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Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Accolate tab (Zafirlukast) 20 mg BID
ICS inhaler (QVAR or *Flovent or
Asmanex) plus a long acting B2-agonist
(Serevent) OR an ICS and B2 agonist
Accu-Check Advantage blood glucose test strips
One Touch Ultra glucose test strips
Touch Ultra 2 machine -only
Accupril tablet (Quinapril) 10-20 mg QD
Prinivil (Lisinopril) tablet 10 mg QD
Accupril tablet (Quinapril)40-80 mg QD
Prinivil (Lisinopril) tablet 20-40 mg QD
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide diuretic
Three Drug Therapy:Add Beta Blocker to ACE-I &
Thiazide diuretic
Four Drug Therapy:Add Long Acting
Dihydropyridine CCB to Beta Blocker, ACE-I &
Thiazide Diuretics
Accuretic (Quinapril/HCTZ 10/12.5mg) see strengths
below
Lisinopril/HCTZ 10/12.5MG QD
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide diuretic
Three Drug Therapy:Add Beta Blocker to ACE-I &
Thiazide diuretic
Four Drug Therapy:Add Long Acting
Dihydropyridine CCB to Beta Blocker, ACE-I &
Thiazide Diuretics
Accuretic (Quinapril/HCTZ 20/12.5mg; 20/25mg)
Lisinopril/HCTZ 20/12.5MG QD or 20/25mg TSPMG Guidelines suggest:
QD
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide diuretic
Three Drug Therapy:Add Beta Blocker to ACE-I &
Thiazide diuretic
Four Drug Therapy:Add Long Acting
Dihydropyridine CCB to Beta Blocker, ACE-I &
Thiazide Diuretics
Accutane caps (Isotretinoin)10-40 mg BID
Sotret (Isotretinoin) Or, consider antibiotic, if Physician should place a dated Sotret
no previous trial: Tetracycline caps 500 mg qualification sticker on Rx that must be dated w/in
QD-BID or Minocycline 50 mg QD-TID
7 days of date Rx is picked up.
Aceon (Perindopril) 4-8mg QD
Prinivil (Lisinopril) 20mg-40mg QD
Page 1
*Flovent 110mcg/puff & 220mcg/puff are nonformulary. If patient is already using steroid and
serevent inhaler and asthma symptoms persist,
candidate for singulair
One Lifescan monitor is formulary and may be
obtained, by prescription, at KP pharmacy at copayment. Members will be charged full price for
Lifescan monitor at Eckerd
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I &
Thiazide diuretic
Four Drug Therapy:Add Long Acting
Dihydropyridine CCB to Beta Blocker, ACE-I &
Thiazide Diuretics
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide diuretic
Three Drug Therapy:Add Beta Blocker to ACE-I &
Thiazide diuretic
Four Drug Therapy:Add Long Acting
Dihydropyridine CCB to Beta Blocker, ACE-I &
Thiazide Diuretics
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Aciphex tablet (Rabeprazole) 20-60 mg QD to BID
Aciphex is a NF No Initial Fill drug. If Prilosec
40mg QD failure, then consider NF No Initial
Fill drug, Protonix titrated up to 80mg QD.
(Protonix 40mg=Aciphex 20mg=Prilosec 20mg)
Must document failure or intolerance to Prilosec
40mg QD if requesting PPI coverage.
OTC Prilosec 20 to 40mg QD
Aclovate (Aclometasone) 0.05% cream, oint
DesOwen (Desonide) 0.05% cream, oint,
Low potency topical corticosteroids.
lotion or Synalar (Fluocinolone) 0.01% soln,
oil or Hytone (Hydrocortisone) 2.5% cream,
oint, lotion
Activella (1mg 17beta estradiol / 0.5mg norethindrone Estrace (17beta estradiol) 1mg QD plus
Two individual prescriptions are required.
acetate)
NorQD 0.35mg (norethindrone) QD
Norethindrone 0.35mg functional equivalent
dosing to Norethindrone acetate 0.5mg.
Actonel (Residronate) 5mg QD or 35mg Qweek
Fosamax (Alendronate) 5mg QD or 35mg
If preventing osteoporosis, convert 5mg Actonel
tablets
every week for osteoporosis prevention OR QD to 5mg Fosamax QD OR convert 35mg
Fosamax 10mg QD or 70mg w/D Q week
Actonel once a week to Fosamax 35mg [37.5ml]
for osteoporosis treatment. Fosamax
PO once a week. Fosamax Liquid is the
70mg/75ml liquid & Fosamax w/D tablets
preferred formulary alternative for this dose :
available. Fosamax w/D is the preferred
37.5ml = 35mg dose. If treating osteoporosis,
formulary alternative for once-weekly
convert 5mg Actonel QD to 10mg Fosamax QD
dosing if a 70mg dose is required for the OR convert 35mg Actonel once weekly to
Fosamax w/D once weekly. Fosamax w/D
treatment of osteoporosis .
tablets is the preferred formulary alternative
when a 70mg dose is required for once-weekly
treatment of osteoporosis .
Actonel (Residronate) 30mg tablet (30mg tablet is
only indicated for Paget's disease treatment)
Actoplus Met
Acular (ketorolac) 0.5% ophth soln
Acular PF (preservative free) 0.5%
Adalat CC (Nifedipine XL) 30, 60, 90 mg tab
Adderall (Amphetamine mixtures) XR extended
release 5mg, 10mg, 15mg, 20mg, 25mg, 30mg
capsules
Treatment Paget's Disease: Fosamax 40mg .
QD
Metformin & pioglitazone as 2 separate
agents
If using for allergic conjunctivitis: OTC
Opcon-A (pheniramine and naphazoline)
If treating post-op inflammation: Voltaren
0.1% ophth soln
If using for allergic conjunctivitis: OTC
Opcon-A (pheniramine and naphazoline)
If treating post-op inflammation: Voltaren
0.1% ophth soln
Nifedipine XL 30, 60 or 90 mg tablet
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I &
Thiazide diuretic
Four Drug Therapy: Add Long Acting
Dihydropyridine CCB to Beta Blocker, ACE-I &
Thiazide Diuretics
Adderall regular release 5, 10, 20, 30mg
tablets, Concerta 18, 27, 36 and 54mg
tablets, Methylphenidate 5, 10, 20mg and
SR 20mg; Methylin (Methylphenidate) ER
10mg; or generic Dexedrine spansules
(Dextroamphetamine) 5, 10, 15mg
Controlled substances level 2 requiring
prescription written by prescriber.
Page 2
Adderall XR is restricted to pediatrics, child
neurology and behavioral health. Titrate to
appropriate dosage using Adderall regular
release tablets before transitioning to once daily
Adderall XR. Document failed trial on
Methylphenidate, Dextroamphetamine and
Adderall IR products before a Non-formulary
Product is considered.
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Advair (Fluticasone/Salmeterol 100/50, 250/50,
500/50) diskus oral inhaler
Advair restricted to Peds Pulm, Pulmonology
and Allergy. Document failure on 1 combination
of alternatives QVAR and Serevent -or- Asmanex
and Serevent before nonformulary product
considered. **Advair 500/50 may warrant approval
because of high dose of steroid ingredient . If
patient has failed a trial on QVAR 40 inhaler,
consider Flovent (Fluticasone) 44/puff inhaler
AND Serevent (Salmeterol) 50mcg diskus.
Advair 100/50 i puff BID =
QVAR 80mcg i puff BID & Serevent
50mcg diskus i puff BID
-OR
Flovent 44mcg ii puffs BID &
Serevent 50mcg i puff BID;
Advair 250/50 i puff BID =
QVAR
80mcg ii puffs BID & Serevent 50mcg i
puff BID -OR
Asmanex 220mcg i puff BID [or ii puffs
QHS] & Serevent 50mcg diskus i puff
BID
Advair 500/50 i puff BID -submit
.nf form
Advicor (niacin ER/lovastatin) 500/20mg or
1000/20mg QHS
OTC Slo-niacin or Time-release niacin.
Initiate at 500 mg QD titrated up by 500mg
every 4 weeks up to desired dose plus Rx
Lovastatin 20MG QPM with meal.
Do not recommend flush-free niacin. For
improving HDL, regular niacin is recommended.
Titrate immediate release niacin 100 mg QD x
1week, then 200 mg QDx 1 week, 300 mg QD x 1
week, 500 mg QD x 1 week, then 500 mg BID
thereafter. Slow release or Time release niacin is
preferred for LDL lowering. Counsel pt to take
niacin with food and try taking an aspirin 30
minutes before niacin to prevent flushing and
itching. For questions, consider calling Pharmacy
Cardiac Risk Service at 770-496-3560 between
8:30AM and 5:30PM.
Aerobid oral inhaler (Flunisolide)
QVAR (Beclomethasone HFA) oral inhaler
80 mcg i-ii puffs BID or Asmanex
(mometasone furoate) oral dry powder
inhaler 200mcg per puff inhale i-ii puffs
QHS (or i puff BID)
OTC Hydrocortisone 0.5% cream
QVAR is the preferred formulary alternative. If
patient has failed QVAR, consider Asmanex i-ii
puffs QHS.
ii-iiii puffs BID
Aeroseb-HC (Hydrocortisone) aerosol 0.5%
Akineton (Biperiden) 2mg tablet 2mg BID-TID
Alamast (Pemirolast) 0.1% ophthalmic solution i-ii
drops QID
Cogentin (Benztropine) tablet 1-4mg QDBID
For allergic conjunctivitis: OTC Opcon-A
(Pheniramine & Naphazoline) or OTC
Zaditor 0.25% [NOTE: OTC products are
not a covered benefit]
Albuterol (Proventil or Ventolin) nebulizer solution
0.083% 3 ml via nebulizer TID-QID
Albuterol 20% concentrated nebulizer
solution 0.5 ml with 2.5 ml saline via
nebulizer TID-QID
Aldactone 50 &100 mg tabs
Spironolactone (generic Aldactone) 25 mg
Alesse (0.1 Levonorgestrel/20mcg EE)
If require a product for the scalp, consider Synalar
(Fluocinolone) soln or oil 0.01% (low potency)
Parkinson's drug therapy
OTC Zaditor 0.25% and Patanol are both dual
action antihistamine/mast cell stabilizers, are
dosed twice daily, and have the same FDA
approved indications. If treating steroid
responsive inflammatory condition consider at
least 2 formulary products before
prescribing/authorizing NF product:
Dexamethasone 0.1% ophth soln or Prednisolone
0.12%-1% ophth soln or Flarex, FML
(Fluorometholone) ophth soln 0.1% i-ii drops in
affected eye(s) QID
Premixed nebulized solutions are non formulary.
Component medications are available separately,
Albuterol 20% soln (formulary) and OTC saline for
nebulizer dilution
50 mg and 100 mg tablets are non-formulary.
May substitute 25 mg tablets as appropriate to
obtain 50 mg or 100 mg dose.
Levlen (0.15mg Levonorgestrel / 30mcg EE) May consider Microgestin FE 1/20 (1mg
or Tri-Levlen (0.05mg Lvngl/30mcg EE x 6 Norethindrone/ 20mcg EE) Document at least 3
days, 0.075mg Lvngl/40mcg EE x 5 days,
formulary alternatives before
0.125mg lvngl/ 30mcg EE x 10 days)
prescribing/approving a NF product.
Page 3
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Allegra (Fexofenadine) 180mg tabs
Allegra remains formulary for Medicare Part D
patients. Intranasal steroid (Nasarel or Flonase)
more effective than nonsedating antihistamines
for allergic rhinitis.
Nasarel ii sprays per nostril BID or generic
Flonase (fluticasone) i spray per nostril QD
and/or Claritin OTC or Zyrtec OTC
Allegra-D (Fexofenadine 60mg and Pseudoephedrine Nasarel ii sprays each nostril BID or generic Allegra (not Allegra-D) remains formulary for
120mg) caps
Flonase (fluticasone) i spray each nostril
Medicare Part D patients. Allegra-D is
QD and/or Claritin D OTC or Zyrtec D OTC excluded from the benefit because
pseudoephedrine is available OTC.
Alocril (Nedocromil) 2% ophth soln
For allergic conjunctivitis: OTC Opcon-A
(Pheniramine & Naphazoline) or OTC
Zaditor 0.25% [NOTE: OTC products are
not a covered benefit]
OTC Zaditor 0.25% and Patanol are both dual
action antihistamine/mast cell stabilizers, are
dosed twice daily, and have the same FDA
approved indications. If treating steroid
responsive inflammatory condition consider at
least 2 formulary products before
prescribing/authorizing a NF product:
dexamethasone 0.1% ophth soln or prednisolone
0.12%-1% ophth soln or Flarex, FML
(Fluorometholone) ophth soln 0.1% i-ii drops in
affected eye(s) QID
Alomide (Lodoxamide) ophth 0.1% ophth soln (mast
cell stabilizing properties)
For allergic conjunctivitis: OTC Opcon-A
(Pheniramine & Naphazoline) or OTC
Zaditor 0.25% [NOTE: OTC products are
not a covered benefit]
OTC Zaditor 0.25% and Patanol are both dual
action antihistamine/mast cell stabilizers, are
dosed twice daily, and have the same FDA
approved indications. If treating steroid
responsive inflammatory condition consider at
least 2 formulary products before
prescribing/authorizing a NF product:
dexamethasone 0.1% ophth soln or prednisolone
0.12%-1% ophth soln or Flarex, FML
(Fluorometholone) ophth soln 0.1% i-ii drops in
affected eye(s) QID
Alora (Estradiol transdermal system) delivers 0.025,
0.05, 0.075, 0.1 mg Estradiol transdermally per day
when each 9cm2, 18cm2, 27cm2 and 36cm2 patch
applied twice weekly
If an estrogen patch is required, Climara.
Climara 0.025mg, 0.0375mg, 0.05mg,
0.06mg, 0.075mg, 0.1mg patches apply one
patch weekly; or Estrace 0.5, 1 or 2mg
(Estradiol)
Alphagan P (Brimonidine 0.15%) ophth solution i drop Brimonidine 0.2% ophth solution 1 drop in
in affected eye TID
affected eye TID
Other formulary alternatives include: Propine
(Dipivefrin 0.1%) i drop BID or Levobunolol 0.25%0.5% or Timolol i drop in affected eye(s) BID if a
beta-blocker trial has not been used.
Alrex (Loteprednol) 0.2% ophth soln i drop QID
Dexamethasone 0.1% ophth soln or
Prednisolone 0.12%-1% ophth soln or
Flarex, FML (Fluorometholone) ophth soln
0.1% i-ii drops in affected eye(s) QID
Post op inflammation: [Loteprednol 0.5%
(Lotemax) less effective than Prednisolone
Acetate 1% in treatment of acute anterior uveitis]
Altace (Ramipril) 1.25 - 20mg QD
Prinivil (Lisinopril) 5mg-40mg QD
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide diuretic
Three Drug Therapy:Add Beta Blocker to ACE-I &
Thiazide diuretic
Four Drug Therapy:Add Long Acting
Dihydropyridine CCB to Beta Blocker, ACE-I &
Thiazide Diuretics
Page 4
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Altocor (Lovastatin extended release) 10mg, 20mg,
40mg or 60mg
Lovastatin 10mg, 20mg, or 40mg tablets
Amaryl (Glimepiride) tablet 1-4 mg QD
Glyburide (generic Micronase) 2.5-10 mg
QD or Glipizide (generic Glucotrol) 5-15
mg QD or Metformin (Glucophage) 500 mg
BID or Actos 15mg QD
Altocor 10mg QD equivalent to Lovastatin 10mg
QD dose. Simvastatin (generic Zocor) is another
formulary option: Altocor 40 mg is equivalent to
Lovastatin 40 mg or Simvastatin 20 mg. For
questions, consider calling Pharmacy Cardiac
Risk Service at 770-496-3560 between 830AM
and 530PM.
Dose of Glyburide, Glipizide, Metformin and Actos
must be titrated based on individual needs.
Amaryl (Glimepiride) tablet 4mg BID or 8 mg QD
Glyburide (generic Micronase) 7.5-10 mg
BID or Glipizide (generic Glucotrol) or 10-20
mg BID or Metformin (Glucophage) 850 mg
BID or Actos 15mg 1 - 3 tablets QD
Ambien (Zolpidem) tabs 10 mg QHS
Generic Ambien (Zolpidem 5 & 10mg)
Ambien CR (Zolpidem controlled-release) 6.25mg and Zolpidem 5 - 10mg 1T PO QHS
12.5mg tablets
Amerge (Naratriptan) 2.5mg
Maxalt (Rizatriptan) MLT 10mg tablet
(Maxalt MLT 5mg tablet is also available)
Dose of Glyburide, Glipizide, Metformin and Actos
must be titrated based on individual needs.
Consider other oral antidiabetics such as
Glipizide in patients >65 due to prolonged half life
of Glyburide.
Consider lower doses in geriatric patients.
Consider lower doses in geriatric patients.
Maxalt MLT 10 mg is preferred, QTY limit of 9
tablets/copay. If failed a trial on Maxalt MLT
consider formulary alternative Imitrex 50 mg
tablets (qty limit of 9 tablets/copay), nasal, or
injectable dosage forms.
Quantity limit for Nonformulary Amerge 2.5 mg tablets is 9
tablets/copay).
.
Americaine (Benzocaine) 20% otic drops
Auralgan Otic drops
(benzocaine/antipyrine/glycerin)
Amevive (Alefacept) IM or IV injection (requires
administration in medical office, not covered by
outpatient drug benefit)
Humira or Enbrel.
Amevive requires administration in the
medical clinic under the medical benefit rather
than under the drug benefit and cannot be
dispensed at a copayment from a pharmacy.
Amevive coverage criteria for psoriasis: (1)
patient is an adult with moderate to severe
chronic plaque psoriasis, and (2) has a
documented failure, or is not a candidate for
topical or systemic therapies (methotrexate,
acitretin, PUVA, UVB), and (3) patient has a
documented failure, or is not a candidate for a
combination of the above treatment options,
(4) prescriber must be a Dermatologist
Amiloride 5mg
Spironolactone (generic Aldactone) 25 mg
.
Amitiza 24 mcg capsules
Amoxicillin 875mg tablet
Lactulose, Polyehtylene glycol 3350 [OTC
Miralax]
Amoxicillin 500mg capsules
Amiloride/HCTZ 5/50mg QD
Triamterene/HCTZ 75/50mg 1/2-1 QD
Page 5
Convert from Amoxicillin 875mg to #2 Amoxicillin
500mg capsules
.
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Androgel (Testosterone) 1% gel
Androderm 2.5 mg/24 hr - 5 mg/24 hr
Document indication for medication and failure on
transdermal patch; Testosterone injection
alternatives. (If patient is using for Sexual
400 mg IM q2-4weeks administered in
Dysfunction confirm sexual dysfunction benefits.)
medical office. Injectables administered in
a medical office are covered under the
medical office benefit, NOT the drug benefit
and are not available from a pharmacy for a
copayment. Methyltestosterone (generic
Android or Testred) tabs 10-20 mg QD-BID
or Fluoxymesterone (Halotestin) 10 mg QD
(tablets require baseline and periodic liver
function testing).
Ansaid tabs (Flurbiprofen) 100 mg BID
Ibuprofen (generic Motrin) tabs 600-800 mg
TID or Salsalate (Disalcid)1500mg BID or
Naproxen 500mg BID or Sulindac (Clinoril)
200mg BID
Additional formulary alternatives: Diclofenac
(Voltaren) 75mg BID or Choline Magnesium
Trisalicylate (Trilisate) 750mg BID-TID or
Nambumetone (Relafen) 500mg - 750mg #1-2 QDBID or Etodolac (Lodine) 200mg-500mg Q8-12H
up to 1200mg/day or Indomethacin 25-50mg TID
or Mobic (Meloxicam) 7.5mg or 15mg.
Antara (Fenofibrate) 43mg, 87mg, & 130mg
Fenofibrate 54mg and 160mg QD OR
Gemfibrozil 600mg BID
If patient is on Antara (Fenofibrate) 130mg
capsule QD convert to Fenofibrate 160mg QD; If
patient is on Antara 43mg, convert to Fenofibrate
54 mg QD. Fenofibrate preferred if pt also taking
statin. If pt has reduced renal function, consider
offering gemfibrozil 600mg BID which is safer per
kidney guidelines. Cost of fenofibrate and
gemfibrozil similar. For questions, consider calling
Pharmacy Cardiac Risk Service at 770-496-3560
between 830AM and 530PM.
Antivert (Meclizine) 12.5mg, 25mg or 50mg
all strengths available OTC
Anzemet 100mg tablet
Zofran (Ondansetron) tabs 4mg-8mg BID,
Zofran (ondansetron) ODT 4mg-8mg
OTC medications are not covered by the drug
benefit
Zofran oral liquid & IV available via pediatric
floorstock for in office dose to break pediatric n/v
cycle & allow hydration in children unable to use
phenergan safely (</= 2 yoa)
Apidra 100 Units/mL (U-100) 10mL vials or 3mL
cartridge system(for use in Opticlick)
1 Unit of Apidra has the same glucoselowering effects as 1 Unit of Regular Human
Insulin [Novolin R is administered 30
minutes prior to a meal].
Levlen (0.15mg Levonorgestrel / 30mcg EE)
or Tri-Levlen (0.05mg Lvngl/30mcg EE x 6
days, 0.075mg Lvngl/40mcg EE x 5 days,
0.125mg Lvngl/ 30mcg EE x 10 days)
Apri (0.15mg Desogestrel/ EE 0.03mg) generic
Desogen
Aricept ODT (Donepezil orally disintegrating tablet)
Aricept (Donepezil) 5mg or 10mg
5mg or 10mg
Armour Thyroid Tablet
15mg (1/4 grain);
Levothroid (levothyroxine)
30mg (1/2 grain); 60mg (1 grain); 90mg (1&1/2 grain);
120mg (2 grains); 180mg (3 grains); 240mg (4 grains);
300mg (5 grains) levothyroxine and liothyronine
Page 6
Pyridium plus (Phenazopyridine 150mg, 0.3mg
Hyoscyamine, 15mg Butabarbital)
Zovia 1/35 (1mg Ethynodiol Diacetate/ 35mcg EE)
or Microgestin 1.5/30 (1.5 Norethindrone / 30mcg
EE) or Sprintec (0.25mg Norgestimate/35mcg EE)
or Tri-Sprintec, generic Ortho-Tricyclen, (0.18mg
Norgestimate x 7 days, 0.215mg Norgestimate x 7
days, 0.25mg Norgestimate x 7 days/ 35 mcg EE)
Document at least 3 formulary alternatives
before prescribing/approving a NF product.
1 grain Armour thyroid converts to 50 - 60 mcg of
levothroid. Calculate each conversion
individually
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Arthrotec (Diclofenac/Misoprostol) 50/200 or 75/200
TID
Monotherapy with Relafen (nabumetone)
500mg to 750mg 1-2T QD - BID (first
choice) or Lodine (etodolac) 200-500mg Q812H up to 1200mg/day or Voltaren
(diclofenac) 50 - 75mg TID AND Cytotec
(misoprostol) 200mcg TID
If patient high risk for GI bleed and NSAID is
required, consider: nambumetone (Relafen)
500mg to 750mg #1-2 QD-BID or etodolac
(Lodine) 200-500mg Q8-12H up to 1200mg/day or
Salsalate (Disalcid)1500mg BID or choline
magnesium trisalicylate (Trilisate) 750mg BIDTID. Consider adding Prilosec OTC 20mg QD to
further reduce GI risk. Other formulary NSAIDS
include: Ibuprofen (generic Motrin) tabs 600-800
mg TID or naproxen 500mg BID or sulindac
(Clinoril) 200mg BID
Astelin (Azelastine) ii puffs each nostril BID
Nasarel ii sprays each nostril BID or generic Document diagnosis (Consider OTC Claritin or
Flonase (fluticasone) i spray each nostril
OTC Zyrtec and Nasarel or Flonase before
QD or OTC Claritin or OTC Zyrtec
prescribing Astelin unless being used for
Vasomotor rhinitis.)
Prinivil (lisinopril) 10-20 mg QD or Cozaar Prinivil is preferred, if no previous ACE inhibitor
(losartan) 25 mg - 100mg tab QD
trial. If angiotensin 2 receptor blocker is required,
convert to Cozaar. Conversion equivalents:
Atacand 4mg = Prinivil 5mg = Cozaar 25mg;
Atacand 8mg = Prinivil 10mg = Cozaar 25mg;
Atacand 16mg = Prinivil 20mg = Cozaar 50mg;
Atacand 32mg = Prinivil 40mg = Cozaar 100mg
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide diuretic
Three Drug Therapy:Add Beta Blocker to ACE-I &
Thiazide diuretic
Four Drug Therapy:Add Long Acting
Dihydropyridine CCB to Beta Blocker, ACE-I &
Thiazide Diuretics
Atacand (Candesartan) tab 8-32 mg QD
Atacand HCT (Candesartan/HCTZ) tab 16/12.5mg,
32/12.5mg QD
Lisinopril/HCTZ 10/12.5mg, 20/12.5mg QD
or Cozaar(losartan) 25 mg - 100mg QD
AND HCTZ (hydrochlorothiazide) 12.5mg
QD
Prinivil is preferred, if no previous ACE inhibitor
trial. If angiotensin 2 receptor blocker is required,
convert to Cozaar. Conversion equivalents:
Atacand 4mg = Prinivil 5mg = Cozaar 25mg;
Atacand 8mg = Prinivil 10mg = Cozaar 25mg;
Atacand 16mg = Prinivil 20mg = Cozaar 50mg;
Atacand 32mg = Prinivil 40mg = Cozaar 100mg
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide diuretic
Three Drug Therapy:Add Beta Blocker to ACE-I &
Thiazide diuretic
Four Drug Therapy:Add Long Acting
Dihydropyridine CCB to Beta Blocker, ACE-I &
Thiazide Diuretics
Atrovent nasal spray 0.03% or 0.6%
nostril BID-QID
ii sprays each Nasarel ii sprays each nostril BID or generic Inhaled steroid sprays are used for allergic
Flonase (fluticasone) i spray each nostril
rhinitis, not for common cold.
QD
Atrovent HFA (ipratropium bromide) oral inhaler
Atrovent (ipratropium bromide) oral inhaler Puff per puff conversion; differ only in the
propellant used.
Augmentin 125mg/5ml suspension
Augmentin 200mg/5ml suspension
,
Augmentin 250mg/5ml suspension
Augmentin 400mg/5ml suspension
,
Page 7
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Augmentin XR
(1000mg
Amoxicillin/62.5mg Clavulanic Acid) #2 Q 12 Hours =
2000mg Amoxicillin / 125mg Clavulanic Acid Q 12
Hours
Avage (Tazarotene) 0.1% Cream
Comments
Alternatively may consider generic
Alternatively may consider: Cefuroxime 250mg Q
Augmentin 875mg (875mg
12 hours OR Biaxin 250mg Q 12 hours OR Avelox
Amoxicillin/125mg Clavulanic Acid) #1 Q 12 400mg QD
Hours PLUS Amoxicillin 500mg capsules 2
PO Q 12 hours
Drugs for cosmetic use are NOT covered on
drug benefit. Member pays retail price.
Avalide (Irbesartan/HCTZ) tabs 75/12.5 - 300/12.5 mg Lisinopril/HCTZ 10/12.5MG, 20/12.5MG OR Prinivil is preferred, if no previous ACE inhibitor
QD
20/25MG QD -OR- Cozaar (losartan) 25 trial. If angiotensin 2 receptor blocker is required,
100 mg QD AND HCTZ 12.5mg QD
convert to Cozaar. Conversion equivalents:
Avapro 75mg = Prinivil 5mg = Cozaar 25mg;
Avapro 150mg = Prinivil 10-20mg = Cozaar 50mg;
Avapro 300 = Prinivil 20-40mg = Cozaar 50100mg
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide diuretic
Three Drug Therapy:Add Beta Blocker to ACE-I &
Thiazide diuretic
Four Drug Therapy:Add Long Acting
Dihydropyridine CCB to Beta Blocker, ACE-I &
Thiazide Diuretics
Avandamet: 2/500: Rosiglitazone 2 mg and metformin Metformin & Actos (pioglitazone) are
hydrochloride 500 mg; Avandamet: 4/500:
formulary agents.
Rosiglitazone 4 mg and metformin hydrochloride 500
mg; Avandamet: 2/1000: Rosiglitazone 2 mg and
metformin hydrochloride 1000 mg; Avandamet:
4/1000: Rosiglitazone 4 mg and metformin
hydrochloride 1000 mg
Avandia (Rosiglitazone) 2 - 8 mg QD or divided BID
Avapro (Irbesartan) tabs 75 - 300 mg QD
Conversion equivalents: Avandia 2mg=Actos
15mg; Avandia 4mg = Actos 30mg; Avandia
8mg=Actos 45mg. (At KP pharmacies, Actos 15
mg tablet is the only strength available).
Actos 15 - 45 mg QD
Conversion equivalents: Avandia 2mg=Actos
15mg; Avandia 4mg = Actos 30mg; Avandia
8mg=Actos 45mg. (At KP pharmacies, Actos 15
mg tablet is the only strength available).
Prinivil (lisinopril) 2.5 - 40 mg QD or Cozaar Prinivil is preferred, if no previous ACE inhibitor
trial. If angiotensin 2 receptor blocker is required,
(losartan) 25 - 100 mg QD
convert to Cozaar. Conversion equivalents:
Avapro 75mg = Prinivil 5mg = Cozaar 25mg;
Avapro 150mg = Prinivil 10-20mg = Cozaar 50mg;
Avapro 300 = Prinivil 20-40mg = Cozaar 50100mg TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide diuretic
Three Drug Therapy:Add Beta Blocker to ACE-I &
Thiazide diuretic
Four Drug Therapy:Add Long Acting
Dihydropyridine CCB to Beta Blocker, ACE-I &
Thiazide Diuretics
AVC (Sulfanilamide) vaginal cream
No Formulary alternative
OTC Monistat vaginal cream or Vagistat
Aviane (0.1 Levonorgestrel/20mcg EE)
Levlen (0.15mg Levonorgestrel / 30mcg EE)
or Tri-Levlen (0.05mg Lvngl/30mcg EE x 6
days, 0.075mg Lvngl/40mcg EE x 5 days,
0.125mg lvngl/ 30mcg EE x 10 days)
May consider Microgestin FE 1/20 (1mg
Norethindrone/ 20mcg EE) Document at least 3
formulary alternatives before
prescribing/approving a NF product.
Page 8
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Avinza (Morphine Sulfate Extended Release
Capsules) 30mg, 60mg, 90mg, 120mg QD Capsules
contain both immediate release and extended release
morphine beads.
Generic of MS Contin covered (morphine
controlled release) 15mg, 30mg, 60mg,
100mg, 200mg BID & as necessary,
Morphine immediate release tablet 10mg,
30mg, Roxanol (morphine solution
10mg/5ml, 20mg/5ml, 100mg/5ml)
Avodart 0.5mg (Dutasteride)
Proscar (Finasteride) 5mg
Avinza capsules are dosed daily & contain both
immediate release and extended release
morphine. When converting from Avinza,
calculate total daily Morphine dose QD. Divide
total daily morphine dose by 2 to yield generic MS
Contin dose to administer BID. If prescribing
immediate release morphine for break thru pain,
remember to subtract from the total daily
morphine when calculating generic MS Contin
dose.
Alpha blockers:Doxazosin (generic Cardura)
titrated to therapeutic doses (e.g. Doxazosin 2mg
1/2 tab po QHS X 1 week, then 1 tab po QHS x 2
weeks, then 2 tabs po QHS and follow-up w/MD
for refill) or Terazosin (generic Hytrin) titrated
slowly to therapeutic doses. (eg. 1mg QHS days 13, 2mg QHS days 4-15 then 5mg QHS, if
necessary may further increase to 10mg QHS).
Axert (Almotriptan) 12.5mg
Maxalt (Rizatriptan) MLT 10mg tablet
(Maxalt MLT 5mg tablet is also available)
Axid puvules 300mg QD or 150mg BID
Cimetidine (Tagamet) 400mg BID or 800mg OTC alternatives:
QD -or
Ranitidine (Zantac)
Pepcid OTC 20mg or Zantac OTC 75mg or
300mg QD -or Famotidine (Pepcid) 40mg
150mg
QD
Azelex (Azelaic acid) 20% cream BID
Acne treatment alternatives: Tretinoin
0.025% cream (Retin-A or Avita cream
brand names) -or
2% Erythromycin
solution & 5% Benzoyl Peroxide aqueous
gel -or clindamycin 1% solution or sulfacet
R lotion or clindamycin 1% gel & 5%
Benzoyl Peroxide aqueous gel Rosacea
treatment alternative: metronidazole 0.75%
cream BID
Smallest available tube Tretinoin covered per
copay, larger tubes not covered. Benzamycin and
Benzaclin are nonformulary, but 2% Erythromycin
solution & 5% Benzoyl Peroxide aqueous gel OR
1 % Clindamycin gel & 5% Benzoyl Peroxide
aqueous gel, respectively, may be prescribed
separately and purchased as a pack for one
copayment at a Kaiser Permanente pharmacy. At
Eckerd, the patient must purchase the OTC
product, at KP it will be included at no charge.
Azmacort (triamcinolone) oral inhaler ii-iiii puffs BIDTID
QVAR (beclomethasone HFA) 80mcg/puff
oral inhaler, i-ii puffs BID OR Asmanex
(mometasone furoate) oral dry powder
inhaler 200mcg/puff i-ii puffs QHS (or i puff
BID)
QVAR (Beclomethasone HFA) 40mcg/puff
oral inhaler i-ii puffs BID -or Flovent
44mcg/puff i-ii puffs BID
QVAR is almost 4 times as potent as Azmacort (2
puffs Azmacort 100mcg/puff = 1 puff QVAR 80
mcg/puff) If patient has failed trial with QVAR
consider conversion to Asmanex.
Beclovent (Beclomethasone CFC) 42mcg/puff oral
inhaler ii-iiii puffs BID-TID
Maxalt MLT 10 mg is preferred, QTY limit of 9
tablets/copay. If failed a trial on Maxalt MLT
consider formulary alternative Imitrex 50 mg
tablets (qty limit of 9 tablets/copay), nasal, or
injectable dosage forms. Quantity limit for Nonformulary Axert is 6 tablets per copay
QVAR is twice as potent as Beclovent (2 puffs
Beclovent 42mcg/puff = 1 puff QVAR 40 mcg/puff)
and equipotent to Flovent 44mcg (1 puff QVAR
40mcg = 1 puff Flovent 44mcg/puff). QVAR
remains the preferred inhaled corticosteroid at
KP GA.
