 0.1% Ointment AAA QD-BID Very High Potency Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 2) Clobetasol Propionate 0.05% Solution AAA BID 3) Clobetasol 0.05% Aerosol AAA BID NF Lybrel (20mcg Ethinyl Estradiol/0.09mg 1) Aviane (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel) Levonorgestrel) Tablet QD QD 2) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD Lyrica (Pregabalin) 25, 50, 75, 100, 150, 200, Diabetic Peripheral Neuropathic Pain 225, 300mg Capsule BID-TID 1) Amitriptyline* 50mg QHS 2) Nortriptyline* (<65 YOA: 25mg QHS / > 65 YOA: 10mg QHS) 3) Cyclobenzaprine* 10mg TID 4) Tramadol* 50mg BID 5) Venlafaxine ER 150 ā 225mg QD Non-Diabetic Peripheral Neuropathic Pain 1) Amitriptyline* 50mg QHS 2) Nortriptyline* (<65 YOA: 25mg QHS / > 65 YOA: 10mg QHS) 3) Cyclobenzaprine* 10mg TID 4) Tramadol* 50mg BID Fibromyalgia 1) Amitriptyline* 50mg QHS 2) Nortriptyline* (<65 YOA: 25mg QHS / > 65 YOA: 10mg QHS) 3) Cyclobenzaprine* 10mg TID 4) Tramadol* 50mg BID Post Herpetic Neuralgia 1) Nortriptyline* (<65 YOA: 25mg QHS / > 65 YOA: 10mg QHS) 2) Gabapentin 600mg TID 3) Lidocaine 5% Ointment AAA of allodynia and localized pain Lysteda (Tranexamic Acid) 650mg Tablet 2T TID X5D 1) Combination Oral Contraceptive 2) Medroxyprogesterone 5-10mg QD 3) Norethindrone 5mg QD Macrodantin (Nitrofurantoin Macrocrystal) 100mg Capsule QD-BID UTI Prophylaxis Nitrofurantoin Monohydrate 100mg QD UTI Treatment 1) SMZ-TMP DS BID X3D 2) Ciprofloxacin 250mg BID X3D 3) Levofloxacin 250mg QD X3D 4) Nitrofurantoin Monohydrate 100mg BID X7D Page 30 Last Updated: 6/20/2012 Excluded Medication Document adequate trial or intolerance to all formulary SSRIs Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Diabetic Peripheral Neuropathic Pain Document adequate therapeutic trial or intolerance to 1 TCA*, Tramadol*; and Venlafaxine Non-Diabetic Peripheral Neuropathic Pain Document adequate therapeutic trial or intolerance to 1 TCA*, Tramadol*, and Cyclobenzaprine Fibromyalgia Document adequate therapeutic trial or intolerance to 1 TCA*, Tramadol*, and Cyclobenzaprine Post Herpetic Neuralgia Document adequate therapeutic trial or intolerance to 1 TCA* and Gabapentin *Not recommended in the elderly and not a required medication for patients over 65 years old Quantity Limit Lysteda 650mg (30 Day Supply)=30 Tablets Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Comments Makena (Hydroxyprogesterone Caproate) 250mg/ml Intramuscular Solution QW Preservative Free Hydroxyprogesterone 250mg/ml QW Hydroxyprogesterone compounded by PharMerica is delivered directly to patient via Alere Obstetrical Homecare Administered by Alere Obstetrical Homecare Nurse Mavik (Trandolapril) 1, 2, 4mg Tablet QD 1) Lisinopril 20-40mg QD 2) Benazepril 20-40mg QD 3) Dose Conversion Enalapril 10-40mg QD 4) Captopril 25-100mg TID 5) Ramipril Trandolapril 1mg=Lisinopril 10mg / Trandolapril 2mg=Lisinopril 20mg / Trandolapril 4mg=Lisinopril 2.5-20mg QD 40mg Proair HFA (Albuterol) 0.09mg Inhalation Aerosol Powder Maxair Autohaler to Proair HFA is a 1:1 Conversion Q4H PRN 1) Sumatriptan 25-100mg PRN 2) Sumatriptan 20mg Nasal Quantity Limit Maxalt MLT 5-10mg=9 Tablets Spray PRN 3) Naratriptan 1-2.5mg PRN 4) Sumatriptan 6mg/ml Subcutaneous Solution PRN 5) Maxalt MLT 5-10mg Naratriptan 1-2.5mg=9 Tablets Sumatriptan 25-100mg=9 Tablets PRN NF 1) Sumatriptan 25-100mg PRN 2) Sumatriptan 20mg Nasal Quantity Limit Maxalt MLT 5-10mg=9 Tablets Spray PRN 3) Naratriptan 1-2.5mg PRN 4) Sumatriptan Naratriptan 1-2.5mg=9 Tablets 6mg/ml Subcutaneous Solution PRN Sumatriptan 25-100mg=9 Tablets High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BID-QID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QD-BID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Maxair Autohaler (Pirbuterol) 200mcg Inhalation Aerosol Powder Q4H PRN Maxalt (Rizatriptan) 5, 10mg Tablet PRN Maxalt MLT (Rizatriptan) 5, 10mg Orally Disintegrating Tablet PRN Maxiflor (Diflorasone Diacetate) 0.05% Ointment AAA QD-QID High Potency Alere Obstetrical Homecare MD Line 404-316-2013 Maxivate (Betamethasone Dipropionate) Medium Potency 0.05% Lotion AAA QD-BID Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BID-QID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BID-QID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID Medrol (Methylprednisolone) 2, 8, 16, 32mg Methylprednisolone 4mg QD Tablet QD Melanex (Hydroquinone) 3% Solution AAA BID Mentax (Butenafine) 1% Cream AAA QD-BID 1) OTC Lamisil Ultra (Butenafine 1%) QD-BID 2) OTC Lotrimin AF (Clotrimazole 1%) BID 3) OTC Micatin (Miconazole 1%) BID 4) Ketoconazole 2% Cream QD Meridia (Sibutramine) 5, 10, 15mg Capsule QD Metadate CD (Methylphenidate) 10, 20, 30, 1) Methylin 5-20mg BID-TID 2) Adderall 5-30mg QD-BID 3) 40, 50, 60mg Extended Release Capsule Methylin ER 10-20mg BID-TID 4) Dextroamphetamine CR 5QAM 15mg QD-BID 5) Adderall XR 5-30mg QAM 6) Methylphenidate ER 18-72mg QAM Metadate ER (Methylphenidate) 20mg 1) Methylin 5-20mg BID-TID 2) Adderall 5-30mg QD-BID 3) Extended Release Tablet QD Methylin ER 10-20mg BID-TID 4) Dextroamphetamine CR 515mg QD-BID 5) Adderall XR 5-30mg QAM 6) Methylphenidate ER 18-72mg QAM MetroGel Vaginal (Metronidazole) 0.75% Gel 1) Clindamycin 300mg BID 2) Metronidazole 500mg BID QD Micardis (Telmisartan) 20, 40, 80mg Tablet 1) Lisinopril QD NOTE: If Angiotensin Converting Enzyme QD Inhibitor allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan QD Page 31 Last Updated: 6/20/2012 Excluded Medication Excluded Medication (Exception: Obesity Rider) Document adequate therapeutic trial or intolerance to at least 3 formulary alternatives Document adequate therapeutic trial or intolerance to at least 3 formulary alternatives Dose Conversion Micardis 40mg=Lisinopril 10mg=Losartan 25mg / Micardis 80mg=Lisinopril 20mg=Losartan 50mg Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Micardis HCT (Telmisartan/HCTZ) 40/12.5, 80/12.5, 80/25mg Tablet QD Microgestin 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) Tablet QD Micronor (Norethindrone) 0.35mg Tablet QD Midamor (Amiloride) 5mg Tablet QD Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Comments 2 Separate Medications HCTZ QD AND 1) Lisinopril QD NOTE: If Angiotensin Converting Enzyme Inhibitor allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan QD Dose Conversion Micardis 40mg=Lisinopril 10mg=Losartan 25mg / Micardis 80mg=Lisinopril 20mg=Losartan 50mg NOTE: Consider Lisinopril/HCTZ 10/12.5, 20/12.5, 20/25mg or Losartan/HCTZ 50/12.5mg Document adequate therapeutic trial or intolerance 1) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) QD 2) Aviane (20mcg Ethinyl Estradiol/0.1mg to at least 3 formulary oral contraceptives Levonorgestrel) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD Nora-BE (Norethindrone) 0.35mg QD Equivalent Brand and Generic Products Micronor=Nora-BE 1) Amiloride/HCTZ 5/50mg QD 2) Triamterene/HCTZ 37.5/2575/50mg QD 3) Spironolactone 50-100mg Tablet QD Mirapex ER (Pramipexole) 0.375, 0.75, 1.5, 3, Parkinson's Disease 4.5mg Extended Release Tablet QD 1) Carbidopa/Levodopa ER 25/100mg BID 2) Bromocriptine 2.5mg QD 3) Amantadine 100mg BID 4) Pramipexole 0.1251.5mg TID 5) Ropinirole 2-8mg QD 6) Selegiline 5mg QD 7) Carbidopa/Levodopa/Entacapone 12.5/50/200mg TID 8) Ropinrole ER 2-12mg QD NF 9) Zelapar 1.25 QD NF Restless Leg Syndrome 1) Pramipexole 0.125mg QHS 2) Ropinirole 0.25-4mg QHS Mircette (20mcg Ethinyl Estradiol/0.15mg Desogestrel x 21 days, 10mcg EE x 5 days) Tablet QD Modicon (35mcg Ethinyl Estradiol/0.5mg Norethindrone) Tablet QD 1) Reclipsen 0.25 (30mcg Ethinyl Estradiol/0.15 Desogestrel) QD 2) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Aviane (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel) QD 1) Necon 0.5/35 (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD 2) Necon 1/35 (35mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Brevicon (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD MonoNessa (35mcg Ethinyl Estradiol/0.25mg 1) Sprintec (35mcg Ethinyl Estradiol/0.25mg Norgestimate) Norgestimate) Tablet QD QD 2) Necon 1/35 (35mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Necon 0.5/35 (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD 4) Zovia 1/35 (35mcg Ethinyl Estradiol/1mg Ethynodiol diacetate) QD 5) Brevicon (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Equivalent Brand and Generic Products Modicon=Necon 0.5/35=Brevicon Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Equivalent Brand and Generic Products MonoNessa=Sprintec Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Monopril (Fosinopril) 10, 20, 40mg Tablet QD 1) Lisinopril 20-40mg QD 2) Benazepril 20-40mg QD 3) Dose Conversion Enalapril 10-40mg QD 4) Captopril 25-100mg TID 5) Ramipril Fosinopril 10mg=Lisinopril 10mg / Fosinopril 20mg=Lisinopril 20mg / Fosinopril 40mg=Lisinopril 2.5-20mg QD 40mg Mozobil (Plerixafor) 20mg/ml Subcutaneous Mozobil is dispensed via KP Glenlake Pharmacy Criteria Restricted Medication Solution X4D QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Multaq (Dronedarone) 400mg Tablet BID Amiodarone 200-400mg QD Muse (Alprostadil) 125, 250, 500, 1000mcg Excluded Medication Intraurethral Suppository PRN (Exception: Sexual Dysfunction Rider) Myobloc (Rimabotulinumtoxin B) 2500/0.5, Administered in a healthcare setting by healthcare providers Criteria Restricted Medication 5000/1, 10000/2U/ml Intramuscular Solution QRM approval required prior to being dispensed for Q12-16W Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Page 32 Last Updated: 6/20/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Naftin (Naftifine) 1% Cream AAA QD; 1% Gel 1) OTC Lamisil Ultra (Butenafine 1%) QD-BID 2) OTC AAA BID Lotrimin AF (Clotrimazole 1%) BID 3) OTC Micatin (Miconazole 1%) BID 4) Ketoconazole 2% Cream QD Nalfon (Fenoprofen) 200, 400mg Capsule; 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg BID 3) 600mg Tablet TID-QID Ibuprofen 400-800mg TID-QID 4) Sulindac 150-200mg BID 5) Etodolac 200-500mg BID-TID 6) Nabumetone 500-750mg BID 7) Lidocaine 5% Ointment AAA Q4H 8) Diclofenac 25100mg BID-TID Namenda (Memantine) 10mg/5ml Solution 1) Galantamine 4-12mg BID, Galantamine ER 8-24mg QD 2) QD Namenda 5-10mg BID 3) Rivastigmine 6mg BID 4) Aricept 510mg QD 5) Exelon 2mg/ml Solution 3ml BID 6) Exelon 4.59.6mg/24hr Patch QD NF 7) Razadyne 4mg/ml 1-3 ml BID NF 8) Aricept ODT 5-10mg QD NF Nasacort AQ (Triamcinolone) 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) OTC 55mcg/Actuation Nasal Spray 2 SPRAYS IEN Allegra 60mg BID 4) Fluticasone 2 SPRAYS IEN QD 5) QD Flunisolide 2 SPRAYS IEN BID 6) Triamcinolone 2 SPRAYS IEN QD NF Nasonex (Mometasone) 0.05mg/Actuation 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) OTC Nasal 2 SPRAYS IEN QD Allegra 60mg BID 4) Fluticasone 2 SPRAYS IEN QD 5) Flunisolide 2 SPRAYS IEN BID 6) Triamcinolone 2 SPRAYS IEN QD NF Natazia (3mg Estradiol Valerate x 2 days, 2mg EV/2mg Dienogest x 5 days, 2mg EV/3mg Dienogest x 17 days, 1mg EV x 2 days) Tablet QD 1) Tri-Sprintec (35mcg Ethinyl Estradiol/0.18mg Norgestimate x 7 days, 35mcg EE/0.215mg NG x 7 days, 35mcg EE/0.25mg NGx 7 days) QD 2) Trivora (30mcg Ethinyl Estradiol/0.05mg Levonorgestrel x 6 days, 40mcg EE/0.075mg LVNGL x 5 days, 30mcg EE/0.125mg LVNGL x 10 days) QD 3) Leena (35mcg Ethinyl Estradiol/0.5mg Norethindrone x 7 days, 35mcg EE/1mg NE x 9 days, 35mcg EE/0.5mg NE x 5 days) QD Comments Document adequate therapeutic trial or intolerance to Galantamine, Aricept, Namenda, and Rivastigmine Capsule or Exelon Solution Age Recommendations Fluticasone=4 years of age and older / Flunisolide=6 years of age and older / Triamcinolone=2 years of age and older Age Recommendations Fluticasone=4 years of age and older / Flunisolide=6 years of age and older / Triamcinolone=2 years of age and older / Nasonex=2 years of age and older Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Necon 10/11 (35mcg Ethinyl Estradiol/0.5mg 1) Necon 0.5/35 (35mcg Ethinyl Estradiol/0.5mg Document adequate therapeutic trial or intolerance Norethindrone x 10 days, 35mcg