Beconase AQ (beclomethasone) 0.42% nasal spray ii Nasarel ii sprays each nostril BID or generic If the child is less then 4 years old, Nasonex may
sprays each nostril BID
Flonase (fluticasone) i spray each nostril
warrant approval as Nasarel is not indicated for
patients less than 6 years old & Flonase is not
QD
indicated in patients less than 4 years old.
Page 9
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Benicar (Olmesartan) 20-40mg QD
Prinivil (Lisinopril) 20-40mg QD or
Cozaar(Losartan) 50mg - 100mg tab QD
Prinivil is preferred, if no previous ACE inhibitor
trial. If angiotensin 2 receptor blocker is required,
convert to Cozaar. Conversion equivalents:
Benicar 20mg = Prinivil 20mg = Cozaar 50mg;
Benicar 40mg = Prinivil 40mg = Cozaar 100mg
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide diuretic
Three Drug Therapy:Add Beta Blocker to ACE-I &
Thiazide diuretic
Four Drug Therapy:Add Long Acting
Dihydropyridine CCB to Beta Blocker, ACE-I &
Thiazide Diuretics
Benicar HCT (Olmesartan/HCTZ) 20/12.5mg or
40/12.5mg
Lisinopril/HCTZ 10/12.5mg, 20/12.5mg OR
20/25mg QD or Cozaar (Losartan) 50mg 100mg tab QD PLUS HCTZ 25mg 1/2 tablet
QAM
Prinivil is preferred, if no previous ACE inhibitor
trial. If angiotensin 2 receptor blocker is required,
convert to Cozaar. Conversion equivalents:
Benicar 20mg = Prinivil 20mg = Cozaar 50mg;
Benicar 40mg = Prinivil 40mg = Cozaar 100mg
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide diuretic
Three Drug Therapy:Add Beta Blocker to ACE-I &
Thiazide diuretic
Four Drug Therapy:Add Long Acting
Dihydropyridine CCB to Beta Blocker, ACE-I &
Thiazide Diuretics
Benicar HCT (Olmesartan/HCTZ) 40/25mg
Lisinopril/HCTZ 10/12.5mg, 20/12.5mg or
20/25mg QD or Cozaar(Losartan) 50 mg 100mg tab QD PLUS HCTZ 25mg tablet
QAM
Prinivil is preferred, if no previous ACE inhibitor
trial. If angiotensin 2 receptor blocker is required,
convert to Cozaar. Conversion equivalents:
Benicar 20mg = Prinivil 20mg = Cozaar 50mg;
Benicar 40mg = Prinivil 40mg = Cozaar 100mg
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide diuretic
Three Drug Therapy:Add Beta Blocker to ACE-I &
Thiazide diuretic
Four Drug Therapy:Add Long Acting
Dihydropyridine CCB to Beta Blocker, ACE-I &
Thiazide Diuretics
Benzac AC wash 2.5% wash affected area QD-BID
BenzaClin topical gel
(Benzoyl
Peroxide/Clindamycin)
OTC Benzoyl Peroxide wash QD-BID
Separate Rxs for either
2%
Erythromycin solution PLUS 5% Benzoyl
Peroxide aqueous gel
OR
Clindamycin 1% gel PLUS 5% Benzoyl
Peroxide aqueous gel
Benzac AC wash is available OTC; not covered
Benzamycin and Benzaclin are nonformulary, but
2% Erythromycin solution & 5% Benzoyl Peroxide
aqueous gel OR 1 % Clindamycin gel & 5%
Benzoyl Peroxide aqueous gel, respectively, may
be prescribed separately and purchased as a
pack for one copayment at a Kaiser Permanente
pharmacy. At Eckerd, the patient will receive
Erythromycin 2% soln OR Clindamycin 1% gel at
a copayment & must purchase the OTC Benzoyl
Peroxide product, at KP the OTC will be included
at no additional charge.
Page 10
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Benzamycin topical gel
Peroxide/Erythromycin)
Benzamycin is nonformulary, but 2% Erythromycin
solution & 5% Benzoyl Peroxide aqueous gel may
be prescribed separately and purchased as a
pack for one copayment at a Kaiser Permanente
pharmacy. At Eckerd, the patient will receive
Erythromycin 2% soln for a copayment & must
purchase the OTC Benzoyl Peroxide product, at
KP the OTC will be included at no additional
charge.
If failed other alternatives, consider increasing to
high potency topical corticosteroid fluocinonide
(Lidex) 0.05% cream, oint, or gel
(Benzoyl
Separate Rxs for
2% Erythromycin solution PLUS 5%
Benzoyl Peroxide aqueous gel
Beta-val (Betamethasone valerate) 0.1% cream
[MEDIUM potency]
Triamcinolone (generic Aristocort) cream,
oint 0.1% or Valisone (Betamethasone
valerate) 0.1% lotion
Beta-val (Betamethasone valerate) 0.1% ointment
[high potency]
Lidex (Fluocinonide) 0.05% cream, oint, gel,
soln or Diprolene AF (Augmented
Betamethasone) 0.05%
Betoptic (Betaxolol) 0.5% ophth soln
i drop in affected eye BID
Timolol ophth soln 0.25% and 0.5%
One Touch Ultra glucose test strips
One
Touch Ultra 2 machine -only
Betaxon (Levobetaxolol) 0.5% ophth soln i drop in
affected eye BID
Betimol (Timolol) ophth soln 0.25 and 0.5%
BG Logic Blood Glucose Strips
High potency topical corticosteroids.
Timoptic (Timolol) another formulary alternative
.
Lifescan monitor is formulary and may be
obtained, by prescription, at KP pharmacy at copayment. Members will be charged full price for
Lifescan monitor at Eckerd. If the patient's
insulin pump requires the use of a companion BG
monitor requiring NF BG strips, please note brand
of pump and companion BG monitor on NF Rx for
Freestyle or BG Logic BG strips.
Biaxin XL (Clarithromycin XL) 500mg #2 QD
Biaxin (Clarithromycin) 500mg BID
Convert on a mg per mg basis. Regular release
dose divided every 12 hours (ie. Biaxin XL
1000mg QD converts to Biaxin 500mg Q12H)
BiDil (20mg isosorbide dinitrate/37.5mg hydralazine)
Isosorbide dinitrate 20mg + hydralazine
25mg 1 & 1/2 tabs (equals one tablet of
BiDil)
BiDil's dosing per package insert is 1-2 tabs TID.
Therefore, if patient is taking 2 tabs TID of BiDil,
formulary conversion is isosorbide dinitrate 20mg
2 tabs TID + hydralazine 25mg 3 tabs TID.
Blocadren (Timolol) 5, 10, 20mg tabs 10-20mg BID
Atenolol (Tenormin) 25-100mg QD or
Metoprolol 100 - 400mg QD or Propranolol
40 - 320mg BID
Propranolol is available as 10, 20, 40, 60, 80,
90mg tabs. Inderal LA is non-formulary
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide diuretic
Three Drug Therapy:Add Beta Blocker to ACE-I &
Thiazide diuretic
Four Drug Therapy:Add Long Acting
Dihydropyridine CCB to Beta Blocker, ACE-I &
Thiazide Diuretics
Blood glucose strips, Non Lifescan brands
One Lifescan monitor is formulary and may be
obtained, by prescription, at KP pharmacy for a copayment. Members will be charged full price for
Lifescan monitor at Eckerd
Fosamax (Alendronate) 5mg QD or 35mg
For Fosamax 35mg Qweek dose, consider
every week for osteoporosis prevention OR Fosamax Liquid [37.5ml] PO once a week.
Fosamax 10mg QD or Fosamax w/D Q
Fosamax Liquid is the preferred formulary
week for osteoporosis treatment. Fosamax alternative for this dose: 37.5ml = 35mg dose.
w/D 70mg tablet and Fosamax 70mg/75ml
liquid available.
Boniva 2.5mg QD or 150mg monthly
One Touch Ultra glucose test strips
Touch Ultra 2 machine -only
Page 11
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Botox injection
Criteria Restricted Medication
Criteria Restricted Medication. Provider
phones KP QRM to request authorization
consideration 404-364-7320. Botox (Myoblock)
requires administration in the medical clinic
under the medical benefit rather than under
the drug benefit and cannot be dispensed at a
copayment from a pharmacy.
Brethaire (Terbutaline) 0.2mg aerosol inhaler
Bumex (Bumetanide) 0.5,1,2mg tabs
Albuterol oral inhaler
Furosemide (generic Lasix) tablets
.
Bumetanide 1mg converts to Furosemide 40mg
Byetta (exanatide) 5mcg/dose and 10mcg/dose
prefilled pen
Criteria Restricted Medication. Provider
phones KP QRM to request authorization
consideration 404-364-7320.
Calan (Verapamil) SR tabs 120-240 mg QD
Verapamil SR tabs (generic Calan SR) 120, Substitute on a mg for mg basis.
180, 240 mg tabs 120-240mg QD
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
Dihydropyridine CCB to Beta Blocker, ACE-I &
Thiazide Diuretics
Calderol (Calcifediol) 20, 50 mcg caps 300350mcg/wk titrated to effect
Rocaltrol (Calcitriol) 0.25, 0.5mcg caps 0.25- .
1mcg/day titrated to effect or Calciferol
(Ergocalciferol) 50,000 units/capsule 15,00020,000 units/day titrated to effect
Campral (Acamprosate) 333mg #2 tablets TID
Disulfiram 250mg QD or Revia (Naltrexone) Patients failing to respond to, tolerate or not
50mg QD
eligible for Disulfiram, due to DM, cardiovascular
disease, epilepsy or significant renal/hepatic
insufficiency, consider Naltrexone 50mg QD.
Naltrexone demonstrated a lower relapse rate,
longer time to first relapse & higher number of
abstinence days during alcohol dependence
treatment trial versus Campral. Campral may be
taken concomitantly with opiates. [Campral:
Available Part D group]
Capex (Fluocinolone) 0.01% shampoo
Captique injectable gel
Fluocinolone 0.01% solution
N/A
Carac (Fluorouracil) 0.5% cream
Fluorouracil 1 and 5% cream
Cardene SR (Nicardipine) 30 - 60mg BID
Nifedipine XL 30-90mg QD; or Diltia XT
(diltiazem) 120-480mg QD
Page 12
.
Cosmetic use drug. Not covered on drug benefit.
Member pays retail price.
Used for actinic or solar keratosis of the face or
scalp
If treating hypertension, consider conversion to a
beta blocker (metoprolol, atenolol) or
Hydrochlorothiazide or ACEI (lisinopril) or, if not
monotherapy, alpha blocker (doxazosin,terazosin)
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
Dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Cardizem (Diltiazem) CD 120, 180, 240, 300, 360 mg Diltia (Diltiazem) XT 120, 180 and 240mg
caps 120-480mg QD
caps 120-480mg QD
Convert on a mg for mg basis. If Cardizem CD
300mg, consider conversion to either Diltia XT
240mg QD or #2 180mg (360mg dose) QD. Cartia
XT request conversion to Diltia XT. TSPMG
Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
Dihydropyridine CCB to Beta Blocker, ACE-I &
Thiazide Diuretics
Cardizem SR 60mg BID=Diltia XT 120mg QD,
Cardizem SR 90mg BID=Diltia XT 180mg QD,
Cardizem SR 120mg BID=Diltia XT 240 QD
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
Dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
Cardizem (Diltiazem) SR 60, 90, 120mg caps 60120mg BID
Diltia (Diltiazem) XT 120, 180 and 240mg
caps 120-240mg QD
Carmol-HC (Urea/HC) 1 % cream
Carmol 40% (Urea)
OTC Hydrocortisone 1% cream
OTC alternatives: Carmol 20% cream or
Ultra Mide 25% lotion
Atenolol (Tenormin) 25 - 100mg QD or
Metoprolol 100 - 400mg QD or Propranolol
40 - 320mg bid
Alternative product available OTC
.
Casodex (Bicalutamide) 50mg QD
Eulexin (Flutamide) 250mg TID
Both in the same family of antiandrogens.
Catapres TTS-1 patch applied weekly
Clonidine (generic Catapres) tablet 0.1 mg
QD
Clonidine (generic Catapres) tablet 0.2 mg
QD
Clonidine (generic Catapres) tablet 0.3 mg
QD
N/A
Clonidine patch is non formulary, tablets are
formulary
Clonidine patch is non formulary, tablets are
formulary
Clonidine patch is non formulary, tablets are
formulary
Caverject is not covered for sexual dysfunction
unless member's group has purchased sexual
dysfunction rider for additional coverage.
Cartrol (Carteolol) 2.5, 5mg tabs 2.5 - 10mg QD
Catapres TTS-2 patch applied weekly
Catapres TTS-3 patch applied weekly
Caverject inj 10 mcg
Cedax (Ceftibuten) suspension
Propranolol is available as 10, 20, 40, 60, 80,
90mg tabs. Inderal LA is non-formulary
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
Dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
Omnicef 125mg/5ml; Pediazole
.
(Erythromycin & Sulfamethoxazole);
Augmentin 125-250mg/5ml or 200-400mg
chew tabs;Amoxicillin 125-250mg/5ml;
Biaxin 125-250mg/5ml; Cefaclor suspension
Page 13
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Ceftin (Cefuroxime) 500mg tablets
Cefuroxime 250mg tablets
In most instances, 250mg BID is sufficient dosing.
When 500mg BID dosing is required, mg to mg
conversion. (eg. One cefuroxime 500mg tablet
BID converts to Two Cefuroxime 250mg tablets)
Ceftin suspension
Omnicef 125mg/5ml; Pediazole
Cefuroxime 250mg tablets remain on formulary,
(Erythromycin & Sulfamethoxazole);
Ceftin suspension is non-formulary
Augmentin 125-250mg/5ml or 200-400mg
chew tabs;Amoxicillin 125-250mg/5ml;
Biaxin 125-250mg/5ml; Cefaclor suspension
Cefzil suspension 30 mg/kg/day divided BID
TMP-SMX (generic Septra or Bactrim) 6-12 Pharmacologically, Cefaclor is the closest
mg/kg/day (TMP) divided BID or
antibiotic alternative to Cefzil.
Sulfisoxazole/Erythromycin (generic
Pediazole) 68 mg/kg/day (Erythromycin)
divided TID or Cefaclor (generic Ceclor) 2040 mg/kg/day divided BID-TID or Augmentin
45 mg/kg/day (Amoxicillin/Clavulanate)
divided BID
Celebrex (celecoxib) 100 - 200mg BID ***Caution
may increase cardiovascular toxicity***
Relafen (Nambumetone) 500mg or 750mg 1
- 2 QD-BID or Etodolac (gen. Lodine) 200500mg Q8-12H up to 1200mg/day or
Ibuprofen (gen. Motrin) tabs 600-800 mg
TID or Naproxen (gen. Naprosyn) 500mg
BID or Sulindac (gen. Clinoril) 200mg BID
or Diclofenac (gen. Voltaren) 75mg BID or
Mobic (Meloxicam) 7.5mg or 15mg
OR, if COX 2 inhibitor is appropriate (GI
SCORE > 20), see next column. Clinical
trials document: Adding PPI like, Prilosec
OTC 20mg QD, to NSAID therapy results in
GI ulcer risk equivalent to that with Cox 2
inhibitors
Cenestin (Synthetic Conjugated Estrogen) tabs 0.31.25 mg QD
Estrace (Estradiol) 0.5 - 2 mg po QD
Cox 2 inhibitor (Celebrex) is a NF No Initial Fill
agent, due to safety concerns with its use. KP
NSAID GI SCORE tool will assist provider to
determining if pt is a candidate for Cox-2 inhibitor
benefit coverage. If pt SCORE >20 and patient
has failed a reasonable trial on each of these low
GI risk NSAIDs PLUS PPI: Relafen 500mg or
750mg 1 - 2 QD-BID PLUS Prilosec 20mg QD;
Etodolac 400-500mg BID PLUS Prilosec 20mg
QD; Salsalate 750mg 1-2 BID PLUS Prilosec
20mg QD, meets criteria for Cox 2 inhibitor
coverage. If pt SCORE < 20 and NSAID is
required, consider: Nambumetone (Relafen)
500mg #1-2 QD-BID or etodolac (Lodine) 200500mg Q8-12H up to 1200mg/day or Salsalate
(Disalcid) 1500mg BID or Choline Magnesium
Trisalicylate (Trilisate) 750mg BID-TID.
Chibroxin (Norfloxacin) ophth soln
Prescribed for relief of vasomotor symptoms due
to menopause. 0.5mg estradiol = 0.3mg
Cenestin; 0.75mg estradiol (1&1/2 0.5mg
tablet)=0.45mg Cenestin; 1mg estradiol =
0.625mg Cenestin; 1.5mg estradiol (1&1/2 1mg
tablet) = 0.9mg Cenestin; 2mg estradiol = 1.25mg
Cenestin)
OTC ear wax removal drops
Use OTC ear wax removal product ie Debrox
(Carbamide Peroxide)
OTC Nicotrol (Nicotine transdermal system) Smoking cessation products are non formulary
5, 10, 15mg/day
Ocuflox (Ofloxacin) ophth soln
.
Chlorhexidine topical soln
N/A
Choledyl (Oxtriphylline) tab
(oxtriphylline=approximately 64% theophylline)
Theophylline (generic TheoDur)
Chromagen (Ferrous Fumarate 70mg,
Cyanocobalamin 10mcg, Ascorbic acid 150mg)
OTC alternatives: Niferex 150mg
(Polysaccharide-iron complex) or Ferrous
Fumarate 200mg: With or Without OTC B12
100mcg plus vitamin C 250mg
Cerumenex (Triethanolamine Polypeptide OleateCondensate 10% ear wax removal drops
Chantix (Varenicline) oral tablets 1mg BID
Page 14
Available OTC. May be substituted without calling
provider.
Convert according to appropriate daily dose of
theophylline OR consider inhaled Albuterol and/or
QVAR (Beclomethazone HFA)
Pt may also opt to pay full price for Rx
Chromagen. Vitamins components available OTC
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Chromagen Forte (Ferrous Fumarate 151mg, Folic
acid 1mg, Cyanocobalamin 10mcg, Ascorbic acid
60mg)
OTC alternatives: Niferex 150mg
Pt may also opt to pay full price for Rx
(Polysaccharide-iron complex) or Ferrous
Chromagen. Vitamins components available OTC
Fumarate 200mg: plus B12 100mcg plus
vitamin c 100mg plus Rx Folic Acid 1mg QD
Cialis (Tadalafil)
none
Ciloxan (Ciprofloxacin) ophth soln
Cipro HC otic soln
Cialis is not covered for sexual dysfunction unless
member's group has purchased sexual
dysfunction rider for additional coverage.
Ocuflox (Ofloxacin) ophth soln
.
Cortisporin otic (neomycin/polymyxin/HC) 3 Ciprodex is reserved primarily for use in Acute
drops TID, Or gentamicin ophthalmic
Otitis Media when patient has tubes.
solution 0.3% 3 drops TID -orOther formulary otic solutions include: Vosol
Neomycin/polymyxin/dexamethasone ophth (Acetic Acid) or Vosol HC (Acetic Acid and
susp 0.1% 3 drops TID;
If
Hydrocortisone)
fluoroquinolone antibiotic necessary:
Ofloxacin 0.3% ophthalmic solution 5-10
drops into ear(s) BID.
Clarinex (Desloratadine) 5mg tabs
Claritin OTC or Zyrtec OTC
Clarinex not covered by drug benefit. Claritin
and Zyrtec available OTC. Intranasal steroids
(Nasarel ii sprays per nostril BID or generic
Flonase (fluticasone) i spray each nostril QD)
more effective than nonsedating antihistamines
for allergic rhinitis.
Claritin tabs or redi-tabs 10 mg QD
Claritin OTC or Zyrtec OTC
Claritin not covered by drug benefit. Claritin
and Zyrtec available OTC. Intranasal steroids
(Nasarel ii sprays per nostril BID or generic
Flonase (fluticasone) i spray each nostril QD)
more effective than nonsedating antihistamines
for allergic rhinitis.
Claritin-D 24 hour tabs 10 mg (240 mg
Pseudoephedrine) QD
Claritin-D and Zyrtec-D available OTC.
Claritin D not covered by drug benefit. Claritin
D and Zyrtec D available OTC. Intranasal
steroids (Nasarel ii sprays per nostril BID or
generic Flonase (fluticasone) i spray each nostril
QD) is more effective than nonsedating
antihistamines for allergic rhinitis.
Claritin-D tabs 5 mg (120 mg Pseudoephedrine) BID
Claritin-D and Zyrtec-D available OTC.
Claritin D not covered by drug benefit. Claritin
D and Zyrtec D available OTC. Intranasal
steroids (Nasarel ii sprays per nostril BID or
generic Flonase (fluticasone) i spray each nostril
QD) is more effective than nonsedating
antihistamines for allergic rhinitis.
Cleocin 2% vaginal cream 5 gm vaginally QD x 1
week, vaginal suppository
Metronidazole (generic Flagyl) tabs 2 gm
(500 mg x 4 tablets) for 1 dose
Metronidazole tablets more effective than
cream/gel
ClimaraPro (Estradiol/Levonorgestrel transdermal
patches) 0.045mg/0.015mg
Climara (Estradiol) 0.05mg patch PLUS
medroxyprogesterone 2.5-5mg QD
Also available: Climara 0.025mg, 0.0375mg,
.05mg, 0.06mg, 0.075mg, 0.1mg patches apply
one patch weekly; or Oral Estradiol 0.5, 1 or 2mg
Clindagel (clindamycin 1%)
Generic clindamycin phosphate gel 1%
(Cleocin T gel)
Metronidazole (generic Flagyl) tabs 2 gm
(500 mg x 4 tablets) for 1 dose
Clindesse (Clindamycin phosphate) 2% cream single
dose formulation
Page 15
Metronidazole tablets more effective than
cream/gel. If failed alternatives and vaginal
clindamycin required, NF alternative is
Clindamycin 2% vaginal cream QD x 1 week.
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Cloderm (Clocortolone Pivalate) 0.1% cream
[medium potency]
Triamcinolone (generic Aristocort or
Kenalog) cream, oint 0.1%
If failed other alternatives, consider increasing to
high potency topical corticosteroid Fluocinonide
(Lidex) 0.05% cream, oint, or gel
ClosDes Pack (Desonide 1% Cream, 15 gm tube, &
OTC Clotrimazole 1%, 15 gm tube) Available as a
combination package at KP pharmacies only.
Combination package containing Desonide
1% cream 15 gm tube & Clotrimazole 1%
15 gm tube available for one copay at KP
pharmacies only
Robitussin AC generic Syrup (10 mg
Codeine/100 mg Guaifenesin) 10 ml Q4H or
Robitussin DAC .
Asacol (Mesalamine released primarily in
colon) 400mg #2 TID for 6 wks OR Pentasa
250mg #4 QID or 500mg #2 QID for 8 wks
OR Dipentum 250mg #4 BID OR Azulfidine
(Sulfasalazine) 500mg #2 TID-QID
Outside of KP, Desonide 1% available for one
copay. Patient may purchase Clotrimazole 1% as
an OTC product at outside pharmacies.
Codiclear DH Syrup (5 mg Hydrocodone/100 mg
Guaifenesin) 5ml Q4H PC & HS
Colazal (Balsalazide) #3 750 mg caps TID (total daily
dose of 6.75 grams) for 8 weeks ulcerative colitis
Other alternatives: Phenergan VC with Codeine
or Phenergan with Codeine syrup or Hycodan
tablets
Treatment for ulcerative colitis. Colazal is broken
down in the body to form Mesalamine.
.
Colestid flavored/unflavored granules bulk powder 1-3 Questran bulk powder 1-3 scoopfuls QDteaspoonfuls QD-BID or packet 1-3 packets QD-BID BID or Questran packets 1-3 packets QDBID or Colestid 1 gm tablet i-iiii tablets QDBID
CombiPatch (0.05mg Estradiol / 0.14 Norethindrone or Estrace 0.5, 1 or 2mg (Estradiol) AND
0.05mg Estradiol/ 0.25mg Norethindrone patches)
Medroxyprogesterone 2.5 or 5mg
apply 1 patch, replacing patch twice wkly
Combination estrogen and progesterone patch is
non formulary. Convert to oral estrogen and
progesterone QD.
Combunox (Oxycodone 5mg / ibuprofen 400mg)
combination tabs
Generic MS Contin (Morphine controlled
release) 15,30,60,100,200mg PLUS
ibuprofen 400mg tablets; generic Percocet
or Percodan (oxycodone 5mg/325mg apap
or asa, respectively), Tylox (oxycodone
5mg/500mg apap), generic Demerol 50mg,
100mg, Fentanyl patches 25mcg, 50mcg,
75mcg, 100mcg/hr
Many alternative narcotic pain relievers No fixed
conversion ratios will fit all patients, especially
when large opioid doses are involved. The
following is a starting point and may need
individual adjustment or titration: Oxycontin
package insert states that multiplying the daily
oxycontin dose by 2, yields a suggested daily
Morphine dose.
Compazine (Prochlorperazine) spansules
Compazine tablets or suppositories
Spansules are non formulary, tablets and supp
are formulary
Solution is non formulary, gel is formulary
Condylox topical solution
Condylox 0.5% gel BID x 3 days then
withold x 4 days. May repeat cycle up to 4
times
Copegus (Ribavirin) 200mg tab
generic Ribavirin 200mg capsule
Cordran (Flurandrenolide) 0.025%-0.05% cream, oint, Triamcinolone (generic Aristocort) cream,
0.05% lotion or 4mcg/cm2 tape [Medium potency]
oint 0.1%
Cortef Susp (10mg/5mL Hydrocortisone) 20-240
mg/day
Prelone Syrup generic or Orapred
(15mg/5mL) divide Cortef dose by 4 when
converting
Corzide (Bendroflumethiazide/Nadolol) 5/40 or 5/80mg Convert to two Rx products
Hydrochlorothiazide 25mg and either
Nadolol 40mg or Nadolol 80mg
Cosopt (Dorzolamide 2%/Timolol 0.5%) i drop in
affected eye BID
Azopt (Brinzolamide 1%) i drop TID and
Timoptic (Timolol 0.5%) i drop BID
Page 16
If failed other alternatives, consider increasing
steroid potency to fluocinonide (Lidex) 0.05%
cream, oint, or gel
N/A
Match the Nadolol dose to the original
combination product Nadolol dose. TSPMG
Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
Dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
Combination product, Cosopt, is non formulary.
Individual medications, (Azopt and Timoptic not
XE) are formulary.
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Cotazyme (Pancrelipase enzymes)
Pangestyme is a generic of Pancrease
Pancrease (Pancrelipase enzymes) or
pangestyme
OTC equivalents available
All cough and cold medications are non-formulary
with the exception of Codeine, Hydrocodone,
methscopalamine, and Promethazine containing
products.
Coumadin (Warfarin) tablet
Warfarin tablet (Barr generic brand)
Brand name non formulary.
Covera-HS (Verapamil controlled release) 180, 240mg Verapamil SR tabs (generic Calan SR) 180, Substitute on a mg for mg basis.
tabs
180-480mg QHS
240mg tabs
180-480mg QHS TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
Cough and Cold Products
Cozaar (Losartan) 50mg tablets (50mg strength is NF) Cozaar (Losartan) 25mg #2 QD or 100mg
1/2 tablet QD
-or if
ACE Inhibitor naïve, Lisinopril 20mg QD
Cozaar 50mg strength is non-formulary, please
prescribe 25mg or 100mg tablets. If ACE
Inhibitor naïve, consider conversion to
Lisinopril:
Cozaar 50mg QD = Lisinopril
20mg QD.
TSPMG
Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
& Thiazide diuretic
Four Drug Therapy: Add Long Acting
dihydropyridine CCB to Beta Blocker, ACE-I &
Thiazide Diuretic
Creon (Pancrelipase enzymes)
Crestor (Rosuvastatin) 10mg
Pancrease (Pancrelipase enzymes)
Lovastatin 80 mg QPM w/ meal or
Simvastatin 40 mg QPM
Pangestyme is a generic of Pancrease
Doses of lovastatin > 40mg QD and simvastatin >
20mg QD are not recommended in combination
with Diltiazem, Verapamil, Amiodarone, or a
protease inhibitor. Continue crestor to minimize
drug interaction and chance for muscle aches. If
crestor is continued, use half tablets. Doses of
Lovastatin > 20mg QD and simvastatin > 10mg
QD, crestor > 5mg QD not recommended with
cyclosporine. For questions, consider calling
Pharmacy Cardiac Risk Service at 770-496-3560
between 830AM and 530PM.
Crestor (Rosuvastatin) 20mg
Simvastatin 80 mg QPM
Doses of lovastatin > 40mg QD and simvastatin >
20mg QD are not recommended in combination
with Diltiazem, Verapamil, Amiodarone, or a
protease inhibitor. Continue crestor to minimize
drug interaction and chance for muscle aches. If
crestor is continued, use half tablets. Doses of
Lovastatin > 20mg QD and simvastatin > 10mg
QD, crestor > 5mg QD not recommended with
cyclosporine. For questions, consider calling
Pharmacy Cardiac Risk Service at 770-496-3560
between 830AM and 530PM. If pt is also on
gemfibrozil, please consult PCRS for
recommendations.
Page 17
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Crestor (Rosuvastatin) 40mg
Doses of lovastatin > 40mg QD and simvastatin >
20mg QD are not recommended in combination
with Diltiazem, Verapamil, Amiodarone, or a
protease inhibitor. Continue crestor to minimize
drug interaction and chance for muscle aches. If
crestor is continued, use half tablets. Doses of
Lovastatin > 20mg QD and simvastatin > 10mg
QD, crestor > 5mg QD not recommended with
cyclosporine.For questions, consider calling
Pharmacy Cardiac Risk Service at 770-496-3560
between 830AM and 530PM. If pt is also on
gemfibrozil, please consult PCRS for
recommendations.
Crestor (Rosuvastatin) 80mg
Cresylate (M-Cresyl acetate) 25% otic
Consider simvastatin 80mg QD plus SloNiacin/ time release niacin or BAS first if
appropriate. Otherwise, Vytorin 10/80 mg
QHS can be considered.
Crinone (Progesterone) 4% vaginal gel
Domeboro (Aluminum Acetate and Acetic
Acid) otic
Medroxyprogesterone 2.5 mg QD
Crinone (Progesterone) 8% vaginal gel
N/A
Crolom (Cromolyn) 4% ophth soln i-ii drops q6hrs
(mast cell stabilizing properties)
For allergic conjunctivitis: OTC Opcon-A
(Pheniramine & Naphazoline) or OTC
Zaditor 0.25% [NOTE: OTC products are
not a covered benefit]
Cryselle (0.3 Norgestrel / 30mcg EE) tablet i QD
Levlen (0.15mg Levonorgestrel / 30mcg EE)
or Tri-Levlen (0.05mg Lvngl/30mcg EE x 6
days, 0.075mg Lvngl/40mcg EE x 5 days,
0.125mg Lvngl/ 30mcg EE x 10 days)
Cutivate (Fluticasone) 0.05% cream, 0.005% oint
[medium potency]
Cyanocobalamin (vitamin b12) injection
Cyclessa (tricyclic Desogestrel/EE) 0.1mg/25mcg x
7days; 0.125mg/25mcg x 7days; 0.15mg/25mcg x 7
days
(generic soon available as Velivet by
Barr)
Cyclocort (Amcinonide) 0.1% cream, oint, lotion [high
potency]
No formulary alternative at this dosage.
N/A
Crinone 4% vaginal gel is non-formulary, used for
post-menopausal hormone replacement.
Crinone 8% vaginal gel is used for fertility
treatment and is covered only for those patient
groups who have purchased a fertility treatment
rider to expand their drug benefit.
OTC Zaditor 0.25% and Patanol are both dual
action antihistamine/mast cell stabilizers, are
dosed twice daily, and have the same FDA
approved indications. If treating steroid
responsive inflammatory condition:
Dexamethasone 0.1% ophth soln or Prednisolone
0.12%-1% ophth soln or Flarex, FML
(Fluorometholone) ophth soln 0.1% i-ii drops in
affected eye(s) QID
May consider Tri-Norinyl (.5/1/.5 Norethindrone/
35 EE) or Microgestin FE (1 mg Norethindrone/ 20
EE) or Zovia 1/35 (1mg Ethynodiol Diacetate/ 35
EE) Document at least 3 formulary
alternatives before prescribing/approving a NF
product.
Triamcinolone (generic Aristocort, Kenalog) If failed other alternatives, consider increasing
cream, oint 0.1%
steroid potency to Fluocinonide (Lidex) 0.05%
cream, oint, or gel
OTC: Vitamin B12 1mg orally
TSPMG clinical practice resource indicates oral
b12 may be used in pernicious anemia
Microgestin 1/20 (1mg
Other formulary alternatives: Tri-Norinyl (0.5mg
Norethindrone/20mcg EE) or Microgestin
Norethindrone x 7days, 1mg NE x 7 days, 0.5mg
1.5/30 (1.5NE/30mcgEE) or Levlen (0.15
NE x 7 days/ 35 mcg EE) or Zovia 1/35
Levonorgestrel/30mcg EE) or Tri-Levlen
(Ethynodiol 1mg/35mcg EE), Brevicon (.5mg NE/
(0.05mg Levonorgestrel & 30mcg EE x 6
35mcg EE), Zovia1/35 (Ethynodiol 1mg/35mcg
days, 0.075mg Lvn & 40 EE x 5 days,
EE), Norinyl 1/35 (1mg NE/ 35mcg EE) Norinyl
0.125mg Lvn & 30mcg EE x 10 days)
1/50 (1mg NE/ 50mcg Mestranol), or NorQD (0.35
NE only)
A Desogestrel
containing product substitution is not available on
formulary. Document at least 3 formulary
alternatives before prescribing/approving a NF
product.