EE/1mg NE Norethindrone) QD 2) Necon 1/35 (35mcg Ethinyl to at least 3 formulary oral contraceptives x 11 days) Tablet QD Estradiol/1mg Norethindrone) QD 3) Leena (35mcg Ethinyl Estradiol/0.5mg Norethindrone x 7 days, 35mcg EE/1mg NE x 9 days, 35mcg EE/0.5mg NE x 5 days) QD 4) Brevicon (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD Neulasta (Pegfilgrastim) 6mg/0.6ml Subcutaneous Solution 24 hours after chemotherapy Nevanac (Nepafenac) 0.1% Ophthalmic Suspension 1 GTT TID Neupogen (Filgrastim) 5mg/kg/day QD 24 hours after chemotherapy Nexium (Esomeprazole) 20, 40mg Capsule QD-BID 1) Diclofenac 0.1% 1GTT QID 2) Ketorolac 0.5% 1 GTT QID 3) Prednisolone 1% 1-2 GTTS BID-QID 4) Fluorometholone 0.1% 1-2 GTTS BID-QID 5) Dexamethasone 0.1% 1-2 GTTS BID-QID 6) Ketorolac 0.4% 1 GTT QID 7) Flurbiprofen 0.03% 1 GTT QID NF 8) Vexol 1% 1-2 GTT QID NF 9) Bromfenac 0.09% 1 GTT QD-BID NF 10) Lotemax 0.5% 1-2 GTT QID NF 1) Torisel 25mg IV QW 2) Sutent 50mg QD NOTE: 4 weeks Sutent preferred when initiating therapy on then 2 weeks off FDA approved for treatment of advanced renal cell cancer (RCC) or unresectable hepatocellular cancer (HCC) 1) Pantoprazole 40mg QD 2) OTC Omeprazole 20mg QD 3) Excluded Medication OTC Zegerid 20/1100mg QD 4) OTC Prevacid 15mg QD Niaspan (Niacin) 500, 750, 1000mg Extended Release Tablet QD Nitro-Dur (Nitroglycerin) 0.1, 0.2, 0.3, 0.4, 0.6, 0.8mg/hr Transdermal Patch Apply 12-14 hours then remove 10-12 hours OTC Slo-Niacin 500mg QD (Titrate to 2000mg/day as tolerated using .PITTTSLONIACIN) 1) Minitran 0.1-0.6mg/hr Patch Apply 12-14 hours then remove 10-12 hours 2) Nitro-Dur 0.8mg/hr Patch Apply 12-14 hours then remove 10-12 hours Nexavar (Sorafenib) 200mg Tablet 2T BID Page 33 Last Updated: 6/20/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Nordette (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) Tablet QD 1) Reclipsen (30mcg Ethinyl Estradiol/0.15mg Desogestrel) QD 2) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD 3) Microgestin Fe 1.5/30 (30mcg Ethinyl Estradioll/1.5mg Norethindrone) QD Norflex (Orphenadrine Citrate) 100mg Extended Release Tablet BID 1) Cyclobenzaprine 10mg TID 2) Chlorzoxazone 250-500mg TID 3) Carisoprodol 350mg TID 4) Tizanidine 4mg TID 5) Methocarbamol 500-750mg QID 6) Baclofen 10-20mg TID Norgesic (Orphenadrine Citrate/Aspirin/Caffeine) 25/385/30mg Tablet TID-QID 2 Separate Medications OTC Aspirin 325mg TID-QID AND 1) Cyclobenzaprine 10mg TID 2) Chlorzoxazone 250-500mg TID 3) Carisoprodol 350mg TID 4) Tizanidine 4mg TID 5) Methocarbamol 500750mg QID 6) Baclofen 10-20mg TID Metronidazole 0.75% Cream, Gel AAA BID Noritate (Metronidazole) 1% Cream AAA QD Noroxin (Norfloxacin) 400mg Tablet BID NovoLog (Insulin Aspart) 100U/ml Subcutaneous Solution SC 5-10 minutes AC Prostatitis 1) SMZ-TMP DS BID X14D 2) Ciprofloxacin 500mg BID X14D Urinary Tract Infection 1) SMZ-TMP DS BID X3D 2) Ciprofloxacin 250mg BID X3D 3) Levofloxacin 250mg QD X3D 4) Nitrofurantoin Monohydrate 100mg BID X7D Novolin R (Insulin Regular) SC 30 minutes AC Comments Equivalent Brand and Generic Products Nordette=Levora Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives NovoLog to Novolin R is a 1:1 Conversion Document a) member with DM1 b) adequate therapeutic trial or intolerance (Persistent hypoglycemia) to Novolin R c) member using NovoLog via Insulin Pump d) member using Humulin R (Insulin Regular) 500U/ml e) Isolated post-prandial hyperglycemia despite titration and A1c within 0.5% of goal Dose Conversion NovoLog 70/30 20U=Novolin 70/30 20U=Novolin N (NPH) 14U+Novolin R (Insulin Regular) 6U Insulin Administration Device Document a) member is unable to accurately draw up insulin due to upper extremity amputation, visual impairment, young age, Parkinson's Disease, Rheumatoid Arthritis b) member administers doses < 5U c) school or day care requires insulin cartridge device for insulin administration while member is outside of primary caretaker's care NovoLog 70/30 (Insulin Aspart Protamine/Insulin Aspart) 100U/ml Injection Solution SC 15 minutes AC Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC OR 2 Separate Medications Novolin N (NPH) SC 15-30 minutes AC AND 1) Novolin R (Insulin Regular) SC 30 minutes AC 2) NovoLog (Insulin Aspart) SC 5-10 minutes AC NF NovoLog FlexPen (Insulin Aspart) 100U/ml Injection Solution SC 15 minutes AC 1) Novolin R (Insulin Regular) SC 30 minutes AC 2) NovoLog Adjust based on patient response Insulin Administration Device (Insulin Aspart) SC 5-10 minutes AC NF Document a) member is unable to accurately draw up insulin due to upper extremity amputation, visual impairment, young age, Parkinson's Disease, Rheumatoid Arthritis b) member administers doses < 5U c) school or day care requires insulin cartridge device for insulin administration while member is outside of primary caretaker's care Noxafil (Posaconazole) 40mg/ml Suspension QD-QID 1) Fluconazole 50-200mg QD 2) Itraconazole 100mg QD-BID 3) Sporanox 10mg/ml QD-BID Nucynta (Tapentadol) 50, 75, 100mg Tablet TID-QID 1) Oxycodone/Acetaminophen 5/325mg Q6H 2) Morphine 1530mg Q4H 3) Hydromorphone 2-8mg Q4-6H 4) Oxycodone 530mg Q4-6H 5) Morphine Solution 20mg/ml 0.5-1.5ml Q4H 6) Meperidine 50-150mg Q3-4H 1) Amitriptyline 50-75mg QD 2) Citalopram 10-30mg QD 3) Nortriptyline 50-100mg QD 4) Imipramine 10-20mg QD Nuedexta (Dextromethorphan Hydrobromide/Quinidine Sulfate) 20/10mg Capsule BID Page 34 Last Updated: 6/20/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Nuquin HP (Hydroquinone) 4% Cream, Gel AAA BID NuvaRing (15mcg Ethinyl Estradiol/0.12mg Etonogestrel) Vaginal Insert Insert for 3 weeks and remove for 1 week Nuvigil (Armodafinil) 50, 150, 250mg Tablet QAM Ocella (30mcg Ethinyl Estradiol/3mg Drospirenone) Tablet QD Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Excluded Medication 1) Aviane (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel) QD 2) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD Narcolepsy 1) OTC Caffeine 100-200mg Q3-4H 2) Methylin 10-60mg Divided BID-TID 3) Adderall 5-60mg Divided dose 4) Dextroamphetamine CR 5-60mg QD Obstructive Sleep Apnea Modafinil 100-200mg QAM NF 1) Reclipsen (30mcg Ethinyl Estradiol/0.15mg Desogestrel) QD 2) Microgestin Fe 1.5/30 (30mcg Ethinyl Estradiol/1.5mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD Ocufen (Flurbiprofen) 0.03% Ophthalmic Solution 1 GTT QID 1) Diclofenac 0.1% 1GTT QID 2) Ketorolac 0.5% 1 GTT QID 3) Prednisolone 1% 1-2 GTTS BID-QID 4) Fluorometholone 0.1% 1-2 GTTS BID-QID 5) Dexamethasone 0.1% 1-2 GTTS BID-QID 6) Ketorolac 0.4% 1 GTT QID Ocupress (Carteolol) 1% Ophthalmic Solution 1 GTT BID Oforta (Fludarabine) 10mg Tablet 40mg/m2 QD X5D Q28D Ogestrel (50mcg Ethinyl Estradiol/0.5mg Norgestrel) Tablet QD 1) Timolol 0.25-0.5% 1 GTT QD-BID 2) Levobunolol 0.250.5% 1-2 GTT QD-BID 3) Betaxolol 0.5% 1-2 GTT BID Fludara 25mg/m2 X5D Q28D NF Oleptro (Trazodone) 150, 300mg Extended Release Tablet QPM Olux (Clobetasol Propionate) 0.05% Foam AAA BID Ultra High Potency 1) Zovia 1/50 (50mcg Ethinyl Estradiol/1mg Ethynodiol Diacetate) QD 2) Necon 1/50 (50mcg Mestranol/1mg Norethindrone) QD 1) Citalopram 20-40mg QD 2) Fluoxetine 20-40mg QD 3) Trazodone 150-400mg QD 4) Sertraline 50-100mg QD 5) Mirtazapine 30mg QHS 6) Bupropion SR/XL 300mg QD 7) Venlafaxine ER 225mg QD Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID Omnaris (Ciclesonide) 50mcg/Actuation Nasal 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) OTC Spray 2 SPRAYS IEN QD Allegra 60mg BID 4) Fluticasone 2 SPRAYS IEN QD 5) Flunisolide 2 SPRAYS IEN BID 6) Triamcinolone 2 SPRAYS IEN QD NF 7) Nasonex 2 SPRAYS IEN QD NF 8) Veramyst 2 SPRAYS IEN QD NF Omnicef (Cefdinir) 300mg Capsule BID 3rd Generation Omnitrope (Somatropin) 5/1.5, 10/1.5mg/ml Subcutaneous Solution QW Comments Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Dose Conversion Modafinil 50mg=Nuvigil 50mg / Modafinil100mg=Nuvigil 150mg 0.5T / Modafinil 200mg=Nuvigil 250mg 0.5T / Modafinil 300mg=Nuvigil 250mg Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Dose Conversion Oleptro 150mg=Trazodone 150mg 0.5T BID / Oleptro 300mg=Trazodone 150mg BID Age Recommendations Fluticasone=4 years of age and older / Flunisolide=6 years of age and older / Triamcinolone=2 years of age and older / Nasonex=2 years of age and older / Veramyst=2 years of age and older / Omnaris=6 years of age and older 1) Cefdinir 125mg/5ml-250mg/5ml 7mg/kg BID 3rd Generation Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Page 35 Last Updated: 6/20/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Onglyza (Saxagliptin) 2.5, 5mg Tablet QD 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin 5001000mg (Maximum 2550mg QD) 3) Metformin ER 500750mg (Maximum 2000mg QD) 4) Novolin R (Insulin Regular) SC 30 minutes AC 5) Novolin N (NPH) SC 15-30 minutes AC 6) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos 15mg (Maximum 45mg QD) Opana ER (Oxymorphone) 5, 7.5, 10, 15, 20, 1) Morphine ER 60-100mg BID 2) Fentanyl 25-100mcg/hr 30, 40mg Extended Release Tablet BID Q72H 3) Avinza 30-120mg QD NF Optivar (Azelastine) 0.05% Ophthalmic Solution 1 GTT BID Oracea (Doxycycline) 40mg Extended Release Capsule QD Ortho-Cept 28 (30mcg Ethinyl Estradiol/0.15mg Desogestrel) Tablet QD Comments Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Dose Conversion Morphine 30mg=Oxycodone 20mg=Oxymorphone 10mg / Morphine 90mg=Fentanyl 25mcg/hr Document adequate therapeutic trial or intolerance to Morphine ER and Fentanyl 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q3-4 HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID 4) Crolom 4% 1-2 GTTS Q4-6 HOURS NF 5) Emadine 0.05% 1 GTT QID NF 6) Alocril 2% 12 GTTS BID NF 1) Doxycycline 50-100mg BID 2) Minocycline 50-100mg BID Oracea 40mg=Doxycyline 30mg Immediate Release + Doxycycline 10mg Delayed Release 3) Tetracycline 250-500mg BID 4) Metronidazole 0.75% Gel/Cream AAA BID 1) Reclipsen (30mcg Ethinyl Estradiol/0.15mg Desogestrel) Equivalent Brand and Generic Products QD 2) Microgestin Fe 1.5/30 (30mcg Ethinyl Estradioll/1.5mg Ortho-Cept=Reclipsen Document adequate therapeutic trial or intolerance Norethindrone) QD 3) Levora (30mcg Ethinyl to at least 3 formulary oral contraceptives Estradiol/0.15mg Levonorgestrel) QD Ortho-Cyclen (35mcg Ethinyl Estradiol/0.25mg Norgestimate) Tablet QD 1) Sprintec (35mcg Ethinyl Estradiol/0.25mg Norgestimate) QD 2) Necon 1/35 (35mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Necon 0.5/35 (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD 4) Zovia 1/35 (35mcg Ethinyl Estradiol/1mg Ethynodiol diacetate) QD 5) Brevicon (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD Equivalent Brand and Generic Products Ortho-Cyclen=Sprintec Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Ortho Evra (20mcg Ethinyl Estradiol/0.15mg Norelgestromin) Transdermal Patch Apply QW 1) Sprintec (35mcg Ethinyl Estradiol/0.25mg Norgestimate) QD 2) Aviane (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel) QD 3) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) QD 1) Sprintec (35mcg Ethinyl Estradiol/0.25mg Norgestimate) QD 2) Necon 1/35 (35mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Necon 0.5/35 (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD 4) Zovia 1/35 (35mcg Ethinyl Estradiol/1mg Ethynodiol diacetate) QD 5) Brevicon (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives 1) Necon 1/50 (50mcg Mestranol/1mg Norethindrone) QD 2) Zovia 1/50 (50mcg Ethinyl Estradiol/1mg Ethynodiol Diacetate) QD 1) Nortrel 7/7/7 (35mcg Ethinyl Estradiol/ 0.5mg Norethindrone x 7 days, 35mcg EE/0.75mg NE x 7 days, 35mcg EE/1mg NE x 7 days) QD 2) Tri-Sprintec (35mcg Ethinyl Estradiol/0.18mg Norgestimate x 7 days, 35mcg EE/0.215mg NG x 7 days, 35mcg EE/0.25mg NGx 7 days) QD 3) Trivora (30mcg Ethinyl Estradiol/0.05mg Levonorgestrel x 6 days, 40mcg EE/0.075mg LVNGL x 5 days, 30mcg EE/0.125mg LVNGL x 10 days) QD 4) Leena (35mcg Ethinyl Estradiol/0.5mg Norethindrone x 7 days, 35mcg EE/1mg NE x 9 days, 35mcg EE/0.5mg NE x 5 days) QD Equivalent Brand and Generic Products Ortho-Novum 