Lidex (fluocinonide) 0.05% cream, oint, gel, High potency topical corticosteroids. If require a
soln or Diprolene AF (augmented
lotion, consider stepping down to medium potency
betamethasone) 0.05%
Valisone (betamethasone valerate) 0.1% lotion
Page 18
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Cymbalta (duloxetine) 20mg
If treating depression: Fluoxetine 20mg or
Citalopram 20mg or Sertraline 25mg or
Venlafaxine IR 25mg BID or Effexor XR
37.5mg (Effexor XR restricted to
psychiatry and mental health ). Titrate to
response. Sertraline added to formulary as
of 3/8/07. Document response to all
formulary SSRI alternatives before
prescribing a NF SSRI. Document
reason, when patient is medically unable
to convert to Formulary alternative.
If treating neuropathic pain: Nortriptyline (if <65
yrs old: 25mg QHS, increase dose 25mg/day at 37 day intervals prn. If > 65 years old: 10mg QHS,
increase dose 10mg/day at 3-7 day intervals prn).
Consider adding Gabapentin if needed. Consider
topical capsaicin OTC if area is small. ( Duloxetine
is available to MMA group )
Cytomel (liothyronine) tablet 25-75 mcg QD
Levothroid tabs 0.05-0.1 mg QD, see
suggested conversions in next column
If interested in converting, please refer to
approximate conversions: 15-37.5mg cytomel =
50-60mcg levothroid; 37.5mg cytomel = 75-90mcg
levothroid; 50mcg cytomel = 100-120mcg
levothroid; 75mcg cytomel = 150-180 levothroid.
Cytovene (gancyclovir) cap 1000mg TID
maintenance therapy for CMV retinitis (following
induction with IV gancyclovir or insertion of vitrasert)
Valcyte 450mg tablet
Valcyte (valgancyclovir) - CMV prophylaxis 900mg
QD; AIDS or s/p organ transplantation 900mg BID
(Treatment doses if Crcl 40-59 = 450mg BID;crcl
25-39 = 450mg QD;crcl 10 - 24 = 450mg Q 2
days; dialysis - valcyte not recommended; also
adjust for WBC)
Darvocet-N 50 & -N 100
(Propoxyphene/acetaminophen)
APAP 1000mg TID-QID,
Hydrocodone/APAP 5/500mg 1/2 -1T TID,
Nabumetone 500mg BID, Etodolac 300mg 400mg BID -TID
CAUTION: propoxyphene/acetaminophen
(generic Darvocet) and other propoxyphene
combinations are on the list to be avoided in
the elderly due to increased risks for falls.
[Available Part D group]
Darvon & Darvon-N (Propoxyphene)
APAP 1000mg TID-QID,
Hydrocodone/APAP 5/500mg 1/2 -1T TID,
Nabumetone 500mg BID, Etodolac 300mg 400mg BID -TID
CAUTION: propoxyphene/acetaminophen
(generic Darvocet) and other propoxyphene
combinations are on the list to be avoided in
the elderly due to increased risks for falls.
[Available Part D group]
Daytrana (Methylphenidate)
Concerta 18,27,36,54mg, or Methylin ER
10mg, Methylphenidate 5, 10, 20mg and SR
20mg; or generic Dexedrine spansules
(Dextroamphetamine) 5, 10, 15mg or
Adderall regular release 5, 10, 20, 30mg
tablets or Adderall XR 5,10,20,25,30mg
capsules. Controlled substances level 2
requiring prescription written by prescriber.
Methylphenidate is the preferred formulary
alternative.
Adderall XR is restricted to pediatrics, child
neurology and behavioral health. Titrate to
appropriate dosage using adderall regular
release tablets before transitioning to once
daily Adderall XR. Document failed trial on
Methylphenidate, Dextroamphetamine and
Adderall IR products before a Non-formulary
Product is considered.
Daypro (Oxaprozin) 600mg tab
1200- 1800mg QD Relafen (Nambumetone) 500mg or 750mg 1
- 2 QD-BID or Etodolac (Lodine) 200-500mg
Q8-12H up to 1200mg/day or Ibuprofen
(Motrin) tabs 600-800mg TID or Naproxen
(Naprosyn) 500mg BID or Sulindac
(Clinoril) 200mg BID or Diclofenac
(Voltaren) 75mg BID or Mobic (Meloxicam)
7.5mg or 15mg
Page 19
Additional formulary alternatives: Salsalate
(Disalcid)1500mg BID or choline magnesium
trisalicylate (Trilisate) 750mg BID-TID or
Indomethacin 25-50mg TID.
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Decadron (Dexamethasone sodium phosphate) 0.1% DesOwen (Desonide) 0.05% cream, oint,
Low potency topical corticosteroids.
cream
[low potency]
lotion or Synalar (Fluocinolone) 0.01% soln,
oil or Hytone (Hydrocortisone) 2.5% cream,
oint, lotion
Decaspray (Dexamethasone) aerosol spray [low
potency]
DesOwen (Desonide) 0.05% cream, oint,
Low potency topical corticosteroids.
lotion or Synalar (Fluocinolone) 0.01% soln,
oil or Hytone (Hydrocortisone) 2.5% cream,
oint, lotion
Demadex (Torsemide) tabs 5-100 mg QD
Furosemide (generic Lasix) tabs 10-200 mg Multiply daily Demadex dose by 2 to obtain daily
per day
furosemide dose (example: Demadex 10 mg QD
x 2 = furosemide 20 mg QD). Furosemide doses
> 60 mg/day should be divided BID.
Demulen 1/35 compak i QD
Zovia 1/35 (generic Demulen) i QD
May be substituted without calling provider.
Demulen 1/50 compak i QD
Zovia 1/50 (generic Demulen) i QD
May be substituted without calling provider.
Denavir Cream (Penciclovir) apply Q2H while awake X Herpes Labialis: OTC Abreva. OTC
4 days
Carmex or Orabase to prevent drying and
fissuring. Domoboro soaks may relieve
itching and dry blisters; Acyclovir (generic
Zovirax) tab 400 mg TID x 5 days
OTC Abreva (Docosanol cream) has been shown
to reduce herpes labialis course by 18 hours.
Abreva blocks viral entry into cells; therefore, not
likely to lead to viral resistance. [ Available Part
D group]
Depakote ER (Divalproex sodium extended release)
Depakote (Divalproex sodium) tablets
regular release are covered
Depakote ER does not offer clinical benefit over
Depakote regular release. Unlike Depakote,
Depakote ER may not be dosed higher than
1000mg/day
Depo-Testosterone 200 mg/ml inj
Methyltestosterone (generic Android or
Testred) tabs 10-20 mg QD-BID or
Fluoxymesterone (Halotestin) 10 mg QD
Check baseline and periodic liver function
tests if using oral supplementation.
Testosterone injection 400 mg IM q2-4weeks
administered in medical office. Injectables
administered in a medical office are covered
under the medical office benefit, NOT the drug
benefit and are not available from a pharmacy for
a copayment.
Dermatop (Prednicarbate 0.1%)
Lidex (Fluocinonide) 0.05% cream, oint, gel High potency topical corticosteroids. If require a
lotion, consider stepping down to medium potency
or Diprolene AF (Augmented
Valisone (Betamethasone valerate) 0.1% lotion
Betamethasone) 0.05%
Desogen (Desogestrel 0.15mg/EE 30mcg) 28 tabs i
QD
Levlen (0.15mg Levonorgestrel / 30mcg EE)
or Tri-Levlen (0.05mg Lvngl/30mcg EE x 6
days, 0.075mg Lvngl/40mcg EE x 5 days,
0.125mg Lvngl/ 30mcg EE x 10 days)
Detrol Regular Release (Tolterodine) tab 1-2mg BID
(regular release is non formulary)
Oxybutynin (generic Ditropan) 5-10 mg tab i .
QD-BID (immediate release tablet) or
Oxybutynin XL (generic Ditropan XL) 515mg QD or Oxytrol patch
Detrol LA (Tolterodine long-acting) 2-4mg QD
(removed from formulary as of 7/1/07)
Oxybutynin (generic Ditropan) 5-10 mg tab i
QD-BID (immediate release tablet) or
Oxybutynin XL (generic Ditropan XL) 515mg QD or Oxytrol patch
One Touch Ultra glucose test strips
One Lifescan monitor is formulary and may be
obtained, by prescription, at KP pharmacy at a coTouch Ultra 2 machine -only
payment. Members will be charged full price for
Lifescan monitor at Eckerd
Dextrostix blood glucose test strips
Page 20
Zovia 1/35 (1mg Ethynodiol Diacetate/ 35mcg EE)
or Microgestin 1.5/30 (1.5 Norethindrone / 30mcg
EE) or Sprintec (0.25mg Norgestimate/35mcg EE)
or Tri-Sprintec, generic Ortho-Tricyclen, (0.18mg
Norgestimate x 7 days, 0.215mg Norgestimate x 7
days, 0.25mg Norgestimate x 7 days/ 35 mcg EE)
Document at least 3 formulary alternatives
before prescribing/approving a NF product.
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
DHT (Dihydrotachyesterol) aka Hytakerol 0.125, 0.2,
0.4mg tabs 0.1-0.25mg QD and titrate to effect
Comments
Rocaltrol (Calcitriol) 0.25, 0.5mcg caps 0.251mcg/day titrated to effect or Calciferol
(Ergocalciferol) 50,000 units/capsule 15,00020,000 units/day titrated to effect
Diatx (1.5mg B1;1.5mg B2; 20mg B3; 10mg B5; 50mg OTC Nephro-vite (Vitamin C 100mg, folate Nephro-vite OTC NDC # 54391-0002-01.
B6; 1mcg B12; 60mg C; 5mg folic acid; 300mg d
0.8mg, niacin B3 20mg, thiamin B1 1.5mg,
Biotin)
riboflavin B2 1.7mg, Pantothenic Acid B5
5mg, Pyridoxine B6 10mg, Cyanocobalamin
B12 6mcg, d biotin 300mcg) PLUS folic acid
OTC (if need greater than .8mg in Nephro
Vite)
Didrex (Benzphetamine)
N/A
Weight loss agents not covered.
Differin (Adapalene) 0.1% gel and cream
Retin A Micro 0.04% and 0.1% gel, 20gm or Retin A Micro is restricted to Dermatology.
Retin-A 0.01% 15gm gel or Retin A 0.1%
Only the smallest unit size is covered for Retin A
20gm cream
products. Covered only for the treatment of acne,
member pays copay. Not covered for cosmetic
treatment (wrinkles), member pays full price.
Diflucan (Fluconazole) tab 50mg, 100mg, 200mg tab
QD
50mg, 100mg and 200mg strengths are not
covered for vaginal yeast infections.
Diflucan (Fluconazole) tab 150 mg i x 1 dose
Fluconazole 150mg strength is Formulary with
a quantity limit of 1 tablet per copay.
Fluconazole 150mg covered for vaginal yeast
infections when OTC vaginal preps cannot be
used.
Diflunisal (generic Dolobid) tabs 500 mg BID
Ibuprofen (Motrin) tabs 600-800 mg TID or
Salsalate (Disalcid)1500mg BID or
Naproxen 500mg BID or Sulindac (Clinoril)
200mg BID
Diltiazem Gel (compounded formulation for anal
fissure, not commercially available)
Nitroglycerin 0.2% Ointment (commercially
available), apply very small amount (to
avoid/minimize absorption related side
effects) via Q-tip to anal fissure
Diovan (Valsartan) 80-320 mg QD
Prinivil (Lisinopril) 5-40mg QD or Cozaar 25- Prinivil (Lisinopril) is preferred, if no previous
100mg QD
ACE inhibitor trial. If angiotensin 2 receptor
blocker is required, convert to Cozaar.
Conversion:
Diovan 80mg=Prinivil 5-10mg=Cozaar 25mg;
Diovan 160mg=Prinivil 10-20mg=Cozaar 50mg;
Diovan 320mg=Prinivil 20-40mg=Cozaar 100mg
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
Page 21
Additional formulary alternatives: Diclofenac
(Voltaren) 75mg BID or Choline Magnesium
Trisalicylate (Trilisate) 750mg BID-TID or
Nambumetone (Relafen) 500mg or 750mg 1 - 2
QD-BID or Etodolac (Lodine) 200-500mg Q8-12H
up to 1200mg/day or Indomethacin 25-50mg TID
or Mobic (Meloxicam) 7.5mg or 15mg
.
.
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Diovan HCT (160mg Valsartan/ 12.5mg
Hydrochlorothiazide) QD
Prinzide (lisinopril & HCTZ) 10/12.5mg,
20/12.5mg or 20/25mg OR Cozaar 50mg
(25mg tabs x 2=50mg) QD plus HCTZ
(Hydrochlorothiazide) 25 mg 1/2 tab QD
Prinzide (lisinopril & HCTZ) is preferred, if no
previous ACE inhibitor trial. Must have
separate prescription for HCTZ if Cozaar
prescribed.
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
Diovan HCT 80mg Valsartan /12.5mg
Hydrochlorothiazide QD
Prinivil 5-10 mg QD or Cozaar 25mg tab QD
plus HCTZ (hydrochlorothiazide) 25 mg 1/2
tab QD or Prinzide (lisinopril & HCTZ)
10/12.5mg
Prinivil (lisinopril)+ HCTZ or Prinzide is
preferred, if no previous ACE inhibitor trial.
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
Diprosone (Betamethasone Dipropionate) 0.05%
cream, oint [high potency]
Lidex (Fluocinonide) 0.05% cream, oint, gel, High potency topical corticosteroids.
soln or Diprolene AF (Augmented
Betamethasone) 0.05%
Diprosone (Betamethasone Dipropionate) 0.05%
lotion [medium potency]
Valisone (Betamethasone Valerate) 0.1%
lotion or Triamcinolone (generic Aristocort
or Kenalog) cream, oint 0.1%
Ditropan (Oxybutynin) XL 5-10 mg tab i QD
Oxybutynin (generic Ditropan) 5-10 mg tab i
QD-BID (immediate release tablet) or
Oxybutynin XL (generic Ditropan XL) 515mg QD or Oxytrol patch
Diuril (Chlorothiazide) tablet
Hydrochlorothiazide tablet
If failed other alternatives, consider increasing
steroid potency to Fluocinonide (Lidex) 0.05%
cream, oint, or gel
N/A
Climara (.025mg, .0375mg, .05mg, .06mg,
Divigel (Estradiol) .1%
0.25mg estradiol/day, 0.5mg estradiol/day, and 1.0mg .075mg, .075mg, .1mg patches) apply 1
patch a week; Estrace (Estradiol) .5mgestradiol/day
2mg po daily, OR Premarin Vaginal Cream
Divigel (Estradiol) .1% is available in 3 doses of
0.25mg, 0.5mg, and 1.0mg corresponding to
Estradiol 0.25mg, 0.5mg, and 1.0mg
Dolobid (Diflunisal) tabs 500 mg BID
Ibuprofen (generic Motrin) tabs 600-800 mg
TID or Salsalate (Disalcid)1500mg BID or
Naproxen 500mg BID or Sulindac (Clinoril)
200mg BID
Additional formulary alternatives: Diclofenac
(Voltaren) 75mg BID or Choline Magnesium
Trisalicylate (Trilisate) 750mg BID-TID or
Nambumetone (Relafen) 500mg or 750mg #1-2
QD-BID or Etodolac (Lodine) 200mg-500mg Q812H up to 1200mg/day or Indomethacin 25-50mg
TID or Mobic (Meloxicam) 7.5mg or 15mg.
Donnatal elixir
Antispasmodic elixir (generic Donnatal)
Doryx 100mg (Doxycycline)
Doxycycline 50mg or 100mg
Generic may be substituted. Brand is nonformulary and not covered.
.
Page 22
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Duac gel (Clindamycin gel/Benzoyl peroxide gel)
Benzamycin and Duac are nonformulary, but 2%
Erythromycin solution & 5% Benzoyl Peroxide
aqueous gel OR 1 % Clindamycin gel & 5%
Benzoyl Peroxide aqueous gel, respectively, may
be prescribed separately and purchased as a
pack for one copayment at a Kaiser Permanente
pharmacy. At Eckerd, the patient will receive
Erythromycin 2% soln OR Clindamycin 1% gel at
a copayment & must purchase the OTC Benzoyl
Peroxide product, at KP the OTC will be included
at no additional charge.
Separate Rxs for either
2%
Erythromycin solution PLUS 5% Benzoyl
Peroxide aqueous gel
OR
Clindamycin 1% gel PLUS 5% Benzoyl
Peroxide aqueous gel
DuoNeb (Albuterol 3mg/Ipratropium 0.5mg) inhalation Combivent (Albuterol/Ipratropium) oral
solution for use with nebulizer
inhaler
Albuterol inhalation solution 0.5% 20ml AND
Ipratropium 0.02% 2.5ml for use with nebulizer
Duricef (Cefadroxil) cap 500 mg BID
Cephalexin (generic Keflex) cap 500 mg
BID
Triamterene 75 mg/HCTZ 50 mg (generic
Maxzide) 1/2 tab dose
Erythromycin (base or estolate) 250-500 mg
Q6-8H (adult)
First generation cephalosporins
Minocycline 50mg or 100mg capsules
.
Dyazide (Triamterene 37.5 mg/HCTZ 25 mg) tabs
Dynabac (Dirithromycin) tab: 500 mg QD for 7-14
days (adults)
Dynacin (Minocycline HCL) 50, 75, or 100mg
Capsules
Dynacirc (Isradipine) caps 10 mg BID
Dynacirc (Isradipine) caps 2.5 mg BID
Cut Generic Maxzide tablet in half to obtain
equivalent dose.
Dynabac offers no clinical advantage over
erythromycin when dosed appropriately
Nifedipine XL (generic Procardia XL) tab 60 Nifedipine XL, generic of Procardia XL, is
mg QD
covered. TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
Nifedipine XL tab 30 mg QD
Nifedipine XL, generic of Procardia XL, is
covered. TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
Dynacirc (Isradipine) caps 5 mg BID
Nifedipine XL tab 30 mg QD
Edecrin (Ethacrynic acid) 25 and 50mg loop diuretic
Lasix (Furosemide) Or, if allergic to
sulfonamide drugs, Spironolactone
Page 23
Nifedipine XL, generic of Procardia XL, is
covered. TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
Dose of converted diuretic to be adjusted for each
individual
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Effexor (Venlafaxine) XR caps 37.5-225 mg QD
Venlafaxine IR 25mg - 100mg BID or
Prozac (Fluoxetine) caps 20 mg QD or
Celexa (Citalopram) 20mg QD or Sertraline
25-100 mg QD. Please titrate to response
Effexor XR is restricted to Psychiatry and
Mental Health. Venlafaxine IR is formulary
without restrictions. Prozac is the preferred
formulary SSRI. (Prozac may also be prescribed
to manage hot flashes in women with a history of
breast cancer) [Effexor XR: Available Part D]
Efudex (Fluorouracil) 2% cream, soln
Efudex 5% cream, Fluoroplex 1%
Efudex 2% is non formulary
Elestat (Epinastine) 0.05% ophth soln
For allergic conjunctivitis: OTC Opcon-A
(Pheniramine & Naphazoline) first line
option; or OTC Zaditor 0.25% [NOTE: OTC
products are not a covered benefit]
Formulary alternatives: prednisolone.
Eldoquin (Hydroquinone) cream or lotion
No formulary alternative
Eligard (Leuprolide acetate) 7.5mg injection
Lupron or Eligard to be supplied by the
prescribing physician and administered in
MD office under the patient's medical
benefit.
Elocon (Mometasone) 0.1% cream, oint, lotion
[medium potency]
Triamcinolone (generic Aristocort/ gen.
Kenalog) cream, oint 0.1%; If elocon lotion
use gen. Valisone (Betamethasone
Valerate) 0.1% lotion
For allergic conjunctivitis: OTC Opcon-A
(Pheniramine & Naphazoline) or OTC
Zaditor 0.25% [NOTE: OTC products are
not a covered benefit]
OTC Zaditor 0.25% and Patanol are both dual
action antihistamine/mast cell stabilizers, are
dosed twice daily, and have the same FDA
approved indications. If treating steroid
responsive inflammatory condition consider at
least 2 formulary products before
prescribing/authorizing a NF product:
Dexamethasone 0.1% ophth soln or Prednisolone
0.12%-1% ophth soln or Flarex, FML
(Fluorometholone) ophth soln 0.1% i-ii drops in
affected eye(s) QID. Consider at least 2
formulary products before prescribing/authorizing
a NF product.
Cosmetic drug is not covered on drug benefit.
Member pays retail price. If prescribed along with
Differin, Retin A, or Avita creams, they are also
being used as cosmetic therapy and are not
covered.
TSPMG physicians provide injectables
administered in medical office through floor stock.
If network physicians cannot obtain Lupron or
Eligard, please complete KP NF Rx form for
Lupron requesting benefit coverage at the time of
dispensing.
If failed other alternatives, consider increasing
steroid potency to Fluocinonide (Lidex) 0.05%
cream, oint, or gel
Emadine (Emedastine) .05% ophth soln 1 drop QID
Emend (Aprepitant) 125mg prior to chemotherapy
then 80mg on days 2 and 3. (neurokinin 1 receptor
antagonist)
Zofran (Ondansetron) 24 mg and
Dexamethasone 12mg PO prior to
chemotherapy followed by 8mg PO QD on
days 2 thru 4
Embeline E (Clobetasol propionate) 0.05% emollient
cream
Temovate (Clobetasol) 0.05% cream, oint,
gel, scalp soln or Diprolene (Augmented
Betamethasone Dipropionate) 0.05% oint
E-mycin tablet EC 333 mg TID or 500 mg BID
Ery-tab 333 mg TID or 500 mg BID
Page 24
OTC Zaditor 0.25% and Patanol are both dual
action antihistamine/mast cell stabilizers, are
dosed twice daily, and have the same FDA
approved indications. If treating steroid
responsive inflammatory condition consider at
least 2 formulary products before
prescribing/authorizing a NF product:
Dexamethasone 0.1% ophth soln or Prednisolone
0.12%-1% ophth soln or Flarex, FML
(Fluorometholone) ophth soln 0.1% i-ii drops in
affected eye(s) QID
Emend is NF, consider adding only after failed
Zofran & Dexamethasone combination therapy.
Emend is administered as part of a three drug
regimen including Zofran, Dexamethasone and
Emend.
Very high potency topical corticosteroids.
Different Erythromycin formulations
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Enablex (Darifenacin) extended release 7.5mg and
15mg tablets
Comments
Enpresse (0.05mg Levonorgestrel/ 30mcg EE x 6
days, 0.075mg Lvngl/ 40 mcg EE x 5 days, 0.125mg
Lvngl/30mcg EE x 10 days)
Oxybutinin (generic Ditropan) 5-10 mg tab i .
QD-BID (immediate release tablet) or
Oxybutynin XL (generic Ditropan XL) 515mg QD or Oxytrol patch
Estrace (Estradiol) 0.5, 1 or 2mg QD
Estradiol (generic estrace) preferred. 0.5mg
Estradiol = 0.3mg Premarin; 0.75mg Estradiol
(1&1/2 0.5mg tablet) = 0.45mg Premarin; 1mg
Estradiol = 0.625mg Premarin; 1.5mg Estradiol
(1&1/2 1mg tablet) = 0.9mg Premarin; 2mg
Estradiol = 1.25mg Premarin
Tri-Levlen (0.05 Lvngl/30mcg EE x 6 days, Document at least 3 formulary alternatives
0.075mg Lvngl/40mcg EE x 5 days,
before prescribing/approving a NF product.
0.125mg Lvngl/30mcg EE x 10days)
Entex LA
OTC Robitussin CF or Congestac
Entocort (budesonide)
Asacol (Mesalamine released primarily in
colon) 400mg #2 TID for 6 wks OR Pentasa
250mg #4 QID or
500mg #2 QID for 8 wks OR
Dipentum 250mg #4 BID OR
Azulfidine (Sulfasalazine) 500mg #2
TID-QID
Enjuvia (Synthetic Conjugated Estrogens) 0.3mg1.25mg
All cough and cold medications with OTC
equivalents are non-formulary with exception of
Codeine, Hydrocodone, and Promethazine
containing products.
E-pilo (Epinephrine 1% and Pilocarpine 1,2,4 or 6%) i- Epinephrine 1% i-ii drops QD - QID AND
ii drops QD - QID
Pilocarpine 1, 2, 4, or 6% i-ii drops QD QID
Epivir HBV (lamivudine) tablet
Epivir 150 mg tablet QD
Climara 0.025mg, 0.0375mg, 0.05mg,
Esclim (Estradiol transdermal patches) apply twice
0.06mg, 0.075mg, 0.1mg patches apply one
weekly
Patch strengths 5mg, 7.5mg, 10mg
patch weekly; or Estrace 0.5, 1 or 2mg
15mg, 20mg deliver 0.025mg, 0.0375mg, 0.05mg,
(Estradiol)
0.075mg, 0.1mg Estradiol QD
Esgic tabs
Butalbital Compound 1-2 tabs Q4H (max: 6
tabs/day)
Estraderm transdermal patch 0.05 mg/day
Climara .025mg, 0.0375mg, .05mg, 0.06mg,
0.075mg, 0.1mg patches apply one patch
weekly; or Estrace 0.5, 1 or 2mg (Estradiol)
Combination eye drop is not covered, but
component eye drops are individually covered.
Estraderm transdermal patch 0.1 mg/day
Climara 0.025mg, 0.0375mg, .05mg,
0.06mg, 0.075mg, 0.1mg patches apply one
patch weekly; or Estrace 0.5, 1 or 2mg
(Estradiol)
Climara 0.025mg, 0.0375mg, .05mg,
0.06mg, 0.075mg, 0.1mg patches apply one
patch weekly; or Estrace (Estradiol) 0.5mg
(note larger estrogen dose when
administered orally) or Premarin Vaginal
Cream
If an estrogen patch is required, Climara.
Climara 0.025mg, 0.0375mg, .05mg,
0.06mg, 0.075mg, 0.1mg patches apply one
patch weekly; or Estrace 0.5, 1 or 2mg
(Estradiol)
Syntest DS and Syntest HS respectively
Climara 0.025mg, 0.0375mg, .05mg,
0.06mg, 0.075mg, 0.1mg patches apply one
patch weekly; or Estrace (Estradiol) 0.5mg
(note larger estrogen dose when
administered orally) or Premarin Vaginal
Cream
If an estrogen patch is required, Climara.
Estrasorb (estradiol topical emulsion) 1.74 gram foil
pouch
Estratab tablet 0.3-1.25 mg QD
Estratest and Estratest HS tab
EstroGel (Estradiol gel) 1.25gm
Page 25
If an estrogen patch is required, Climara.
.
If an estrogen patch is required, Climara.
The dose of estradiol topical emulsion for the
treatment of moderate to severe vasomotor
symptoms is 3.48 grams daily (two foil pouches of
1.74 grams, one half dose rubbed into the thigh
and calf area of each leg) which delivers 0.05
milligrams of estradiol per day
The dose of estradiol gel for the treatment of
moderate to severe vasomotor symptoms is 1.25
grams daily (two foil pouches of 1.74 grams, one
half dose rubbed into the thigh and calf area of
each leg) which delivers 0.75 milligrams of
estradiol
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
EstroStep (1mg Norethindrone/20mcg EE x 5day,
1mg NE/30mcg EE x 7 day, 1mg NE/35mcg EE x 9
day)
Or may consider Microgestin FE (1mg NE/20mcg
EE x 21 day plus 75mg Ferrous Fumarate)
EstroStep FE (1mg Norethindrone/20mcg EE x 5day,
1mg NE/30mcg EE x 7 day, 1mg NE/35mcg EE x 9
day, 75mg Ferrous Fumarate x 7 days)
Tri-Norinyl (0.5mg NE/35mcg EE x7 day,
1mg NE/35mcg EE x 7 day, 0.5mg NE/35
mcg EE x 7 day) or Norinyl 1/35 (1mg
NE/35mcg EE) plus OTC Iron Supplement
(Ferrous Fumerate 75 mg)
Tri-Norinyl (0.5mg NE/35mcg EE x7 day,
1mg NE/35mcg EE x 7 day, 0.5mg NE/35
mcg EE x 7 day) or Norinyl 1/35 (1mg
NE/35mcg EE) plus OTC Iron Supplement
(Ferrous Fumerate 75 mg)
Or may consider Microgestin FE (1mg NE/20mcg
EE x 21 day plus 75mg Ferrous Fumarate)
Document at least 3 formulary alternatives
before prescribing/approving a NF product.
Ethyl Chloride spray (topical anesthetic, vapocoolant) OTC topical anesthetic alternatives:
Pt may also choose to purchase NF Ethyl
Aerofreeze spray (topical anesthetic,
Chloride spray at full prescription price.
vapocoolant) OR OTC L-M-X4 (4% topical
lidocaine cream) or OTC Lidosense 4 (4%
topical lidocaine cream) or Rx Lidocaine 4%
topical soln apply to affected area Q3-4H
Ethyol inj
N/A
Ethyol is indicated for prevention of xerostomia in
patients receiving radiation therapy (head and
neck cancer). Northside Radiation Therapy group
may prescribe up to 20 vials for a member to pick
up at KP facility pharmacy only (zero copay,
pharmacist override), to be administered prior to
radiation therapy.
Evoxac (Cevimeline) 30mg capsules TID
Pilocarpine 3% ophthalmic solns 5 - 10
drops TID taken orally
OTC Lamisil AT or clotrimazole containing
OTC products: Lotrimin AF or OTC Mycelex
or OTC Micatin cream
N/A
Exelderm (Sulconazole) 1% cream
Exforge (Amlodipine/Valsartan)
5/160, 10/160, 5/325, 10/325mg
Clotrimazole or Terbinafine (Lamisil) for tinea
pedis, tinea corporis, tinea circinata (ringworm of
body), tinea cruris, tinea inguinalis (jock itch),
tinea versicolor; Clotrimazole for intertrigo (rash in
body folds or beneath breasts) or candidiasis
(including rash on penis or corners of mouth)
[OTC alternatives are not recommended for tinea
capitis (ringworm of scalp), tinea faceii or barbae
(ringworm of the beard…barber's itch]
Amlodipine(Norvasc) generic 5mg or 10mg+ Prinivil (Lisinopril) is preferred, if no previous ACE
Prinivil (Lisinopril) 5-40mg QD or Cozaar
inhibitor trial. If angiotensin 2 receptor blocker is
(Losartan) 25-100mg QD
required, convert to Cozaar.
Conversion:
Diovan 160mg=Prinivil 10-20mg=Cozaar 50mg;
Diovan 320mg=Prinivil 20-40mg=Cozaar 100mg
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
& Thiazide diuretic
Four Drug Therapy: Add Long Acting
dihydropyridine CCB to Beta Blocker, ACE-I &
Thiazide Diuretic
Page 26
Non-formulary conversion document 02.08.xls
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Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Famvir (Famcyclovir) 125, 250, 500mg tabs Herpes
zoster 500mg Q8H x 7 days; genital herpes
recurrence 125mg BID x 5 days
Herpes zoster Acyclovir 800mg Q4H, 5
Acyclovir only oral antiviral covered for herpes.
times daily x 7 days (10 days if
For recommendations please see TSPMG clinical
immunocompromised); genital herpes
practice resource
acyclovir 400mg TID x 7-10 days (5 days
when treating recurrences, may use 800mg
BID x 5 days for recurrence); chronic
suppressive therapy 400mg BID, titrate to
lowest effective suppressive dose
Felbatol (Felbamate)
Tegretol (carbamazepine), Neurontin
(gabapentin), Topamax (topiramate),
Tranxene (clorazepate), Lamotrigine 525mg chews and Lamictal 100mg-200mg
oral tablets
Adjunctive therapy for partial seizures
[conversion to a formulary alternative not
recommended when patient is stable on non
formulary antiseizure medication for seizure
management]
Feldene (Piroxicam)
Relafen (Nambumetone) 500mg or 750mg 1
- 2 QD-BID or Etodolac (Lodine) 200-500mg
Q8-12H up to 1200mg/day or Ibuprofen
(Motrin) tabs 600-800mg TID or Naproxen
(Naprosyn) 500mg BID or Sulindac
(Clinoril) 200mg BID or Diclofenac
(Voltaren) 75mg BID or Mobic (Meloxicam)
7.5mg or 15mg
Estradiol 0.5mg or 1mg QD plus
Medroxyprogesterone 2.5-5mg QD
Additional formulary alternatives: Salsalate
(Disalcid)1500mg BID or choline magnesium
trisalicylate (Trilisate) 750mg BID-TID or
Indomethacin 25-50mg TID. CAUTION: Feldene
(Piroxicam) is on the list to be avoided in the
elderly due to increased risks of GI complications.
[Available Part D group]
OTC Mycelex3 (2% butoconazole) Other
OTC alternatives include: Monistat vaginal
cream or Vagistat
OTC Mucinex (600mg Guaifenesin long
acting) or OTC Guaifenesin 400mg regular
release or OTC Guaifenesin syrup ii
teaspoonfuls Q4H or OTC Guaifenesin gel
cap ii capsules Q6H (generic Robitussin)
Products that are available Over the Counter are
not covered by the drug benefit.
Femhrt (5mcg Ethinyl Estradiol / 1 mg Norethindrone
acetate)
Femstat (2% Butoconazole) vaginal cream OTC
Fenesin (Guaifenesin) ER tabs 600 mg BID
Two individual prescriptions are required.
0.5mg Estradiol = 0.3mg Premarin; 0.75mg
Estradiol (1&1/2 0.5mg tablet) = 0.45mg
Premarin; 1mg Estradiol = 0.625mg Premarin;
1.5mg Estradiol (1&1/2 1mg tablet) = 0.9mg
Premarin; 2mg Estradiol = 1.25mg Premarin
Cold products are non formulary. Member may
select OTC product or pay cash for prescription
cold product
Cold products are non formulary. Member may
select OTC product or pay cash for prescription
cold product
Fenesin tablet SA
OTC Mucinex (600mg Guaifenesin long
acting) or OTC Guaifenesin 400mg regular
release or OTC Guaifenesin syrup ii
teaspoonfuls Q4H or OTC Guaifenesin gel
cap ii capsules Q6H (generic Robitussin)
Ferrlicit injectable
InFeD injectable
Finevin or Finacea (Azelaic Acid) Cream
Acne treatment alternatives: Tretinoin
0.025% cream (Retin-A or Avita cream
brand names) or 2% Erythromycin solution
& 5% Benzoyl Peroxide aqueous gel or
clindamycin 1% solution or sulfacet R lotion
or clindamycin 1% gel & 5% Benzoyl
Peroxide aqueous gel Rosacea treatment
alternative: metronidazole 0.75% cream
BID
Smallest available tube Tretinoin covered per
copay, larger tubes not covered. Benzamycin and
Benzaclin are nonformulary, but 2% Erythromycin
solution & 5% Benzoyl Peroxide aqueous gel OR
1 % Clindamycin gel & 5% Benzoyl Peroxide
aqueous gel, respectively, may be prescribed
separately and purchased as a pack for one
copayment at a Kaiser Permanente pharmacy. At
Eckerd, the patient must purchase the OTC
product, at KP it will be included at no charge.
Fioricet/Codeine caps
Fioricet tabs (Butalbital/apap/caff), tylenol
#3 (generic), Fiorinal with Codeine
(Butalbital Compound with Codeine)
.
Page 27
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Flomax (Tamsulosin) 0.4-0.8 mg QD
Comments
Doxazosin (generic Cardura) titrated to
Restricted to Urology and KP Hospitalists.
therapeutic doses (eg. Doxazosin 2mg 1/2
tab PO QHS X 1 week, then 1 tab QHS x 2
weeks, then 2 tabs QHS and follow-up
w/MD for refill) -or- Terazosin (Hytrin)
titrated slowly to therapeutic doses (eg.
Terazosin 1mg po QHS x 3 nights then 2
caps QHS x 7 nights, then 5 caps QHS and
follow-up with MD for refill)
Flovent (Fluticasone) 110mcg/puff and 220mcg/puff i- QVAR 80mcg/puff i-ii puffs PO BID or
ii puffs BID
Asmanex (mometasone furoate) oral dry
powder inhaler 200mcg per puff inhale i-ii
puffs QHS (or i puff BID)
QVAR is the preferred corticosteroid formulary
alternative. The dry powder inhaler Asmanex
(mometasone) may offer another formulary ICS
alternative for patients ≥ 12 yrs old more likely to
adhere to once daily maintenance therapy.
Asmanex is considered equipotent to fluticasone
and approx twice as potent as beclomethasone.
Florone (Diflorasone) 0.05% cream, oint
High potency topical corticosteroids.
Lidex (Fluocinonide) 0.05% cream, oint, gel,
soln or Diprolene AF (Augmented
Betamethasone) 0.05%
Cipro tab 250 mg BID
Cipro tab 500 mg BID
Cipro tab 500 mg BID
Ofloxacin 0.3% Ophthalmic solution 5ml
bottle
Cipro and Avelox are formulary quinolones
Cipro and Avelox are formulary quinolones
Cipro and Avelox are formulary quinolones
Ophthalmic solution may be administered in the
ear
Fluocinonide 0.05% soln
Fluocinolone 0.01% soln or Fluocinonide
0.05% cream, gel or ointment
Fluocinonide is a high potency steroid.
Fluocinolone is a low potency steroid.
Fluonid (Fluocinolone) 0.01% soln
Fluor-op (Fluorometholone) 0.1% ophth susp
Fluorouracil 2% cream
Flurosyn (Fluocinolone) 0.01% cream
Synalar (Fluocinolone) 0.01% soln
FML (Fluorometholone 0.1%) ophth susp
Fluorouracil 1% or 5% cream
DesOwen (Desonide) 0.05% cream, oint,
lotion or Synalar (Fluocinolone) 0.01% soln,
oil or Hytone (Hydrocortisone) 2.5% cream,
oint, lotion
FML (Fluorometholone 0.1%) ophth susp;
Dexamethasone 0.1% ophth soln or
Prednisolone 0.12%-1% ophth soln
FML (Fluorometholone 0.1%) AND Bleph-10
(Sulfacetamide 10%) Or Blephamide
(Prednisolone 0.2% / Sulfacetamide 10%)
Generic available
The smallest available unit size only
2% is non formulary
Low potency topical corticosteroids.
Methylphenidate 5 to 20mg BID
No clinical advantage of Focalin over Ritalin.
Plasma-level data suggest the d-enantiomer is
bioequivalent to racemic methylphenidate in a 1:2
dose ratio (eg, 5 mg dexmethylphenidate
bioequivalent to 10 mg methylphenidate)
Document failed trial on Methylphenidate,
Dextroamphetamine and Adderall IR products
before a Non-formulary Product is considered
Floxin tab 200 mg BID
Floxin tab 300 mg BID
Floxin tab 400 mg BID
Floxin (Ofloxacin) 0.3% Otic Solution 5ml bottle
FML Forte (Fluorometholone) 0.25% ophth susp
FML-S (Fluorometholone 0.1%/Sulfacetamide10%)
Focalin (Dexmethylphenidate) 2.5 to 10mg BID
Eye drops are covered for the smallest available
unit size only
FML-S is non formulary, but component eye drops
are formulary individually. Eye drops are covered
for the smallest available unit size only.
Folic Acid 1mg
OTC (National Vitamin Company brand)
FolpaceRx (folic acid 2.05mg; hydroxycobalamin B12a OTC vitamin supplement components
425mcg; pyridoxine B6 25mg; d-alpha tocopheryl
succinate Vit E 100IU; magnesium oxide 100mg)
Foradil (Formoterol) dry powder oral inhaler
12mcg/puff i puff BID
Fortamet (Metformin extended release) 500mg,
1000mg tablets
Serevent (Salmeterol) diskus 50mcg
i
puff BID
Metformin regular release 500mg, 850mg or Metformin ER is also a formulary alternative.
1000mg tablets
Page 28
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Forteo (Teriparatide) 20mcg injection recombinant
human parathyroid hormone subcutaneous injection
Fosamax 10mg QD or Fosamax w/ D 70mg
Q week for osteoporosis treatment.
Fortovase (Saquinavir) cap
Invirase (saquinavir) 200mg capsule
Fosamax (Alendronate) 70mg plain tablet
Fosrenol (Lanthanum carbonate) 250mg or 500mg
Tablets
Fosamax w/D 70 mg Q week is formulary.
Phoslo 667mg (Calcium Acetate) tablet ii-iiii Lanthanum and Sevelamer are Calciumtablets with each meal
/Aluminum-free Phosphate binders for
hypophosphatemia in patients with end stage
renal disease. If a NF calcium/aluminum free
phosphate binder is required, Sevelamer is KP NF
alternative of choice.
Lovenox (Enoxaparin) injections
Limit of 10 syringes Lovenox, 5 day supply, for
initial fill
Fragmin (Dalteparin) injection
New patients may self refer to ID by phoning
770-431-4360.
Freestyle Blood Glucose test strips
One Touch Ultra glucose test strips
Touch Ultra 2 machine -only
Frova (Frovatriptan) 2.5mg
Maxalt (Rizatriptan) MLT 10mg tablet
(Maxalt MLT 5mg tablet is also available)
Fulvicin U/F (Griseofulvin microsized)
Fulvicin P/G (Griseofulvin ultra-microsized)
Gabitril (Tiagabine)
Generet-500 w/folic tab SA i QD
Geodon (Ziprasidone) 20-80mg bid
Glucose meter
Glucotrol (Glipizide) XL tab 10 mg QD
Glucotrol (Glipizide) XL tab 20 mg QD
One Lifescan monitor is formulary and may be
obtained, by prescription, at KP pharmacy at copayment. Members will be charged full price for
Lifescan monitor at Eckerd. If the patient's
insulin pump requires the use of a companion BG
monitor requiring NF BG strips, please note brand
of pump and companion BG monitor on NF Rx for
Freestyle or BG Logic BG strips.
Maxalt MLT 10 mg is preferred, QTY limit of 9
tablets/copay. If failed a trial on Maxalt MLT
consider formulary alternative Imitrex 50 mg
tablets (qty limit of 9 tablets/copay), nasal, or
injectable dosage forms. Quantity limit for Nonformulary Frova is 9 tablets per copay
Fulvicin U/F is no longer available from the
Grifulvin V 500mg tablets and Grifulvin
suspension (125mg/ml) Dosing:Adults 500- manufacturer
1000mg as single or divided doses;
Children: 10-20 mg/kg/day in single or
divided doses
Griseofulvin ultra-microsized products are no
Grifulvin V 500mg tablets and Grifulvin
suspension (125mg/ml) Dosing:Adults 500- longer being manufactured. Griseofulvin
microsized remains available. Griseofulvin
1000mg as single or divided doses;
conversion factor: 0.66mg ultramicrosize = 1mg
Children: 10-20 mg/kg/day in single or
microsize (eg. Ultramicrosize 330mg=microsize
divided doses
500mg)
Adjunctive therapy for partial seizures
Tegretol (carbamazepine), Neurontin
(gabapentin), Topamax (topiramate),
[conversion to a formulary alternative not
recommended when patient is stable on non
Tranxene (clorazepate), Lamotrigine 525mg chews and Lamictal 100mg-200mg
formulary antiseizure medication for seizure
management]
oral tablets
OTC prenatal vitamin i QD
Prescription prenatal vitamins are not covered
Seroquel (Quetiapine) 25, 100, 200, 300mg Consider 1/2 tablet dosing whenever possible.
(eg. Seroquel 200mg 1/2 tablet for Seroquel
or Zyprexa (Olanzapine) 2.5, 5, 7.5, 10,
100mg dose. Risperdal 1mg 1/2 tablet for
15mg tabs 10-15mg qd or Risperdal
(Risperidone) 4-6mg qd
Risperdal 0.5mg dose.) [Ziprasidone: Available
Part D group]
One Touch Ultra glucose test strips
One Lifescan monitor is formulary and may be
obtained, by prescription, at KP pharmacy at a coTouch Ultra 2 machine -only
payment. Members will be charged full price for
Lifescan monitor at Eckerd
Glipizide (generic Glucotrol) tab 10 mg QD XL Glucotrol (glipizide XL) is non-formulary,
regular release is formulary and is equally
effective
Glipizide (generic Glucotrol) tab 10 mg BID XL Glucotrol (glipizide XL) is non-formulary,
regular release is formulary and is equally
effective
Page 29
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Glucotrol (Glipizide) XL tab 5 mg QD
Glucovance (Glyburide/Metformin) 1.25/250mg,
2.5/500, 5/500 tabs BID
Glynase (Micronized Glyburide) tab 1.5 mg QD
Comments
Glipizide (generic Glucotrol) tab 5 mg QD
XL Glucotrol (glipizide XL) is non-formulary,
regular release is formulary and is equally
effective
Glyburide 1.25-5mg tab BID AND Metformin Combination product is non-formulary, but
500mg BID
component medications are formulary individually.
In order to increase metformin efficacy, consider
converting Glucovance 1.25/250mg BID to
glyburide 1.25mg BID PLUS metformin 500mg
BID.
Glyburide (generic Micronase) tab 2.5 mg
Glynase (Micronized Glyburide) is non formulary,
QD
regular Glyburide is formulary. Consider other
oral antidiabetics such as Glipizide in patients
>65 due to prolonged half life of Glyburide.
Glynase (Micronized Glyburide) tab 3 mg QD
Glyburide (generic Micronase) tab 5 mg QD Glynase (Micronized Glyburide) is non formulary,
regular Glyburide is formulary. Consider other
oral antidiabetics such as Glipizide in patients
>65 due to prolonged half life of Glyburide.
Glynase (Micronized Glyburide) tab 6 mg BID
Glyburide (generic Micronase) tab 10 mg
BID
Glynase (Micronized Glyburide) tab 6 mg QD
Glyburide (generic Micronase) tab 10 mg
Glynase (Micronized Glyburide) is non formulary,
QD
regular Glyburide is formulary
Glyburide (generic Micronase) 2.5-5 mg QD Alpha-glucosidase inhibitors are non formulary.
Glyset (Miglitol) 25 - 100mg TID
GoLYTELY (Polyethylene Glycol electrolyte soln)
Gris-PEG (Griseofulvin Ultramicrosized)
Grisactin (Griseofulvin Microsized)
Grisactin Ultra (Griseofulvin Ultramicrosized)
Guaifenesin LA tab i BID
Gynezole 1 (2% butoconazole) vaginal cream
Colyte (Polyethylene Glycol 3350) powder
(only stable 48 hours after mixing) for bowel
cleaning
Grifulvin V 500mg tablets and Grifulvin
suspension (125mg/ml) Dosing:Adults 5001000mg as single or divided doses;
Children: 10-20 mg/kg/day in single or
divided doses
Glynase (Micronized Glyburide) is non formulary,
regular Glyburide is formulary. Consider other
oral antidiabetics such as Glipizide in patients
>65 due to prolonged half life of Glyburide.
.
Griseofulvin Ultra-microsized products are no
longer being manufactured. Griseofulvin
microsized remains available. Griseofulvin
conversion factor: 0.66mg ultramicrosize = 1mg
microsize (eg. Ultramicrosize 330mg=microsize
500mg)
Grifulvin V 500mg tablets and Grifulvin
Grisactin is no longer available from
suspension (125mg/ml) Dosing:Adults 500- manufacturer.
1000mg as single or divided doses;
Children: 10-20 mg/kg/day in single or
divided doses
Griseofulvin Ultra-microsized products are no
Grifulvin V 500mg tablets and Grifulvin
suspension (125mg/ml) Dosing:Adults 500- longer being manufactured. Griseofulvin
microsized remains available. Griseofulvin
1000mg as single or divided doses;
Children: 10-20 mg/kg/day in single or
conversion factor: 0.66mg ultramicrosize = 1mg
microsize (eg. Ultramicrosize 330mg=microsize
divided doses
500mg)
All cough and cold medications with OTC
OTC Mucinex (600mg Guaifenesin long
acting) or OTC 400mg Guaifenesin regular equivalents are non-formulary with exception of
codeine, hydrocodone, and promethazine
release or OTC Guaifenesin syrup ii
teaspoonfuls Q4H or OTC Guaifenesin gel containing products.
cap ii capsules Q6H (generic Robitussin)
OTC Mycelex3 (2% butoconazole) Other
Products that are available over the counter are
OTC alternatives include: Monistat vaginal not covered by the drug benefit.
cream or Vagistat
Page 30
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
H Pylori treatment pack (only available at KP
pharmacies for one copayment. At Eckerd, dispense
as Rx for Metronidazole 500mg QID #56 &
Tetracycline 500mg QID #56 and OTC Pepto-bismol 2
tablets QID & Prilosec OTC 20mg BID
Habitrol (Nicotine transdermal system) 7, 14,
21mg/day
Halcion (Triazolam) tabs 0.125-0.25 mg at HS
Comments
Metronidazole 500mg QID, Tetracycline
500mg QID (or Amoxicillin if Ten allergic),
and Pepto-bismol 2 tabs QID x 14 days and
Prilosec OTC 20mg BID -- packet of all 4
available for one copayment at KP
pharmacies
Alternative, if failed first treatment course: Biaxin
(Clarithromycin) 500mg bid, Flagyl
(Metronidazole) 500mg bid and Prilosec OTC
20mg bid x 14 days
Either treatment pack is
recommended for 14 days; however, if patient
able to tolerate at least 7 days may not be
necessary to initiate alternate H Pylori treatment
course.
OTC Nicotrol (Nicotine transdermal system) Nicotine replacement products are non formulary
5, 10, 15mg/day
Consider lower doses in geriatric patients.
Temazepam (generic Restoril) 15-30 mg
capsule at HS or Oxazepam (gen Serax) 10- Consider OTC melatonin to reduce
30mg or Lorazepam 0.5mg QHS or
benzodiazepine usage Caution: do not abruptly
Hydroxyzine (generic Atarax) 10-25 mg at discontinue benzodiazepines after long-term use.
HS
[Haloperidol: Available Part D group]
Halog (Halcinonide) 0.1% cream, oint [high potency]
Lidex (Fluocinonide) 0.05% cream, oint, gel,
soln or Diprolene AF (Augmented
Betamethasone) 0.05%
Helidac (250mg Metronidazole QID, 500mg
HP Pack: Tetracycline 500 mg QID x 14
Tetracycline QID, 2x262mg Bismuth subsalicylate QID days, Metronidazole 500 mg QID x 14 days,
x 14 days)
Bismuth subsalicylate 2 tabs QID x 14 days
and Prilosec OTC 20mg BID x 14 days (HP
Pack available at KP pharmacies for one
copayment)
High potency topical corticosteroids.
Hemocyte Plus
OTC equivalent (Fe 106 mg, B1, B2, B3,
B5, B6, B12, C 200 mg, folic acid 1 mg)
N/A
For allergic conjunctivitis: OTC Opcon-A
(Pheniramine & Naphazoline) or OTC
Zaditor 0.25% [NOTE: OTC products are
not a covered benefit]
Vitamins components available OTC in one or
more OTC preparations for equivalency.
Available OTC, may be substituted.
OTC Zaditor 0.25% and Patanol are both dual
action antihistamine/mast cell stabilizers, are
dosed twice daily, and have the same FDA
approved indications. If treating steroid
responsive inflammatory condition consider at
least 2 formulary products before
prescribing/authorizing a NF product
:Dexamethasone 0.1% ophth soln or Prednisolone
0.12%-1% ophth soln or Flarex, FML
(Fluorometholone) ophth soln 0.1% i-ii drops in
affected eye(s) QID
Humabid LA
OTC Mucinex (600mg Guaifenesin long
acting) or OTC Guaifenesin 400mg regular
release or OTC Guaifenesin syrup ii
teaspoonfuls Q4H or OTC Guaifenesin gel
cap ii capsules Q6H (generic Robitussin)
All cough and cold medications with OTC
equivalents are non-formulary with exception of
codeine, hydrocodone, and promethazine
containing products.
Humalog (insulin Lispro) inj 100 u/ml
NovoLog (insulin Aspart) U-100 vial, OR, if Humalog converts to Novolog on a unit for unit
no previous trial on regular insulin, consider basis. [Humalog and NovoLog are administered
conversion to Novolin Regular Insulin
15 minutes prior to meals, whereas Novolin R is
administered 30-60 minutes before meals.]
Novolog vial is compatible with currently marketed
insulin pumps. NF Novolog cartridge is preferred if
older pump requiring cartridge.
Hibiclens (Chlorhexidine) top soln
HMS (Medrysone) 1% ophth susp
Page 31
HP Pack (Helicobacter pylori treatment pack)
Individual components dispensed as 2 individual
prescriptions (500mg Metronidazole QID and
500mg Tetracycline QID) PLUS OTC Pepto
Bismol (bismuth subsalicylate) & Prilosec OTC at
Eckerds. [If member allergic to or failed TEN,
substitute Amoxicillin 500mg QID] Second line
alternative: Prilosec OTC 20mg BID, Biaxin
500mg BID, and Flagyl 500mg BID or Amoxicillin
1000mg BID x 14 days
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Humalog Mix 50/50 (50% insulin lispro protamine/
50% insulin lispro) vial 100 u/ml
Consider conversion to both Novolin NPH
and either NovoLog or Novolin R,
individually. Converting physician specifies
the number of units of each. Draw the
NovoLog or Novolin R (which ever ordered)
into the syringe before drawing the NPH into
the syringe.
[Humalog and NovoLog are administered 15
minutes prior to meals, whereas Novolin R is
administered 30-60 minutes before meals.] eg.
20 units of Humalog mix 50/50 converts to 10
units of NovoLog mixed with 10 units of Novolin
NPH to equal a total of 20 units mixed insulin
Humalog Mix 75/25 (75% insulin lispro protamine /
25% insulin lispro) vial 100u/ml
Consider conversion to Novolin 70/30 (70%
isophane insulin susp / 30% regular insulin
OR
both Novolin NPH and NovoLog,
individually. Converting physician specifies
the number of units of each. Draw the
NovoLog into the syringe before drawing the
NPH into the syringe
Consider Novolin 70/30 [Humalog and NovoLog
are administered 15 minutes prior to meals,
whereas Novolin R is administered 30-60 minutes
before meals.] eg. 20 units of humalog mix 75/25
converts to 20 units of novolin 70/30 OR 20
units of humalog mix 75/25 converts to 15 units
NPH and 5 units NovoLog.
Humalog pen
NovoLog (insulin Aspart) U-100 vial, OR, if Humalog converts to Novolog on a unit for unit
no previous trial on regular insulin, consider basis. Humalog is administered 15 minutes prior
conversion to Novolin Regular Insulin
to meals, Novolin R is administered 30-60
minutes before meals. Insulin pens are nonformulary. However, Insulin pens may be
available thru the NF Rx process when the
physician documents the member is unable to
accurately draw up insulin due to young age,
visual impairment, Parkinson's Disease,
rheumatoid arthritis or upper extremity
amputation; or, when administering doses less
than 5 units; or, when pediatric patient's school or
day care requires use of insulin cartridge device
for insulin administration while outside of their
primary caretaker's care.
Criteria Restricted Medication. Once
Criteria Restricted Medication. Pediatric
approved, the approval and date range
Endocrinologist phone KP QRM to request
for approval is noted in the Kaiser
authorization consideration 404-364-7320. May
pharmacy computer system. Norditropin only be dispensed at a Kaiser Pharmacy.
Normally vials are approved. If Humatrope
(somatropin) is preferred growth
cartridges are medically necessary, Novofine 30
hormone and must be tried prior to
needle tips will be dispensed. The prescribing
approval for other growth hormone
Endocrinologist will provide the Humatropen.
products
Humatrope (Human Growth Hormone) vial
Humegon injection
Repronex injection
May be substituted on a unit for unit basis without
calling practitioner. Menotropins are only covered
for members with fertility benefit.
Humibid DM tablet SA i tablet BID
OTC Mucinex (600mg Guaifenesin long
acting) or OTC Guaifenesin 400mg regular
release or OTC Guaifenesin syrup ii
teaspoonfuls Q4H or OTC Guaifenesin gel
cap ii capsules Q6H (generic Robitussin)
All cough and cold medications with OTC
equivalents are non-formulary with exception of
Codeine, Hydrocodone, and Promethazine
containing products.
Humibid LA tabs i tablet BID
OTC Mucinex (600mg Guaifenesin long
acting) or OTC Guaifenesin 400mg regular
release or OTC Guaifenesin syrup ii
teaspoonfuls Q4H or OTC Guaifenesin gel
cap ii capsules Q6H (generic Robitussin)
All cough and cold medications with OTC
equivalents are non-formulary with exception of
codeine, hydrocodone, and promethazine
containing products.
Humorsol (Demecarium) 0.125 - 0.25% ophth soln
reversible cholinesterase inhibitor
Phospholine iodide (echothiophate 0.030.25%) ophth soln irreversible
cholinesterase inhibitor
Cholinesterase inhibitors to reduce IOP in
glaucoma. Smallest package size is formulary.
Ophthalmologist to determine appropriateness of
conversion and dose.
Page 32
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Humulin N, R, L or U-100 vials
Novolin N or R U-100 vials
May be substituted without calling provider.
Penfills are not covered. Humulin Ultralente and
Lente will soon be discontinued by manufacturer.
Humulin R 500 units/ml vials
Novolin R 100 units/ml vials
Hylaform Plus (hylan-b) gel
N/A
If injection volume of 100units/ml concentration
can be safely administered SQ, do not convert to
more concentrated 500units/ml.
Cosmetic use drug. Not covered on drug benefit.
Member pays retail price.
Hycodan (Hydrocodone/Homatropine) syrup i
teaspoonful Q4-6H prn
Hydrocodone/Homatropine (Hycodan) tab i Hycodan syrup is non-formulary, tablets are
tablet Q4-6H prn
formulary. Robitussin AC generic Syrup (10 mg
Codeine/100 mg Guaifenesin) 10 ml Q4H or
Robitussin DAC; phenergan VC with codeine or
phenergan with codeine syrup
Hydroquinone cream or lotion
No formulary alternative
Cosmetic use drug. Not covered on drug
benefit. Member pays retail price. If prescribed
along with Differin, Retin A, or Avita creams, they
are also being used as cosmetic therapy and are
not covered.
Hydroxyzine pamoate caps (generic Vistaril) 25-50 mg Hydroxyzine HCl tabs (generic Atarax) 25- Substitute on a mg for mg basis.
TID-QID
50 mg TID-QID
Hygroton (chlorthalidone) tabs
Hydrochlorothiazide tabs
.
Hytakerol (Dihydrotachyesterol) aka DHT 0.125, 0.2, Rocaltrol (Calcitriol) 0.25, 0.5mcg caps 0.25- .
0.4mg tabs 0.1-0.25mg qd and titrate to effect
1mcg/day titrated to effect or Calciferol
(Ergocalciferol) 50,000 units/capsule 15,00020,000 units/day titrated to effect
Indapamide tab 2.5 mg QD
Two separate prescriptions for Cozaar and HCTZ
are required. TSPMG guidelines recommend
trial on ACEI (Prinivil) before prescribing ARB
(Cozaar)
Cozaar 50 mg QD plus Hydrochlorothiazide Two separate prescriptions for Cozaar and HCTZ
25 mg 1/2 tablet QD.
are required. TSPMG guidelines recommend
trial on ACEI (Prinivil) before prescribing ARB
(Cozaar)
Novolin NPH, R & L 100U/ML vials
May be substituted on a unit for unit basis
Pancrease (pancrelipase enzymes) or
Pangestyme is a generic of Pancrease
pangestyme
Maxalt (Rizatriptan) MLT 10mg tablet
Maxalt MLT 10 mg is preferred, QTY limit of 9
(Maxalt MLT 5mg tablet is also available)
tablets/copay. If failed a trial on Maxalt MLT
consider formulary alternative Imitrex 50 mg
tablets (qty limit of 9 tablets/copay), nasal, or
injectable dosage forms.
Imitrex 20 mg nasal spray
Imitrex 20 mg nasal spray is significantly more
effective than Imitrex 5 mg nasal spray. The
same precautions and contraindications apply for
both strengths of nasal spray. Maximum
prescription quantity for Imitrex 20 mg spray is 6
bottles/prescription.
Hydrochlorothiazide (HCTZ) tab 12.5 mg
N/A
QD
Hydrochlorothiazide (HCTZ) tab 25 mg QD N/A
Indapamide tab 5 mg QD
Hydrochlorothiazide (HCTZ) tab 50 mg QD
Hyzaar tabs 100mg (Cozaar100/HCTZ25) QD or
50mg (Cozaar 50mg/HCTZ 12.5mg) BID
Hyzaar tabs 50mg (Cozaar 50mg/12.5mg HCTZ) i
tablet QD
Iletin NPH, R &L 100U/ml vial
Ilozyme (Pancrelipase enzymes)
Imitrex (Sumatriptan) 25 tabs OR 100mg tabs
Imitrex 5 mg nasal spray
Indapamide tab (generic Lozol)1.25 mg QD
Cozaar 100 mg QD plus
Hydrochlorothiazide 25 mg tablet QD.
Page 33
N/A
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Inderal LA (Propranolol) capsule
Atenolol 25, 50mg, 100mg tablets QD or
metoprolol 50mg,100mg tablets QD-BID or- Propranolol (10, 20, 40, 60, 80, 90mg
tabs) 40-320mg divided BID-TID or
Nadolol 20, 40, 80, 120, 160mg tablets QD
HTN: may effectively use Atenolol,
Metoprolol, Nadolol or Propranolol regular
release. For Migraine Prophylaxis:
Propranolol regular release BID - TID,
Nadolol, Metoprolol or Atenolol. For Tremor
Prophylaxis: Propranolol regular release
BID-TID, Metoprolol or Nadolol.
Migraine or Tremor Prophylaxis: Propranolol tabs
80-320mg divided BID - TID -OR- Metoprolol
(less than 80mg, Propranolol converts to 50mg
Metoprolol; 80-120mg of Propranolol converts to
100mg Metoprolol; 120-160mg Propranolol
converts to 150mg Metoprolol; >160mg
Propranolol converts to 200mg Metoprolol divide
dose BID) -OR- Nadolol 80mg-240mg QD (2mg
Propranolol roughly equivalent to 1mg Nadolol);
Atenolol is an option for migraine, not tremor (less
than 160mg Propranolol converts to Atenolol
50mg QD, more than 160mg Propranolol converts
to Atenolol 100mg QD (beta blocker dosages are
titrated to patient's lowest effective dose)
Infergen (interferon alpha con)
Peg-Intron (Pegylated Interferon alpha 2 b
injection) vials OR Redipen
OR
Pegasys (Pegylated Interferon alpha 2 a
injection) vials or prefilled syringe
Innohep (Tinzaparin) injection
Lovenox (Enoxaparin) injections
Per Hepatitis C clinic, Infergen generally reserved
for patients who have failed to maintain clearance
of viral load with Peg-Intron or Pegasys. If no
response to Infergen in 12 weeks, consider d/c
Infergen.
Limit of 10 syringes Lovenox, 5 day supply, for
initial fill
Inspirease spacer device
EZ spacer or aerochamber spacer devices
N/A
Inspra (Eplerenone) 25-100mg QD
If using for CHF and desire aldosterone
antagonism formulary alternative is:
Spironolactone 25mg tablets
Intrinsa (Testosterone) Transdermal
Estratest or Estratest HS oral
Use 25mg Spironolactone tablets to obtain 50mg
or 100mg dose. If prescribing to treat HTN:
consider HCTZ 25mg QD or another first line
antihypertensive medication ie. Metoprolol,
Atenolol, Lisinopril.
Medications used expressly for the treatment of
sexual dysfunction are excluded from the drug
benefit. Patients without a sexual dysfunction
benefit may choose to purchase Intrinsa at the full
retail price. Intrinsa is marketed to modestly
improve sexual desire in women with hypoactive
sexual desire following surgically-induced
menopause on concurrent estrogen therapy.
Iressa (Gefitinib)
Platinum containing combination
chemotherapy with paclitaxel or Docetaxel
chemotherapy
Isoptin (Verapamil) SR tabs 120, 180, 240mg QD
Januvia (sitagliptin) 25mg, 50mg and 100mg oral
tablets
Iressa Survival Evaluation in Lung Cancer (ISEL)
trial compared Iressa with best supportive care in
the treatment of Non small cell lung cancer
patients who had received one to two prior
chemotherapy regimens. Iressa treatment was
not associated with a significant survival
improvement.
Verapamil SR tabs (generic Calan SR) 120, Substitute on a mg for mg basis.
180, 240 mg tabs 120-240mg QD
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
dihydropyridine Calcium channel Blocker to Beta
Blocker, ACE-Inhibitor and Thiazide Diuretics
Metformin regular release 500mg, 850mg or
1000mg tablets twice daily dosing -orextended release 500mg-750mg tabs up to
4 tablets, once daily dosing
Page 34
TSPMG guidelines suggest:
Second line - metformin plus sulfonylurea
Third line - Actos 15-45mg QD
Januvia provided no significant advantages over
metformin or SFUs to obtain glucose goals.
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Jenest-28 (0.5mg Norethindrone/ 35mcg Ethinyl
Estradiol x 10 days, 1mg NE/ 35mcg EE x 11 days)
Tri-Levlen (EE 30/40/30 / Levonorgestrel
0.05/.075/.125)
Other alternatives: Norinyl 1/35
(EE35/Norethindrone 1mg) OR Microgestin FE
(EE 20mcgl/ Norethindrone 1mg) Document at
least 3 formulary alternatives before
prescribing/approving a NF product.
Junel 1/20 (1mg Norethindrone / 20 mcg)
Microgestin FE (1mg Norethindrone/ 20
mcg EE x 21 days then 75mg Ferrous
Fumarate x 7 days
Levlen (0.15mg Levonorgestrel / 30mcg EE)
or Tri-Levlen (0.05mg Lvngl/30mcg EE x 6
days, 0.075mg Lvngl/40mcg EE x 5 days,
0.125mg Lvngl/ 30mcg EE x 10 days) or
Microgestin FE 1/20 (1mg Norethindrone /
20mcg EE)
Document at least 3 formulary alternatives
before prescribing/approving a NF product.
K-Dur (Potassium Chloride) tab
K-Tab (10meq/tab)
Kerlone (Betaxolol) 10, 20mg tabs 10-20mg qd
Atenolol (gen Tenormin) 25-100mg QD or
Metoprolol 100 - 400mg QD or Propranolol
40 - 320mg BID
K-Tab tablets cannot be split, prescribe in
appropriate dosage. Potassium is slowly released
from a wax matrix as it passes thru the GI tract.
The expended inert, porous, wax/polymer matrix
is not absorbed and may be excreted intact in the
stool.
Propranolol is available as 10, 20, 40, 60, 80,
90mg tabs. Inderal LA is non-formulary. Atenolol
max dose is 200mg QD; Metoprolol maximum
dose is 450mg daily in divided doses; Propranolol
maximum dose is 480mg per day in divided doses
Ketek (Telithromycin) 800mg QD
Biaxin 500mg BID or Avelox (Moxifloxacin)
400 mg QD or Augmentin 875 mg BID or
Cefuroxime (gen Ceftin) 250mg BID
Kariva (20 mcg Ethinyl Estradiol / 0.15mg
Desogestrel)
A Desogestrel containing product substitution is
not available on formulary. or may consider
Brevicon (0.5mg Norethindrone/ 35 EE) or Zovia
1/35 (Ethynodiol Diacetate 1mg/ 35mcg EE) or
Norinyl 1/35 (Norethindrone 1mg/ 35mcg EE)
Document at least 3 formulary alternatives
before prescribing/approving a NF product.
.
Ketoprofen (generic Orudis) 100-300mg daily (divided Ibuprofen (generic Motrin) tabs 600-800 mg
TID-QID)
TID or Salsalate (Disalcid)1500mg BID or
Naproxen 500mg BID or Sulindac (Clinoril)
200mg BID
Additional formulary alternatives: Diclofenac
(Voltaren) 75mg BID or Choline Magnesium
Trisalicylate (Trilisate) 750mg BID-TID or
Nambumetone (Relafen) 500mg or 750mg #1-2
QD-BID or Etodolac (Lodine) 200mg-500mg Q812H up to 1200mg/day or Indomethacin 25-50mg
TID or Mobic (Meloxicam) 7.5mg or 15mg.
Ketorolac (generic Toradol) tab 10 mg Q4-6H PRN
Due to the risk of renal failure and GI bleeding,
ketorolac tablets should not be administered more
than 5 days. Ketorolac tablets are FDA approved
for use after Ketorolac injection only.