1/50=Necon 1/50 Ortho-Novum 1/35 (35mcg Ethinyl Estradiol/1mg Norethindrone) Tablet QD Ortho-Novum 1/50 (50mcg Mestranol/1mg Norethindrone) Tablet QD Ortho-Novum 7/7/7 (35mcg Ethinyl Estradiol/0.5mg Norethindrone x 7 days, 35mcg EE/0.75mg NE x 7 days, 35mcg EE/1mg NE x 7 days) Tablet QD Page 36 Last Updated: 6/20/2012 Equivalent Brand and Generic Products Ortho-Novum 1/35=Necon 1/35 Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Equivalent Brand and Generic Products Ortho-Novum 7/7/7=Nortrel 7/7/7 Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Comments Ortho-Novum 10/11 (35mcg Ethinyl Estradiol/0.5mg Norethindrone x 10 days, 35mcg EE/1mg NE x 11days) Tablet QD 1) Necon 0.5/35 (35mcg Ethinyl Estradiol/0.5mg Equivalent Brand and Generic Products Ortho-Novum 10/11=Necon 10/11 Norethindrone) QD 2) Necon 1/35 (35mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Leena (35mcg Ethinyl Estradiol/0.5mg Norethindrone x 7 days, 35mcg EE/1mg NE x 9 days, 35mcg EE/0.5mg NE x 5 days) QD 4) Brevicon (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD Ortho Tri-Cyclen (35mcg Ethinyl Estradiol/0.18mg Norgestimate x 7 days, 35mcg EE/0.215mg NG x 7 days, 35mcg EE/0.25mg NG x 7 days) Tablet QD 1) Tri-Sprintec (35mcg Ethinyl Estradiol/0.18mg Norgestimate x 7 days, 35mcg EE/0.215mg NG x 7 days, 35mcg EE/0.25mg NGx 7 days) QD 2) Sprintec (35mcg Ethinyl Estradiol/0.25mg Norgestimate) Tablet QD 3) Trivora (30mcg Ethinyl Estradiol/0.05mg Levonorgestrel x 6 days, 40mcg EE/0.075mg LVNGL x 5 days, 30mcg EE/0.125mg LVNGL x 10 days) QD 4) Leena (35mcg Ethinyl Estradiol/0.5mg Norethindrone x 7 days, 35mcg EE/1mg NE x 9 days, 35mcg EE/0.5mg NE x 5 days) QD Equivalent Brand and Generic Products Ortho Tri-Cyclen=Tri-Sprintec Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Ortho Tri-Cyclen Lo (25mcg Ethinyl Estradiol/0.18mg Norgestimate x 7 days, 25mcg EE/0.215mg NG x 7 days, 25mcg EE/ 0.25mg NG x 7 days) Tablet QD 1) Tri-Sprintec (35mcg Ethinyl Estradiol/0.18mg Norgestimate x 7 days, 35mcg EE/0.215mg NG x 7 days, 35mcg EE/0.25mg NGx 7 days) QD 2) Sprintec (35mcg Ethinyl Estradiol/0.25mg Norgestimate) Tablet QD 3) Aviane (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel) QD 4) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) QD 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg BID 3) Ibuprofen 400-800mg TID-QID 4) Sulindac 150-200mg BID 5) Etodolac 200-500mg BID-TID 6) Nabumetone 500-750mg BID 7) Lidocaine 5% Ointment AAA Q4H 8) Diclofenac 25100mg BID-TID 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg BID 3) Ibuprofen 400-800mg TID-QID 4) Sulindac 150-200mg BID 5) Etodolac 200-500mg BID-TID 1) Sprintec (35mcg Ethinyl Estradiol/0.25mg Norgestimate) QD 2) Necon 1/35 (35mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Necon 0.5/35 (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD 4) Zovia 1/35 (35mcg Ethinyl Estradiol/1mg Ethynodiol diacetate) QD 5) Brevicon (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Orudis (Ketoprofen) 50, 75mg Capsule TIDQID Oruvail (Ketoprofen) 150, 200mg Extended Release Capsule QD Ovcon 35 (35mcg Ethinyl Estradiol/0.4mg Norethindrone) Tablet QD Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Ovcon 50 (50mcg Ethinyl Estradiol/1mg Norethindrone) Tablet QD 1) Zovia 1/50 (50mcg Ethinyl Estradiol/1mg Ethynodiol Diacetate) QD 2) Necon 1/50 (50mcg Mestranol/1mg Norethindrone) QD Ovide (Malathion) 0.5% Lotion Apply to scalp, 1) OTC Nix (Permethrin 1%) 2) OTC Rid, Pronto Plus Shampoo hair after 8-12 hours, Repeat (Pyrethrins 0.33%/Piperonyl Butoxide 4%) 3) OTC Cetaphil application if lice present 7 days after initial Cleanser Lotion 4) Ulesfia 5% Lotion NF treatment Oxistat (Oxiconazole) 1% Cream, Lotion BID 1) OTC Lamisil Ultra (Butenafine 1%) QD-BID 2) OTC Lotrimin AF (Clotrimazole 1%) BID 3) OTC Micatin (Miconazole 1%) BID 4) Ketoconazole 2% Cream QD Oxycontin (Oxycodone) 10, 15, 20, 30, 40, 60, 1) Morphine ER 60-100mg BID 2) Fentanyl 25-100mcg/hr 80mg Extended Release Tablet QD-BID Q72H 3) Avinza 30-120mg QD NF 4) Opana ER 5-40mg BID NF 5) Kadian 10-200mg QD NF 6) Exalgo 8-16mg QD NF Page 37 Last Updated: 6/20/2012 Apply to scalp, Leave on for 10 minutes, Rinse, Repeat application if lice present 7 days after initial treatment Quantity Limit Oxycontin 10-80mg (30 Day Supply)=60 Tablets Dose Conversion Hydromorphone 7.5mg=Morphine 30mg=Oxycodone 20mg=Oxymorphone 10mg / Morphine 90mg=Fentanyl 25mcg/hr Document adequate therapeutic trial or intolerance to Morphine ER and Fentanyl Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Comments Pamine (Methscopolamine) 2.5mg Tablet BID Allergic Rhinitis 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) OTC Allegra 60mg BID 4) Fluticasone 2 SPRAYS IEN QD 5) Flunisolide 2 SPRAYS IEN BID 6) Ipratropium 0.03-0.06% 2 SPRAYS IEN BID-QID NF Peptic Ulcer 1) Pantoprazole 40mg QD 2) OTC Omeprazole 20mg QD 3) OTC Zegerid 20/1100mg QD 4) OTC Prevacid 15mg QD Pandel (Hydrocortisone Probutate) 0.1% Cream AAA QD-BID Medium Potency Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BID-QID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BID-QID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID Panretin (Alitretinoin) 0.1% Gel AAA BID-QID Parlodel (Bromocriptine) 5mg Capsule QDBID Pataday (Olopatadine) 0.2% Ophthalmic Solution 1 GTT QD Document a) AIDS-related Kaposi's Sarcoma b) less than 10 new Kaposi's Sarcoma lesions in the prior month c) adequate therapeutic trial or intolerance to cryotherapy Bromocritpine 2.5mg QD-BID 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q3-4 HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID 4) Crolom 4% 1-2 GTTS Q4-6 HOURS NF 5) Emadine 0.05% 1 GTT QID NF 6) Alocril 2% 12 GTTS BID NF 7) Optivar 0.05% 1 GTT BID NF 8) Alomide 0.1% 1-2 GTTS QID NF 9) Lastacaft 0.25% 1 GTT QD NF Patanase (Olopatadine) 0.6% Nasal Spray 2 SPRAYS IEN BID Document adequate therapeutic trial or intolerance 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) OTC to Claritin, Zyrtec, or Allegra, at least 1 Nasal Allegra 60mg BID 4) Fluticasone 2 SPRAYS IEN QD 5) Flunisolide 2 SPRAYS IEN BID 6) Azelastine 2 SPRAYS IEN Steroid, and Azelastine BID NF Patanol (Olopatadine) 0.1% Ophthalmic 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q3-4 Solution 1 GTT BID HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID 4) Crolom 4% 1-2 GTTS Q4-6 HOURS NF 5) Emadine 0.05% 1 GTT QID NF 6) Alocril 2% 12 GTTS BID NF 7) Optivar 0.05% 1 GTT BID NF 8) Alomide 0.1% 1-2 GTTS QID NF 9) Lastacaft 0.25% 1 GTT QD NF 10) Pataday 0.2% 1 GTT QD NF 11) Alrex 0.2% 1 GTT QID NF Paxil CR (Paroxetine) 12.5, 25, 37.5mg Document adequate trial or intolerance to all 1) Citalopram 20-40mg QD 2) Fluoxetine 20-40mg QD 3) Extended Release Tablet QD formulary SSRIs Sertraline 50-100mg QD 4) Mirtazapine 30mg QHS 5) Bupropion SR/XL 300mg QD 6) Venlafaxine ER 225mg QD 7) Paroxetine 10-40mg QD 8) Fluvoxamine 50-300mg QD NF 9) Escitalopram 10-20mg QD NF Paxil CR (Paroxetine) 12.5, 25, 37.5mg Document adequate trial or intolerance to all 1) Citalopram 20-40mg QD 2) Fluoxetine 20-40mg QD 3) Extended Release Tablet QD formulary SSRIs Sertraline 50-100mg QD 4) Mirtazapine 30mg QHS 5) Bupropion SR/XL 300mg QD 6) Venlafaxine ER 225mg QD 7) Paroxetine 10-40mg QD 8) Fluvoxamine 50-300mg QD NF 9) Lexapro 10-20mg QD NF Pediapred (Prednisolone Sodium Phosphate) Prednisolone Sodium Phosphate 15mg/5ml 5-60mg QD 5mg/5ml Solution 5-60mg QD Penlac (Ciclopirox) 8% Solution QD Thymol/Isopropyl Alcohol 4/99% Solution QD KPGA Approved Compound Finger Onychomycosis Document positive fungal culture prior to approval of one 6 week treatment Toe Onychomycosis Document a) positive fungal culture b) DM or Vascular Disease prior to approval one 12 week treatment Page 38 Last Updated: 6/20/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Comments Pennsaid (Voltaren) 1.5% Topical Solution Apply 10 GTTS QID 1) OTC Aspercreme AAA BID-QID 2) LidoPatch (Lidocaine 3.99%/Menthol 1%) Apply 1 patch up to 12 hours 3) Meloxicam 7.5-15mg QD 4) Naproxen 250-550mg BID 5) Ibuprofen 400-800mg TID-QID 6) Sulindac 150-200mg BID 7) Etodolac 200-500mg BID-TID 8) Nabumetone 500-750mg BID 9) Lidocaine 5% Ointment AAA Q4H 10) Diclofenac 25100mg BID-TID Pepcid (Famotidine) 40mg Tablet QD-BID 1) OTC Famotidine 10-20mg QD-BID 2) OTC Ranitidine 75- Excluded Medication 150mg QD-BID 3) Cimetidine 400-800mg QD-BID Percocet (Oxycodone/Acetaminophen) Oxycodone/Acetaminophen 5/325mg Q6H OR 7.5/325, 10/325, 7.5/500, 10/650mg Tablet 2 Separate Medications Q6H OTC Acetaminophen 325-650mg Q6H AND Oxycodone 510mg Q6H Periostat (Doxycycline) 20mg Tablet BID 1) Doxycycline Hyclate 50-100mg BID 2) Minocycline 50100mg BID 3) Tetracycline 250-500mg BID Phendiet (Phendimetrazine) 35mg Tablet BIDExcluded Medication TID (Exception: Obesity Rider) Poly-Pred 1) Neomycin/Polymyxin/Hydrocortisone 1% Suspension 1-2 (Neomycin/Polymyxin/Prednisolone) GTTS Q4 HOURS 2) Neomycin/Polymyxin/Dexamethasone Ophthalmic Solution 1-2 GTTS Q4 HOURS 0.1% Suspension 1-2 GTTS Q4 HOURS 3) Tobramycin/Dexamethasone 0.3/0.1% 1-2 GTTS Q4-6 HOURS Ponstel (Mefenamic Acid) 250mg Capsule 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg BID 3) QID Ibuprofen 400-800mg TID-QID 4) Sulindac 150-200mg BID 5) Etodolac 200-500mg BID-TID 6) Nabumetone 500-750mg BID 7) Lidocaine 5% Ointment AAA Q4H 8) Diclofenac 25100mg BID-TID 9) Indomethacin 25-75mg QD-BID 10) Tolmetin 200-600mg TID Portia (30mcg Ethinyl Estradiol/0.15 1) Reclipsen (30mcg Ethinyl Estradiol/0.15 Desogestrel) Equivalent Brand and Generic Products Levonorgestrel) Tablet QD Portia=Levora Tablet QD 2) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) Tablet QD 3) Microgestin Fe 1.5/30 (30mcg Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Ethinyl Estradiol/1.5mg Norethindrone) QD Pradaxa (Dabigatran) 75, 150mg Capsule 150mg BID Warfarin 1-10mg QD (Tiitrate to target INR) Pramosone (Hydrocortisone Acetate/Pramoxine) 1/1% Cream, Lotion, Ointment QD-BID 1) OTC Hydrocortisone 0.5-1% Cream, Ointment AAA BIDQID 2) OTC Prax 1% Cream, Lotion AAA BID-QID 3) Hydrocortisone 2.5% Cream, Lotion, Ointment AAA BID-QID 4) Hydrocortisone 25mg Suppository BID 5) Hydrocortisone 100mg/60ml Enema QD-BID 6) Proctofoam-HC 1/1% QDBID Adjust based on patient response 1) Glipizide 5-15mg QD 2) Glyburide 2.5-10mg QD Glipizide preferred if 65 years of age and older due to prolonged half life of Glyburide Prandin (Repaglinide) 0.5, 1mg Tablet TIDQID Page 39 Last Updated: 6/20/2012 Document inclusion of: a) Irreversible atrial fibrillation If CHADS2 Score=1 b) Identified as an anticoagulation candidate (not ASA) c) Uninterrupted Warfarin therapy for at least 22 weeks d) TTR < 54% If CHADS2 Scoreā„2 b) Uninterrupted Warfarin therapy for at least 22 weeks c) TTR < 54% AND exclusion of: a) CHADS2 Score=0 b) TTR ā„ 67% c) History of heart valve disorder d) Severe, disabling stroke within the last 6 months e) Stroke within the previous 14 days f) Increased risk for bleeding g) CrCl<30mL/min h) Active liver disease i) Active infective endocarditis j) Anemia or thrombocytopenia k) Malignancy l) Reversible causes of atrial fibrillation m) Pregnancy n) Women of childbearing potential who refuse to use a form of contraception o) Contraindication to warfarin treatment p) Need for anticoagulant treatment of disorders other than atrial fibrillation Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Prandin (Repaglinide) 2mg Tablet TID-QID Premarin (Conjugated Estrogen) 0.3, 0.45, 0.625, 0.9, 1.25, 2.5mg Tablet QD Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Comments Adjust based on patient response Glipizide preferred if 65 years of age and older due to prolonged half life of Glyburide Adjust to the lowest dose needed to control Vasomotor Symtoms symptoms based on patient response 1) Estradiol QD 2) Climara Patch 0.025-0.1mg/24hr Apply Dose Conversion weekly Premarin 0.3mg=Estradiol 0.5mg / Premarin Vaginal/Vulvar Atrophy 0.45mg=Estradiol 0.75mg / Premarin 1) Estradiol QD 2) Climara Patch 0.025-0.1mg/24hr Apply weekly 3) Premarin Vaginal 1gm