Ibuprofen 800 mg TID PRN or Naproxen
250-500 mg Q6-8H or sulindac (Clinoril)
200mg BID or diclofenac (Voltaren) 75mg
BID or Relafen 500mg or 750mg 1 -2 QD BID or etodolac (Lodine) 200-500mg Q812H up to 1200mg/day or Mobic
(Meloxicam) 7.5mg or 15mg
Kineret (Anakinra) IL-1 blocker
Enbrel 25 mg SQ twice weekly (TNF
blocker)
Klaron Lotion (Sulfacetamide only)
Sulfacetamide/sulfur lotion
K-Lor or K-Lyte (Potassium Chloride) 25 meq packets Potassium Chloride 20meq packet
Kytril (granisitron) 1mg BID
Lac-Hydrin cream 12%
Lacriserts (Hydroxypropyl Methylcellulose)
N/A
Prescribe according to meq per packet
Zofran (ondansetron) 100mg QD
Ammonium Lactate lotion OTC
May be substituted without calling provider.
Hydroxypropyl Methylcellulose is available OTC products are available
in various OTC products (Clear Eyes, Alcon
ophthalmic solution)
Page 35
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Lamisil (Terbinafine) 250mg tab
Fungal nail infection is considered cosmetic
treatment and is not covered Unless : fungal
culture positive and i) If a finger nail, limited to
one 6 week treatment course, ii) If a toe nail, only
covered if the patient has diabetes or vascular
disease, then restricted to one 12 wk course.
Lantus (Insulin Glargine) vials dosed QHS
Novolin NPH
(Humulin
Ultralente will soon be discontinued by
manufacturer)
Lescol (Fluvastatin) 20 mg QHS
Lovastatin 10mg QHS or Simvastatin 20 mg Simvastatin 20mg dose would be expected to
QHS
provide significantly more LDL lowering than
lescol 20mg dose. Consider maximizing dose of
Lovastatin to 80mg QPM or Simvastatin to 80 mg
QHS before determining that the formulary
alternatives are ineffective. For questions,
consider calling Pharmacy Cardiac Risk Service
at 770-496-3560 between 830AM and 530PM.
Lescol (Fluvastatin) 40 mg QHS
Lovastatin 20 mg QHS or Simvastatin 20
mg QHS
Simvastatin 20mg dose would be expected to
provide significantly more LDL lowering than
lescol 40mg dose. Consider maximizing dose of
Lovastatin to 80mg QPM or Simvastatin to 80 mg
QHS before determining that the formulary
alternatives are ineffective. For questions,
consider calling Pharmacy Cardiac Risk Service
at 770-496-3560 between 830AM and 530PM.
Lescol (Fluvastatin) 80 mg QHS
Lovastatin 40 mg QHS or Simvastatin 20
mg QHS
Consider maximizing dose of Lovastatin to 80mg
QPM or Simvastatin to 80mg QHS before
determining that the formulary alternatives are
ineffective. For questions, consider calling
Pharmacy Cardiac Risk Service at 770-496-3560
between 830AM and 530PM
Lescol XL (Fluvastatin) 80mg QHS
Lovastatin 40 mg QHS or Simvastatin
20mg
Consider Maximizing dose of Lovastatin to 80mg
QPM and Simvastatin to 80mg QHS before
determining that the formulary alternatives are
ineffective. For questions, consider calling
Pharmacy Cardiac Risk Service at 770-496-3560
between 830AM and 530PM
Page 36
Restricted to Pediatric Endocrinology and
Endocrinology. Must call practitioner for
conversion. Lantus must not be mixed or diluted
with any other insulin or solution. Insulin pens are
non-formulary. Lantus Insulin pens are not
generally covered for pediatrics, as once daily
administration may be administered under the
primary caregiver's care.
Insulin pens may be available thru the NF Rx
process when the physician documents the
member is unable to accurately draw up insulin
due to young age, visual impairment, Parkinson's
Disease, rheumatoid arthritis or upper extremity
amputation; or, when administering doses less
than 5 units; or, when pediatric patient's school or
day care requires use of insulin cartridge device
for insulin administration while outside of their
primary caretaker's care.
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Lessina ((0.1mg Levonorgestrel/20mcg Ethinyl
Estradiol)
Levlen (0.15mg Levonorgestrel / 30mcg EE)
or Tri-Levlen (0.05mg Lvngl/30mcg EE x 6
days, 0.075mg Lvngl/40mcg EE x 5 days,
0.125mg Lvngl/ 30mcg EE x 10 days)
or may consider Microgestin FE 1/20 (1mg
Norethindrone/ 20mcg ee) or Brevicon (0.5mg
Norethindrone/ 35 EE) or Zovia 1/35 (Ethynodiol
Diacetate 1mg/ 35mcg EE) or Norinyl 1/35
(Norethindrone 1mg/ 35mcg EE) Document at
least 3 formulary alternatives before
prescribing/approving a NF product.
Letaris (ambrisentan)
5mg, 10mg tablets
Remodulin (Trepostinil), Flolan
(epoprostenol) and Tracleer (Bosentan)
Flolan requires administration in the medical
clinic under the drug benefit.
Leukine (Sargramostim) injection
N/A
No refills, pt must present a new rx for each fill
Levaquin 500 mg QD for sinusitis
Avelox (Moxifloxacin) 400 mg QD
Levaquin tab 250 mg QD for UTI
Levaquin (levofloxacin) tab 500 mg QD for bronchitis
or community acquired pneumonia
Levatol (Pensutolol) 20mg tabs 20 - 40mg QD
Levbid tab 0.375 mg BID
Levemir (detemir) long-acting insulin; administered
once or twice daily
See TSPMG Practice Resource for
recommendations
Do not use Avelox for UTI
Cipro 250 - 500 mg BID
Avelox (moxifloxacin) 400 mg QD or generic .
Augmentin 875 mg BID or Biaxin 500 mg
BID
Atenolol (gen Tenormin) 25 - 100mg QD or Propranolol is available as 10, 20, 40, 60, 80,
Metoprolol 100 - 400mg QD or Propranolol 90mg tabs. Inderal LA is Non-formulary.
40 - 320mg bid
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
Hyoscyamine (Levsin) 0.125 mg tab TIDQID
Novolin NPH
N/A
Must call practitioner for conversion. Changing the
basal insulin to Levemir can be done on a unit-tounit basis, then adjusted to meet glycemic targets.
Levemir must not be mixed or diluted with any
other insulin or solution. Levemir is not to be used
in infusion pumps. Insulin pens are non-formulary.
Levitra (Vardenafil) 2.5mg, 5mg, 10mg, 20mg
none
Levitra is not covered for sexual dysfunction
unless member's group has purchased sexual
dysfunction rider for additional coverage.
Consider Levitra 20mg 1/2 tablet when prescribing
Levitra 10mg dose to reduce patient expense.
Levlite (0.1mg Levonorgestrel/20mcg Ethinyl
Estradiol) [generic now manufactured: Lessina;
Alesse; Aviane]
Levlen (0.15mg Levonorgestrel / 30mcg EE)
or Tri-Levlen (0.05mg Lvngl/30mcg EE x 6
days, 0.075mg Lvngl/40mcg EE x 5 days,
0.125mg Lvngl/ 30mcg EE x 10 days)
or may consider Microgestin FE 1/20 (1mg
Norethindrone/ 20mcg ee) or Brevicon (0.5mg
Norethindrone/ 35 EE) or Zovia 1/35 (Ethynodiol
Diacetate 1mg/ 35mcg EE) or Norinyl 1/35
(Norethindrone 1mg/ 35mcg EE) Document at
least 3 formulary alternatives before
prescribing/approving a NF product.
Levora ((0.15 Levonorgestrel/30mcg EE)
Levlen (0.15 Levonorgestrel/30mcg EE)
Document at least 3 formulary alternatives
before prescribing/approving a NF product.
Page 37
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Lexapro (Escitalopram) 5mg, 10mg, 20mg
Lexxel (Enalapril/Felodipine) 5/2.5mg, 5/5mg
extended release tabs
Comments
Prozac (Fluoxetine) caps 10-40 mg QD or
Celexa (Citalopram) 20 - 40mg or Sertraline
25-100mg QD, conversion dosing to be
determined by physician
Lexapro (Escitalopram) is the S-isomer of Celexa
(Citalopram). Consider a trial on Citalopram 2040mg prior to Lexapro 10-20mg. Citalopram 20mg
dosing equivalent is Lexapro 10mg.Consider
Citalopram 40mg 1/2 tablet for Citalopram 20mg
dose. Document response to all formulary
SSRI alternatives before prescribing a NF
SSRI. Document reason, when patient is
medically unable to convert to Formulary
alternative.
Prinivil (Lisinopril) 5mg QD AND Felodipine Combination product is non formulary. Felodipine
ER 2.5mg or 5mg
2.5mg is equivalent to generic Nifedipine XL 30mg
or Diltia XT 120mg; felodipine ER 5mg = generic
Nifedipine XL 30 to 60mg or Diltia XT 240mg.
Liadla (Meslamine) 1.2 g delayed-release tablets
Asacol (Mesalamine released primarily in
colon) 400mg #2 TID for 6 wks OR Pentasa
250mg #4 QID or
500mg #2 QID for 8 wks OR
Dipentum 250mg #4 BID OR
Azulfidine (Sulfasalazine) 500mg #2
TID-QID
Lidoderm 5% (Lidocaine) Patch
Lidocaine topical gel (per chronic pain
guideline) or OTC L-M-X4 (4% topical
lidocaine cream) or OTC Lidosense 4 (4%
topical lidocaine cream) or OTC Axsain
cream (4% lidocaine combined with 0.25%
capsaicin cream)
If physician would like to consider an
alternative anti-inflammatory agent,
consider these formulary
alternatives:Relafen (Nambumetone)
500mg or 750mg 1 - 2 QD-BID or Etodolac
(gen. Lodine) 200-500mg Q8-12H up to
1200mg/day or Ibuprofen (gen. Motrin) tabs
600-800 mg TID or Naproxen (gen.
Naprosyn) 500mg BID or Sulindac (gen.
Clinoril) 200mg BID or Diclofenac (gen.
Voltaren) 75mg BID or Mobic (Meloxicam)
7.5mg or 15mg
Lovastatin 40mg QPM w/ meal OR
Simvastatin 20mg po QPM
Capsaicin cream is another OTC alternative for
post herpetic neuralgia.
Lovastatin 80 mg QPM w/ meal or
Simvastatin 40 mg QPM
Doses of lovastatin > 40mg QD and simvastatin >
20mg QD are not recommended in combination
with Diltiazem, Verapamil, Amiodarone, or a
protease inhibitor. Doses of Lovastatin > 20mg
QD and simvastatin > 10mg QD not
recommended with cyclosporine. Continue Lipitor
to minimize drug interaction and chance for
muscle aches. If Lipitor is continued, use half
tablets. For questions, consider calling Pharmacy
Cardiac Risk Service at 770-496-3560 between
830AM and 530PM.
Limbrel (flavocoxid) capsules **this is a prescription
food supplement, not an FDA approved drug. The
product consists of Flavonoids and flavans from
phytochemical food source materials which may
posses anti-inflammatory and analgesic properties.
Lipitor tab 10 mg QD
Lipitor tab 20 mg QD
Page 38
Limbrel is a food supplement marketed for an antiinflammatory effect. Though a prescription is
required, this food supplement is not covered by
the KP drug benefit. The patient may choose to
purchase this food supplement at the full
prescription price .
If pt needs Lipitor, use half tabs. Consider
maximizing dose of Lovastatin to 80mg and
Simvastatin to 80mg before determining that the
formulary alternatives are ineffective. See box
below for drug interactions. For questions,
consider calling Pharmacy Cardiac Risk Service
at 770-496-3560 between 830AM and 530PM.
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Lipitor tab 40 mg QD
Simvastatin 80 mg QPM
Doses of lovastatin > 40mg QD and simvastatin >
20mg QD are not recommended in combination
with Diltiazem, Verapamil, Amiodarone, or a
protease inhibitor. Doses of Lovastatin > 20mg
QD and simvastatin > 10mg QD not
recommended with cyclosporine. Continue Lipitor
to minimize drug interaction and chance for
muscle aches. If Lipitor is continued, use half
tablets. For questions, consider calling Pharmacy
Cardiac Risk Service at 770-496-3560 between
830AM and 530PM.
Lipitor tab 80 mg QD
Consider simvastatin 80mg QD plus SloNiacin/ time release niacin or BAS first if
appropriate. Otherwise, Vytorin 10/80 mg
QHS can be considered.
Doses of lovastatin > 40mg QD and simvastatin >
20mg QD are not recommended in combination
with Diltiazem, Verapamil, Amiodarone, or a
protease inhibitor. Doses of Lovastatin > 20mg
QD and simvastatin > 10mg QD not
recommended with cyclosporine. Continue Lipitor
to minimize drug interaction and chance for
muscle aches. If Lipitor is continued, use half
tablets. For questions, consider calling Pharmacy
Cardiac Risk Service at 770-496-3560 between
830AM and 530PM.
Livostin (Levocabastine) .05% i drop QID up to 2
weeks (antihistamine eye drop)
For allergic conjunctivitis: OTC Opcon-A
(Pheniramine & Naphazoline) or OTC
Zaditor 0.25% [NOTE: OTC products are
not a covered benefit]
OTC Zaditor 0.25% and Patanol are both dual
action antihistamine/mast cell stabilizers, are
dosed twice daily, and have the same FDA
approved indications. If treating steroid
responsive inflammatory condition consider at
least 2 formulary products before
prescribing/authorizing a NF product :
Dexamethasone 0.1% ophth soln or Prednisolone
0.12%-1% ophth soln or Flarex, FML
(Fluorometholone) ophth soln 0.1% i-ii drops in
affected eye(s) QID
Locoid (Hydrocortisone Butyrate) 0.1% topical oint,
soln [medium potency]
Triamcinolone (generic Aristocort or
Kenalog) cream, oint 0.1% OR Valisone
(Betamethasone Valerate) 0.1% lotion (if
lotion needed)
Kenalog (Triamcinolone) 0.1% cream, oint or- Lidex (Fluocinonide) 0.025-0.05%
cream, oint
Etodolac ( gen. Lodine) 200-500mg Q8-12H
up to 1200mg/day or Relafen
(Nambumetone) 500mg or 750mg tablet #2
QD-BID or Ibuprofen (gen. Motrin) tabs 600800 mg TID or Naproxen (gen. Naprosyn)
500mg BID or Sulindac (gen. Clinoril)
200mg BID Diclofenac (gen. Voltaren) 75mg
BID or Mobic (Meloxicam) 7.5mg or 15mg
If failed other alternatives, consider increasing
steroid potency to Fluocinonide (Lidex) 0.05%
cream, oint, or gel
Locoid Lipocream (hydrocortisone) 0.1%
Lodine XR tabs 400-600 mg QD
Loestrin 21 (1mg Norethindrone/ 20 mcg EE)
Microgestin FE (1mg Norethindrone/ 20
mcg EE x 21 days then 75mg Ferrous
Fumarate x 7 days
Loestrin 24 Fe
Levlen, microgestin fe 1/20 and 1.5/30,
zovia 1/35, norinyl 1+35, brevicon, Norinyl
1+50, trilevlen, trinorinyl, depo-provera
injection
Page 39
Locoid lipocream is restricted to Dermatology.
Salsalate (Disalcid)1500mg BID or choline
magnesium trisalicylate (Trilisate) 750mg BID-TID
or nambumetone (Relafen) 500mg or 750mg #12 QD-BID
Final 7 days of Loestrin FE pack are iron rather
than placebo tablets. (NF Giselle are equivalent
to microgestin 1/20, with 7 placebo rather than
iron tabs) Document at least 3 formulary
alternatives before prescribing/approving a NF
product.
All-flex diaphragms or paragard T380 and Mirena
(levonorgestrel) IUDs also formulary contraceptive
options Document at least 3 formulary
alternatives before prescribing/approving a NF
product.
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Loniten (Minoxidil) tablet 10-40 mg QD
Comments
Minoxidil 10-40mg QD is on the formulary
Minoxidil is not covered for the treatment of male
pattern baldness.
Lo/Ovral-28 (0.3 Norgestrel / 30mcg EE) tablet i QD
Levlen (0.15mg Levonorgestrel / 30mcg EE) May consider Tri-Norinyl (.5/1/.5 Norethindrone/
[generic Lo/Ovral is also manufactured, Low-Ogestrel, or Tri-Levlen (0.05mg Lvngl/30mcg EE x 6 35 EE) or Microgestin FE (1 mg Norethindrone/ 20
Cryselle]
days, 0.075mg Lvngl/40mcg EE x 5 days,
EE) or Zovia 1/35 (1mg Ethynodiol Diacetate/ 35
0.125mg Lvngl/ 30mcg EE x 10 days)
EE) Document at least 3 formulary
alternatives before prescribing/approving a NF
product.
Loprox (Ciclopirox) lotion
Lamisil AT Cream OTC
Loprox non formulary.
Lorabid (Loracarbef) suspension
Omnicef 125mg/5ml; pediazole
.
(Erythromycin & Sulfamethoxazole);
Augmentin 125-250mg/5ml or 200-400mg
chew tabs;Amoxicillin 125-250mg/5ml;
Biaxin 125-250mg/5ml; cefaclor suspension
Lortab elixir
Generic Tylenol #3 elixir (Codeine
12mg/acetaminophen120mg per 5ml) or
(Hydrocodone/acetaminophen (generic
Lortab) tabs, caps
Lotemax (Loteprednol) 0.5% ophth soln i-ii drops QID Dexamethasone 0.1% ophth soln or
Prednisolone 0.12%-1% ophth soln or
Flarex, FML (Fluorometholone) ophth soln
0.1% i-ii drops in affected eye(s) QID
N/A
Lotensin (Benazepril) 5-80 mg QD (generic also
marketed)
Prinivil (Lisinopril) tab 5-80 mg QD
Substitute on a mg for mg basis.
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACEInhibitor and Thiazide diuretic
Four Drug Therapy: Add Long Acting
dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
Lotrel (Amlodipine/Benazepril) 2.5/10, 5/10, 5/20mg,
10/20mg tabs
Nifedipine XL 30mg or 60mg OR Diltia XT
120mg - 480mg QD OR Felodipine ER
2.5mg-10mg OR Amlodipine 2.5mg-10mg
AND Prinivil (Lisinopril) 10 or 20mg QD
Lotronex (Alosetron)
Generic Levsin 0.125mg
Last line agent for women with severe diarrhea
prominent Irritable bowel syndrome. Lotronex not
available at all pharmacies due to restricted
prescribing process. [Alosetron: Available Part
D group]
Lovenox
Lovenox is formulary
Lovenox initial dispensing limit of 10 syringes, 5
day supply. Larger quantities will need approval
from Pharmacy call 404-365-4234
[Loteprednol 0.5% (Lotemax) less effective than
Prednisolone Acetate 1% in treatment of acute
anterior uveitis]
Amlodipine 2.5, 5 & 10mg are equivalent to
Nifedipine XL 30, 30 &60mg, respectively OR
Diltia XT 120, 240 & 360mg respectively OR
Felodipine ER 2.5, 5 & 10mg respectively;
Benazepril 10 -20mg is equivalent to Lisinopril 10 20 mg. Convert to either Amlodipine & Lisinopril,
Nifedipine XL & Lisinopril or Diltia XT & Lisinopril
or Felodipine ER & Lisinopril.
Lotrisone (Clotrimazole/Betamethasone) cream apply OTC Lotrimin (Clotrimazole) cream plus Rx Lotrisone/Desonide combination pack only
to affected area BID
Desonide 0.05% cream apply both creams available at KP facility pharmacies for a single
to affected area BID
copay. At Eckerd pharmacy, patient will pay one
copay for Desonide and will purchase OTC
Lotrimin (Clotrimazole) cream at full OTC price.
Page 40
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Low-Ogestrel (0.3 Norgestrel / 30mcg EE) tablet i QD Levlen (0.15mg Levonorgestrel / 30mcg EE)
or Tri-Levlen (0.05mg Lvngl/30mcg EE x 6
days, 0.075mg Lvngl/40mcg EE x 5 days,
0.125mg Lvngl/ 30mcg EE x 10 days)
May consider Tri-Norinyl (.5/1/.5 Norethindrone/
35 EE) or Microgestin FE (1 mg Norethindrone/ 20
EE) or Zovia 1/35 (1mg Ethynodiol Diacetate/ 35
EE) Document at least 3 formulary
alternatives before prescribing/approving a NF
product.
Lozol (Indapamide) tab 1.25 mg QD
N/A
Lozol (Indapamide) tab 2.5 mg QD
Hydrochlorothiazide (HCTZ) tab 12.5 mg
QD
Hydrochlorothiazide (HCTZ) tab 25 mg QD
N/A
Lozol (Indapamide) tab 5 mg QD
Hydrochlorothiazide (HCTZ) tab 50 mg QD
N/A
Lunesta (Eszopiclone) 1mg, 2mg or 3mg tablets
Temazepam (generic Restoril) 15-30 mg
Consider lower doses in geriatric patients.
capsule at HS or Oxazepam (gen Serax) 10- Consider OTC Melatonin to reduce
30mg or Lorazepam 0.5mg QHS or
benzodiazepine usage Caution: do not abruptly
Hydroxyzine (generic Atarax) 10-25 mg at discontinue benzodiazepines after long-term use.
HS, Trazodone 50-100mg QHS, or
Caution: do not abruptly discontinue
Zolpidem (gen Ambien) 5-10mg
benzodiazepines after long-term use. Document
failed trial on at least 1 Benzodiazepine,
Trazodone, and Zolpidem before prescribing NF
product.
Lupron or Eligard to be supplied by the
TSPMG physicians provide injectables
prescribing physician and administered in
administered in medical office through floor stock.
MD office under the patient's medical
If network physicians cannot obtain Lupron,
benefit.
please complete KP NF Rx form requesting
benefit coverage at the time of Lupron dispensing.
Lupron 1 mg/0.2 mg 2-wk kit
Lupron depot 3.75 mg kit
Lupron or Eligard to be supplied by the
prescribing physician and administered in
MD office under the patient's medical
benefit.
TSPMG physicians provide injectables
administered in medical office through floor stock.
If network physicians cannot obtain Lupron,
please complete KP NF Rx form requesting
benefit coverage at the time of Lupron dispensing.
Lustra (Hydroquinone) cream 4%
No formulary alternative
Drugs for cosmetic use are NOT covered on
drug benefit. Member pays retail price. If
prescribed along with Differin, Retin A, or Avita
creams, they also are not covered as they are
being used as cosmetic therapy.
Luvox tab 25-100 mg QD or 100-150 mg BID
Consult Psychiatrist to determine
appropriateness of conversion to Prozac.
Luxiq (Betamethasone Valerate) foam for scalp
Synalar (Fluocinolone) 0.01% soln, oil or
Temovate (Clobetasol) .0.05% scalp soln
(Restricted to Derm)
Gabapentin 100mg, 300mg and 400mg
capsules
When conversion appropriate, Prozac is the
preferred agent. Initiation of low-dose Prozac 20
mg QD with dosage titration to desired response
is suggested.
Luxiq is medium potency, Synalar 0.01% is a low
potency topical corticosteroid product,
Lyrica (pregabalin) capsules **
Page 41
If treating neuropathic pain: Nortriptyline is
considered first-line agent (if <65 yrs old: 25mg
QHS, increase dose 25mg/day at 3-7 day
intervals prn. If > 65 years old: 10mg QHS,
increase dose 10mg/day at 3-7 day intervals
prn).**For discontinuation, Lyrica should be
tapered gradually over a minimum 1 week period
rather than abruptly discontinued per
manufacturer
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Mavik (Trandolapril) 1, 2, 4mg tabs 1-4mg QD
Prinivil is preferred ACE inhibitor. Conversion
equivalents: Mavik 1mg=Prinivil 5-10mg; Mavik
2mg=Prinivil 10-20mg; Mavik 4mg=Prinivil 2040mg TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
Prinivil (Lisinopril) 5 - 40mg QD
Maxair (Pirbuterol) 0.2 mg oral inhaler ii puffs Q4H prn Ventolin oral inhaler ii puffs Q4H prn
Substitute on a puff for puff basis.
Maxalt (Rizatriptan)
Dose on a mg for mg basis. QTY limit of #9 tabs
per co-pay. Patients on Propranolol require dose
reduction of Maxalt or Maxalt MLT to 5 mg.
Maxalt (Rizatriptan) MLT 10mg tablet
(Maxalt MLT 5mg tablet is also available)
Maxiflor (Diflorasone) 0.05% cream, oint
Lidex (Fluocinonide) 0.05% cream, oint, gel,
soln or Diprolene AF (Augmented
Betamethasone) 0.05%
Maxivate (Betamethasone Dipropionate) 0.05%
Lidex (Fluocinonide) 0.05% cream, oint, gel,
cream, oint
soln or Diprolene AF (Augmented
Betamethasone) 0.05%
Maxivate (Betamethasone Dipropionate) 0.05% lotion Valisone (Betamethasone Valerate) 0.1%
[medium potency]
lotion or Triamcinolone (generic Aristocort,
Kenalog) cream, oint 0.1%
Maxzide (Triamterene/HCTZ) 75/50 tablet
Triamterene/hydrochlorothiazide 75/50 mg
(generic Maxzide) tabs
High potency topical corticosteroids.
Mazanor (mazindol)
n/a
Weight loss agents not covered.
Medrol 2, 8, 16, 24 & 32 mg tabs
Methylprednisolone 4 mg (generic Medrol)
tab
Melanex (Hydroquinone) soln 3%
N/A
Methylprednisolone 4 mg tablet may be
substituted to obtain appropriate dose without
calling provider.
Drugs for cosmetic use are NOT covered on
drug benefit. Member pays retail price. If
prescribed along with Differin, Retin A, or Avita
creams, they also are not covered as they are
being used as cosmetic therapy.
Mentax (Butenafine) 1% cream
OTC Lotrimin Ultra (Butenafine) 1% cream
Meridia caps 10-15 mg QD
N/A
Metadate CD 20mg (Methylphenidate)
High potency topical corticosteroids.
If failed other alternatives, consider increasing
steroid potency to Fluocinonide (Lidex) 0.05%
cream, oint, or gel
May be substituted mg for mg without calling
practitioner. Brand name is non-formulary
Mentax not covered since also available as
Lotrimin Ultra available over-the-counter
Agents for obesity or weight loss not covered.
Patient pays full retail price.
Concerta 18,27,36,54mg, or Methylin ER
Adderall XR is restricted to pediatrics, child
10mg, Methylphenidate 5, 10, 20mg and SR neurology and behavioral health. Titrate to
20mg; or generic Dexedrine spansules
appropriate dosage using adderall regular
(Dextroamphetamine) 5, 10, 15mg or
release tablets before transitioning to once
Adderall regular release 5, 10, 20, 30mg
daily Adderall XR. Document failed trial on
tablets or Adderall XR 5,10,20,25,30mg
Methylphenidate, Dextroamphetamine and
capsules. Controlled substances level 2
Adderall IR products before a Non-formulary
requiring prescription written by prescriber. Product is considered.
Methylphenidate is the preferred formulary
alternative.
Page 42
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Metadate ER 10mg or 20mg (Methylphenidate)
Methylin ER 10mg (methylphenidate),
Concerta, Methylphenidate 5, 10, 20mg and
SR 20mg; or generic Dexedrine spansules
(Dextroamphetamine) 5, 10, 15mg or
Adderall regular release 5, 10, 20, 30mg
tablets or Adderall XR 5,10,20,25,30mg
capsules. Controlled substances level 2
requiring prescription written by prescriber.
Methylphenidate is the preferred formulary
alternative.
Adderall XR is restricted to pediatrics, child
neurology and behavioral health. Titrate to
appropriate dosage using adderall regular
release tablets before transitioning to once
daily Adderall XR. Document failed trial on
Methylphenidate, Dextroamphetamine and
Adderall IR products before a Non-formulary
Product is considered. Methylphenidate is the
preferred formulary alternative.
Metimyd (10% Sulfacetamide/ 0.5% Prednisolone)
ophth oint or soln
Metrogel vaginal gel 0.75% i applicatorful vaginally
BID x 5 days
Blephamide (10% Sulfacetamide/ 0.2 %
Prednisolone) ophth oint or soln
Metronidazole (generic Flagyl) tabs 2 gm
(500 mg x 4 tablets) for 1 dose
.
Metrogel 1%
Micardis (Telmisartan) 40-80 mg tab QD
Metrogel 0.75%
Prinivil (Lisinopril) 10-20 mg QD or Cozaar
(Losartan) 25-50 mg tab QD
Availabe at internal KP pharmacies only
Prinivil is preferred, if no previous ACE inhibitor
trial. If angiotensin 2 receptor blocker is required,
convert to Cozaar. Conversion:
Micardis 40mg=Prinivil 10-20mg=Cozaar 25mg;
Micardis 80mg=Prinivil 20-40mg=Cozaar 50mg
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
Micardis HCT (Telmisartan/HCTZ) 40/12.5mg80/12.5mg tab QD
Prinivil (lisinopril) 10-20 mg QD or Cozaar
(losartan) 25-50 mg tab QD AND HCTZ
12.5mg QD
Prinivil is preferred, if no previous ACE inhibitor
trial. If angiotensin 2 receptor blocker is required,
convert to Cozaar. Conversion:
Micardis 40mg=Prinivil 10-20mg=Cozaar 25mg
AND a prescription for HCTZ 12.5mg QD;
Micardis 80mg=Prinivil 20-40mg=Cozaar 50mg
AND a prescription for HCTZ 12.5mg QD
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
dihydropyridine CCB to Beta Blocker, ACEInhibitor and Thiazide Diuretics
Microgestin (1mg Norethindrone/ 20 mcg)
Microgestin FE (1mg Norethindrone/ 20
mcg EE x 21 days then 75mg Ferrous
Fumarate x 7 days
NorQD (norethindrone) 0.35mg
Document at least 3 formulary alternatives
before prescribing/approving a NF product.
Micronor (Norethindrone) 0.35mg {other generic
names: Camila, Nora-Be, Errin, Jolivette}
Miralax (polyethylene glycol 3350)
.
Vaginal gel not covered, oral tablets offer greater
efficacy. Metrogel vaginal gel is only
manufactured as 45 gram package.
May substitute without contacting practitioner
Miralax is now available OTC. OTC products are
not a covered benefit.
Page 43
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Mircette (20 mcg Ethinyl Estradiol / 0.15mg
Desogestrel) [generic Mircette is now manufactured:
Kariva]
Levlen (0.15mg Levonorgestrel / 30mcg EE)
or Tri-Levlen (0.05mg Lvngl/30mcg EE x 6
days, 0.075mg Lvngl/40mcg EE x 5 days,
0.125mg Lvngl/ 30mcg EE x 10 days) or
Microgestin FE 1/20 (1mg Norethindrone /
20mcg EE)
A Desogestrel containing product substitution is
not available on formulary. or may consider
Brevicon (0.5mg Norethindrone/ 35 EE) or Zovia
1/35 (Ethynodiol Diacetate 1mg/ 35mcg EE) or
Norinyl 1/35 (Norethindrone 1mg/ 35mcg EE)
Document at least 3 formulary alternatives
before prescribing/approving a NF product.
Modicon (0.5mg Norethindrone / 35 mcg EE)
generic Brevicon (0.5mg Norethindrone / 35 May substitute without contacting practitioner
mcg EE)
Sprintec (0.25mg Norgestimate/ 35 mcg
Document at least 3 formulary alternatives
EE)
before prescribing/approving a NF product.
Mononessa (0.25mg Norgestimate/ 35mcg EE)
Monopril (Fosinopril) tab 10-80 mg QD
Prinivil (Lisinopril) tab 10-80 mg QD
Substitute on a mg for mg basis.
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
MS Contin (Morphine CR)
Generic of MS Contin covered (Morphine
controlled release) 15mg, 30mg, 60mg,
100mg, 200mg Morphine immediate release
tablet 10mg, 30mg, roxanol (Morphine
solution 10mg/5ml, 20mg/5ml, 100mg/5ml)
Generic Percocet or Percodan (Oxycodone
5mg/325mg APAP or ASA, respectively), Tylox
(Oxycodone 5mg/500mg APAP), generic Demerol
50mg, 100mg, Fentanyl patches 25mcg, 50mcg,
75mcg, 100mcg/hr
Mupirocin 2% Cream
MUSE supps
Mupirocin 2% Ointment
N/A
Mysoline tablets
Primidone tabs (generic Mysoline)
.
Muse is not covered for sexual dysfunction unless
member's group has purchased sexual
dysfunction rider for additional coverage.
May be substituted on a mg for mg basis without
calling practitioner. Brands are non-formulary
Naftin (Naftifine) 1% cream or gel
OTC Lamisil AT or Clotrimazole containing Clotrimazole or Terbinafine (Lamisil) for tinea
OTC products: Lotrimin AF or OTC Mycelex pedis, tinea corporis, tinea circinata (ringworm of
body), tinea cruris, tinea inguinalis (jock itch),
or OTC Micatin cream
tinea versicolor; Clotrimazole for intertrigo (rash in
body folds or beneath breasts) or candidiasis
(including rash on penis or corners of mouth)
[OTC alternatives are not recommended for tinea
capitis (ringworm of scalp), tinea faceii or barbae
(ringworm of the beard…barber's itch or fungal
nails]
Nalfon (Fenoprofen) 300-600 mg TID - QID
Ibuprofen (generic Motrin) tabs 600-800 mg
TID or Salsalate (Disalcid)1500mg BID or
Naproxen 500mg BID or Sulindac (Clinoril)
200mg BID
Nasacort or Nasacort AQ or Nasacort HFA
(Triamcinolone) 25mcg/spray nasal inhaler ii sprays
each nostril BID
Nasarel ii sprays each nostril BID or generic Please document failure of both Nasarel & generic
Flonase (fluticasone) i spray each nostril
Flonase (fluticasone) before prescribing/approving
QD
a NF product.
Page 44
Additional formulary alternatives: Diclofenac
(Voltaren) 75mg BID or Choline Magnesium
Trisalicylate (Trilisate) 750mg BID-TID or
Nambumetone (Relafen) 500mg or 750mg 1-2 QDBID or Etodolac (Lodine) 200mg-500mg Q8-12H
up to 1200mg/day or Indomethacin 25-50mg TID
or Mobic (Meloxicam) 7.5mg or 15mg.
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Nasalide (Flunisolide) 25mcg/spray nasal spray ii
sprays in each nostril BID-TID
Please document failure of both Nasarel & generic
Flonase (fluticasone) before prescribing/approving
a NF product.
See TSPMG Adult Practice Resource for Anemia.
Nascobal (Cyanocobalamin) nasal spray
Nasonex (mometasone) nasal spray ii sprays each
nostril QD
Nasarel ii sprays each nostril BID or generic
Flonase (fluticasone) i spray each nostril
QD
OTC B12 (cyanocobalamin) 1mg tablet
orally QD
Nasarel ii sprays each nostril BID or generic
Flonase (fluticasone) i spray each nostril
QD
If the child is less then 4 years old, Nasonex may
warrant approval as Nasarel is not indicated for
patients less than 6 years old & Flonase is not
indicated in patients less than 4 years old.
Necon 0.5/35 (0.5mg Norethindrone/ 35 mcg EE)
Brevicon (0.5mg Norethindrone/ 35mcgEE) Another alternative: generic Demulen (1mg
Ethynodiol Diacetate / 35mcg EE) Document at
least 3 formulary alternatives before
prescribing/approving a NF product.
Necon 1/35 (1mg Norethindrone/ 35 mcg EE)
Norinyl 1/35 (1mg Norethindrone/ 35mcg
N/A
EE)
Norinyl 1+50 (1mg NE/mestranol 0.5mg) or Document at least 3 formulary alternatives
Zovia (generic Demulen) 1/50 (1mg
before prescribing/approving a NF product.
Ethynodiol Diacetate / 50mcg EE) i QD
Necon 1/50 (1mg Norethindrone/ 50 mcg EE)
Necon 10/11 (0.5mg Norethindrone/ 35mcg Ethinyl
Estradiol x 10 days, 1mg NE / 35mcg EE x 11 days)
Nelova 0.5/35 (0.5mg Norethindrone / 35 mcg EE)
Nelova 1/35 (1mg Norethindrone / 35 mcg EE)
Nelova 1/50M (1mg Norethindrone/ 50 mcg EE)
Nelova 10/11 (0.5mg Norethindrone/ 35mcg Ethinyl
Estradiol x 10 days, 1mg NE/ 35mcg EE x 11 days)
Brevicon (0.5mg NE/35mcg EE) or Norinyl
1/35 (1mg NE/35mcg EE) or Tri-Norinyl
(0.5mg NE x 7days, 1mg NE x 7 days,
0.5mg NE x 7 days /35mcg EE)
Brevicon (0.5mg Norethindrone/ 35mcgEE)
or generic Demulen (1mg Ethynodiol
Diacetate / 35mcg EE)
Norinyl 1/35 (1mg Norethindrone/ 35mcg
EE)
Norinyl 1+50 (1mg NE/Mestranol 0.5mg) or
Zovia (generic Demulen) 1/50 (1mg
Ethynodiol Diacetate / 50mcg EE) i QD
Document at least 3 formulary alternatives
before prescribing/approving a NF product.
Brevicon (0.5mg NE/35mcg EE) or Norinyl
1/35 (1mg NE/35mcg EE) or Tri-Norinyl
(0.5mg NE x 7days, 1mg NE x 7 days,
0.5mg NE x 7 days /35mcg EE)
Document at least 3 formulary alternatives
before prescribing/approving a NF product.
N/A
N/A
Document at least 3 formulary alternatives
before prescribing/approving a NF product.
Neo-Synalar (Neomycin/Fluocinolone) 0.025% cream Triamcinolone (generic Aristocort, Kenalog) If failed other alternatives, consider increasing
cream, oint 0.1%
steroid potency to fluocinonide (Lidex) 0.05%
cream, oint, or gel. Pt may also use OTC
neomycin, in addition to Rx topical steroid, if
needed.
Nephrocaps (Vitamin C 100mg, folate 1mg, niacin B3
20mg, thiamin B1 1.5mg, riboflavin B2 1.7mg,
Pantothenic Acid B5 5mg, Pyridoxine B6 10mg,
Cyanocobalamin B12 6mcg, biotin 150mcg)
OTC Nephro-vite (Vitamin C 100mg, folate Nephro-vite OTC NDC # 54391-0002-01
0.8mg, niacin B3 20mg, thiamin B1 1.5mg,
riboflavin B2 1.7mg, Pantothenic Acid B5
5mg, Pyridoxine B6 10mg, Cyanocobalamin
B12 6mcg, biotin 300mcg)
Nephro-Vite RX (Vitamin C 60mg, folate 1mg, niacin
B3 20mg, thiamin B1 1.5mg, riboflavin B2 1.7mg,
Pantothenic Acid B5 10mg, Pyridoxine B6 10mg,
Cyanocobalamin B12 6mcg, biotin 300mcg)
OTC Nephro-vite (Vitamin C 60mg, folate
Nephro-vite OTC NDC # 54391-0002-01
0.8mg, niacin B3 20mg, thiamin B1 1.5mg,
riboflavin B2 1.7mg, Pantothenic Acid B5
10mg, Pyridoxine B6 10mg,
Cyanocobalamin B12 6mcg, biotin 300mcg)
Page 45
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Neulasta (Pegfilgrastim) injection
Neupogen (Filgrastim) injection
Pegylated Filgrastim prolongs the Filgrastim half
life, resulting in one Neulasta injection roughly
comparable to 11 daily Neupogen injections. MD
to address dosage conversion individually.
Neupogen (Filgrastim) injection
Neupro Patch (Rotigotine) 2mg, 4mg and 6mg patch
N/A
Carbidopa/Levodopa
Entecapone (Comtan)
Benztropine (Cogentin)
Tolcapone (Tasmar)
No refills. Requires a new Rx for each fill
Tolcapone (Tasmar) is on the formulary but all
other therapies should be tried first due to risk
of death or hepatic failure. The patient and the
prescriber must complete informed consent
forms provided by the manufacturer
Neutrogena Melanex
N/A
Drugs for cosmetic use are NOT covered on
drug benefit. Member pays retail price. If
prescribed along with Differin, Retin A, or Avita
creams, they also are not covered as they are
being used as cosmetic therapy.
Nexium (Esomeprazole) DR 20mg cap 20-40mg QD
OTC Prilosec 20mg - 40mg QD
Nexium is a NF No Initial Fill drug. If Prilosec
40mg QD failure, consider NF No Initial Fill
drug, Protonix titrated up to 80mg QD.
(Protonix 40mg=Nexium 20mg=Prilosec 20mg)
Must document failure or intolerance to Prilosec
40mg QD if requesting PPI coverage.
Niaspan (Niacin extended release) 500mg, 750mg,
1000mg tablets
Contact Prescriber to request conversion to Niaspan may be appropriate if OTC niacin
OTC niacin. (Do NOT recommend flushineffective or if pt intolerant. If patient not taking a
free niacin)
statin, consider converting to Lovastatin or
Simvastatin. For LDL lowering consider Sloniacin or Time-release niacin: 500 mg QD
titrated up by 500mg every 4 weeks up to desired
dose. Maximum 2000mg daily dose. For HDL
increase or to lower Lipoprotein a 'Lp(a)', consider
niacin immediate release: initiate Niacin IR daily
after dinner: titrate dose from 100mg QD x 1
week; 200mg QD x 1 week; then 300mg QD x 1
week; then 500mg QD, titrate up to lowest
effective & tolerated dose. For questions,
consider calling Pharmacy Cardiac Risk Service
at 770-496-3560 between 830AM and 530PM.
Nicoderm (Nicotine) Transdermal system
7,14,21mg/day
Nicorette (Nicotine) gum
OTC Nicotrol (Nicotine transdermal system) Nicotine replacement products are non formulary.
5, 10, 15mg/day
OTC Nicotrol (Nicotine transdermal system) Nicotine replacement products are non formulary.
5, 10, 15mg/day
Niferex-150 forte (150mg polysaccharide iron
complex, 1mg folic acid, 25mcg B12) capsule i QD
OTC Niferex-150 plus OTC B12 100mcg
and Folic acid 0.4mg or plus folic acid 1mg
Rx
Minitran (Nitroglycerin) transdermal 0.1, 0.2,
0.4, 0.6mg/hr patches
Nitro-Dur (Nitroglycerin) transdermal 0.1,0.2,0.4,
0.6mg/hr patches
Page 46
OTC products available: Niferex 150mg, B12
100mcg, Folic acid 0.4mg
Nitro-Dur 0.3 and 0.8mg/hr patches are covered,
since Minitran is not available in these 2
strengths.
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Nizoral (Ketoconazole) cream
Lamisil AT cream available OTC.
Nizoral tablets are covered. Clotrimazole or
Terbinafine (Lamisil AT) for tinea pedis, tinea
corporis, tinea circinata (ringworm of body), tinea
cruris, tinea inguinalis (jock itch), tinea versicolor;
Clotrimazole for intertrigo (rash in body folds or
beneath breasts) or candidiasis (including rash on
penis or corners of mouth) [OTC alternatives are
not recommended for tinea capitis (ringworm of
scalp), tinea faceii or barbae (ringworm of the
beard…barber's itch or fungal nails]
Nizoral (Ketoconazole) shampoo 2%
Nizoral A-D shampoo available OTC or
Selenium sulfide 2.5% shampoo is
formulary alternative
Levlen (0.15 Levonorgestrel/30mcg EE)
Nizoral A-D shampoo available OTC
Flexeril (Cyclobenzaprine) 10mg tab or
Robaxin (Methocarbamol) 750mg tab or
Soma (Carisoprodol) 350mg or Parafon
Forte DSC (Chlorzoxazone) 500mg
Flexeril (Cyclobenzaprine) 10mg tab or
Robaxin (Methocarbamol) 750mg tab or
Soma (Carisoprodol) 350mg or Parafon
Forte DSC (Chlorzoxazone) 500mg
Metrocream 0.75% cream or Metrogel
0.75% gel
Cipro tab 500 mg BID
.
Novolin N U-100 vial
Use Cyclobenzaprine 10mg 1/2 tablet for
Cyclobenzaprine 5mg.
Nordette (0.15 Levonorgestrel/30mcg EE)
Norflex (Orphenadrine Citrate) 100mg
Norgesic (25mg Orphenadrine Citrate/385mg
Aspirin/30mg Caffeine)
Noritate (Metronidazole) 1% cream
Noroxin tablet 400 mg BID
Norplant system (discontinued by manufacturer)
Novolin L U - 100 vial (Novolin Lente no longer
manufactured)
Novolin N Penfill
Novolin N U-100 vial
Novolin R Penfill
Novolin R U-100 vial
Document at least 3 formulary alternatives
before prescribing/approving a NF product.
Pt may also take OTC aspirin or ibuprofen, for
analgesia. Use Cyclobenzaprine 10mg 1/2 tablet
for Cyclobenzaprine 5mg.
.
.
Both Novolin L and NPH are intermediate acting
insulins.
Insulin pens are non-formulary. However, Insulin
pens may be available thru the NF Rx process
when the physician documents the member is
unable to accurately draw up insulin due to young
age, visual impairment, Parkinson's Disease,
rheumatoid arthritis or upper extremity
amputation; or, when administering doses less
than 5 units; or, when pediatric patient's school or
day care requires use of insulin cartridge device
for insulin administration while outside of their
primary caretaker's care.
Insulin pens are non-formulary. However, Insulin
pens may be available thru the NF Rx process
when the physician documents the member is
unable to accurately draw up insulin due to young
age, visual impairment, Parkinson's Disease,
rheumatoid arthritis or upper extremity
amputation; or, when administering doses less
than 5 units; or, when pediatric patient's school or
day care requires use of insulin cartridge device
for insulin administration while outside of their
primary caretaker's care.
Page 47
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
NovoLog 70/30 (70% Insulin aspart protamine / 30%
Insulin aspart) penfill
Novolog 70/30 penfills non-formulary. Insulin
pens are non-formulary. However, Insulin pens
may be available thru the NF Rx process when
the physician documents the member is unable to
accurately draw up insulin due to young age,
visual impairment, Parkinson's Disease,
rheumatoid arthritis or upper extremity
amputation; or, when administering doses less
than 5 units; or, when pediatric patient's school or
day care requires use of insulin cartridge device
for insulin administration while outside of their
primary caretaker's care.
Novolog is administered 15 minutes prior to
meals, whereas Novolin R is administered 30-60
minutes before meal
Novolin 70/30 administering the same units
per dose as previous NovoLog 70/30
regimen (administer Novolin 70/30 30
minutes prior to a meal, administer
NovoLog 15 minutes prior to a meal)
OR
Novolin NPH (intermediate acting)
administering 70% of previous NovoLog
70/30 as NPH PLUS Novolin R (short acting
insulin) vials administering 30% of previous
NovoLog 70/30 dose (administering Regular
30 minutes prior to a meal)
OR, if an
Endocrinologist, 70% of dose from Novolin
NPH (intermediate acting) plus 30% of dose
from Novolog (short acting insulin)
Physician to specify the number of units of
each insulin. Draw the NovoLog or Novolin
R (whichever ordered) into the syringe
before drawing the NPH into the syringe.
NuvaRing (Etonogestrel 0.12mg/EE 0.015mg released Levlen, microgestin fe 1/20 and 1.5/30,
per day)
zovia 1/35, norinyl 1+35, brevicon, Norinyl
1+50, trilevlen, trinorinyl, depo-provera
injection Document at least 3 formulary
alternatives before
prescribing/approving a NF product.
All-flex diaphragms or paragard T380 and Mirena
(levonorgestrel) IUDs also formulary contraceptive
options. NuvaRing may not be suitable for
women with conditions that make the vagina more
susceptible to vaginal irritation/vaginitis. Consider
oral progestin only contraception with NorQD to
minimize oral contraceptive associated BP
elevation.
Drugs for cosmetic use are NOT covered on
drug benefit. Member pays retail price. If
prescribed along with Differin, Retin A, or Avita
creams, they are also being used as cosmetic
therapy and are not covered.
.
Nuquin HP cream 4% (Solaquin forte)
topical depigmenting agent--cosmetic use,
no formulary agent available.
Ocufen (Flurbiprofen 0.03%) ophth soln
If using for allergic conjunctivitis: OTC
Opcon-A (Pheniramine & Naphazoline)
If treating steroid responsive inflammatory
condition consider at least 2 formulary
products before prescribing/authorizing a
NF product consider at least 2 formulary
products before prescribing/authorizing a
NF product: Dexamethasone 0.1% ophth
soln or Prednisolone 0.12%-1% ophth soln
or Flarex, FML (Fluorometholone) ophth
soln 0.1% i-ii drops in affected eye(s) QID
Ocupress (Carteolol) 1% ophth soln i drop in affected
eye BID
Timoptic (Timolol) ophth soln 0.25-0.5% i
drop in affected eye(s) BID or Betoptic
(Betaxolol) 0.5% or Betagan (Levabunolol)
0.25-0.5%
Ogestrel (0.5mg Norgestrel/ 50mcg EE) tablets i QD
Norinyl 1+50 (1mg Norethindrone/ 50mcg
Document at least 3 formulary alternatives
Mestranol) i QD or Zovia (generic Demulen) before prescribing/approving a NF product.
1/50 (1mg Ethynodiol Diacetate/50mcg EE)
i QD
Olux (Clobetasol) 0.05% foam
Omacor (Omega-3 acid ethyl ester)
Temovate (Clobetasol) 0.05% scalp soln
.
Omnicef (Cefdinir) capsule 300mg
N/A
This is a prescription omega-3 fatty acid product.
It is a dietary supplement. Dietary supplements
are not eligible for drug benefit coverage.
Cefuroxime 250mg or Augmentin or Bactrim Omnicef suspension 125mg or 250mg/5ml are
DS or Biaxin
formulary; Omnicef capsules are non-formulary
Page 48
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Optivar (Azelastine) 0.05% ophth soln
OTC Zaditor 0.25% and Patanol are both dual
action antihistamine/mast cell stabilizers, are
dosed twice daily, and have the same FDA
approved indications. If treating steroid
responsive inflammatory condition:
Dexamethasone 0.1% ophth soln or Prednisolone
0.12%-1% ophth soln or Flarex, FML
(Fluorometholone) ophth soln 0.1% i-ii drops in
affected eye(s) QID
For allergic conjunctivitis: OTC Opcon-A
(Pheniramine & Naphazoline) or OTC
Zaditor 0.25% [NOTE: OTC products are
not a covered benefit]
Ortho-Cept 28 (0.15mg Desogestrel/ 30mcg EE) tab i Levlen (0.15mg Levonorgestrel / 30mcg EE)
QD
or Tri-Levlen (0.05mg Lvngl/30mcg EE x 6
days, 0.075mg Lvngl/40mcg EE x 5 days,
0.125mg Lvngl/ 30mcg EE x 10 days)
Zovia 1/35 (1mg Ethynodiol Diacetate/ 35mcg EE)
or Microgestin 1.5/30 (1.5 Norethindrone / 30mcg
EE) or Sprintec (0.25mg Norgestimate/35mcg EE)
or Tri-Sprintec, generic Ortho-Tricyclen, (0.18mg
Norgestimate x 7 days, 0.215mg Norgestimate x 7
days, 0.25mg Norgestimate x 7 days/ 35 mcg EE)
Document at least 3 formulary alternatives
before prescribing/approving a NF product.
Ortho-Cyclen (0.25mg Norgestimate/ 35mcg EE)
(generics:sprintec, mononessa)
Document at least 3 formulary alternatives
before prescribing/approving a NF product.
Sprintec (0.25mg Norgestimate/ 35 mcg
EE)
Ortho Evra (150 Norelgestromin/ 20 EE) contraceptive Microgestin 1/20 (1mg Norethindrone /
patch {Norelgestromin is a metabolite of
20mcg EE) or Levlen (0.15 Levonorgestrel /
Norgestimate}
30mcg EE) or Sprintec (0.25mg
Norgestimate/35 mcg EE) or Brevicon
(.5mg NE/ 35mcg EE), or Norinyl 1/35 (1mg
NE/ 35mcg EE)
Zovia 1/35 (1mg Ethynodiol Diacetate/ 35mcg EE)
or Microgestin 1.5/30 (1.5 Norethindrone / 30mcg
EE) or Norinyl 1/50 (1mg NE/ 50mcg Mestranol),
or Tri-Norinyl (0.5mg Norethindrone x 7days, 1mg
NE x 7 days, 0.5mg NE x 7 days/ 35 mcg EE) OR
Tri-Levlen (0.05mg Levonorgestrel & 30mcg EE x
6 days, 0.075mg Lvngl & 40mcg EE x 5 days,
0.125mg Lvngl & 30mcg EE x 10 days)or Nor-qd
(0.35 NE only) Document at least 3 formulary
alternatives before prescribing/approving a NF
product.
Ortho-Novum 1/35
(1mg NE/35mcg EE) Norinyl 1/35
(1mg
Norethindrone/35mcgEE)
Ortho-Novum 1/50 (1mg Norethindrone/ Mestranol
Norinyl 1/50 (1mg Norethindrone/ 50mcg
50mcg)
Mestranol)
.
Ortho-Novum 10/11 (0.5mg Norethindrone/ 35mcg
Ethinyl Estradiol x 10 days, 1mg NE/ 35mcg EE x
11days) {generic: Necon 10/11}
Brevicon (0.5mg NE/35mcg EE) or Norinyl
1/35 (1mg NE/35mcg EE) or Tri-norinyl
(0.5mg NE x 7days, 1mg NE x 7 days,
0.5mg NE x 7 days /35mcg EE)
Aranelle is a generic name for Tri-Norinyl (0.5mg
Norethindrone x 7days, 1mg NE x 7 days, 0.5mg
NE x 7 days/ 35 mcg EE) Document at least 3
formulary alternatives before
prescribing/approving a NF product.
Ortho-prefest (1mg 17beta Estradiol / 90 mcg
Norgestimate cyclic)
Estrace (Estradiol) 0.5 - 2mg plus
Medroxyprogesterone 2.5-5mg QD or plus
NorQD 0.35mg (norethindrone) QD
Two individual prescriptions are required. 0.5mg
Estradiol = 0.3mg Premarin; 0.75mg Estradiol
(1&1/2 0.5mg tablet) = 0.45mg Premarin; 1mg
Estradiol = 0.625mg Premarin; 1.5mg Estradiol
(1&1/2 1mg tablet) = 0.9mg Premarin; 2mg
Estradiol = 1.25mg Premarin
Page 49
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Ortho-Novum 7/7/7 (0.5mg NE x 7 days, 0.75mg NE x Nortrel 7/7/7 (0.5mg NE x 7 days, 0.75mg
7 days, 1 mg NE x 7 days/ 35 mcg EE)
NE x 7 days, 1 mg NE x 7 days/ 35 mcg
EE)
Tri-Norinyl (0.5mg Norethindrone x 7days, 1mg
NE x 7 days, 0.5mg NE x 7 days/ 35 mcg EE) OR
Tri-Levlen (0.05mg Levonorgestrel & 30mcg EE x
6 days, 0.075mg Lvngl & 40mcg EE x 5 days,
0.125mg Lvngl & 30mcg EE x 10 days Document
at least 3 formulary alternatives before
prescribing/approving a NF product.
Ortho-tricyclen (0.18mg Norgestimate x 7 days,
0.215mg Norgestimate x 7 days, 0.25mg
Norgestimate x 7 days/ 35 mcg EE)
Tri-Sprintec (0.18mg Norgestimate x 7 days,
0.215mg Norgestimate x 7 days, 0.25mg
Norgestimate x 7 days/ 35 mcg EE); or,
Sprintec (0.25mg Norgestimate/ 35 mcg
EE), or Zovia1/35 (Ethynodiol 1mg/35mcg
EE) or Tri-Norinyl (0.5mg Norethindrone x
7days, 1mg NE x 7 days, 0.5mg NE x 7
days/ 35 mcg EE)
Tri-Levlen (0.05mg Levonorgestrel & 30mcg EE x
6 days, 0.075mg Lvngl & 40mcg EE x 5 days,
0.125mg Lvgn & 30mcg EE x 10 days) or
Brevicon (.5mg NE/ 35mcg EE), Levlen (0.15
Lvngl/30mcg EE), Microgestin 1/20 (1 NE/20mcg
EE), Microgestin 1.5/30 (1.5 NE/30 EE), Norinyl
1/35 (1mg NE/ 35mcg EE) Norinyl 1/50 (1mg NE/
50mcg Mestranol), or NorQD (0.35 NE only)
Document at least 3 formulary alternatives
before prescribing/approving a NF product.
Ortho Tri-Cyclen Lo (0.18mg Norgestimate x 7 days,
0.215mg Norgestimate x 7 days, 0.25mg
Norgestimate x 7 days/ 25 mcg EE)
Tri-Sprintec (0.18mg Norgestimate x 7 days,
0.215mg Norgestimate x 7 days, 0.25mg
Norgestimate x 7 days/ 35 mcg EE); or,
Sprintec (0.25mg Norgestimate/ 35 mcg
EE), or Zovia1/35 (Ethynodiol 1mg/35mcg
EE) or Tri-Norinyl (0.5mg Norethindrone x
7days, 1mg NE x 7 days, 0.5mg NE x 7
days/ 35 mcg EE)
Microgestin FE 1/20 (1 NE/20mcg EE), Tri-Levlen
(0.05mg Levonorgestrel & 30mcg EE x 6 days,
0.075mg Lvngl & 40mcg EE x 5 days, 0.125mg
Lvgn & 30mcg EE x 10 days) or Brevicon (.5mg
NE/ 35mcg EE), Levlen (0.15 Lvngl/30mcg EE),
Microgestin FE 1.5/30 (1.5 NE/30 EE), Norinyl
1/35 (1mg NE/ 35mcg EE) Norinyl 1/50 (1mg NE/
50mcg Mestranol), or NorQD (0.35 NE only)
Document at least 3 formulary alternatives
before prescribing/approving a NF product.
Orudis (Ketoprofen) 50mg - 75mg TID - QID
Ibuprofen (generic Motrin) tabs 600-800 mg
TID or Salsalate (Disalcid)1500mg BID or
Naproxen 500mg BID or Sulindac (Clinoril)
200mg BID
Additional formulary alternatives: Diclofenac
(Voltaren) 75mg BID or Choline Magnesium
Trisalicylate (Trilisate) 750mg BID-TID or
Nambumetone (Relafen) 500mg or 750mg 1-2 QDBID or Etodolac (Lodine) 200mg-500mg Q8-12H
up to 1200mg/day or Indomethacin 25-50mg TID
or Mobic (Meloxicam) 7.5mg or 15mg..
Oruvail (Ketoprofen ER) 100 - 200mg QD
Ibuprofen (generic Motrin) tabs 600-800 mg
TID or Salsalate (Disalcid)1500mg BID or
Naproxen 500mg BID or Sulindac (Clinoril)
200mg BID
Additional formulary alternatives: Diclofenac
(Voltaren) 75mg BID or Choline Magnesium
Trisalicylate (Trilisate) 750mg BID-TID or
Nambumetone (Relafen) 500mg or 750mg 1-2 QDBID or Etodolac (Lodine) 200mg-500mg Q8-12H
up to 1200mg/day or Indomethacin 25-50mg TID
or Mobic (Meloxicam) 7.5mg or 15mg.
Ovcon 35 (0.4mg norethindrone/ 35mcg EE)
Brevicon (0.5mg ne/35mcg EE) or Norinyl
1/35 (1mg ne/35mcg EE) or Tri-Norinyl
(0.5mg ne x 7days, 1mg ne x 7 days, 0.5mg
ne x 7 days /35mcg EE)
Zovia (generic Demulen) 1/50 (1mg
Ethynodiol Diacetate/50mcg EE) i QD or
Norinyl 1+50 (1mg Norethindrone/ 50mcg
Mestranol) i QD
Norinyl 1+50 (1mg Norethindrone/ 50mcg
Mestranol) i QD or Zovia (generic Demulen)
1/50 (1mg Ethynodiol Diacetate/50mcg EE)
i QD
Document at least 3 formulary alternatives
before prescribing/approving a NF product.
Ovcon 50
Ovral (0.5mg Norgestrel/ 50mcg EE) tablets i QD
(generic Ovral (Ogestrel) is now manufactured)
Page 50
Document at least 3 formulary alternatives
before prescribing/approving a NF product.
Document at least 3 formulary alternatives
before prescribing/approving a NF product.
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Ovrette (Norgestrel 0.075mg) qd
Nor-QD (Norethindrone 0.35mg) QD
Document at least 3 formulary alternatives
before prescribing/approving a NF product.
Oxistat (Oxiconazole cream)
OTC Lamisil AT or clotrimazole containing Clotrimazole or Terbinafine (Lamisil) for tinea
OTC products: Lotrimin AF or OTC Mycelex pedis, tinea corporis, tinea circinata (ringworm of
or OTC Micatin cream
body), tinea cruris, tinea inguinalis (jock itch),
tinea versicolor; Clotrimazole for intertrigo (rash in
body folds or beneath breasts) or candidiasis
(including rash on penis or corners of mouth)
[OTC alternatives are not recommended for tinea
capitis (ringworm of scalp), tinea faceii or barbae
(ringworm of the beard…barber's itch or fungal
nails]
Oxycodone IR
Oxycodone 5mg/325mg APAP
Oxycontin 160 mg ER
Generic oxycodone extended release
(available in 10mg, 20mg, 40mg & 80mg
strengths)
Hydromorphone regular release 2mg or
4mg tablets
Palladone (hydromorphone hcl) extended release
12mg, 16mg, 24mg, 32mg capsules
Panretin (Alitretinoin) 0.1% topical gel
Morphine sulfate immediate release 15 or 30mg
tabs [Morphine 30-40mg converts to Oxycodone
15-30mg]
Do not consume any form of alcohol while taking
Palladone as it will result in destruction of
extended release mechanism, acute drug release
and overdose potential.
Criteria: (1)Patient has AIDS-related KS, and (2)
has signs and symptoms indicative of localized
disease (e.g. few lesions,low rate of growth,no
visceral KS identified, no fevers, drenching night
sweats or weight loss, no prior opportunistic
infection), and (3) has failed cryotherapy (this is
treatment of choice), OR (4) patient not
considered candidate for other treatment options,
or patient has failed other treatment options.
Paremyd (Hydroxyamphetamine hydrobromide
1%/Tropicide 0.25%) ophth soln
Cyclogyl (Cyclopentolate) ophth soln
Pupil dilation in ophth. Diagnostic procedures and
eye exams
Patanol (Olopatadine) 0.1%
For allergic conjunctivitis: OTC Opcon-A
(Pheniramine & Naphazoline) or OTC
Zaditor 0.25% [NOTE: OTC products are
not a covered benefit]
OTC Zaditor 0.25% and Patanol are both dual
action antihistamine/mast cell stabilizers, are
dosed twice daily, and have the same FDA
approved indications. If treating steroid
responsive inflammatory condition:
Dexamethasone 0.1% ophth soln or Prednisolone
0.12%-1% ophth soln or Flarex, FML
(Fluorometholone) ophth soln 0.1% i-ii drops in
affected eye(s) QID
Paxil (Paroxetine regular release) 10 - 40mg tabs
and Paxil CR (Paroxetine Controlled Release)
12.5mg, 25mg tabs
(Paxil regular
release is non-formulary as of 1/1/2008)
Prozac caps 10-40 mg QD or Celexa
(Citalopram) 20-40mg QD or Sertraline 25 100mg QD (added to formulary Mar 8th
2007)
The controlled-release product is non formulary.
Paxil 10mg bioequivalent to Paxil CR 12.5mg.
Paxil (Paroxetine) is non-formulary as of 1/1/2008.
Document response to all formulary SSRI
alternatives before prescribing a NF SSRI.
Document reason, when patient is medically
unable to convert to Formulary alternative.
Peak Flow Meter
Not covered by drug benefit
Obtain peak flow meter at MD office
PediaPred (5mg/5ml Prednisolone)
Prelone 5mg or15mg/5ml, Orapred
15mg/5ml
Watch change in solution strength, Prelone
available 5mg/5ml and 15mg /5ml
Page 51
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Penlac (Ciclopirox) 8% topical solution
N/A
Penlac demonstrates a very low cure rate.
Fungal nail infection is considered cosmetic
treatment and is not covered Unless : fungal
culture positive and i) If a finger nail, limited to
one 6 week treatment course, ii) If a toe nail, only
covered if the patient has diabetes or vascular
disease, then restricted to one 12 wk course.
Percocet tablet 2.5mg, 7.5mg or 10mg Oxycodone
preparations
Oxycodone 5mg/325mg acetaminophen
Brand names non-formulary. Controlled
(generic Percocet) or Oxycodone
substance level 2 requires hand written Rx by
5mg/500mg acetaminophen (generic Tylox) physician
Pergonal injection
Repronex injection
Periostat (Doxycycline) caps 20 mg BID up to 9
months
Doxycycline 50mg capsule QD OR 100 mg Periostat is not covered. Member will pay full
tablets 1/4 tab (25 mg) BID
price if dispensed Periostat.
Phendimetrazine
Phentermine HCL caps
Pilagan (Pilocarpine nitrate) 1 - 4% ophth soln i-ii
drops in affected eye TID-QID
N/A
Weight loss agents not covered.
N/A
Weight loss agents not covered.
Pilocarpine HCL (generic Isopto Carpine)
Direct acting miotics to lower IOP in glaucoma
0.25-10% ophth soln i-ii drops in affected
eye TID-QID OR Isopto Carbachol
(Carbachol) 0.75-2.25% ophth soln ii drops
in affected eye TID
Sulfacetamide/sulfur lotion
Plexion (Sodium Sulfacetamide 10% and Sulfur 5%)
lotion
Poly-pred (Neomycin/Polymyxin/Prednisolone) ophth
susp or ophth oint
May be substituted on a unit for unit basis without
calling practitioner. Menotropins are only covered
for members with fertility benefit rider.
Maxitrol (Dexamethasone/Neomycins/Poly- .
myxin) ophth susp or ophth oint
Ponstel (Mefenamic acid) 250mg QID (not
recommended for longer than 1 week)
Ibuprofen (generic Motrin) tabs 600-800 mg
TID or Salsalate (Disalcid)1500mg BID or
Naproxen 500mg BID or Sulindac (Clinoril)
200mg BID
Portia (0.15 Levonorgestrel/30mcg EE)
Pramasone (Pramoxine 1%/Hydrocortisone 2.5%)
lotion
Levlen (0.15 Levonorgestrel/30mcg EE)
.
Pramasone (Pramoxine 1%/Hydrocortisone OTC Amlactin AP (ammonium lactate
2.5%) Rectal foam
12%/Pramoxine 1%) or HC cream 2.5% & OTC
Benadryl cream
Glyburide (generic Micronase) 5-10 mg QD- Both Prandin and Glyburide stimulate beta cell
BID or Metformin 500mg BID or Glipizide
receptors to increase insulin production
Prandin (Repaglinide) 1-4 mg TID
Premarin
Premphase packets: premarin 0.625mg QD days 114, then (premarin / medroxyprogesterone)
0.625mg/5mg tab i QD days 15-28
Prempro (Premarin /
Medroxyprogesterone)0.45/1.5mg QD
Additional formulary alternatives: Diclofenac
(Voltaren) 75mg BID or Choline Magnesium
Trisalicylate (Trilisate) 750mg BID-TID or
Nambumetone (Relafen) 500mg or 750mg 1-2 QDBID or Etodolac (Lodine) 200mg-500mg Q8-12H
up to 1200mg/day or Indomethacin 25-50mg TID
or Mobic (Meloxicam) 7.5mg or 15mg.
Estradiol 0.5mg-2mg QD
0.5mg Estradiol = 0.3mg Premarin; 0.75mg
Estradiol (1&1/2 0.5mg tablet) = 0.45mg
Premarin; 1mg Estradiol = 0.625mg Premarin;
1.5mg Estradiol (1&1/2 1mg tablet) = 0.9mg
Premarin; 2mg Estradiol = 1.25mg Premarin
Estrace (Estradiol) 1mg QD plus
Two individual prescriptions are required. 0.5mg
Medroxyprogesterone 5mg QD days 15 thru Estradiol = 0.3mg Premarin; 0.75mg Estradiol
28
(1&1/2 0.5mg tablet) = 0.45mg Premarin; 1mg
Estradiol = 0.625mg Premarin; 1.5mg Estradiol
(1&1/2 1mg tablet) = 0.9mg Premarin; 2mg
Estradiol = 1.25mg Premarin
Estrace (Estradiol) 0.75mg (1&1/2 0.5mg
Two individual prescriptions are required. 0.5mg
Estradiol tablet) QD PLUS
Estradiol = 0.3mg Premarin; 0.75mg Estradiol
Medroxyprogesterone 1/2 to one 2.5mg
(1&1/2 0.5mg tablet) = 0.45mg Premarin; 1mg
tablet QD
Estradiol = 0.625mg Premarin; 1.5mg Estradiol
(1&1/2 1mg tablet) = 0.9mg Premarin; 2mg
Estradiol = 1.25mg Premarin
Page 52
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Prempro (Premarin / Medroxyprogesterone)
0.625/2.5mg -0.625mg/5mg tab i QD
Estrace (Estradiol) 1mg QD plus
Medroxyprogesterone 2.5-5mg QD
Prenatal vitamins
Prevacid-DR (Lansoprazole) cap 15-30 mg QD
no formulary alternative
OTC Prilosec 20mg - 40mg QD
Two individual prescriptions are required. 0.5mg
Estradiol = 0.3mg Premarin; 0.75mg Estradiol
(1&1/2 0.5mg tablet) = 0.45mg Premarin; 1mg
Estradiol = 0.625mg Premarin; 1.5mg Estradiol
(1&1/2 1mg tablet) = 0.9mg Premarin; 2mg
Estradiol = 1.25mg Premarin
Prenatal vitamins are available OTC
Prevacid is a NF No Initial Fill Drug. If Prilosec
40mg QD failure, consider NF No Initial Fill
drug, Protonix titrated up to 80mg QD.