Apply three times a week 4) 0.625mg=Estradiol 1mg / Premarin 0.9mg=Estradiol Vagifem 10mcg Insert twice weekly 5) Estring 2mg Insert for 1.5mg / Premarin 1.25mg=Estradiol 2mg / Premarin 2.5mg=No Formulary Alternative 90 days 1) Glipizide 10-20mg BID 2) Glyburide 7.5-10mg BID Premphase (Conjugated Estrogen/Medroxyprogesterone) 0.625/5mg Tablet Day 1-14: Conjugated Estrogen QD Day 15-28: Conjugated Estrogen/Medroxyprogesterone QD Prempro (Conjugated Estrogen/Medroxyprogesterone) 0.3/1.5, 0.45/1.5mg, 0.625/2.5, 0.625/5mg Tablet QD 2 Separate Medications Day 1-14: Estradiol 1mg QD Day 15-28: Estradiol 1mg QD AND Medroxyprogesterone 5mg QD Dose Conversion Premarin 0.625mg=Estradiol 1mg 2 Separate Medications Vasomotor Symtoms 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.0250.1mg/24hr Apply weekly AND 1) Medroxyprogesterone 2.55mg QD 2) Nora-BE 0.35mg QD 3) Norethindrone 5mg QD Vaginal/Vulvar Atrophy 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.0250.1mg/24hr Apply weekly 3) Premarin Vaginal 1gm Apply three times a week 4) Vagifem 10mcg Insert twice weekly 5) Estring 2mg Insert for 90 days AND 1) Medroxyprogesterone 2.5-5mg QD 2) Nora-BE 0.35mg QD 3) Norethindrone 5mg QD Adjust to the lowest dose needed to control symptoms based on patient response Dose Conversion Premarin 0.3mg=Estradiol 0.5mg / Premarin 0.45mg=Estradiol 0.75mg / Premarin 0.625mg=Estradiol 1mg Prenatal Vitamins (Citranatal DHA, Generet, Prenate Elite) QD Prevacid (Lansoprazole) 15, 30mg Capsule QD-BID OTC Natures Best Prenatal QD Excluded Medication Available OTC Excluded Medication 1) Pantoprazole 40mg QD 2) OTC Omeprazole 20mg QD 3) OTC Zegerid 20/1100mg QD 4) OTC Prevacid 15mg QD Prevacid Solutab (Lansoprazole) 15, 30mg Orally Disintegrating Tablet QD-BID 1) Pantoprazole 40mg QD 2) OTC Omeprazole 20mg QD 3) Omeprazole 2mg/ml Liquid 10ml QD 4) Lansoprazole 3mg/ml Liquid 10ml QD 5) OTC Zegerid 20/1100mg QD 6) OTC Prevacid 15mg QD Prevpac (Lansoprazole, Amoxicillin, First Line Clarithromycin) 30mg BID, 500mg 2C BID, Tetracycline Hydrochloride 500mg QID, Metronidazole 500mg BID X14D 250mg QID, OTC Omeprazole 20mg BID, OTC Bismuth Subsalicylate 262.4mg 2T QID X14D Second Line Clarithromycin 500mg BID or Amoxicillin 500mg 2C BID, Metronidazole 250mg QID, OTC Omeprazole 20mg BID, OTC Bismuth Subsalicylate 262.4mg 2T QID X14D Prilosec (Omeprazole) 10, 20mg Capsule QD- 1) Pantoprazole 40mg QD 2) OTC Omeprazole 20mg QD TID Pristiq (Desvenlafaxine) 50,100mg Tablet QD 1) Citalopram 20-40mg QD 2) Fluoxetine 20-40mg QD 3) Sertraline 50-100mg QD 4) Mirtazapine 30mg QHS 5) Bupropion SR/XL 300mg QD 6) Venlafaxine ER 225mg QD 7) Fluvoxamine 50-300mg QD NF 8) Escitalopram 10-20mg QD NF 9) Paxil CR 12.5-37.5mg QD NF 10) Viibryd 10-40mg QD NF Proamatine (Midodrine) 2.5, 5, 10mg Tablet Fludrocortisone 0.1-0.2mg QD TID Proctosol HC (Hydrocortisone) 2.5% Cream Hydrocortisone 2.5% Cream, Lotion, Ointment AAA BID-QID AAA BID-QID Prodigy Glucometer and Test Strips One Touch Ultra 2 Glucometer and One Touch Ultra Test Strips Page 40 Last Updated: 6/20/2012 Excluded Medication Dispense Antibiotics for copays and purchase OTC Bismuth Subsalicylate and OTC Omeprazole Excluded Medication Document adequate therapeutic trial or intolerance to 2 SSRIs and Venlafaxine Document member is unable to accurately use One Touch Ultra 2 Glucometer and One Touch Ultra Test Strips due to visual impairment Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Prolia (Denosumab) 60mg/ml Subcutaneous Solution Q6M Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Administered in a healthcare setting by healthcare providers 1) Alendronate 10mg QD 2) Alendronate 70mg QW 3) Fortical 200IU QD Alternate nostrils 4) Ibandronate 150mg QM NF 5) Actonel 5mg QD NF 6) Actonel 150mg QM NF 7) Evista 60mg QD 8) Actonel 35mg QW NF Promacta (Eltrombopag Olamine) 25, 50, 75mg Tablet QD Prescribing Physician must call Promacta Cares Distribution Program 877-9-PROMACTA Promacta is delivered directly to patient via KP CA Specialty Pharmacy Prometrium (Progesterone) 100, 200mg 1) Medroxyprogesterone 2.5-5mg QD 2) Nora-BE 0.35mg Tablet QD QD 3) Norethindrone 5mg QD Propecia (Finasteride) 1mg Tablet QD OTC Rogaine (Minoxidil) BID Prosom (Estazolam) 1, 2mg Tablet QHS 1) Temazepam 15mg QHS 2) Lorazepam 0.5mg QHS 3) Oxazepam 10-30mg QHS 4) Trazodone 50-100mg QHS 5) Zolpidem 5-10mg QHS Protonix (Pantoprazole) 20, 40mg Tablet QD- Pantoprazole 40mg QD BID Protopic (Tacrolimus) 0.03, 0.1% Ointment Atopic Dermatitis AAA BID Elidel 1% Cream AAA BID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BID-QID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BID-QID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QD-BID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID Proventil HFA (Albuterol) 0.09mg Inhalation Aerosol Powder Q4H PRN Provigil (Modafinil) 100, 200mg Tablet QAM Prozac Weekly (Fluoxetine) 90mg Delayed Release Capsule QW Psorcon (Diflorasone Diacetate) 0.05% Cream AAA QD-QID High Potency Comments Proair HFA (Albuterol) 0.09mg Inhalation Aerosol Powder Q4H PRN Narcolepsy 1) OTC Caffeine 100-200mg Q3-4H 2) Methylin 10-60mg Divided BID-TID 3) Adderall 5-60mg Divided dose 4) Dextroamphetamine CR 5-60mg QD Obstructive Sleep Apnea Modafinil 100-200mg QAM NF 1) Citalopram 20-40mg QD 2) Fluoxetine 20-40mg QD 3) Sertraline 50-100mg QD 4) Mirtazapine 30mg QHS 5) Bupropion SR/XL 300mg QD 6) Venlafaxine ER 225mg QD 7) Fluvoxamine 50-300mg QD NF 8) Escitalopram 10-20mg QD NF 9) Paxil CR 12.5-37.5mg QD NF 10) Viibryd 10-40mg QD NF 11) Pristiq 50-100mg QD NF High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BID-QID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QD-BID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Page 41 Last Updated: 6/20/2012 KP CA Specialty Pharmacy MD Line 650-301-5799 / Patient Line 1-877-4045777 / Fax Line 650-301-5790 Excluded Medication Document adequate therapeutic trial or intolerance to Trazodone, Zolpidem, and at least 1 Benzodiazepine Excluded Medication Protopic preferred over Elidel if Vitiligo Proventil HFA to Proair HFA is a 1:1 Conversion Dose Conversion Modafinil 50mg=Nuvigil 50mg / Modafinil100mg=Nuvigil 150mg 0.5T / Modafinil 200mg=Nuvigil 250mg 0.5T / Modafinil 300mg=Nuvigil 250mg Document adequate trial or intolerance to all formulary SSRIs Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Psorcon (Diflorasone Diacetate) 0.05% Ointment AAA QD-QID Very High Potency Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID Pulmicort Flexhaler (Budesonide) 90, 180mcg 1) Qvar 40-80mcg 1-2 PUFFS QD-BID 2) Flovent HFA Inhalation Powder 2 PUFFS BID 44mcg 2 PUFFS BID NOTE: Flovent HFA 44mcg for patients 4-11 years of age 3) Asmanex 110-220mcg 1-2 PUFFS QD 4) Aerobid 0.25mg 2 PUFFS BID NF Quixin (Levofloxacin) Ophthalmic Solution 0.5% 1-2 GTTS Q4H Comments Document adequate trial or intolerance to Qvar 80mcg 2 PUFFS BID and Asmanex 220mcg 2 PUFFS QD within the past 3 months Dose Conversion Pulmicort Flexhaler 90mcg 2 PUFFS BID=Qvar 80mcg 1PUFF BID=Flovent 44mcg 2 PUFFS BID / Pulmicort 180mcg 2 PUFFS BID=Qvar 80mcg 2 PUFFS BID=Asmanex 220mcg 2 PUFFS QD Pulmicort is the preferred Inhaled Corticosteroid during pregnancy 1) Ofloxacin 0.3% Solution 1-2 GTTS QID 2) Ciprofloxacin 0.3% Solution 1-2 GTTS Q4HS NF 3) Sodium Sulfacetamide 10% Solution 1-3 GTTS Q2-3H 4) Gentamicin 0.3% Solution 1-2 GTTS QID 5) Erythromycin 0.5% Ointment APPLY RIBBON Q4H 6) Vigamox Solution 0.5% 1 GTT BID NF 7) Ciloxan 0.3% Ointment APPLY RIBBON BID-TID NF 8) Zymaxid 0.5% Solution 1 GTT QID Qutenza (Capsaicin) 8% Patch Apply up to 4 patches for 60 mintues every 3 months 1) OTC LMX 4 (Lidocaine 4% Cream) AAA QID 2) OTC Axsain cream (Lidocaine 4%/Capsaicin 0.25% Cream) AAA QID 3) LidoPatch (Lidocaine 3.99%/Menthol 1%) Apply 1 patch up to 12 hours 4) Lidocaine 2% Gel AAA QID 5) Lidocaine 5% Ointment AAA 5G QID Ranexa (Ranolazine) 500, 1000mg Extended 1) Atenolol 50-100mg QD 2) Nitroglycerin CR 6.5mg BID-TID Release Tablet BID 3) Isosorbide Mononitrate ER 30-60mg QD 4) Isosorbide Dinitrate 5-40mg TID 5) Metoprolol Tartrate 50-100mg BID 6) Verapamil SR 240mg QD 7) Diltiazem ER 240mg QD 8) Nifedipine ER 30-690mg QD Rapaflo (Silodosin) 4, 8mg Capsule QD 1) Terazosin 1-10mg QD 2) Doxazosin 1-8mg QD 3) Tamsulosin 0.4mg QD Razadyne (Galantamine) 4mg/ml Solution 3ml 1) Galantamine 4-12mg BID, Galantamine ER 8-24mg QD 2) BID Namenda 5-10mg BID 3) Rivastigmine 6mg BID 4) Aricept 510mg QD 5) Exelon 2mg/ml Solution 3ml BID 6) Exelon 4.59.6mg/24hr Patch QD NF Rectiv (Nitroglycerin) 0.4% Ointment Apply Nitroglycerin 0.2% Ointment Apply intra-anally Q12H intra-anally Q12H Relpax (Eletriptan) 20, 40mg Tablet PRN 1) Sumatriptan 25-100mg PRN 2) Sumatriptan 20mg Nasal Spray PRN 3) Naratriptan 1-2.5mg PRN 4) Sumatriptan 6mg/ml Subcutaneous Solution PRN 5) Maxalt MLT 5-10mg PRN NF 6) Zomig 5mg PRN NF 7) Zomig 2.5mg PRN NF Remeron Soltab (Mirtazapine) Orally Disintegrating Tablet 15, 30, 45mg QD 1) Citalopram 20-40mg QD 2) Fluoxetine 20-40mg QD 3) Sertraline 50-100mg QD 4) Mirtazapine 15-45mg QHS 5) Bupropion SR/XL 300mg QD 6) Venlafaxine ER 225mg QD Remicade (Infliximab) 100mg Intravenous Powder for Solution 5mg/kg Q8W 1) Humira 40mg QOW 2) Enbrel 50mg QW Page 42 Last Updated: 6/20/2012 Qutenza is only indicated for postherpetic neuralgia Document adequate trial or intolerance to Beta Blocker (NOTE: If Beta Blocker allergy or contraindication consider Verapamil ER or Diltiazem ER) and Long-Acting Nitrate (NOTE: If patient is hypertensive consider Nifedipine ER) Document adequate therapeutic trial or intolerance to Galantamine, Aricept, Namenda, and Exelon Capsule or Solution KPGA Approved Compound Quantity Limit Maxalt MLT 5-10mg=9 Tablets Naratriptan 1-2.5mg=9 Tablets Relpax 20-40mg=6 Tablets Sumatriptan 25-100mg=9 Tablets Zomig 2.5mg=6 Tablets Zomig 5mg=3 Tablets Document adequate therapeutic trial or intolerance to 2 SSRIs and Venlafaxine KP Dermatology, GI, or Rheumatology Contact CU Infusion Center 770-431-4367 or SW Infusion Center 770-603-3663 Network Dermatology, GI, or Rheumatology Contact Provider Relations 404-364-4934 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Renal Vitamins (Nephrocaps, Nephronex, Nephrotrans) QD Renova (Tretinoin) 0.02, 0.05% Cream AAA QHS Renvela 0.8, 2.5gm/Packet Powder for Suspension 1 Packet with meals Requip XL (Ropinirole) 2, 4, 6, 8, 12mg Extended Release Tablet QD Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy OTC Full Spectrum B with Vitamin C QD Retin-A 0.025-0.1% Cream, Gel AAA QHS Rozerem (Ramelteon) 8mg Tablet QHS Sabril (Vigabatrin) 500mg Tablet BID Salagen (Pilocarpine) 5mg Tablet TID-QID Samsca (Tolvaptan) 15, 30mg Tablet QD Sanctura (Trospium) 20mg Tablet BID Sanctura XR (Trospium) 60mg Extended Release Capsule QD Excluded Medication Available OTC Excluded Medication for patients > 36 YOA 1) Phoslyra 667mg/5ml 15ml with meals 2) Eliphos 667mg 3C with meals 3) Renvela 800mg 3T with meals Parkinson's Disease 1) Carbidopa/Levodopa ER 25/100mg BID 2) Bromocriptine 2.5mg QD 3) Amantadine 100mg BID 4) Pramipexole 0.1251.5mg TID 5) Ropinirole 2-8mg QD 6) Selegiline 5mg QD 7) Carbidopa/Levodopa/Entacapone 12.5/50/200mg TID 8) Ropinrole ER 2-12mg QD NF Restless Leg Syndrome 1) Pramipexole 0.125mg QHS 2) Ropinirole 0.25-4mg QHS Restoril (Temazepam) 7.5, 22.5mg Capsule Temazepam 15, 30mg QHS QHS Retin-A Micro (Tretinoin) 0.04, 0.1% Gel AAA Retin-A 0.025-0.1% Cream, Gel AAA QHS QHS Revatio (Sildenafil) 20mg Tablet TID Pulmonary Hypertension 1) Viagra 50mg 0.5T TID 2) Cialis 20mg 2T QD 3) Adcirca 20mg 2T QD Revlimid (Lenalidomide) 5, 10, 15, 25mg Prescribing Physician must call RevAssist Program 888-423Capsule 5436 Revlimid is delivered directly to patient via KP CA Specialty Pharmacy Rhinocort Aqua (Budesonide) 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) OTC 0.032mg/Actuation Nasal Spray 2 SPRAYS Allegra 60mg BID 4) Fluticasone 2 SPRAYS IEN QD 5) IEN BID Flunisolide 2 SPRAYS IEN BID 6) Triamcinolone 2 SPRAYS IEN QD NF 7) Nasonex 2 SPRAYS IEN QD NF 8) Veramyst 2 SPRAYS IEN QD NF 9) Omnaris 