(Protonix 40mg=Prevacid 30mg=Prilosec 20mg)
Must document failure or intolerance to Prilosec
40mg QD if requesting PPI coverage.
Preven Emergency Contraception kit (0.25mg
Levonorgestrel/0.05 Ethinyl Estradiol) 2 tablets now
then 2 tablets in 2 hours
Levlen (0.15mg Levonorgestrel / 0.03mg
Ethinyl Estradiol) #4 Levlen tablets now and
then repeat in 12 hours OR Plan B (0.75mg
Levonorgestrel) 1 tablet now then 1 tablet in
2 hours
HP Pack: Tetracycline 500 mg QID x 14
days, Metronidazole 500 mg QID x 14 days,
Bismuth subsalicylate 2 tabs QID x 14 days
& Prilosec OTC 20mg BID x 14 days (HP
Pack available at KP pharmacies for one
copayment)
Must be taken within 72 hours of unprotected
intercourse.
Prilosec (Omeprazole) 20mg cap 20-60mg QD
OTC Prilosec 20mg tablet. (If cannot
swallow tablet, OTC prilosec will disperse in
5cc of water in less than 60 seconds with
gentle agitation)
If patient has failed Prilosec 40mg QD, consider
NF No Initial Fill drug, Protonix titrated up to 80mg
daily (Protonix 40mg=Prilosec 20mg). Must
document failure or intolerance to Prilosec 40mg
QD if requesting PPI coverage;
Initial dosing for kids >/= 20kg or 3 years of age is
Prilosec 20mg QD
Proamatine (midodrine) 2.5-10 mg TID
Fludrocortisone (generic Florinef) dosing to Consider Fludrocortisone if patient has not yet
be determined by prescriber.
been stabilized on Midodrine. If orthostatic
hypotension stabilized on Midodrine, consider
continuing Midodrine.
Nifedipine XL 30, 60 or 90 mg tablet
We cover generic Procardia XL (nifedipine XL)
instead of generic Adalat CC (nifedipine XL).
Substitute on a mg per mg basis.
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
Prevpack (Prevacid DR (Lansoprazole) 30mg BID,
Biaxin (Clarithromycin) 500mg BID and Amoxicillin
500mg QID x 10-14 days)
Procardia XL tablet 30-90 mg QD
Proctocort 1% (1% Hydrocortisone) cream
Proctofoam HC (1%
Hydrocortisone/pramoxine 1%) OR
Hydrocortisone cream 2.5% with rectal tip
OR Hydrocortisone 25mg suppository
Proctocream HC (2.5% Hydrocortisone cream) or (1% Proctofoam HC (1%
Hydrocortisone and 1% Pramoxine)
Hydrocortisone/Pramoxine 1%) OR
Hydrocortisone cream 2.5% with rectal tip
OR Hydrocortisone 25mg suppository
Page 53
HP Pack (Helicobacter pylori treatment pack)
Individual components dispensed as 2 individual
prescriptions PLUS OTC Pepto Bismol & Prilosec
OTC at Eckerd. Second line alternative: Prilosec
OTC 20mg BID, Biaxin 500mg BID, and Flagyl
500mg BID or Amoxicillin 1000mg BID x 14 days
Select appropriate option
Select appropriate option
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Proctosol HC Cream 2.5%
Proctofoam HC (1%
Hydrocortisone/pramoxine 1%) OR
Hydrocortisone cream 2.5% with rectal tip
OR Hydrocortisone 25mg suppository
OTC congestac (60mg Pseudoephedrine
and 400mg Guaifenesin/tablet) Q6H or OTC
Mucinex (600mg Guaifenesin long acting) or
OTC Guaifenesin 400mg regular release
plus OTC Pseudoephedrine
Select appropriate option
Medroxyprogesterone 2.5-5 mg QD or
Aygestin (norethindrone) 5mg
N/A
If Prometrium is being used in early pregnancy,
coverage is addressed by the fertility benefit.
Cosmetic drug use is not covered under drug
benefit. Propecia for male pattern baldness or
removal of female facial hair is considered
cosmetic. Member pays full retail price.
Profen II tab 37.5-600 i tablet BID
Prometrium capsule 100 mg QD-BID
Propecia
All cough and cold medications are non-formulary
with the exception of Codeine, Hydrocodone, and
Promethazine containing products.
ProStep (Nicotine) Transdermal system 11,22mg/day OTC Nicotrol (Nicotine transdermal system) Nicotine replacement products are non formulary.
5, 10, 15mg/day
Protonix (Pantoprazole) 40mg QD to BID
Prilosec OTC 20 - 40mg QD
Protonix is a NF No Initial Fill drug. If patient has
failed Prilosec (Omeprazole) titrated up to 40mg
daily, consider NF No Initial Fill drug, Protonix.
Must document failure or intolerance to Prilosec
40mg QD if requesting PPI coverage.
Protopic (Tacrolimus) 0.03% and 0.1% oint
Corticosteroid potency to be determined by
ind patient need. very high potency:
Diprolene (augmented Betamethasone
Dipropionate) 0.05% oint or Temovate
(Clobetasol) 0.05% cream, oint, gel, scalp
soln. High potency: Lidex (Fluocinonide)
0.05% cream, oint, gel, soln or Diprolene
AF (Augmented Betamethasone) 0.05%
Medium potency: Triamcinolone (generic
Aristocort, Kenalog) cream, oint 0.1% or
Valisone (Betamethasone Valerate) 0.1%
lotion or Locoid Lipocream (Hydrocortisone
Butyrated) 0.1% Low potency: DesOwen
(Desonide) 0.05% cream, oint, lotion or
Synalar (Fluocinolone) 0.01% soln, oil or
Hytone (Hydrocortisone) 2.5% cream, oint,
lotion
Locoid lipocream restricted to derm. Covered
corticosteroid topicals listed by potency under
formulary alternative column. ***Protopic is
preferred over Elidel for diagnosis of Vitiligo and
should be approved for that condition***
Proventil (Albuterol) oral inhaler ii puffs Q4H prn
Albuterol oral inhaler ii puffs Q4H prn
May be substituted on a puff for puff basis without
calling practitioner.
Proventil HFA (Albuterol) oral inhaler ii puffs Q4H prn Albuterol oral inhaler ii puffs Q4H prn
May be substituted on a puff for puff basis.
Proventil (Albuterol) tabs, SR tabs, oral soln, neb soln Albuterol (generic Ventolin) immediate
release tablets or oral inhaler
Extended release Albuterol tablets are no longer
manufactured. Consider Albuterol inhaler or
immediate release tablets. If long acting beta 2
agonist necessary, consider serevent inhaler. If
steroid inhaler necessary, QVAR
(Beclomethasone) inhaler is preferred formulary
agent
May be substituted on a mg for mg basis without
calling practitioner.
Provera tablets 2.5-10 mg QD
Medroxyprogesterone tabs 2.5 -10 mg QD
Page 54
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Prozac (Fluoxetine) Weekly 90mg enteric coated
capsule
Prozac (Fluoxetine) 20mg QD
Prozac Weekly is non formulary, Prozac
administered daily is formulary. Document
response to all formulary SSRI alternatives
before prescribing a NF SSRI. Document
reason, when patient is medically unable to
convert to Formulary alternative.
Psorcon (Diflorasone) 0.05% cream, oint (emolient
base oint)
Lidex (Fluocinonide) 0.05% cream, oint, gel,
soln or Diprolene AF (Augmented
Betamethasone) 0.05%
Diprolene (Augmented Betamethasone
Dipropionate) 0.05% oint or Temovate
(Clobetasol) 0.05% cream, oint, gel, scalp
soln
QVAR (Beclomethasone HFA) 80mcg i-ii
puffs BID or Asmanex (Mometasone
furoate) oral dry powder inhaler 200mcg per
puff i - ii puffs QHS (or i puff BID)
High potency topical corticosteroids.
Psorcon (Diflorasone) 0.05% oint (not the emolient
base oint)
Pulmicort (Budesonide) 200 mcg turbuhaler i-ii puff
BID
Very high potency topical corticosteroids.
QVAR 80mcg (preferred agent) is equipotent to
Pulmicort 200mcg. If patient has failed QVAR,
consider Asmanex (≥12 yrs old). Asmanex is
equipotent to fluticasone and approx twice as
potent as budesonide and beclomethasone.
QVAR remains the preferred inhaled
corticosteroid at KP GA. TSPMG guidelines
support Pulmicort when an oral inhaled steroid is
needed during pregnancy.
Pulmicort (Budesonide) respules for nebulization
If child can use inhaler, consider (5-11 yoa) Pulmicort respules are formulary when
QVAR 40mcg i puff BID
nebulization is required. Pulmicort is the only
inhaled steroid available for nebulization.
Pyridium (Phenazopyridine) 100mg or 200mg tablets
OTC Pyridium 95mg or 100mg tablets
Pyridium plus (Phenazopyridine 150mg, 0.3mg
Hyoscyamine, 15mg Butabarbital)
Pyridium 95mg or 100mg OTC
OTC generic Pyridium (95mg or 100mg
Phenazopyridine) with or without Rx generic
Levsin (Hyoscyamine 0.125mg)
Quinamm (Quinine sulfate) tabs
N/A
Quixin (Levofloxacin) 0.5% ophth soln
Raptiva (Efalizumab)
.
Available on exception basis for malaria. Not
covered for leg cramps since potential risk
outweighs potential benefit.
Lasik ophthalmic surgery is not a covered benefit.
Ofloxacin 0.3% or Gentamicin 0.3% or
Tobramycin 0.3% or Sodium Sulfacetamide Medications related to non covered procedures,
eg. Lasik surgery, are not covered by the drug
ophth soln or Zymar 0.3%
benefit.
Humira preferred in psoriasis.
Raptiva coverage criteria for psoriasis: (1) patient
is an adult with moderate to severe chronic plaque
psoriasis, and (2) has a documented failure, or is
not a candidate for topical or systemic therapies
(methotrexate, acitretin, PUVA, UVB), and (3)
patient has a documented failure, or is not a
candidate for a combination of the above
treatment options, (4) prescriber must be a
Dermatologist
Razadyne (Galantamine) 8-16mg BID
Aricept (Donazepril) 5 - 10mg tab QD;Exelon Consider Aricept 10mg 1/2 tablet when
prescribing Aricept 5mg.
Relenza 5 mg dose inhalation (diskhaler device)
Oseltamivir (Tamiflu)
Relpax (Eletriptan) 20mg, 40mg
Maxalt (Rizatriptan) MLT 10mg tablet
(Maxalt MLT 5mg tablet is also available)
Page 55
See special criteria for oseltamivir during flu
season only.
Maxalt MLT 10 mg is preferred, QTY limit of 9
tablets/copay. If failed a trial on Maxalt MLT
consider formulary alternative Imitrex 50 mg
tablets (qty limit of 9 tablets/copay), nasal, or
injectable dosage forms. Quantity limit for Nonformulary Relpax is 6 tablets per copay
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Remeron (Mirtazapine) Sol-Tab15mg or 30mg
Consider Celexa 40mg 1/2 tablet when
prescribing Celexa 20mg. Consider Paroxetine
40mg 1/2 tablet when prescribing Paroxetine
20mg dose. [Mirtazapine - Available Part D
group]
Remicade is provided and administered at a KP
Infusion center. Physician to provide referral to
KP infusion center for Remicade administration
(contact Jill Broner at Cumberland 770-431-4367
or at SWD Kim 770-603-3572). IV infusion to be
ordered by Rheumatology or GI. Refer
practitioner questions regarding medical benefit
coverage to provider relations.
Remicade (Infliximab) administered IV TNF blocker
Reminyl (Galantamine) 8-16mg BID
Renagel (Sevelamer) 800-1600mg with each meal
Renova (Tretinoin) 0.02% cream
Rescula (Unoprostone isopropyl) 0.15% ophth soln
Restoril (Temazepam) 7.5mg QHS
Mirtazapine regular release tablets 15mg,
30mg or 45mg Or, Prozac (Fluoxetine)
caps 10-40 mg QD or Celexa (Citalopram)
20 - 40mg QD or Paxil (Paroxetine) tabs 2040 mg QD
Enbrel 25 mg SQ twice weekly. Humira
preferred in psoriasis.
Aricept (Donazepril) 5 - 10mg tab QD
Consider Aricept 10mg 1/2 tablet when
prescribing Aricept 5mg.
Phoslo 667mg (Calcium acetate) tablet ii-iiii Sevelamer is a calcium-/aluminum-free phosphate
tablets with each meal
binder for hypophosphatemia in patients with end
stage renal disease
N/A
Drugs for cosmetic use are NOT covered on
drug benefit. Member pays retail price.
Lumigan (Bimatoprost) 0.03% ophth
solution 1 drop in affected eye QHS
Prostamide analog to reduce IOP in glaucoma.
Lumigan is not as effective when administered
more often than QD. Separate Lumigan from
administration of other eye drops by at least 5
minutes.
Temazepam (generic Restoril) 15 mg
Temazepam 15mg and 30mg strengths are
capsule at HS or Oxazepam (gen Serax) 10- available on the formulary.
30mg or Lorazepam 0.5mg QHS or
Hydroxyzine (generic Atarax) 10-25 mg at
HS or Trazodone 50-100mg QHS
Retin-A (Tretinoin) 0.025% cream or gel
Avita (Tretinoin) 0.025% cream or gel
Formulary for acne only. Smallest unit size is
covered. Drugs for cosmetic use (eg. Wrinkles)
are not covered on drug benefit, member will retail
price.
Retin-A micro gel 0.04% or 0.1% apply QHS
Retin-A cream 0.1% (20 gm tube) apply
QHS or Retin-A gel 0.025% (15 gm tube)
apply QHS
Retin A Micro gel is restricted to Dermatology.
Formulary for acne only. Smallest unit size is
covered. Drugs for cosmetic use (eg. Wrinkles)
are not covered on drug benefit, member will retail
price.
Revatio (Sildenafil) 20mg TID
Rhinocort (Budesonide) nasal spray ii-iiii sprays each
nostril BID
Tracleer (Bosetan)
Nasarel ii sprays each nostril BID or generic
Flonase (fluticasone) i spray each nostril
QD
Metformin oral tablets
Riomet (Metformin) oral solution
Ritalin LA (Methylphenidate HCL extended release)
20, 30 & 40mg beaded capsules
Concerta 18, 27, 36, 54mg, or Methylin ER
10mg (methylphenidate), Methylphenidate
5, 10, 20mg and SR 20mg; or generic
Dexedrine spansules (Dextroamphetamine)
5, 10, 15mg or Adderall regular release 5,
10, 20, 30mg tablets or Adderall XR 5, 10,
20, 25, 30mg capsules. Controlled
substances level 2 requiring prescription
written by prescriber. Methylphenidate is
the preferred formulary alternative.
Page 56
Please document failure of both Nasarel & generic
Flonase (fluticasone) before prescribing/approving
a NF product.
.
Adderall XR is restricted to pediatrics, child
neurology and behavioral health.
Titrate to appropriate dosage using adderall
regular release tablets before transitioning to
once daily Adderall XR.
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Rowasa suppositories
Cortenema 100mg/60ml, Rowasa enema or Rowasa suppositories are unavailable from mftr
Canasa (Mesalamine) 1000mg suppository indefinitely (10/01) so Rowasa removed from
formulary and replaced by Canasa suppositories
Rozerem (Ramelteon) 8mg QHS
Generic Ambien (Zolpidem 5 & 10mg) has
been added to the formulary as of 6/1/07.
Please consider less costly alternatives
before prescribing Zolpidem. Oxazepam
(gen Serax) 10-30mg or Lorazepam 0.5mg
QHS or Hydroxyzine (generic Atarax) 10-25
mg at HS or Trazodone 50-100mg QHS or
Temazepam (generic Restoril) 15-30 mg
capsule at HS are all much less costly than
Zolpidem.
Consider lower doses in geriatric patients.
Consider OTC Melatonin to reduce
benzodiazepine usage Caution: do not abruptly
discontinue benzodiazepines after long-term use.
Document failed trial on at least 1
Benzodiazepine, Trazodone, and Zolpidem before
prescribing NF product.
Rynatan suspension (Chlorpheniramine,
Phenylephrine) new formulation removed Pyrilamine
Nasarel ii sprays each nostril BID or generic
Flonase (fluticasone) i spray each nostril
QD or OTC Claritin syrup and OTC
Phenylephrine HCl
Criteria Restricted Medication. Once
approved, the approval and date range
for approval is noted in the Kaiser
pharmacy computer system. Norditropin
(somatropin) is preferred growth
hormone and must be tried prior to
approval for other growth hormone
products
OTC alternatives: Triaminic cold and cough; cold
and allergy (see Triaminic dosing sheet) or
Robitussin product sheet. Claritin syrup OTC
Saizen (Somatotropin) injection
Criteria Restricted Medication. Pediatric
Endocrinologist phone KP QRM to request
authorization consideration 404-364-7320.
Salagen (Pilocarpine) 5mg tablets
Pilocarpine 4% (4mg/0.1ml) ophthalmic soln Symptomatic treatment. Please consider titrating
3 drops TID taken orally (equivalent to 5mg the number of drops and frequency of
administration to patient's response and
Pilocarpine TID)
tolerance.
{Pilocarpine 6% (6mg/0.1ml)
ophthalmic soln 2 drops TID (equiv to 6mg
Pilocarpine TID}
Sanorex (Mazindol)
N/A
Weight loss agents not covered.
Santyl 30gm (Collagenase)
Accuzyme (papain-urea) ointment 30gm
Santyl on MMA formulary only. Accuzyme first
line formulary option
Sarafem (Fluoxetine) 20mg caps
Prozac (Fluoxetine) 20mg QD
Document response to all formulary SSRI
alternatives before prescribing a NF SSRI.
Document reason, when patient is medically
unable to convert to Formulary alternative.
Sculptra (poly-l-lactic acid)
N/A
Cosmetic use drug. Not covered on drug benefit.
Member pays retail price.
Seasonale (Levonorgestrel 0.15mg / Ethinyl Estradiol Levlen (Levonorgestrel 0.15mg /30mcg
30mcg) 84 active tablets followed by 7 placebo tabs = Ethinyl Estradiol) 28 day packet
90 day supply
Instruct pt to take one active Levlen tablet per day
for 84 days (do not take the 7 placebo tablets
included with the first 3 Levlen packets) on day 85
patient will take one placebo tablet daily for 7 days
Semprex D
Semprex D is an Antihistamine/Decongestant
combo
Brand name Serzone is no longer manufactured.
Generic Nefazodone is manufactured but remains
NF.
*Flovent 110mcg/puff & 220mcg/puff are nonformulary. If patient is already using steroid and
serevent inhaler and asthma symptoms persist,
candidate for singulair
OTC products, Dimetapp
Serzone (Nefazodone) 100-300mg BID
Consider Prozac caps 10-40 mg QD or
Celexa (Citalopram) 20-40mg QD or Paxil
tabs 20-40 mg QD
Singulair 4mg chew tab or granules OR 5mg chew tab ICS inhaler (QVAR or *Flovent or
QD
Asmanex) plus a long acting B2-agonist
(Serevent) OR an ICS and B2 agonist
Page 57
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Singulair 5-10 mg QD
ICS inhaler (QVAR or *Flovent or
Asmanex) plus a long acting B2-agonist
(Serevent) OR an ICS and B2 agonist
*Flovent 110mcg/puff & 220mcg/puff are nonformulary. If patient is already using steroid and
serevent inhaler and asthma symptoms persist,
candidate for singulair
Skelaxin (Metaxalone) 400mg-800mg TID-QID
Use Cyclobenzaprine 10mg 1/2 tablet for
Cyclobenzaprine 5mg.
Solage (Mequinol 2%, Tretinoin 0.01%)
Flexeril (Cyclobenzaprine) 10mg tab or
Robaxin (Methocarbamol) 750mg tab or
Soma (Carisoprodol) 350mg or Parafon
Forte DSC (Chlorzoxazone) 500mg
N/A
Solaquin-Forte cream or gel
N/A
Drugs for cosmetic use are NOT covered on
drug benefit. Member pays retail price. If
prescribed along with Differin, Retin A, or Avita
creams, they also are not covered as they are
being used as cosmetic therapy.
Soma Compound (200mg carisoprodol/325mg aspirin) Soma (carisoprodol) 350mg plus OTC
aspirin
Sonata (Zaleplon) capsule 10 mg at HS
Soriatane (Acitretin) cap
Drugs for cosmetic use are NOT covered on
drug benefit. Member pays retail price. If
prescribed along with Differin, Retin A, or Avita
creams, they also are not covered as they are
being used as cosmetic therapy.
Other Formulary alternatives include: Flexeril
(Cyclobenzaprine) 10mg tab or Robaxin
(Methocarbamol) 750mg tab or Parafon Forte
DSC (Chlorzoxazone) 500mg plus OTC aspirin
Consider lower doses in geriatric patients.
Temazepam (generic Restoril) 15-30 mg
capsule at HS or Oxazepam (gen Serax) 10- Consider OTC melatonin to reduce
benzodiazepine usage Caution: do not abruptly
30mg or Lorazepam 0.5mg QHS or
Hydroxyzine (generic Atarax) 10-25 mg at discontinue benzodiazepines after long-term use.
Caution: do not abruptly discontinue
HS, Trazodone 50-100mg QHS, or
benzodiazepines after long-term use. Document
Zolpidem (gen Ambien) 5-10mg
failed trial on at least 1 Benzodiazepine,
Trazodone, and Zolpidem before prescribing NF
product.
N/A
Soriatane is restricted to Dermatology.
Spectazole (Econazole) cream
OTC Lamisil AT or Clotrimazole containing Clotrimazole or Terbinafine (Lamisil) for tinea
OTC products: Lotrimin AF or OTC Mycelex pedis, tinea corporis, tinea circinata (ringworm of
body), tinea cruris, tinea inguinalis (jock itch),
or OTC Micatin cream
tinea versicolor; Clotrimazole for intertrigo (rash in
body folds or beneath breasts) or candidiasis
(including rash on penis or corners of mouth)
[OTC alternatives are not recommended for tinea
capitis (ringworm of scalp), tinea faceii or barbae
(ringworm of the beard…barber's itch or fungal
nails]
Stadol NS 10 mg/ml i spray in one nostril Q3-4H
Ibuprofen 600-800 mg TID or
Acetaminophen with Codeine i-ii tablets
Q6H or morphine or Oxycodone /
acetaminophen or NSAID
25mg Carbidopa / 100mg Levodopa regular
release 1/2 tablet PLUS Comtan
(Entacapone) 200mg tablet
25mg Carbidopa /100mg Levodopa regular
release tablet PLUS Comtan (Entacapone)
200mg tablet
25mg Carbidopa /100mg Levodopa regular
release 1 &1/2 tablets PLUS Comtan
(Entacapone) 200mg tablet
Stalevo 50 (12.5mg Carbidopa / 50mg Levodopa/
200mg Entacapone)
Stalevo 100 (25mg Carbidopa/ 100mg
Levodopa/200mgEntacapone)
Stalevo 150 (37.5mg Carbidopa/ 150mg
Levodopa/200mgEntacapone)
Page 58
The Federal Drug Enforcement Agency (DEA)
ranks Stadol nasal spray among the top abused
drugs.
.
.
.
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Starlix (Nateglinide) 120mg TID
Glyburide (generic Micronase) 5-10 mg QD- Both Starlix and Glyburide stimulate beta cell
BID or Glucophage (Metformin) 500mg BID receptors to increase insulin production. Caution
or glipizide
patient to monitor for big shifts when changing
diabetic Rx. Consider other oral antidiabetics
such as Glipizide in patients >65 due to prolonged
half life of Glyburide.
Strattera (Atomoxetine) 10mg, 18mg, 25mg, 40mg
and 60mg
Concerta 18,27,36,54mg, or Methylin ER
10mg (Methlyphenidate) Methylphenidate
5, 10, 20mg and SR 20mg; or generic
Dexedrine spansules (Dextroamphetamine)
5, 10, 15mg or Adderall regular release 5,
10, 20, 30mg tablets or Adderall XR
5,10,20,25,30mg capsules.
Controlled substances level 2 requiring
prescription written by prescriber.
Methylphenidate is the preferred formulary
alternative.
Adderall XR is restricted to pediatrics, child
neurology and behavioral health. Titrate to
appropriate dosage using adderall regular
release tablets before transitioning to once
daily Adderall XR. Document failed trial on
Methylphenidate, Dextroamphetamine and
Adderall IR products before a Non-formulary
Product is considered. Methylphenidate is the
preferred formulary alternative.
Sular (Nisoldipine) 10-40mg QD
Nifedipine XL (generic Procardia XL) 3090mg QD or Felodipine ER (generic
Plendil) 2.5mg-10mg, or Amlodipine
(generic Norvasc) 2.5mg-10mg or Diltia XT
(Diltiazem) 120-480mg QD
Nisoldipine 10-20, 30 & 40mg are equivalent to
Nifedipine XL 30, 60 &90mg, respectively OR
Felodipine ER 2.5mg, 5mg & 10mg respectively,
OR Amlodipine 2.5mg, 5mg, & 10mg respectively
OR Diltia XT 120, 240 & 360-480mg respectively
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
Supartz (Hyaluronic sodium)
Suprax 200-400 mg tablets or suspension
Symbicort (Budesonide/Formeterol 80/4.5, 160/4.5,
Turbuhaler)
Ceftin 250 mg tab BID or Augmentin 500
mg tab BID or Biaxin (no XL) 500mg BID
Suspensions: Omnicef 125mg/5ml;
pediazole (erythromycin &
sulfamethoxazole); augmentin 125250mg/5ml or 200-400mg chew
tabs;amoxicillin 125-250mg/5ml; Biaxin 125250mg/5ml
For the 80/4.5 dose try:
QVAR 80 mcg i puff BID & Serevent 50
mcg i puff BID OR Asmanex i puff qhs &
Serevent 50 mcg i puff BID
Criteria Restricted Medication. Provider
phones KP QRM to request authorization
consideration 404-364-7320.
Ceftin tablets are formulary. Ceftin suspension is
non-formulary.
For the 160/4.5 dose try:
QVAR 80 mcg ii puffs BID & Serevent 50
mcg i puff BID OR Asmanex ii puffs qhs or i
puff BID & Serevent 50 mcg i puff BID
Symbyax (Olanzapine/Fluoxetine) 6mg/25mg;
6mg/50mg; 12mg/25mg; and 12mg/50mg
Zyprexa (Olanzapine) 2.5mg, 5mg,
Each component of this combination product is
7.5mg,10mg or 15mg tabs PLUS Fluoxetine Formulary when dispensed individually as Zyprexa
20mg capsules
5mg or 10mg QD and Fluoxetine 20mg #1 or #2
QD.
Page 59
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Symlin (pramlintide) 0.6mg/ml injection
Criteria Restricted Medication. Provider phone KP
QRM 404-364-7320 to request authorization
consideration.
Synagis (Palivizumab) injection is a humanized
monoclonal antibody targeted to the F protein of
respiratory syncytial virus (RSV)
N/A
Injectables administered in medical office and are
covered under medical office benefit, not drug
benefit. Synagis is only covered when
administered in a Kaiser Permanente office. Call
KP Synagis clinic (770) 931-6059 for more
information.
Synalar (Fluocinolone) 0.01% cream [low potency]
DesOwen (Desonide) 0.05% cream, oint,
Low potency topical corticosteroids. Synalar
lotion or Synalar (Fluocinolone) 0.01% soln, 0.01% soln and oil are covered. Synalar 0.025%
oil or Hytone (Hydrocortisone) 2.5% cream, cream, oint and synalar 0.2% are not covered.
oint, lotion
Synalar (fluocinolone) 0.025% cream, oint [medium
potency]
Triamcinolone (generic Aristocort) cream,
oint 0.1% or Valisone (betamethasone
valerate) 0.1% lotion or Locoid lipocream
(hydrocortisone butyrate) 0.1% apply to
affected area BID
Synalar (Fluocinolone) 0.2% cream [high potency]
Lidex (Fluocinonide) 0.05% cream, oint, gel, High potency topical corticosteroids.
soln or Diprolene AF (Augmented
Betamethasone) 0.05%
Synthroid tablet 0.025-0.3 mg QD
Levothroid tabs 0.025-0.3 mg QD
Taclonex (Calcipotriene and betamethasone)
Dovonex (calcipotriene) and
Betamethasone diprionate ointment 0.05%
Talwin NX i tablet Q3-4H
Acetaminophen with codeine (generic
Tylenol #3) i-ii tablets Q6H
.
Tamiflu (Oseltamivir) capsule 75 mg Tamiflu must be
initiated w/in 48 hrs of symptom onset
Amantadine caps 100 mg BID
Amantadine dose should be reduced to 100 mg
QD in adults > 65 years of age. Pediatric dose is
4.4 mg/kg/day, max 150 mg/day. Rimantadine
(Flumadine) 100mg tablets are also available.
(Tamiflu covers flu strains A and B, Amantadine
covers strain A only)
Tarceva (Erlotinib) 25mg, 100mg, 150mg tablets
Platinum containing combination
chemotherapy with paclitaxel or Docetaxel
chemotherapy
Tarceva indicated for local advanced or
metastatic non-small cell lung cancer after failure
of at least one prior chemotherapy regimen
(platinum containing first line)
Targretin (Bexarotene) 1% topical gel
interferon alpha, topical carmustine
Criteria: (1) patient has cutaneous T-cell
lymphoma (CTCL) and (2) patient has cutaneous
lesions, and (3) patient has failed interferon alfa,
topical carmustine, PUVA, electron beam
radiotherapy OR (5) patient is not considered
candidate or has failed other treatment options
Page 60
Locoid lipocream is restricted to Dermatology.
If failed other alternatives, consider increasing
steroid potency to fluocinonide (Lidex) 0.05%
cream, oint, or gel
Substitute on a mg for mg basis. (ie. if Synthroid
0.1mg convert to levothroid 0.1mg)
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Tarka (Trandolapril/Verapamil) 1mg/240mg, 2/180mg, Prinivil (Lisinopril) 5-40mg QD AND
4/240mg tablets
Verapamil SR 180mg or 240mg
Combination product is not covered. Conversion
Trandolapril 1mg=Prinivil 5-10mg; Trandolapril
2mg=Prinivil 10-20mg; Trandolapril 4mg=Prinivil
20-40mg. TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
Tasmar (Tolcapone) tab 100-200 mg TID
Comtan (Entacapone) 200 mg tabs with
each dose of Levodopa/Carbidopa, MAX
1600mg/day
Tasmar is on the formulary; however, all other
Parkinson's therapies should be tried before
Tasmar due to risk of severe hepatic damage and
death, liver function tests must be completed
every two weeks while on therapy. Patient and
practitioner must complete informed consent
(provided by manufacturer) prior to initiation of
therapy.
Tazorac (Tazarotene) 0.05%, 0.1% cream (severe
psoriasis)
For Psoriasis: Dovonex (Calcipotriene)
0.005% oint or Diprolene (Augmented
Betamethasone) oint or Temovate
(Clobetasol) oint, cream or Lidex
(Fluocinonide) 0.05% oint, cream For Acne:
Retin-A cream 0.1% (20 gm tube) apply
QHS or Retin-A gel 0.025% (15 gm tube)
apply QHS or Retin A Micro gel
If failed several very high potency steroids,
consider Tazorac severe psoriasis.
(Betamethasone Dipropionate 0.05% cream
demonstrates good efficacy when nec to use a
steroid crm w/ Tazorac) Acne: Retin A Microgel
is restricted to Dermatology. Smallest unit size
is covered, larger tubes are not covered. Retin-A,
Differin not covered for cosmetic use (wrinkles)
Taztia XT (Diltiazem extended release) 120, 180, 240, Diltia (Diltiazem) XT 120, 180 and 240mg
300, 360mg 120 - 480mg QD
caps 120-480mg QD
Substitute on a mg for mg basis. Convert Taztia
XT 300mg to Diltia XT 240mg or 360mg (#2 x
180mg), Taztia XT 480mg convert to Diltia XT
480mg (#2 x 240mg cap) TSPMG Guidelines
suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
Teczem (5mg Enalapril/180mg Diltiazem) extended
release tab
Prinivil (Lisinopril) 5mg QD AND Diltia XT
(Diltiazem) 180mg QD
Combination product is non formulary. Individual
medications are formulary.
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
Tegison (Etretinate) capsules
Soritaine (Acitretin) capsules
Soriatane is restricted to Dermatology.
Page 61
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Tegretol-XR (Carbamazepine) 100, 200, 400mg tab
BID
Carbatrol (Carbamazepine) 200, 300mg
extended release caps BID
Substitute on a mg for mg basis to produce same
total daily dose. Note Carbatrol strengths differ
from Tegretol XR strengths.
Tekturna (Aliskerin) 150 mg and 300 mg tablets
Lisinopril 10 -20 mg daily or Cozaar 25100 mg daily
Clonidine (generic Catapres) tab 0.1 mg
BID or Methyldopa (generic Aldomet) 250
mg TID
Tenex tablet 1 mg QD
Titrate dose to blood pressure response.