2 SPRAYS IEN QD NF Riomet (Metformin) 500mg/5ml Solution QDBID Ritalin LA (Methylphenidate) 10, 20, 30, 40mg Extended Release Capsule QAM Comments 1) Metformin 500-1000mg (Maximum 2550mg QD) 2) Metformin ER 500-750mg (Maximum 2000mg QD) 1) Methylin 5-20mg BID-TID 2) Adderall 5-30mg QD-BID 3) Methylin ER 10-20mg BID-TID 4) Dextroamphetamine CR 515mg QD-BID 5) Adderall XR 5-30mg QAM 6) Methylphenidate ER 18-72mg QAM 1) Trazodone 50-100mg QHS 2) Temazepam 15-30mg QHS 3) Zolpidem 5-10mg QHS 4) Zaleplon 5-10mg QHS 5) Ambien CR 6.25-12.5mg QHS NF Precribing Physician must call SHARE Distribution Program 888-45-SHARE Sabril is delivered directly to patient via CuraScript Specialty Pharmacy Excluded Medication for patients > 36 YOA KP CA Specialty Pharmacy MD Line 650-301-5799 / Patient Line 1-877-4045777 / Fax Line 650-301-5790 Age Recommendations Fluticasone=4 years of age and older / Flunisolide=6 years of age and older / Triamcinolone=2 years of age and older / Nasonex=2 years of age and older / Veramyst=2 years of age and older / Omnaris=6 years of age and older / Rhinocort Aqua=6 years of age and older Adjust based on patient response Document adequate therapeutic trial or intolerance to at least 3 formulary alternatives Document adequate therapeutic trial or intolerance to Trazodone, Zolpidem, and at least 1 Benzodiazepine Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Ophthalmic Solution may be administered orally Pilocarpine 0.5, 1, 2, 3, 4, 6% Ophthalmic Solution 5-10 GTTS PO TID 1) OTC Sodium Chloride 1gm QD 2) Demeclocycline 300mg Quantity Limit BID-TID Samsca 15-30mg=10 Tablets 1) Oxybutinin 5mg BID-TID 2) Oxybutynin XL 5-15mg QD 3) Oxytrol 3.9mg/day Patch Apply twice weekly 1) Oxybutinin 5mg BID-TID 2) Oxybutynin XL 5-15mg QD 3) Oxytrol 3.9mg/day Patch Apply twice weekly 4) Trospium 20mg BID NF 5) Detrol LA 2-4mg QD NF 6) Toviaz 4-8mg QD NF 7) Enablex 7.5-15mg QD NF 8) Vesicare 5-10mg QD NF Page 43 Last Updated: 6/20/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Sancuso (Granisetron) 3.1mg/24hr 1) Metoclopramide 1-2mg/kg 30 minutes prior to Transdermal Patch Apply 24-48 hours prior to chemotherapy 2) Prochlorperazine 5-10mg Q6H 3) chemotherapy Dexamethasone 20mg 30 minutes prior to chemotherapy 4) Ondansetron 4-8mg 30 minutes prior to chemotherapy 5) Ondansetron 4-8mg ODT 30 minutes prior to chemotherapy 6) Transderm Scop 1.5mg Apply Q72H NF 7) Granisetron 2mg 1 hour prior to chemotherapy NF Sandostatin (Octreotide) 50, 100, 200, 500, 1000mcg/ml Injection Solution TID Sandostatin LAR Depot (Octreotide) 10, 20, 30mg Intramuscular Powder for Suspension Q4W Santyl (Collagenase) 250U/gm Ointment AAA QD Saphris (Asenapine) 5, 10mg Sublingual Tablet BID Octreotide 50mcg TID NF Comments Document Acromegaly, Metastatic carcinoid tumor, or Vasoactive intestinal peptide secreting tumor Document Acromegaly, Metastatic carcinoid tumor, or Vasoactive intestinal peptide secreting tumor Urea 40% Cream AAA BID 1) Risperidone 4mg QD 2) Haloperidol 0.5-5mg BID-TID 3) Thiothixene 2mg TID 4) Quetiapine 400-800mg QD 5) Ziprasidone 20-80mg BID 6) Olanzapine 10mg QD 7) Olanzapine ODT 10mg QD 8) Latuda 40-80mg QD NF 9) Abilify 10-15mg QD Sarafem (Fluoxetine) 10mg Capsule; 10, 15, 1) Citalopram 20-40mg QD 2) Fluoxetine 20-40mg QD 3) 20mg Tablet QD Sertraline 50-100mg QD 4) Mirtazapine 30mg QHS 5) Bupropion SR/XL 300mg QD 6) Venlafaxine ER 225mg QD 7) Fluvoxamine 50-300mg QD NF 8) Escitalopram 10-20mg QD NF 9) Paxil CR 12.5-37.5mg QD NF 10) Viibryd 10-40mg QD NF 11) Pristiq 50-100mg QD NF 12) Cymbalta 30-60mg BID NF Savella (Milnacipran) 12.5, 25, 50, 100mg 1) Amitriptyline* 50mg QHS 2) Nortriptyline* (<65 YOA: 25mg Tablet BID QHS / > 65 YOA: 10mg QHS) 3) Cyclobenzaprine* 10mg TID 4) Tramadol* 50mg BID Document adequate trial or intolerance to all formulary SSRIs Document adequate therapeutic trial or intolerance to 1 TCA*, Tramadol*, and Cyclobenzaprine *Not recommended in the elderly and not a required medication for patients over 65 years old Seasonale (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel x 84 days) Tablet QD Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD Day 1-84: Take 1 active tablet QD (Discard placebo tablets from first 3 packets) Day 85-91: Take 1 placebo tablet QD Seasonique (30mcg Ethinyl Estradiol/0.15mg Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD Day 1-84: Take 1 active tablet QD (Discard placebo Levonorgestrel x 84 days, 10mcg EE x 7 tablets from first 3 packets) days) Tablet QD Day 85-91: Take 1 placebo tablet QD Serzone (Nefazodone) 50, 100, 150, 200, Document adequate therapeutic trial or intolerance 1) Citalopram 20-40mg QD 2) Fluoxetine 20-40mg QD 3) 250mg Tablet BID to 2 SSRIs and Venlafaxine Sertraline 50-100mg QD 4) Mirtazapine 15-45mg QHS 5) Bupropion SR/XL 300mg QD 6) Venlafaxine ER 225mg QD Silenor (Doxepin) 3, 6mg Tablet QHS Simponi (Golimumab) 50mg/0.5ml Subcutaneous Solution Q4W 1) Trazodone 50-100mg QHS 2) Temazepam 15-30mg QHS 3) Zolpidem 5-10mg QHS 4) Zaleplon 5-10mg QHS 5) Ambien CR 6.25-12.5mg QHS NF 6) Rozerem 8mg QHS NF 7) Lunesta 1-3mg QHS NF 1) Humira 40mg QOW 2) Enbrel 50mg QW 3) Remicade 5mg/kg Q8W NF Page 44 Last Updated: 6/20/2012 Document adequate therapeutic trial or intolerance to Trazodone, Zolpidem, and at least 1 Benzodiazepine Document adequate therapeutic trial or intolerance to Humira, Enbrel, and Remicade Remicade Infusion KP Rheumatology Contact CU Infusion Center 770-431-4367 or SW Infusion Center 770-603-3663 Network Rheumatology Contact Provider Relations 404-364-4934 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Singulair (Montelukast) 4mg Granule; 4,5 mg Asthma Chew Tablet; 5,10mg Tablet QHS 1) Qvar 40-80mcg 1-2 PUFFS QD-BID 2) Flovent HFA 44mcg 2 PUFFS BID NOTE: Flovent HFA 44mcg for patients 4-11 years of age 3) Asmanex 110-220mcg 1-2 PUFFS QD 4) Budesonide 0.25-0.5mg/2ml QD-BID Allergic Rhinitis 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) OTC Allegra 60mg BID 4) Fluticasone 2 SPRAYS IEN QD 5) Flunisolide 2 SPRAYS IEN BID Urticaria 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) OTC Allegra 60mg BID 4) OTC Ranitidine 150mg BID Skelaxin (Metaxalone) 400, 800mg TID-QID Comments Asthma Document adequate therapeutic trial or intolerance to an Inhaled Corticosteroid within the past 3 months *Patients should have prescription for a ShortActing Beta 2 Agonist (e.g. Proair) for asthma exacerbations Allergic rhinitis Document adequate therapeutic trial or intolerance to Claritin, Zyrtec, or Allegra and at least one Nasal Steroid Urticaria Document adequate therapeutic trial or intolerance to Claritin, Zyrtec, or Allegra and Ranitidine. Only approved for add-on therapy (e.g. Claritin 30mg or Zyrtec 30mg + Ranitidine 150mg BID + Singulair) 1) Cyclobenzaprine 10mg TID 2) Chlorzoxazone 250-500mg TID 3) Carisoprodol 350mg TID 4) Tizanidine 4mg TID 5) Methocarbamol 500-750mg QID 6) Baclofen 10-20mg TID Solage (Mequinol/Tretinoin) 2/0.01% AAA BID Excluded Medication Solaquin Forte (Hydroquinone) 4% Cream AAA BID Solodyn (Minocycline) 45, 55, 65, 80, 90, 105, 1) Doxycycline Hyclate 50-100mg BID 2) Minocycline 50115, 135mg Extended Release Tablet QD 100mg BID 3) Tetracycline 250-500mg BID Excluded Medication Soma Compound (Carisoprodol/Aspirin) 200/325mg Tablet QID Somatuline Depot (Lanreotide) 120/0.5, 90/0.3, 60/0.2mg/ml Subcutaneous Solution Q4W Soriatane (Acitretin) 10, 17.5, 22.5, 25mg Capsule QD Dose Conversion Solodyn 45mg QD=Minocycline 50mg QD / Solodyn 135mg=Minocycline 100mg QD 2 Separate Medications OTC Aspirin 325mg TID-QID AND 1) Cyclobenzaprine 10mg TID 2) Chlorzoxazone 250-500mg TID 3) Carisoprodol 350mg TID 4) Tizanidine 4mg TID 5) Methocarbamol 500750mg QID 6) Baclofen 10-20mg TID Document Acromegaly, Metastatic carcinoid tumor, Octreotide 50mcg TID NF or Vasoactive intestinal peptide secreting tumor 1) Vectical 3mcg/gm (Calcitriol) AAA BID 2) Calcipotriene 0.005% Solution AAA QD-BID NF 3) Tazorac 0.05, 0.1% Cream, Gel AAA QHS NF 4) Calcipotriene 0.005% Ointment AAA QD-BID NF 5) Taclonex 0.005/0.064% Ointment, Suspension AAA QD NF OR Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID Spectazole (Econazole) 1% Cream AAA QD- 1) OTC Lamisil Ultra (Butenafine 1%) QD-BID 2) OTC BID Lotrimin AF (Clotrimazole 1%) BID 3) OTC Micatin (Miconazole 1%) BID 4) Ketoconazole 2% Cream QD Page 45 Last Updated: 6/20/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Comments Sprix (Ketorolac) 15.75mg/Actuation Nasal Spray 1 SPRAY IEN Q6-8H 1) Sumatriptan 25-100mg PRN 2) Sumatriptan 20mg Nasal Spray PRN 3) Naratriptan 1-2.5mg PRN 4) Sumatriptan 6mg/ml Subcutaneous Solution PRN 5) Maxalt MLT 5-10mg PRN NF 6) Zomig 5mg PRN NF 7) Zomig 2.5mg PRN NF 8) Relpax 20-40mg PRN NF 9) Axert 6.25-12.5mg PRN NF 10) Treximet 500/85mg PRN NF Stadol (Butorphanol) 10mg/ml Nasal Spray 1 SPRAY IN 1 NOSTRIL Q3-4H PRN Migraine Treatment 1) Sumatriptan 25-100mg PRN 2) Sumatriptan 20mg Nasal Spray PRN 3) Naratriptan 1-2.5mg PRN 4) Sumatriptan 6mg/ml Subcutaneous Solution PRN Pain 1) Oxycodone/Acetaminophen 5/325mg Q6H 2) Morphine 1530mg Q4H 3) Hydromorphone 2-8mg Q4-6H 4) Oxycodone 530mg Q4-6H 5) Morphine Solution 20mg/ml 0.5-1.5ml Q4H 6) Meperidine 50-150mg Q3-4H Adjust based on patient response 1) Glipizide 5-15mg QD 2) Glyburide 2.5-10mg QD Glipizide preferred if 65 years of age and older due to prolonged half life of Glyburide Epilepsy 1) Lamotrigine 100-200mg BID 2) Carbamazepine 8001600mg QD 3) Topiramate 200mg BID 4) Phenytoin 100mg TID 5) Levetiracetam 500-1500mg BID 6) Gabapentin 300600mg TID 7) Levetiracetam ER 1000mg QD 8) Divalproex 250-500mg TID Migraine Prophylaxis 1) Amitriptyline 10-25mg QHS 2) Propranolol 20-40mg BIDTID 3) Topiramate 25-100mg QHS 4) Divalproex 2501000mg BID 5) Propranolol ER 80mg QD NF 6) Divalproex ER 500-1000mg QD Starlix (Nateglinide) 60, 120mg Tablet TID Stavzor (Valproic Acid) 125, 250, 500mg Delayed Release Capsule BID-TID Quantity Limit Axert 6.25-12.5mg=6 Tablets Frova 2.5mg=9 Tablets Maxalt MLT 5-10mg=9 Tablets Naratriptan 1-2.5mg=9 Tablets Relpax 20-40mg=6 Tablets Sumatriptan 25-100mg=9 Tablets Treximet 500/85mg=9 Tablets Zomig 2.5mg=6 Tablets Zomig 5mg=3 Tablets Quantity Limit Naratriptan 1-2.5mg=9 Tablets Sumatriptan 25-100mg=9 Tablets Staxyn (Vardenafil) 10mg Orally Disintegrating Tablet PRN Stelara (Ustekinumab) 90mg/ml, 45mg/0.5ml 1) Humira 40mg QOW 2) Enbrel 50mg QW 3) Remicade Subcutaneous Solution Q12W 5mg/kg Q8W NF Excluded Medication (Exception: Sexual Dysfunction Rider) Document adequate therapeutic trial or intolerance to Humira, Enbrel, and Remicade Remicade Infusion KP Dermatology Contact CU Infusion Center 770-431-4367 or SW Infusion Center 770-603-3663 Network Dermatology Contact Provider Relations 404-364-4934 Strattera (Atomoxetine) 10, 18, 25, 40, 60, 80, 1) Guanfacine 1-4mg QD 2) Methylin 5-20mg BID-TID 3) Document adequate therapeutic trial or intolerance 100mg Capsule QD Adderall 5-30mg QD-BID 4) Methylin ER 10-20mg BID-TID 5) to at least 3 formulary alternatives Dextroamphetamine CR 5-15mg QD-BID 6) Adderall XR 530mg QAM 7) Methylphenidate ER 18-72mg QAM Stromectol (Ivermectin) 3mg Tablet 3mg Single dose Suboxone (Buprenorphine/Naloxone) 2/0.5, 8/2mg Sublingual Film QD Sular (Nisoldipine) 8.5, 10, 17, 20, 25.5, 34, 40mg Extended Release Tablet QD Supartz (Hyaluronate Sodium) 25mg/2.5ml Injection Solution QW Albenza 400mg Single dose Buprenorpine/Naloxone 2/0.5-8/2mg QD 1) Amlodipine 5-10mg QD 2) Verapamil SR 180-240mg BID 3) Diltiazem ER 240-360mg QD 4) Nifedipine ER 30-60mg QD 5) Felodipine 2.5-20mg QD Dose Conversion Nislodipine 10mg=Nifedipine ER 30mg / Nislodipine 20mg=Nifedipine ER 60mg / Nislodipine 40mg=Nifedipine ER 90mg Administered in a healthcare setting by healthcare providers Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Page 46 Last Updated: 6/20/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Suprax (Cefixime) 100mg/5ml, 200mg/5ml Powder for Suspension; 400mg Tablet QD 3rd Generation Sylatron (Peginterferon Alfa-2b) 296, 444, 888mcg Subcutaneous Powder for Solution 1.5mcg/kg QW Symbicort (Budesonide/Formoterol) 80/4.5, 160/4.5mcg Inhalation Aerosol Liquid 2 PUFFS BID 1) Cefdinir 125mg/5ml-250mg/5ml 7mg/kg BID 3rd Generation 2) Pediazole (Erythromycin Ethylsuccinate/Sulfisoxazole) 50mg/kg divided TID-QID 1) Pegasys 180mcg QW 2) PEG-Intron 150mcg QW Symbyax (Fluoxetine/Olanzapine) 25/3, 25/6, 25/12, 50/6, 50/12mg Capsule QD Symlin (Pramlintide) 0.6mg/ml Subcutaneous Solution AC 2 Separate Medications Fluoxetine 20-40mg QD AND Olanzapine 2.5-15mg QD DM1 1) Novolin R (Insulin Regular) SC 30 minutes AC 2) Novolin N (NPH) SC 15-30 minutes AC 3) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 4) NovoLog (Insulin Aspart) SC 5-10 minutes AC DM2 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin 5001000mg (Maximum 2550mg QD) 3) Metformin ER 500750mg (Maximum 2000mg QD) 4) Novolin R (Insulin Regular) SC 30 minutes AC 5) Novolin N (NPH) SC 15-30 minutes AC 6) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos 15mg (Maximum 45mg QD) Administered in a healthcare setting by healthcare providers Synagis (Palivizumab) 50/0.5, 100mg/ml Intramuscular Solution 15mg/kg QM Synalar (Fluocinolone) 0.01% Cream AAA BID-QID Low Potency 1) Qvar 40-80mcg 1-2 PUFFS QD-BID 2) Flovent HFA 44mcg 2 PUFFS BID NOTE: Flovent HFA 44mcg for patients 4-11 years of age 3) Asmanex 110-220mcg 1-2 PUFFS QD 4) Dulera 200/5mcg 2 PUFFS BID NF Comments Document adequate trial or intolerance to Qvar 80mcg 2 PUFFS BID or Asmanex 220mcg 2 PUFFS QD within the past 3 months *Patients should have prescription for a ShortActing Beta 2 Agonist (e.g. Proair) for asthma exacerbations Dose Conversion Symbicort 80/4.5mcg 2 PUFFS BID=Albuterol Q4H PRN + Qvar 80mcg 1PUFF BID =Albuterol Q4H PRN + Flovent 44mcg 2 PUFFS BID / Symbicort 160/4.5mcg 2 PUFFS BID=Albuterol Q4H PRN + Qvar 80mcg 2 PUFFS BID=Albuterol Q4H PRN + Asmanex 220mcg 2 PUFFS QD=Dulera 200/5mcg 2 PUFFS BID NF Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Contact GW Synagis Clinic 770-931-6010 Low Potency 1) Betamethasone Valerate 0.1% Lotion AAA QD-BID 2) Desonide 0.05% Cream, Ointment AAA BID-TID 3) Fluocinolone Acetonide 0.01% Solution AAA QD 4) DermaSmoothe/FS 0.01% Oil AAA QD Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BID-QID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Synalar (Fluocinolone Acetonide) 0.025% Medium Potency Cream AAA BID-QID Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BID-QID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BID-QID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID Synalar (Fluocinolone Acetonide) 0.025% Medium-High Potency Ointment AAA BID-QID Medium-High 1) Triamcinolone Acetonide 0.1% Cream AAA BID-QID 2) Potency Betamethasone Valerate 0.1% Ointment AAA QD-BID High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BID-QID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QD-BID Synthroid (Levothyroxine) 0.025, 0.05, 0.075, Levothroid 0.025-0.3mg QD Synthroid to Levothroid is a 1:1 Conversion 0.088, 0.1, 0.112, 0.125, 0.137, 0.15, 0.175, 0.2, 0.3mg Tablet QD Page 47 Last Updated: 6/20/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Synvisc (Hylan Polymers A and B) 8mg/ml Injection Solution QW Taclonex (Calcipotriene/Betamethasone Dipropionate) 0.005/0.064% Ointment, Suspension AAA QD Very High Potency Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Comments Administered in a healthcare setting by healthcare providers Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. 2 Separate Medications 1) Vectical 3mcg/gm (Calcitriol) AAA BID 2) Calcipotriene 0.005% Solution AAA QD-BID NF 3) Tazorac 0.05, 0.1% Cream, Gel AAA QHS NF 4) Calcipotriene 0.005% Ointment AAA QD-BID NF AND Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID Talwin NX (Pentazocine/Naloxone) 50/0.5mg Tablet Q3-4H 1) Tramadol 50mg Q4-6H PRN 2) Hydrocodone/Acetaminophen 5/325mg Q4-6H 3) Codeine/APAP 15/300, 30/300, 60/300mg Q4H Tarceva (Erlotinib) 25, 100, 150mg Tablet QD 1) Platinum-based Chemotherapy 2) Docetaxel 75mg/m2 IV Q21D Tarka (Trandolapril/Verapamil) 1/240, 2/180, 2/240, 4/240mg Tablets QD-BID 2 Separate Medications Lisinopril QD AND Verapamil SR 180-240mg QD-BID Tasigna (Nilotinib) 150, 200mg Capsule Sprycel 100-180mg QD 400mg BID Tazorac (Tazarotene) 0.05, 0.1% Cream, Gel Acne AAA QHS 1) Retin-A 0.025-0.1% Cream, Gel AAA QHS Psoriasis 1) Vectical 3mcg/gm (Calcitriol) AAA BID 2) Calcipotriene 0.005% Solution AAA QD-BID NF OR Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID Tegretol-XR (Carbamazepine) 100, 200, Carbatrol 100, 200, 300mg BID 400mg Extended Release Tablet BID Tekamlo (Aliskiren/Amlodipine) 150/5, 150/10, 2 Separate Medications 300/5, 300/10mg Tablet QD Amlodipine 5-10mg QD AND Renin-Angiotensin System/Diuretic 1) Lisinopril/HCTZ 10/12.5, 20/12.5, 20/25mg QD NOTE: If Angiotensin Converting Enzyme Inhibitor allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan/HCTZ 50/12.5, 100/12.5, 100/25mg QD Beta Blocker Metoprolol 100-450mg QD Page 48 Last Updated: 6/20/2012 FDA approved for locally advanced or metastatic nonsmall cell lung cancer (NSCLC) failed at least one Chemotherapy Dose Conversion Trandolapril 1mg=Lisinopril 10mg / Trandolapril 2mg=Lisinopril 20mg / Trandolapril 4mg=Lisinopril 40mg Excluded medication for patients > 36 YOA Tegretol-XR to Carbatrol is a 1:1 Conversion Document adequate therapeutic trial or intolerance to maximum tolerated doses of at least 4 Blood Pressure medications Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Tekturna (Aliskiren) 150, 300mg Tablet QD Tekturna HCT (Aliskiren/HCTZ) 150/12.5, 150/25, 300/12.5, 300/25mg Tablet QD Temovate E (Clobetasol Propionate) 0.05% Emollient Cream AAA BID Ultra High Potency Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Renin-Angiotensin System/Diuretic 1) Lisinopril/HCTZ 10/12.5, 20/12.5, 20/25mg QD NOTE: If Angiotensin Converting Enzyme Inhibitor allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan/HCTZ 50/12.5, 100/12.5, 100/25mg QD Calcium Channel Blocker Amlodipine 5-10mg QD Beta Blocker Metoprolol 100-450mg QD Renin-Angiotensin System/Diuretic 1) Lisinopril/HCTZ 10/12.5, 20/12.5, 20/25mg QD NOTE: If Angiotensin Converting Enzyme Inhibitor allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan/HCTZ 50/12.5, 100/12.5, 100/25mg QD Calcium Channel Blocker Amlodipine 5-10mg QD Beta Blocker Metoprolol 100-450mg QD Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID Comments Document adequate therapeutic trial or intolerance to maximum tolerated doses of at least 3 Blood Pressure medications Document adequate therapeutic trial or intolerance to maximum tolerated doses of at least 4 Blood Pressure medications Tenex (Guanfacine) 1, 2mg Tablet QHS Terazol (Terconazole) 0.4, 0.8% Cream; 80mg Vaginal Suppository QHS Guanfacine 1mg QHS 1) OTC Mycelex (Clotrimazole 1%) QHS 2) OTC Monistat (Miconazole) QHS 3) OTC Vagistat (Tioconazole 6.5%) QHS 4) Fluconazole 150mg QD Testim 1% (Testosterone) 50mg/5gm Gel 1) Testosterone Cypionate 200mg/ml IM Q2-4W 2) Apply QAM Androderm Patch 2-4mg/24hr Apply QPM 3) AndroGel Pump 1.62% Apply 2 pumps QAM NF 4) AndrogGel Pump 1% Apply 4 pumps QAM NF 5) AndroGel 1% (25mg/2.5gm50mg/5gm) Apply QAM NF Thyroid (Thyroid) 1/4(15mg), 1/2(30mg), Levothroid QD Dose Conversion 1(60mg), 1&1/2(90mg), 2(120mg), 3(180mg), Thyroid 15mg=Levothroid 25mcg / Thyroid 4(240mg), 5(300mg) Grain Tablet QD 30mg=Levothroid 50mcg / Thyroid 60mg =Levothroid 100mcg / Thyroid 90mg =Levothroid 150mcg / Thyroid 120mg =Levothroid 200mcg / Thyroid 180mg =Levothroid 300mcg / Thyroid 240mg =Levothroid 400mcg / Thyroid 300mg =Levothroid 500mcg Ticlid (Ticlopidine) 250mg Tablet BID 1) Clopidogrel 75mg QD (CVA/CABG) 2) Aggrenox (CVA/CABG) 25/200mg BID (CVA) Tikosyn (Dofetilide) 125, 250, 500mcg Prescribing Physician must call Tikosyn Education Capsule BID Distribution Program 877-TIKOSYN Timoptic-XE (Timolol) 0.25, 0.5% Ophthalmic 1) Timolol 0.25-0.5% 1 GTT QD-BID 2) Levobunolol 0.25Gel-Forming Solution 1 GTT QD 0.5% 1-2 GTT QD-BID 3) Betaxolol 0.5% 1-2 GTT BID Tindamax (Tinidazole) 250, 500mg Tablet 2gm Single dose Tirosint (Levothyroxine) 13, 25, 50, 75, 88, 100, 112, 125, 137, 150mcg Liquid Filled Capsule QAM Bacterial Vaginosis 1) Metronidazole 500mg BID X7D 2) Clindamycin 300mg BID X7D Giardiasis Metronidazole 250mg TID X5-7D Trichomoniasis Metronidazole 500mg BID X7D Levothroid 0.025-0.15mg QD Tirosint to Levothroid is a 1:1 Conversion Page 49 Last Updated: 6/20/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy TOBI (Tobramycin) 300mg/5ml Inhalation Solution BID TobraDex ST (Tobramycin/Dexamethasone) Tobramycin/Dexamethasone 0.3/0.1% 1-2 GTTS Q4-6 0.3/0.05% Ophthalmic Suspension 1-2 GTTS HOURS Q4-6 HOURS Comments Document cystic fibrosis patient requiring treatment of Pseudomonas aeruginosa Topamax (Topiramate) 15, 25mg Capsule; 25, Epilepsy 50, 100, 200mg Tablet QD-BID 1) Lamotrigine 100-200mg BID 2) Carbamazepine 8001600mg QD 3) Topiramate 200mg BID 4) Phenytoin 100mg TID 5) Levetiracetam 500-1500mg BID 6) Gabapentin 300600mg TID 7) Levetiracetam ER 1000mg QD 8) Divalproex 250-500mg TID Migraine Prophylaxis 1) Amitriptyline 10-25mg QHS 2) Propranolol 20-40mg BIDTID 3) Topiramate 25-100mg QHS 4) Divalproex 2501000mg BID 5) Propranolol ER 80mg QD NF 6) Divalproex ER 500-1000mg QD Topicort (Desoximetasone) 0.05% Gel; 0.25% Very High Potency Cream, Ointment AAA BID Very High 1) Betamethasone Dipropionate Augmented 0.05% Cream Potency AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID Topicort LP (Desoximetasone) 0.05% Cream AAA BID High Potency High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BID-QID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QD-BID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Toradol (Ketorolac) 10mg Tablet Q4-6H X5D 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg BID 3) Ibuprofen 400-800mg TID-QID 4) Sulindac 150-200mg BID 5) Etodolac 200-500mg BID-TID 6) Nabumetone 500-750mg BID 7) Lidocaine 5% Ointment AAA Q4H Toviaz (Fesoterodine) 4, 8mg Extended ReleaseTablet QD 1) Oxybutinin 5mg BID-TID 2) Oxybutynin XL 5-15mg QD 3) Oxytrol 3.9mg/day Patch Apply twice weekly 4) Trospium 20mg BID NF 5) Detrol LA 2-4mg QD NF 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin 5001000mg (Maximum 2550mg QD) 3) Metformin ER 500750mg (Maximum 2000mg QD) 4) Novolin R (Insulin Regular) SC 30 minutes AC 5) Novolin N (NPH) SC 15-30 minutes AC 6) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos 15mg (Maximum 45mg QD) Tradjenta (Linagliptin) 5mg Tablet QD Page 50 Last Updated: 6/20/2012 Black Box Warning Ketorolac is only indicated for short-term (up to 5 days) management of moderatley severe acute pain. Ketorolac is not indicated for minor or chronic painful conditions. Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Transderm Scop 1.5mg Transdermal Patch Apply Q72H Tranxene-SD (Clorazepate) 11.25, 22.5mg Extended Release Tablet QD Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Vertigo 1) OTC Benadryl (Diphenhydramine) 25-50mg Q4-6H 2) OTC Dramamine (Dimenhydrinate) 50mg Q4-6H 3) OTC Antivert (Meclizine) 25-50mg QD-QID 4) OTC Bonine (Cyclizine) 50mg Q4-6H 5) Clonazepam 0.5mg TID 6) Diazepam 5mg BID-QID 7) Lorazepam 1-2mg TID 8) Promethazine 25mg Q6H Sialorrhea 1) Benztropine 2mg TID-QID 2) Trihexphenidyl 2mg TID 3) Trihexphenidyl 0.4mg/ml NF 4) Glycopyrrolate 1mg TID-QID 5) Atrovent 1-2 PUFFS TID 1) Clonazepam 0.25-0.5mg BID 2) Alprazolam 0.25-0.5mg TID 3) Diazepam 2-10mg BID-QID 4) Lorazepam 1mg BIDTID 5) Clorazepate 3.75-15mg TID 6) Chlordiazepoxide 510mg TID-QID 7) Oxazepam 10-15mg TID-QID Travatan Z (Travoprost) 0.004% Ophthalmic Solution 1 GTT QPM Treximet (Naproxen/Sumatriptan) 500/85mg Tablet PRN 1) Latanoprost 0.005% 1 GTT QPM 2) Lumigan 0.01-0.03% 1 GTT QPM NF 2 Separate Medications Naproxen 500mg AND 1) Sumatriptan 25-100mg PRN 2) Sumatriptan 20mg Nasal Spray PRN 3) Naratriptan 1-2.5mg PRN 4) Sumatriptan 6mg/ml Subcutaneous Solution PRN 5) Maxalt MLT 5-10mg PRN NF 6) Zomig 5mg PRN NF 7) Zomig 2.5mg PRN NF 8) Relpax 20-40mg PRN NF 9) Axert 6.25-12.5mg PRN NF Trilipix (Fenofibric Acid) 45, 135mg Capsule QD 1) Gemfibrozil 600mg BID 2) Fenofibrate 54-160mg QD Comments Excluded Medication for Travel Dose Conversion Tranxene-SD 11.25mg QD=Clorazepate 3.75mg TID / Tranxene-SD 22.5mg QD=Clorazepate 7.5mg TID Quantity Limit Axert 6.25-12.5mg=6 Tablets Maxalt MLT 5-10mg=9 Tablets Naratriptan 1-2.5mg=9 Tablets Relpax 20-40mg=6 Tablets Sumatriptan 25-100mg=9 Tablets Treximet 500/85mg=9 Tablets Zomig 2.5mg=6 Tablets Zomig 5mg=3 Tablets Triaz (Benzoyl Peroxide) 3, 6, 9% Gel; 6% 1) OTC Benzoyl Peroxide 2.5-10% AAA QD 2) OTC Benzoyl Excluded Medication Foaming Cloth; 3, 6, 9% Pad QD-BID Peroxide 5-10% Liquid AAA QD-BID Tribenzor 3 Separate Medications Dose Conversion (Amlodipine/Hydrochlorothiazide/Olmesartan) Amlodipine 5-10mg QD AND HCTZ QD AND 1) Lisinopril QD Benicar 20mg=Lisinopril 20mg=Losartan 50mg / 5/12.5/20, 5/12.5/40, 10/12.5/40, 5/25/40, NOTE: If Angiotensin Converting Enzyme Inhibitor allergy or Benicar 40mg=Lisinopril 40mg= Losartan 100mg 10/25/40mg Tablet QD NOTE: Consider Lisinopril/HCTZ 20/12.5mg or contraindication consider Angiotensin Receptor Blocker 2) Losartan/HCTZ 50/12.5, 100/12.5, 100/25mg Losartan QD Tricor (Fenofibrate) 48, 145, 160mg Tablet 1) Gemfibrozil 600mg BID 2) Fenofibrate 54-160mg QD Dose Conversion Tricor QD 48mg=Fenofibrate 54mg / Tricor 145,160mg=Fenofibrate 160mg Fenofibrate preferred if current statin therapy Gemfibrozil preferred if reduced renal function Trileptal (Oxcarbazepine) 300mg/5ml 1) Lamotrigine 100-200mg BID 2) Carbamazepine 800Suspension; 150, 300, 600mg Tablet BID 1600mg QD 3) Topiramate 200mg BID 4) Phenytoin 100mg TID 5) Levetiracetam 500-1500mg BID 6) Zonisamide 100mg TID NF 7) Gabapentin 300-600mg TID 8) Levetiracetam ER 1000mg QD 9) Oxcarbazepine 600mg BID NF Tri-Luma (Fluocinolone/Hydroquinone/Tretinoin) 0.01/4/0.05% Cream AAA BID Page 51 Last Updated: 6/20/2012 Dose Conversion Trilipix 45mg=Fenofibrate 54mg / Trilipix 135mg=Fenofibrate 160mg Fenofibric Acid is the active metabolite of Fenofibrate Fenofibrate preferred if current statin therapy Gemfibrozil preferred if reduced renal function Excluded Medication Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Triphasil (30mcg Ethinyl Estradiol/0.05mg Levonorgestrel x 6 days, 40mcg EE/0.075mg LVNGL x 5 days, 30mcg EE/0.125mg LVNGL x 10 days) Tablet QD 1) Tri-Sprintec (35mcg Ethinyl Estradiol/0.18mg Norgestimate x 7 days, 35mcg EE/0.215mg NG x 7 days, 35mcg EE/0.25mg NGx 7 days) QD 2) Trivora (30mcg Ethinyl Estradiol/0.05mg Levonorgestrel x 6 days, 40mcg EE/0.075mg LVNGL x 5 days, 30mcg EE/0.125mg LVNGL x 10 days) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD 4) Leena (35mcg Ethinyl Estradiol/0.5mg Norethindrone x 7 days, 35mcg EE/1mg NE x 9 days, 35mcg EE/0.5mg NE x 5 days) QD Tussionex Pennkinetic (Hydrocodone Bitartrate/Chlorpheniramine Maleate) 10mg/8mg/5ml Extended-Release Suspension Q12H 1) Cheratussin AC (Codeine/Guaifenesin) 10mg/100mg/5ml Q4-6H PRN 2) Promethazine/Codeine 6.25mg/10mg/5ml Q46H PRN 3) Promethazine VC/Codeine (Promethazine/Codeine/Phenylephrine) 6.25mg/10mg/5mg/5ml Q4-6H PRN 4) Benzonatate 100200mg TID PRN 5) Tussigon (Hydrocodone Bitartrate/Homatropine Methylbromide) 5/1.5mg Q4-6H PRN Tysabri (Natalizumab) 20mg/ml Solution 300mg Q4W Precribing Physician must call TOUCH Prescribing Program 800-456-2255 (Option 2) Tysabri is delivered directly to MD office via Tysabri Direct Administered in a healthcare setting by healthcare providers Comments Equivalent Brand and Generic Products Triphasil=Trivora Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. U-Cort (Hydrocortisone/Urea) 1/10% Cream AAA BID-QID Lowest Potency Lowest Potency 1) OTC Hydrocortisone 0.5-1% Cream, Ointment AAA BIDQID 2) Hydrocortisone 2.5% Cream, Lotion, Ointment AAA BID-QID Low Potency 1) Betamethasone Valerate 0.1% Lotion AAA QD-BID 2) Desonide 0.05% Cream, Ointment AAA BID-TID 3) Fluocinolone Acetonide 0.01% Solution AAA QD 4) DermaSmoothe/FS 0.01% Oil AAA QD Ulesfia (Benzyl Alcohol) 5% Lotion Apply to 1) OTC Nix (Permethrin 1%) 2) OTC Rid, Pronto Plus scalp, Leave on for 10 minutes, Rinse, (Pyrethrins 0.33%/Piperonyl Butoxide 4%) 3) OTC Cetaphil Repeat application if lice present 7 days after Cleanser Lotion initial treatment Uloric (Febuxostat) 40, 80mg Tablet QD Allopurinol 300mg BID Ultracet (Acetaminopen/Tramadol) 325/37.5mg Q4-6H PRN Ultravate (Halobetasol Propionate) 0.05% Cream, Ointment AAA QD-BID Ultra High Potency Uniretic (Moexipril/HCTZ) 7.5/12.5, 15/25mg Tablet QD Apply to scalp, Leave on for 10 minutes, Rinse, Repeat application if lice present 7 days after initial treatment Document adequate therapeutic trial or intolerance to maximum tolerated dose of Allopurinol 2 Separate Medications OTC Aspirin 325mg Q4-6H PRN AND Tramadol 50mg Q46H PRN Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID 2 Separate Medications HCTZ QD AND 1) Lisinopril 10-40mg QD 2) Benazepril 20-40mg QD 3) Enalapril 10-40mg QD 4) Captopril 25-100mg TID 5) Ramipril 2.5-20mg QD Univasc (Moexipril) 7.5, 15mg Tablet QD Dose Conversion Moexipril 7.5mg=Lisinopril 10mg / Moexipril 15mg=Lisinopril 20mg NOTE: Consider Lisinopril/HCTZ 10/12.5, 20/25mg 1) Lisinopril 10-40mg QD 2) Benazepril 20-40mg QD 3) Dose Conversion Enalapril 10-40mg QD 4) Captopril 25-100mg TID 5) Ramipril Moexipril 7.5mg=Lisinopril 10mg / Moexipril 15mg=Lisinopril 20mg 2.5-20mg QD Uroxatral (Alfuzosin) 10mg Extended Release 1) Terazosin 1-10mg QD 2) Doxazosin 1-8mg QD 3) Tablet QD Tamsulosin 0.4mg QD Page 52 Last Updated: 6/20/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) UTA (Methenamine Sodium, Phosphate Monobasic, Phenyl Salicylate, Methylene Blue, Hyoscyamine Sulfate) 120/40.8/36/10/0.12mg Capsule QID Valtrex (Valacyclovir) 1gm, 500mg Tablet QDBID Valturna (Aliskiren/Valsartan) 150/160, 300/320mg Tablet QD Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy 1) OTC Azo-Standard (Phenazopyridine) 95mg TID 2) Hyoscyamine SL 0.125mg 1-2T Q4H 3) Hyoscyamine 0.125mg 1-2T Q4H 4) Hyoscyamine Solution 0.125mg/ml 510ml Q4H 5) Elmiron 100mg TID Genital Herpes Episodic Treatment 1) Acyclovir 200mg Q4H 2) Acyclovir 400mg TID 3) Acyclovir 800mg BID Genital Herpes Suppressive Treatment Acyclovir 400mg BID Herpes Zoster Treatment Acyclovir 800mg Q4H Renin-Angiotensin System/Diuretic 1) Lisinopril/HCTZ 10/12.5, 20/12.5, 20/25mg QD NOTE: If Angiotensin Converting Enzyme Inhibitor allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan/HCTZ 50/12.5, 100/12.5, 100/25mg QD Calcium Channel Blocker Amlodipine 5-10mg QD Beta Blocker Metoprolol 100-450mg QD Vaniqa (Eflornithine) 13.9% Cream AAA BID High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BID-QID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QD-BID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Vantin (Cefpodoxime) 50mg/5ml, 100mg/5ml Powder for Suspension; 100, 200mg Tablet BID 3rd Generation Vaseretic (Enalapril/HCTZ) 5/12.5, 10/25mg Tablet QD Veltin (Clindamycin/Tretinoin) 1.2/0.025% Gel AAA QHS 1) Cefdinir 125mg/5ml-250mg/5ml 7mg/kg BID 3rd Generation 2) Pediazole (Erythromycin Ethylsuccinate/Sulfisoxazole) 50mg/kg divided TID-QID 2 Separate Medications Enalapril QD AND HCTZ QD 2 Separate Medications Clindamycin 1% Gel AAA QHS AND Retin-A 0.025% Cream, Gel AAA QHS Proair HFA (Albuterol) 0.09mg Inhalation Aerosol Powder Q4H PRN 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) OTC Allegra 60mg BID 4) Fluticasone 2 SPRAYS IEN QD 5) Flunisolide 2 SPRAYS IEN BID 6) Triamcinolone 2 SPRAYS IEN QD NF 7) Nasonex 2 SPRAYS IEN QD NF Verdeso (Desonide) 0.05% Foam AAA BID Low Potency Verelan PM (Verapamil) 100, 200, 300mg Extended Release Capsule QHS Document adequate therapeutic trial or intolerance to maximum tolerated doses of at least 4 Blood Pressure medications Dose Conversion Diovan 80mg=Lisinopril 10mg=Losartan 25mg / Diovan 160mg=Lisinopril 20mg=Losartan 50mg / Diovan 320mg=Lisinopril 40mg=Losartan 100mg Excluded Medication Vanos (Flucinonide) 0.1% Cream AAA QD Ultra High Potency Ventolin HFA (Albuterol) 0.09mg Inhalation Aerosol Powder Q4H PRN Veramyst (Fluticasone Furoate) 27.5mcg/Actuation Nasal Spray 2 SPRAYS IEN QD Comments Low Potency 1) Betamethasone Valerate 0.1% Lotion AAA QD-BID 2) Desonide 0.05% Cream, Ointment AAA BID-TID 3) Fluocinolone Acetonide 0.01% Solution AAA QD 4) DermaSmoothe/FS 0.01% Oil AAA QD Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BID-QID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Verapamil SR QD-BID Page 53 Last Updated: 6/20/2012 Excluded Medication for patients > 36 YOA Ventolin HFA to Proair HFA is a 1:1 Conversion Age Recommendations Fluticasone=4 years of age and older / Flunisolide=6 years of age and older / Triamcinolone=2 years of age and older / Nasonex=2 years of age and older / Veramyst=2 years of age and older Dose Conversion Verelan PM 100mg=Verapamil SR 120mg / Verelan PM 200mg=Verapamil SR 180mg / Verelan PM 300mg=Verapamil SR 240mg Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Vesicare (Solifenacin) 5, 10mg Tablet QD Vexol (Rimexolone) 1% Ophthalmic Suspension 1-2 GTT QID Vfend (Voriconazole) 40mg/ml Powder for Suspension; 50, 200mg Tablet BID Viagra (Sildenafil) 25, 50, 100mg Tablet PRN Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy 1) Oxybutinin 5mg BID-TID 2) Oxybutynin XL 5-15mg QD 3) Oxytrol 3.9mg/day Patch Apply twice weekly 4) Trospium 20mg BID NF 5) Detrol LA 2-4mg QD NF 6) Toviaz 4-8mg QD NF 7) Enablex 7.5-15mg QD NF 1) Prednisolone 1% 1-2 GTTS BID-QID 2) Fluorometholone 0.1% 1-2 GTTS BID-QID 3) Dexamethasone 0.1% 1-2 GTTS BID-QID 1) Fluconazole 50-200mg QD 2) Itraconazole 100mg QD-BID 3) Sporanox 10mg/ml QD-BID Excluded Medication (Exception: Sexual Dysfunction Rider) Vicoprofen (Hydrocodone/Ibuprofen) 7.5/200mg Tablet Q4-6H PRN 1) Tramadol 50mg Q4-6H PRN 2) Hydrocodone/Acetaminophen 7.5/325mg Q6H 3) Oxycodone/Acetaminophen 5/325mg Q6H 4) Morphine 1530mg Q4H 5) Oxycodone 5-30mg Q4-6H Victoza (Liraglutide) 6mg/ml Subcutaneous Solution QD 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin 5001000mg (Maximum 2550mg QD) 3) Metformin ER 500750mg (Maximum 2000mg QD) 4) Novolin R (Insulin Regular) SC 30 minutes AC 5) Novolin N (NPH) SC 15-30 minutes AC 6) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos 15mg (Maximum 45mg QD) 2 Separate Medications Peg-Intron 1.5mcg/kg QW AND Ribavirin 800-1400mg QD Victrelis (Boceprevir) 200mg Capsule 4T TID Vigamox (Moxifloxacin) 0.5% Ophthalmic Solution 1 GTT BID Viibryd (Vilazodone) 10, 20, 40mg Tablet QD Vimovo (Esomeprazole/Naproxen) 20/375, 20/500mg Delayed Release Tablet BID Vimpat (Lacosamide) 50, 100, 150, 200mg Tablet BID Comments Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. No initial fill Document a) chronic Hepatitis C genotype 1 b) prescription from Gastroenterologist or Infectious Disease Specialist c) compensated liver disease d) completion of 4 week lead-in with Interferon Alfa and Ribavirin 1) Ofloxacin 0.3% Solution 1-2 GTTS QID 2) Ciprofloxacin 0.3% Solution 1-2 GTTS Q4HS NF 3) Sodium Sulfacetamide 10% Solution 1-3 GTTS Q2-3H 4) Gentamicin 0.3% Solution 1-2 GTTS QID 5) Erythromycin 0.5% Ointment APPLY RIBBON Q4H Document adequate therapeutic trial or intolerance 1) Citalopram 20-40mg QD 2) Fluoxetine 20-40mg QD 3) to 2 SSRIs and Venlafaxine Sertraline 50-100mg QD 4) Mirtazapine 30mg QHS 5) Bupropion SR/XL 300mg QD 6) Venlafaxine ER 225mg QD 7) Fluvoxamine 50-300mg QD NF 8) Escitalopram 10-20mg QD NF 9) Paxil CR 12.5-37.5mg QD NF 2 Separate Medications Excluded Medication Naproxen 375-500mg BID AND 1) Pantoprazole 40mg QD 2) OTC Omeprazole 20mg QD 3) OTC Zegerid 20/1100mg QD 4) OTC Prevacid 15mg QD 1) Lamotrigine 100-200mg BID 2) Carbamazepine 8001600mg QD 3) Topiramate 200mg BID 4) Phenytoin 100mg TID 5) Levetiracetam 500-1500mg BID 6) Zonisamide 100mg TID NF 7) Gabapentin 300-600mg TID 8) Levetiracetam ER 1000mg QD 9) Oxcarbazepine 600mg BID NF 10) Divalproex 250-500mg TID 11) Lyrica 50-200mg TID NF Viquin Forte (Hydroquinone/Sunscreen) 4% Cream AAA BID Viramune XR (Nevirapine) 400mg Extended 1) Nevirapine 200mg BID 2) Viramune 50mg/5ml 20ml BID Release Tablet QD Vistaril (Hydroxyzine Pamoate) 25, 50, 100mg 1) Hydroxyzine HCl 10, 25, 50mg TID-QID 2) Hydroxyzine Capsule; 25mg/5ml Suspension TID-QID HCl 10mg/5ml Syrup TID-QID Vivactil (Protriptyline) 5, 10mg Tablet TID-QID 1) Amitriptyline 50-100mg QHS 2) Nortriptyline 25mg TID 3) Imipramine 75mg QHS 4) Clomipramine 25mg TID 5) Desipramine 100-200mg QD Page 54 Last Updated: 6/20/2012 Excluded Medication Vistaril to Hydroxyzine HCl is a 1:1 Conversion Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Vivelle-DOT (Estradiol) 0.025, 0.0375, 0.05, 0.075, 0.1mg/24hr Transdermal Patch Apply twice weekly Voltaren Gel (Diclofenac Sodium) 1% Gel AAA 2-4gm QID Votrient (Pazopanib) 200mg Tablet 4T QD Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Vasomotor Symtoms 1) Estradiol QD 2) Climara Patch 0.025-0.1mg/24hr Apply weekly Vaginal/Vulvar Atrophy 1) Estradiol QD 2) Climara Patch 0.025-0.1mg/24hr Apply weekly 3) Premarin Vaginal 1gm Apply three times a week 4) Vagifem 10mcg Insert twice weekly 5) Estring 2mg Insert for 90 days 1) OTC Aspercreme AAA BID-QID 2) LidoPatch (Lidocaine 3.99%/Menthol 1%) Apply 1 patch up to 12 hours 3) Meloxicam 7.5-15mg QD 4) Naproxen 250-550mg BID 5) Ibuprofen 400-800mg TID-QID 6) Sulindac 150-200mg BID 7) Etodolac 200-500mg BID-TID 8) Nabumetone 500-750mg BID 9) Lidocaine 5% Ointment AAA Q4H 10) Diclofenac 25100mg BID-TID 1) Torisel 25mg IV QW 2) Sutent 50mg QD NOTE: 4 weeks on then 2 weeks off Comments Adjust to the lowest dose needed to control symptoms based on patient response Lower Extremity Application Voltaren Gel 1% AAA 4gm QID Upper Extremity Application Voltaren Gel 1% AAA 2gm QID Sutent preferred when initiating therapy FDA approved for treatment of advanced renal cell cancer (RCC) VPRIV (Velaglucerase Alfa) 400U Powder for 1) Zavesca 100mg TID NF 2) Cerezyme 60U/kg Q2W NF 3) Solution 60U/kg QOW Ceredase 60 U/kg Q2W NF Vytorin (Ezetimibe/Simvastatin) 10/10, 10/20, 2 Separate Medications 10/40mg, 10/80mg Tablet QD OTC Slo-Niacin 500mg QD (Titrate to 2000mg/day as tolerated using .PITTTSLONIACIN) AND 1) Simvastatin 1040mg QD 2) Pravastatin 20-80mg QD 3) Atorvastatin 1080mg QD Vyvanse (Lisdexamfetamine) 20, 30, 40, 50, 1) Methylin 5-20mg BID-TID 2) Adderall 5-30mg QD-BID 3) 60, 70mg Capsule QD Methylin ER 10-20mg BID-TID 4) Dextroamphetamine CR 515mg QD-BID 5) Adderall XR 5-30mg QAM 6) Methylphenidate ER 18-72mg QAM Welchol (Colesevelam) 3.75gm Powder for 1) Cholestyramine 4gm 8-16gm QD 2) Cholestyramine Light Suspension QD; 625mg Tablet 3T BID 4gm 8-16gm QD 3) Colestipol 1gm 2-16gm QD Westcort (Hydrocortisone Valerate) 0.2% Medium Potency Cream, Ointment Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BID-QID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BID-QID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID Xalatan (Latanoprost) 0.005% Ophthalmic 1) Latanoprost 0.005% 1 GTT QPM 2) Lumigan 0.01-0.03% Solution 1 GTT QPM 1 GTT QPM NF 3) Travatan Z 0.004% 1 GTT QPM NF NOTE: Zetia 5mg (25.8%) is expected to give the same LDL reduction as 10mg (26%) Xanax XR (Alprazolam) 0.5, 1, 2, 3mg Extended Release Tablet QAM 1) Clonazepam 0.25-0.5mg BID 2) Alprazolam 0.25-0.5mg TID 3) Diazepam 2-10mg BID-QID 4) Lorazepam 1mg BIDTID 5) Clorazepate 3.75-15mg TID 6) Chlordiazepoxide 510mg TID-QID 7) Oxazepam 10-15mg TID-QID Xarelto (Rivaroxaban) 10, 15, 20mg Tablet QD Hip or Knee Replacement Enoxaparin 40mg QD or 30mg BID Atrial Fibrillation 1) Warfarin 1-10mg QD (Tiitrate to target INR) 2) Pradaxa 150mg BID NF Dose Conversion Xanax XR 0.5mg QAM=Alprazolam 0.25mg BID / Xanax XR 1mg QAM=Alprazolam 0.25mg QID / Xanax XR 2mg QAM=Alprazolam 0.5mg QID / Xanax XR 3mg=Alprazolam 1mg TID Quantity Limit Xarelto 10mg (30 Day Supply)=35 Tablets No initial fill of Xarelto 15, 20mg Document a) Irreversible atrial fibrillation If CHADS2 Score=1 b) Identified as an anticoagulation candidate (not ASA) c) Uninterrupted Warfarin therapy for at least 22 weeks If CHADS2 Scoreā„2 b) Uninterrupted Warfarin therapy for at least 22 weeks Arixtra preferred if history of Heparin-Induced Thrombocytopenia (HIT) Page 55 Last Updated: 6/20/2012 Document adequate therapeutic trial or intolerance to at least 3 formulary alternatives Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Xenazine (Tetrabenazine) 12.5, 25mg Tablet BID-TID Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Excluded Medication (Exception: Obesity Rider) Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Xenical (Orlistat) 120mg Capsule TID Xgeva (Denosumab) 120/1.7mg/ml Subcutaneous Solution Q4W Xiaflex (Collagenase, Clostridium histolyticum) 0.9mg Powder for Solution Q4W Xibrom (Bromfenac) 0.09% Ophthalmic Solution 1 GTT BID 1) Diclofenac 0.1% 1GTT QID 2) Ketorolac 0.5% 1 GTT QID 3) Prednisolone 1% 1-2 GTTS BID-QID 4) Fluorometholone 0.1% 1-2 GTTS BID-QID 5) Dexamethasone 0.1% 1-2 GTTS BID-QID 6) Ketorolac 0.4% 1 GTT QID 7) Flurbiprofen 0.03% 1 GTT QID NF 8) Vexol 1% 1-2 GTT QID NF 9) Bromfenac 0.09% 1 GTT QD-BID NF Xifaxan (Rifaximin) 200, 550mg Tablet BIDTID Hepatic Encephalopathy 1) Metronidazole 500mg BID 2) Lactulose 10gm/15ml Solution 30-45ml TID-QID Traveler's Diarrhea Ciprofloxacin 500mg BID Xolair is delivered directly to MD office via CuraScript Specialty Pharmacy Administered in a healthcare setting by healthcare providers Xolair (Omalizumab) 150mg Subcutaneous Powder for Solution Q2-4W Comments Hepatic Encephalopathy Xifaxan 550mg BID Traveler's Diarrhea Xifaxan 200mg TID X3D Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Xopenex (Levalbuterol Hydrochloride) 0.31mg/3ml, 0.63mg/3ml, 1.25mg/3ml Inhalation Solution Q4H PRN 1) Albuterol 0.5% Inhalation Solution Q4H PRN 2) Albuterol 0.083% Inhalation Solution Q4H PRN 3) Proair HFA (Albuterol) 0.09mg Inhalation Aerosol Powder Q4H PRN 4) Xopenex HFA Q4H PRN NF Xopenex HFA (Levalbuterol Tartrate) Proair HFA (Albuterol) 0.09mg Inhalation Aerosol Powder 0.045mg Inhalation Aerosol Powder Q4H PRN Q4H PRN Xyzal (Levocetirizine) 5mg Tablet, 0.5mg/ml Solution QPM Yasmin (30mcg Ethinyl Estradiol/3mg Drospirenone) Tablet QD Yaz (20mcg Ethinyl Estradiol/3mg Drospirenone) Tablet QD Zanaflex (Tizanidine) 2mg Tablet TID Zantac 300 (Ranitidine) 300mg Tablet QD 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) OTC Allegra 60mg BID 4) Fluticasone 2 SPRAYS IEN QD 5) Flunisolide 2 SPRAYS IEN BID 1) Reclipsen (30mcg Ethinyl Estradiol/0.15mg Desogestrel) QD 2) Microgestin Fe 1.5/30 (30mcg Ethinyl Estradiol/1.5mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD 1) Reclipsen (30mcg Ethinyl Estradiol/0.15 Desogestrel) QD 2) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Aviane (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel) QD 1) Cyclobenzaprine 10mg TID 2) Chlorzoxazone 250-500mg TID 3) Carisoprodol 350mg TID 4) Tizanidine 4mg 0.5T TID 5) Methocarbamol 500-750mg QID 6) Baclofen 10-20mg TID Excluded Medication 1) OTC Famotidine 10-20mg QD-BID 2) OTC Ranitidine 75150mg QD-BID 3) Cimetidine 400-800mg QD-BID Excluded Medication Page 56 Last Updated: 6/20/2012 Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Comments Zegerid (Omeprazole/Sodium Bicarbonate) 40/1100mg Capsule; 20/1680, 40/1680mg Packet QD 1) Pantoprazole 40mg QD 2) OTC Omeprazole 20mg QD 3) Excluded Medication Omeprazole 2mg/ml Liquid 10ml QD 4) Lansoprazole 3mg/ml Liquid 10ml QD 5) OTC Zegerid 20/1100mg QD 6) OTC Prevacid 15mg QD Zelapar (Selegiline) 1.25mg Orally 1) Carbidopa/Levodopa ER 25/100mg BID 2) Bromocriptine Disintegrating Tablet QD 2.5mg QD 3) Amantadine 100mg BID 4) Pramipexole 0.1251.5mg TID 5) Ropinirole 2-8mg QD 6) Selegiline 5mg QD 7) Carbidopa/Levodopa/Entacapone 12.5/50/200mg TID 8) Ropinrole ER 2-12mg QD NF Zelboraf (Vemurafenib) 240mg Tablet 4T BID FDA approved for treatment of unresectable, Stage IIIC or metastatic, BRAF V6003 mutation positive malignant melanoma Zemplar (Paricalcitol) 1, 2, 4mcg Capsule QD Calcitriol 0.25-1mcg QD Zetia (Ezetimibe) 10mg Tablet QD Adjunctive Therapy NOTE: Zetia 5mg (25.8%) is expected to give the same LDL reduction as 10mg (26%) 1) OTC Slo-Niacin 500mg QD (Titrate to 2000mg/day as tolerated using .PITTTSLONIACIN) 2) Cholestyramine 4gm 816gm QD 3) Cholestyramine Light 4gm 8-16gm QD 4) Colestipol 1gm 2-16gm QD Monotherapy 1) Simvastatin 5-40mg QD 2) Pravastatin 10-80mg QD 3) Atorvastatin 10-80mg QD Ziana (Clindamycin/Tretinoin) 1.2/0.025% Gel 2 Separate Medications Excluded Medication for patients > 36 YOA AAA QHS Clindamycin 1% Gel AAA QHS AND Retin-A 0.025% Cream, Gel AAA QHS Zipsor (Diclofenac Potassium) 25mg Liquid 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg BID 3) Filled Capsule 2C BID-TID Ibuprofen 400-800mg TID-QID 4) Sulindac 150-200mg BID 5) Etodolac 200-500mg BID-TID 6) Nabumetone 500-750mg BID 7) Lidocaine 5% Ointment AAA Q4H 8) Diclofenac 25100mg BID-TID 9) Indomethacin 25-75mg QD-BID 10) Tolmetin 200-600mg TID Zirgan (Ganciclovir) 0.15% Ophthalmic Gel 1 Trifluridine 1% 1 GTT Q2H until healed then 1 GTT Q4H X7D GTT 5 times daily until healed then 1 GTT TID X7D Zofran (Ondansetron) 4mg/5ml Solution 30 1) Ondansetron 4-8mg 30 minutes prior to chemotherapy 2) minutes prior to chemotherapy Ondansetron 4-8mg ODT 30 minutes prior to chemotherapy Zomig (Zolmitriptan) 5mg Nasal Spray; 2.5, 5mg Tablet PRN 1) Sumatriptan 25-100mg PRN 2) Sumatriptan 20mg Nasal Spray PRN 3) Naratriptan 1-2.5mg PRN 4) Sumatriptan 6mg/ml Subcutaneous Solution PRN 5) Maxalt MLT 5-10mg PRN NF Quantity Limit Maxalt MLT 5-10mg=9 Tablets Naratriptan 1-2.5mg=9 Tablets Sumatriptan 25-100mg=9 Tablets Zomig 2.5mg=6 Tablets Zomig 5mg=3 Tablets Zonegran (Zonisamide) 25, 50, 100mg Capsule QD 1) Lamotrigine 100-200mg BID 2) Carbamazepine 8001600mg QD 3) Topiramate 200mg BID 4) Phenytoin 100mg TID 5) Levetiracetam 500-1500mg BID 6) Zonisamide 100mg TID NF Zovirax (Acyclovir) 5% Ointment AAA Q4H 1) OTC Abreva 10% Cream AAA Q4H 2) Acyclovir 400mg BID Zyban (Bupropion) 150mg Extended Release 1) OTC Nicoderm 7, 14, 21mg/day Patch Apply QD 2) OTC Tablet BID Nicorette 2, 4mg Gum Chew 3-24 QD 3) Bupropion SR 150mg QD-BID Zyflo CR (Zileuton) 600mg Extended Release 1) Qvar 40-80mcg 1-2 PUFFS QD-BID 2) Flovent HFA Tablet 2T BID 44mcg 2 PUFFS BID NOTE: Flovent HFA 44mcg for patients 4-11 years of age 3) Asmanex 110-220mcg 1-2 PUFFS QD 4) Budesonide 0.25-0.5mg/2ml QD-BID Page 57 Last Updated: 6/20/2012 Document adequate therapeutic trial or intolerance to an Inhaled Corticosteroid within the past 3 months *Patients should have prescription for a ShortActing Beta 2 Agonist (e.g. Proair) for asthma exacerbations Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Initial Fill & Criteria Restricted Medications (CRMs require QRM review) Formulary Alternative(s) NOTE: Options are numbered in the order of cost efficacy Zylet (Loteprednol/Tobramycin) 0.5/0.3% Ophthalmic Suspension 1-2 GTT Q4-6H Comments 2 Separate Medications NOTE: Consider Tobramycin/Dexamethasone 0.3/0.1% 1-2 GTTS Q4-6 HOURS Tobramycin 0.3% 1-2 GTT Q4H AND 1) Diclofenac 0.1% 1GTT QID 2) Ketorolac 0.5% 1 GTT QID 3) Prednisolone 1% 1-2 GTTS BID-QID 4) Fluorometholone 0.1% 1-2 GTTS BIDQID 5) Dexamethasone 0.1% 1-2 GTTS BID-QID 6) Ketorolac 0.4% 1 GTT QID 7) Flurbiprofen 0.03% 1 GTT QID NF 8) Vexol 1% 1-2 GTT QID NF 9) Bromfenac 0.09% 1 GTT QD-BID NF 10) Lotemax 0.5% 1-2 GTT QID NF 11) Nevanac 0.1% 1 GTT TID NF Zytiga (Abiraterone Acetate) 250mg Tablet 4T Docetaxel-based Chemotherapy FDA approved for treatment of castration-resistant QD metastatic prostate cancer who have failed Docetaxel-based Chemotherapy zzUpdated: January 7, 2011 Diana Diaz, Pharm.D. zzUpdated: February 15, 2011 Diana Diaz, Pharm.D. zzUpdated: April 12, 2011 Diana Diaz, Pharm.D. Diana Diaz, Pharm.D. zzUpdated: June 10, 2011 zzUpdated: June 23, 2011 Diana Diaz, Pharm.D. zzUpdated: August 19, 2011 Diana Diaz, Pharm.D. zzUpdated: October 20, 2011 Diana Diaz, Pharm.D. Diana Diaz, Pharm.D. zzUpdated: December 21, 2011 zzUpdated: February 20, 2012 Diana Diaz, Pharm.D. zzUpdated: April 24, 2012 Christine Lord, PharmD zzUpdated: June 20, 2012 Diana Diaz, PharmD Page 58 Last Updated: 6/20/2012
Related documents