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
Tenoretic (Atenolol / Chlorthalidone) 50/25, 100/25mg Atenolol (generic Tenormin) 50mg-100mg
AND 25mg Hydrochlorothiazide
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
Tenuate (Diethylpropion)
Tequin (Gatifloxacin) tab 400 mg QD x 7-10 days for
bronchitis ; 400 mg QD x 7-14 days for communityacquired pneumonia ; 400 mg QD x 10 days for
sinusitis
N/A
If treating URTI:
Avelox
(moxifloxacin) 400mg QD or generic
Augmentin 875 mg BID or Biaxin 500 mg
BID
If treating
UTI:
Fluoroquinolone
of choice is Cipro or consider Bactrim DS.
Weight loss agents not covered.
Terazol vaginal cream or suppositories
Diflucan (Fluconazole) 150mg tablet
OTC products are available. In keeping with
treatment recommendations, Fluconazole 150mg
quantity is limited to 1 tablet per copay.
Tessalon perles (Benzonatate)
Phenergan syrup, Phen. VC with Codeine,
Phen with codeine; Robitussin AC or
Robitussin DAC; Hycodan tablets (not
syrup) or OTC products
Phenergan VC (promethazine, phenylephrine,
codeine); Robitussin AC (guaifenesin, codeine);
Robitussin DAC (Guaifenesin, codeine,
pseudoephedrine); Hycodan tabs
(hydrocodone/homatropine) OR OTC products
Testoderm TTS 5 mg transdermal patch QD are no
longer manufactured.
Androderm 2.5mg-5mg/24 hour transdermal Document indication for medication and failure on
patches; Testosterone injection 400 mg IM alternatives. (If patient is using for Sexual
q2-4weeks administered in medical office. Dysfunction confirm sexual dysfunction benefits.)
Injectables administered in a medical office
are covered under the medical office
benefit, NOT the drug benefit and are not
available from a pharmacy for a copayment.
Methyltestosterone (generic Android or
Testred) tabs 10-20 mg QD-BID or
Fluoxymesterone (Halotestin) 10 mg QD
(tablets require baseline and periodic liver
function testing)
Page 62
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Testoderm Scrotal patch 4mg or 6mg/24 hours are no Androderm 2.5mg-5mg/24 hour transdermal Document indication for medication and failure on
longer manufactured, will remain available until supply patches; Testosterone injection 400 mg IM alternatives. (If patient is using for Sexual
exhausted
q2-4weeks administered in medical office. Dysfunction confirm sexual dysfunction benefits.)
Injectables administered in a medical office
are covered under the medical office
benefit, NOT the drug benefit and are not
available from a pharmacy for a copayment.
Methyltestosterone (generic Android or
Testred) tabs 10-20 mg QD-BID or
Fluoxymesterone (Halotestin) 10 mg QD
(tablets require baseline and periodic liver
function testing)
Testosterone 2 to 3% manually compounded in cream N/A
base
commercially available NF product Testosterone
2% in moisturizing cream ndc# 65628-021-01
Testosterone 2 to 3% manually compounded in an
ointment base
N/A
commercially available NF product Testosterone
2% in ointment ndc# 65628-020-01
Testosterone cyp 200 mg/ml injected Q 2-4 weeks
Testosterone injection 400 mg IM q24weeks administered in medical office.
Injectables administered in a medical office
are covered under the medical office
benefit, NOT the drug benefit and are not
available from a pharmacy for a copayment.
Methyltestosterone (generic Android or
Testred) tabs 10-20 mg QD-BID or
Fluoxymesterone (Halotestin) 10 mg QD
(tablets require baseline and periodic liver
function testing); Androderm 2.5mg-5mg/24
hour transdermal patches
Tevetan (Eprosartan) 400, 600mg tabs 400-800mg
QD (also available as Tevetan HCT (Tevetan and
HCTZ)
Prinivil (Lisinopril) 10 - 40mg QD or Cozaar Prinivil is preferred, if no previous ACE inhibitor
(Losartan) 25 - 100mg QD
trial. If angiotensin 2 receptor blocker is required,
convert to Cozaar. Conversion:
Tevetan 400mg=Prinivil10mg=Cozaar 25mg;
Tevetan 600mg=Prinivil 20mg=Cozaar 50mg;
Tevetan 800mg=Prinivil 40mg=Cozaar 100mg
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
Thalidomide 50mg capsules
N/A
Prescriber must contact mnfctr, Selgine, @ 1-888423-5436 to obtain authorization # which is then
written on the prescription. Prescriptions are then
filled at STEPS participating Eckerd pharmacies.
Page 63
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Tiamate (Diltiazem extended release) 120, 180,
240mg 120 - 480 mg QD
Diltia (Diltiazem) XT 120, 180, 240mg caps Substitute on a mg for mg basis.
120-480mg QD
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
Tiazac (Diltiazem extended release) 120, 180, 240,
300, 360mg 120 - 540mg QD
Diltia (Diltiazem) XT 120, 180, 240mg caps Substitute on a mg for mg basis. Convert Tiazac
120-480mg QD
300mg to Diltia XT 240mg or 360mg (#2 x 180mg)
Tiazac 480mg convert to Diltia XT 480mg (#2 x
240mg cap) TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
Ticlid (Ticlopidine) 250mg BID
Aggrenox (dipyridamole/asa) 25/200mg BID
(if CVA)
Or, Plavix 75mg QD (if
cardiac stent, PTCA, MI or if CVA and ASA
intolerant)
N/A
Tikosyn (Dofetilide) 125-500mcg capsules BID
Aspirin therapy remains first line option.
Formulary alternatives are available for patients
who have failed aspirin trial or who are not
candidates for aspirin trial.
Tikosyn is available at specific Eckerd
pharmacies. Call 1-877-TIKOSYN to locate the
nearest Eckerd pharmacy. The Eckerd
pharmacist will verify that the prescriber is
documented in the database as participating in
the TIKOSYN educational distribution program.
Tilade (Nedocromil) 2 puffs QID
QVAR (Beclomethasone HFA) 40mcg/puff Inhaled corticosteroid QVAR preferred
oral inhaler, i-ii puffs BID -OR- Flovent
(Fluticasone) 44mcg/puff oral inhaler, i - ii
puffs BID -OR- Intal (Cromolyn) 2 puffs QID
Timoptic-XE (Timolol gel forming soln) 0.25-0.5% i
drop in affected eye(s) QD
Timoptic ophth sol'n 0.25-0.5% i drop in
affected eye(s) BID
Tindamax (Tinidazole) 250mg, 500mg tablets
Metronidazole tablets
Tolectin (Tolmetin) 200, 300, 600mg caps 200 600mg TID
Timoptic XE (gel forming solution allows QD
administration with equivalent efficacy) is non
formulary, timolol ophthalmic solution (BID
administration initially, in some patients physician
may reduce to QD when IOP stable) is formulary.
If physician requests alternative beta blocker:
Betoptic (Betaxolol) 0.25-0.5% i drop BID or
Betagan (Levobunolol) 0.25-0.5% i drop BID are
also formulary
Equal efficacy with metronidazole in treatment of
non-metronidazole resistant trichomoniasis or
giardiasis
Ibuprofen (generic Motrin) tabs 600-800 mg Additional formulary alternatives: Diclofenac
TID or Salsalate (Disalcid)1500mg BID or
(Voltaren) 75mg BID or Choline Magnesium
Naproxen 500mg BID or Sulindac (Clinoril) Trisalicylate (Trilisate) 750mg BID-TID or
200mg BID
Nambumetone (Relafen) 500mg or 750mg 1-2 QDBID or Etodolac (Lodine) 200mg-500mg Q8-12H
up to 1200mg/day or Indomethacin 25-50mg TID
or Mobic (Meloxicam) 7.5mg or 15mg.
Page 64
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Topamax tablet
Seizure formulary alternatives - Tegretol,
Neurontin, Lamictal, Depakote, Depakene,
Keppra [R], Trileptal [R]
Triamcinolone (generic Aristocort, Kenalog)
cream, oint 0.1% or Valisone
(Betamethasone Valerate) 0.1% lotion or
Locoid Lipocream (Hydrocortisone Butyrate)
0.1% apply to affected area BID
Topamax is restricted to Neurology. Please
consider half tablets when prescribing.
Lidex (Fluocinonide) 0.05% cream, oint, gel,
soln or Diprolene AF (Augmented
Betamethasone) 0.05%
Ibuprofen (generic Motrin) 600-800 mg TID
or Acetaminophen w/codeine (generic
Tylenol #3) i-ii Q6H
High potency topical corticosteroids.
Ibuprofen 800 mg TID PRN or Naproxen
250-500 mg Q6-8H or sulindac (Clinoril)
200mg BID or diclofenac (Voltaren) 75mg
BID or Relafen 500mg tab #2 QD - BID or
etodolac (Lodine) 200-500mg Q8-12H up to
1200mg/day or Mobic (Meloxicam) 7.5mg or
15mg.
Due to the risk of renal failure and GI bleeding,
ketorolac tablets should not be administered more
than 5 days. Ketorolac tablets are FDA approved
for use after ketorolac injection only.
Topicort (Desoximetasone) 0.05% cream
Topicort (Desoximetasone) 0.25% cream, oint or
0.05% gel
Toradol (Ketorolac) tab 10 mg Q6H
Toradol (Ketorolac) tab 10mg Q4-6H prn
Locoid lipocream is restricted to Dermatology.
If failed other alternatives, consider increasing
steroid potency to Fluocinonide (Lidex) 0.05%
cream, oint, or gel.
Due to the risk of renal failure and GI bleeding,
ketorolac tablets should not be administered more
than 5 days. Ketorolac tablets are FDA approved
for use after ketorolac injection only.
Transderm-Nitro (Nitroglycerin) transdermal patch 0.1, Minitran (Nitroglycerin) transdermal 0.1, 0.2, Nitro-Dur 0.3 and 0.8mg/hr patches are covered,
0.2,0.3, 0.4, 0.6, 0.8mg/hr patches
0.4, 0.6mg/hr patches
since Minitran is not available in these 2
strengths.
Tranxene-SD (Clorazepate) 11.25mg, 22.5mg QD
Clorazepate (generic Tranxene) 3.25, 7.5,
15mg TID
Tranxene-SD 11.25mg QD = Clorazepate 3.25mg
TID; Tranxene-SD 22.5mg QD = Clorazepate
7.5mg TID
Travatan (Travaprost) 1 drop in affected eye QHS
Lumigan (Bimatoprost) 0.03% ophth
solution 1 drop in affected eye QHS
Prostamide analog to reduce IOP in glaucoma.
Not recommended to dose Travatan or Lumigan
more frequently than qd. Separate administration
from other eye drops by at least 5 minutes.
Triamcinolone acetonide (generic Kenalog or
Aristocort) 0.5% cream, oint
Lidex (Fluocinonide) 0.05% cream, oint, gel High potency topical corticosteroids.
or Diprolene AF (Augmented
Betamethasone) 0.05%
Tricor (all formulations and doses 48mg to 200mg
QD)
Fenofibrate 160 mg QD or 54 mg QD. If pt
on Tricor dose < 100mg daily, convert to
54mg dose, if on dose > 100mg daily
convert to 160mg QD.
Fenofibrate preferred if pt also taking statin. If
pt has reduced renal function, consider offering
gemfibrozil 600mg BID which is safer per kidney
guidelines. Cost of fenofibrate and gemfibrozil
similar. For questions, consider calling Pharmacy
Cardiac Risk Service at 770-496-3560 between
830AM and 530PM.
Trileptal (Oxcarbazepine) tabs or liquid
Tegretol (carbamazepine), Neurontin
(gabapentin), Topamax (topiramate),
Tranxene (clorazepate), Lamotrigine 525mg chews and Lamictal 100mg-200mg
oral tablets
Trileptal is restricted to Neurology and
Behavioral Health for the initial prescription
fill. Reserved for patients with a good therapeutic
response to Carbamazepine, but poor tolerability
or drug interactions with Carbamazepine. Lamictal
25mg oral tablets are non-formulary as of 3/22/07;
if a 25mg dose is required, Lamotrigine chewables
are preferred.
Page 65
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Tri-Luma (Fluocinolone Acetonide 0.01%,
Hydroquinone 4%, Tretinoin 0.05%) cream
N/A
Drugs for cosmetic use are NOT covered on
drug benefit. Member pays retail price. If
prescribed along with Differin, Retin A, or Avita
creams, they also are not covered as they are
being used as cosmetic therapy.
Trinalin (1mg Azatadine / 120mg Pseudoephedrine)
repetab i Q12H
OTC Chlor-Trimeton 12-hour Relief i tablet
BID or OTC Drixoral Cold & Allergy i tablet
BID
All cough and cold medications are non-formulary
with the exception of Codeine, Hydrocodone, and
Promethazine containing products.
Tri-Nasal (Triamcinolone) nasal spray
Nasarel ii sprays each nostril BID or generic Please document failure of both Nasarel & generic
Flonase (fluticasone) i spray each nostril
Flonase (fluticasone) before prescribing/approving
QD
a NF product.
Triphasil (0.05mg Levonorgestrel/ 30mcg EE x 6 days, Tri-Levlen (0.05 Lvngl/30mcg EE x 6 days,
0.075mg Lvngl/ 40 mcg EE x 5 days, 0.125mg
0.075mg Lvngl/40mcg EE x 5 days,
Lvngl/30mcg EE x 10 days)
0.125mg Lvngl/30mcg EE x 10days)
Document at least 3 formulary alternatives
before prescribing/approving a NF product.
Trivora-28 (0.05mg Levonorgestrel/ 30mcg EE x 6
days, 0.075mg Lvngl/ 40 mcg EE x 5 days, 0.125mg
Lvngl/30mcg EE x 10 days)
Tri-Levlen (0.05 Lvngl/30mcg EE x 6 days,
0.075mg Lvngl/40mcg EE x 5 days,
0.125mg Lvngl/30mcg EE x 10days)
Document at least 3 formulary alternatives
before prescribing/approving a NF product.
Trusopt (Dorzolamide) 2% ophth soln i drop in
affected eye TID
Tussionex (Chlorpheniramine 8mg and Hydrocodone
10mg) suspension
Azopt (Brinzolamide) 1% ophth susp i drop
in affected eye TID
Phenergan syrup, Phen. VC with Codeine,
Phen with codeine; Robitussin AC or
Robitussin DAC; Hycodan tablets (not
syrup) or OTC products
.
Tympagesic (5% Benzocaine, 5% Antipyrine, 0.25%
Phenylephrine, propylene glycol) Otic drops
Auralgan Otic (1.4% Benzocaine, 5.4%
Antipyrine, Glycerin)
N/A
Tysabri (natalizumab) once every 4 weeks in a dose
of 300 mg diluted in 100 ml Normal Saline given
intravenously over about one hour
Must go through through manufacturer's
TOUCH program and then meet QRM
criteria.
Ultracet (Tramadol 37.5mg/APAP 325mg) Q4-6H
Tramadol 50mg Q 4 - 6 hours PLUS OTC
Acetaminophen 325mg Q 4 - 6 hours
Ultrase (Pancrelipase enzymes)
Pancrease (Pancrelipase enzymes) or
Pangestyme
Diprolene (Augmented Betamethasone
Dipropionate) 0.05% oint or Temovate
(Clobetasol) 0.05% cream, oint, gel, scalp
soln
generic Theo-Dur tab 200 mg BID
generic Theo-Dur tab 300 mg BID
Prinivil (Lisinopril) 5mg - 40mg QD and
HCTZ 12.5mg - 25mg QD
Ultravate (Halobetasol) 0.05% cream, oint
Uniphyl T.R. tab 400 mg QD
Uniphyl T.R. tab 600 mg QD
Uniretic (Moexipril/HCTZ) 7.5/12.5 and 15/25mg
Page 66
Phenergan VC (promethazine, phenylephrine,
codeine); Robitussin AC (guaifenesin, codeine);
Robitussin DAC (Guaifenesin, codeine,
pseudoephedrine); Hycodan tabs
(hydrocodone/homatropine) OR OTC products
Criteria Restricted Medication Natalizumab
should usually be reserved for use in patients who
have had an inadequate response to other MS
therapies or patients who are not able to tolerate
other MS therapies. Patients who are stable and
well-controlled on other MS therapies should not
be changed to natalizumab.
Acetaminophen w/codeine (generic Tylenol #3) i-ii
Q6H or NSAID.
Pangestyme is a generic of Pancrease
Very high potency topical corticosteroids.
N/A
N/A
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
Dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Univasc (Moexipril) 7.5, 15mg tabs 7.5 - 30mg QD
Prinivil (Lisinopril) 5mg - 40mg QD
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
Urised tablet
Usept or Urinary Antiseptic #2 which are
Methenamine compound (generic Urised)
May be substituted tablet for tablet without calling
practitioner.
Urispas (Flavoxate) tabs
Ditropan (Oxybutynin) tablets or Oxytrol
patch
Doxazosin (generic Cardura) titrated to
therapeutic doses (e.g. Doxazosin 2mg 1/2
tab po QHS X 1 week, then 1 tab po QHS x
2 weeks, then 2 tabs po QHS and follow-up
w/MD for refill) or Terazosin (generic Hytrin)
titrated slowly to therapeutic doses. (eg.
1mg QHS days 1-3, 2mg QHS days 4-15
then 5mg QHS, if necessary may further
increase to 10mg QHS
.
Uroxatral (Alfuzosin) 2.5mg IR QID; 5mg ER BID or
10mg ER QD
Both agents are alpha-1 adrenoceptor antagonists
and are capable of producing first-dose orthostatic
hypotension. When initiating therapy, dose
titration will help minimize orthostatic hypotension
risk.
Uticort (Betamethasone Benzoate) 0.025% cream
Triamcinolone (generic Aristocort, Kenalog) If failed other alternatives, consider increasing
cream, oint 0.1%
steroid potency to fluocinonide (Lidex) 0.05%
cream, oint, or gel
Vagifem (25.8mcg Estradiol vaginal tablets)
Premarin vaginal cream 1/2 to 2 grams
inserted vaginally daily to several times
weekly
Triamcinolone (generic Aristocort) cream,
oint 0.1% or Valisone (betamethasone
valerate) 0.1% lotion
Valisone (Betamethasone Valerate) 0.1% cream
.
If failed other alternatives, consider increasing to
high potency topical corticosteroid fluocinonide
(Lidex) 0.05% cream, oint, or gel
Lidex (Fluocinonide) 0.05% cream, oint, gel, High potency topical corticosteroids.
soln or Diprolene AF (Augmented
Betamethasone) 0.05%
Valisone reduced strength (Betamethasone Valerate) Hydrocortisone 2.5% cream, oint or lotion
Hydrocortisone 0.5-1% is available OTC
0.01% cream
Valacyclovir is broken down into Acyclovir by the
Valtrex (Valacyclovir) 500mg tab Herpes Zoster 1000 Herpes zoster Acyclovir 800mg Q4H, 5
body.
mg TID x 7 days; recurrent genital herpes 500 mg BID times daily x 7 days (10 days if
immunocompromised); genital herpes
Herpes Labialis: consider OTC Abreva, Carmex or
x 5 days
Orabase or oral Acyclovir if unresponsive to OTC
acyclovir 400mg TID x 7-10 days (5 days
when tx recurrence, may use 800mg BID x therapy.
5 days for recurrence); chronic suppressive
therapy 400mg BID, titrate to lowest
effective suppressive dose
Vancenase (beclomethasone) nasal inhaler (pts ≥6
Nasarel ii sprays each nostril BID or generic If the child is less then 4 years old, Nasonex may
warrant approval as Nasarel is not indicated for
yrs old)
Flonase (fluticasone) i spray each nostril
QD
patients less than 6 years old & Flonase is not
indicated in patients less than 4 years old.
Valisone (Betamethasone Valerate) 0.1% ointment
Vanceril oral inhaler ii-iiii puffs BID-TID
QVAR (Beclomethasone HFA) 40mcg/puff
oral inhaler, i-ii puffs BID.
Page 67
QVAR is twice as potent as Vanceril (2 puffs
42mcg/puff = 1 puff QVAR 40 mcg/puff) and
equipotent to Flovent 44mcg (1 puff QVAR 40mcg
= 1 puff Flovent 44mcg/puff). QVAR remains the
preferred inhaled corticosteroid at KP GA.
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Vaniqa (Eflornithine) 13.9% cream
N/A
Drugs for cosmetic use are NOT covered on
drug benefit. (Vaniqa removes unwanted facial
hair.) Member pays retail price.
Vanlev (Omapatrilat) 10 - 80mg QD [dual
vasopeptidase (metalloprotease) inhibitor--ACEI and
neutral endopeptidase inhibitor]
CHF dose: 10 40mg QD
HTN dose: 20 - 80mg QD
Lisinopril 20 - 80mg QD (one trial compares
lisinopril 20mg to Vanlev 20-40mg) may
consider adding HCTZ 12.5mg QD to
maintain dual mechanism of action provided
by Vanlev; lisinopril/HCTZ 10/12.5, 20/12.5
or 20/25mg or Cozaar 25 - 100mg QD
No dual vasopeptidase alternative on formulary.
Prinivil (ACEI) is closest mechanistic alternative
with or without HCTZ. Conversion dose should be
individualized and adjusted to patient response.
Vanos (fluocionide)
Lidex (anhydrous fluocinonide cream); LidexE (aqueous fluocinonide cream)
Vantin (Cefpodoxime) suspension
Omnicef 125mg/5ml; Pediazole
.
(Erythromycin & Sulfamethoxazole);
Augmentin 125-250mg/5ml or 200-400mg
chew tabs;Amoxicillin 125-250mg/5ml;
Biaxin 125-250mg/5ml; Cefaclor suspension
Vaseretic tablet 10-25 mg ii tablets QD
Lisinopril/HCTZ 20/25mg QD
Two individual prescriptions are required.
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
Dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
Vaseretic tablet 10-25 mg QD
Lisinopril/HCTZ 10/12.5mg, 20/12.5mg,
20/25mg QD
Two individual prescriptions are required.
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
Vaseretic tablet 5-12.5 mg QD
Lisinopril/ HCTZ 10/12.5mg 1/2-1tab QD
Two individual prescriptions are required. TSPMG
Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
Vasosulf (15% Sulfacetamide/ 0.125% Phenylephrine) 15% Sulfacetamide ophth soln AND OTC
Phenylephrine 0.12% ophth soln
Ventolin
Combination product is non formulary.
Sulfacetamide ophth soln is formulary and
phenylephrine ophth soln is over the counter.
Albuterol
Page 68
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Veramyst (Fluticasone) 27.5 mcg/inhalation
Generic Nasarel (flunisolide) ii sprays each
nostril BID or generic Flonase (fluticasone) i
spray each nostril QD or QVAR i-ii puffs BID
Verelan (Verapamil) 120, 180, 240, 360mg QD
Verapamil SR tabs (generic Calan SR) 120, Convert on a mg for mg basis.
180, 240mg tabs 120-240 mg QD
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
Verelan PM (Verapamil) 100, 200, 300mg caps 100400mg QHS
Verapamil SR tabs (generic Calan SR) 120, Conversion equivalents:
180, 240mg tabs QD
Verelan PM 100mg = Verapamil SR 120mg;
Verelan PM 200mg = Verapamil SR 180-240mg;
Verelan PM 300mg = Verapamil SR 240-360mg;
Verelan PM 400mg = Verapamil SR 360mg
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
Vesicare (Solifenacin succinate) 5mg and 10mg
tablets
Oxybutinin (generic Ditropan) 5-10 mg tab i
QD-BID (immediate release tablet) or
Oxybutynin XL (generic Ditropan XL) 515mg QD or Oxytrol patch
Vexol (Rimexolone) ophth susp 1% i-ii drops in
affected eye(s) QID
N/A
Consider at least 2 formulary products
before prescribing/authorizing a NF product:
Dexamethasone 0.1% ophth soln or
Prednisolone 0.12%-1% ophth soln or
Flarex, FML (Fluorometholone) ophth soln
0.1% i-ii drops in affected eye(s) QID
Vfend (voriconazole)
Viagra 25, 50, 100mg tabs
.
N/A
Vicon forte or Magna C-7 forte i QD
Vitamins components available OTC as:
N/A
OTC Stresstabs + Zinc i QD or OTC
Centrum Silver i QD or other OTC vitamins
Vicoprofen (7.5mg Hydrocodone/ 200mg Ibuprofen)
Hydrocodone/Acetaminophen in the
following strengths: 5mg/500mg;
7.5mg/500mg; 7.5mg/650mg, 10mg/650mg,
7.5mg/750mg AND OTC ibuprofen 200mg
If failed oxybutynin (regular and XL) consider
Detrol LA (Detrol 1mg BID is equivalent to Detrol
LA 2mg QD) If initiating Detrol therapy, the initial
recommended dose Detrol LA is 4 mg QD; may
decrease to 2 mg QD depending on tolerability
and response.
Consult with an ID specialist
Member's group must have purchased sexual
dysfunction rider for coverage. Consider Viagra
100mg 1/2 tablet when prescribing Viagra 50mg
dose to reduce patient expense.
Page 69
Generics of the following used: Lortab 7.5/500;
Lorcet plus 7.5mg/650mg; Lorcet 10mg/650mg;
Vicodin 5mg/500mg; Vicodin 5mg/500mg; Vicodin
ES 7.5mg/750mg.
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Vigamox (Moxifloxacin) 0.5%
Ofloxacin 0.3% or Gentamicin 0.3% or
Lasik ophthalmic surgery is not a covered benefit.
Tobramycin 0.3% or Sodium Sulfacetamide Medications related to non covered procedures
ophth soln or Zymar 0.3%
are not covered by the drug benefit.
Viokase (Pancrelipase enzymes)
Pancrease (Pancrelipase enzymes) or
Pangestyme
no formulary alternative
Viquin forte
Visken (Pindolol) 5, 10mg tabs 5-30mg BID
Pangestyme is a generic of Pancrease
Cosmetic use drug. Not covered on drug benefit.
Member pays full retail price.
Atenolol (generic tenormin) 25 - 100mg QD Propranolol is available as 10, 20, 40, 60, 80,
or metoprolol 100 - 400mg QD or
90mg tabs. Inderal LA is non-formulary.
propranolol 40 - 320mg BID
TSPMG Guidelines suggest:
Initial therapy: Thiazide diuretics
Two Drug Therapy: Add ACE-I to Thiazide
diuretic
Three Drug Therapy: Add Beta Blocker to ACE-I
and Thiazide diuretic
Four Drug Therapy: Add Long Acting
dihydropyridine CCB to Beta Blocker, ACE-I and
Thiazide Diuretics
Vistaril (Hydroxyzine Pamoate) cap 25-50 mg TID-QID Hydroxyzine HCl tabs (generic Atarax) 2550 mg TID-QID
Vivelle (Estradiol) transdermal patch apply twice
Climara 0.025mg, 0.0375mg, 0.05mg,
If an estrogen patch is required, Climara.
weekly 2.17mg, 3.28mg, 4.33mg, 6.57mg, 8.66mg
0.06mg, 0.075mg, 0.1mg patches apply one
patches deliver 0.025mg/day, 0.0375mg/day,
patch weekly; or Estrace 0.5, 1 or 2mg
0.05mg/day, 0.075mg/day, 0.1mg/day respectively.
(Estradiol)
If an estrogen patch is required, Climara.
NF Vivelle DOT delivers the same estradiol dose
as NF Vivelle, though actual patch size is smaller.
Vivelle and Vivelle DOT are AB rated equivalents.
NF Vivelle, not NF Vivelle DOT, may be
dispensed at KP pharmacies.
Extended release Albuterol tablets are no longer
Consider Albuterol inhaler, QVAR
(Beclomethasone) inhaler if asthma and not manufactured.
using steroid inhaler, Serevent inhaler if
long acting beta 2 agonist necessary, or
immediate release albuterol tablets.
Vivelle-DOT (Estradiol) transdermal patch apply twice Climara .025mg, 0.0375mg, .05mg, 0.06mg
.075mg, .1mg patches apply one patch
weekly 0.78mg, 1.17mg, 1.56mg, patches deliver
weekly; or Estrace 0.5, 1 or 2mg (Estradiol)
0.05mg/day, 0.075mg/day, 0.1mg/day respectively.
66% smaller patch size than Vivelle
Volmax (Albuterol extended release) tablets
Vytorin (Ezetimibe/Simvastatin) 10/10, 10/20, 10/40
(effective 9/05,Vytorin 10/80mg is formulary)
Consider trying Simvastatin (generic Zocor)
PLUS either: Cholestyramine powder OR
Cholestyramine light powder 4-8 gm BID
OR Slo-niacin OR Time-release niacin 500
mg BID OR Colestid 1gm tablets 2-4gm
BID. Cholestyramine preferred over
Colestid. The effects of Ezetimibe on
cardiovascular morbidity and mortality have
not been established. For vytorin 10-40mg
dose, consider vytorin 10-80mg tablet, 1/2
tablet po QD.
Wellbutrin SR 200mg (Bupropion)
Wellbutrin SR 150mg or Wellbutrin 75mg or Smoking cessation products are non formulary
100mg tablets.
Wellbutrin XL 150mg & 300mg QD
Wellbutrin SR (bupropion SR) 150mg or
Wellbutrin (bupropion 75mg or 100mg)
tablets
Page 70
Vytorin 10/80mg is formulary. Vytorin may be
appropriate if simvastatin 80mg QD plus niacin or
BAS was ineffective OR if pt on concurrent
medication(s) whose absorption would be
inhibited by BAS such as tranplant medications.
Vytorin is preferred over use of zetia plus statin as
separate prescriptions. All other Vytorin doses
other than 10/80 mg are non-formulary. For
questions, consider calling Pharmacy Cardiac
Risk Service at 770-496-3560 between 830AM
and 530PM.
[Wellbutrin XL: Available Part D group]
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Welchol (Colesevelam) 3 tabs BID
Consider Cholestyramine powder 4 - 8gm
QD -OR- Colestid (colestipol) 1gm tablets: 2
gm BID or 4gm QD -OR- if a statin is not
already being used, consider Lovastatin 2040mg QPM -OR- Simvastatin 20mg QHS Or- Vytorin 10/80 -OR- Zetia
Welchol is a bile acid sequestrant, reducing LDL
cholesterol by 18%. Cholestyramine/Colestipol
reduce LDL cholesterol by 30%. Statins reduce
LDL cholesterol by 30-60%. May prefer to avoid
all BAS including welchol for pts on cyclosporine
or HIV meds. Welchol may have less binding
effects than other BAS. BAS therapy may be
preferred over statin for patients with very
elevated liver tests. Consider adding OTC SloNiacin 500mg QD titrated to BID to statin before
adding BAS, if appropriate for pt. For questions,
consider calling Pharmacy Cardiac Risk Service
at 770-496-3560 between 830AM and 530PM.
Westcort (Hydrocortisone valerate) cream, oint 0.2%
apply to affected are BID [medium potency]
Triamcinolone (generic Aristocort, Kenalog) If failed other alternatives, consider increasing to
cream, oint 0.1%
high potency topical corticosteroid fluocinonide
(Lidex) 0.05% cream, oint, or gel
Xalatan ophth sol'n 1 drop in affected eye QD - BID
Lumigan (Bimatoprost) 0.03% ophth
solution 1 drop in affected eye QHS
Xenical cap 120 mg TID
N/A
Agents for weight loss or obesity are not covered.
Patient pays full retail price.
Xifaxan (Rifaximin) 200mg #2 BID x 3 days for
travelers' diarrhea
For Travelers' Diarrhea: Ciprofloxacin
500mg BID x 3 days
.
Xolair (Omalizumab) injectable
(not self
administered, to be provided by physician in office)
Criteria Restricted Medication
Criteria Restricted Medication. Provider phone
KP QRM 404-364-7320 to request authorization
consideration.
Xopenex inhalation solution 0.625 mg TID-QID via
nebulizer
Albuterol inhalation solution 2.5 mg TID-QID N/A
via nebulizer
Xylocaine 2% jelly
Lidocaine topical gel (per chronic pain
guideline) or OTC L-M-X4 (4% topical
lidocaine cream) or OTC Lidosense 4 (4%
topical lidocaine cream) or OTC Axsain
cream (4% lidocaine combined with 0.25%
capsaicin cream)
Prostamide analog to reduce IOP in glaucoma.
Lumigan is not as effective when administered
more often than QD. Convert Xalatan 1 drop BID
to lumigan 1 drop QD. separate Lumigan from
administration of other eye drops by at least 5
minutes.
Xanax XR 0.5mg, 1mg, 2mg or 3mg tablets QD
alprazolam 0.25mg, 0.5mg, 1mg, 2mg
When converting, Xanax XR once daily is
equivalent to the same total daily dose of
alprazolam (generic Xanax) immediate-release
administered in divided doses TID (e.g. Xanax
XR 2mg would convert to alprazolam 0.5mg TID QID)
Unless converting from an equivalent dose of an
Xatral (Alfuzosin) 7.5 - 10mg divided into 3 daily doses Doxazosin (generic Cardura) titrated to
(alpha 1 adrenergic blocker)
therapeutic doses (e.g. Doxazosin 2mg 1/2 alpha adrenergic blocker, titrate Terazosin slowly
tab po QHS X 1 week, then 1 tab po QHS x to therapeutic doses.
2 weeks, then 2 tabs po QHS and follow-up
w/MD for refill) or Terazosin (generic Hytrin)
titrated slowly to therapeutic doses. (eg.
1mg QHS days 1-3, 2mg QHS days 4-15
then 5mg QHS, if necessary may further
increase to 10mg QHS
Page 71
N/A
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Xyzal (Levocetirizine) tablets
Claritin OTC or Zyrtec OTC
Intranasal steroids (Nasarel ii sprays per nostril
BID or generic Flonase (fluticasone) i spray each
nostril QD) more effective than nonsedating
antihistamines for allergic rhinitis.
Yasmin 28 (3 mg Drospirenone/ 30 mcg EE)
Sprintec, generic Ortho-Cyclen, (0.25mg
Norgestimate/ 35 mcg EE) or Zovia 1/35
(Ethynodiol 1mg/35mcg EE)
Levlen (0.15 Levonorgestrel/ 30 mcg EE) or
Microgestin 1.5/30 (1.5 Norethindrone/30mcg EE)
or Tri-Levlen (0.05mg Levonorgestrel & 30mcg
EE x 6 days, 0.075mg Lvngl & 40mcg EE x 5
days, 0.125mg Lvngl & 30mcg EE x 10 days) or
Brevicon (.5mg ne/ 35EE), Microgestin 1/20 (1
NE/20mcg EE), Zovia1/35 (Ethynodiol 1mg/35
EE), Norinyl 1/35 (1mg NE/ 35mcg EE) Norinyl
1/50 (1mg NE/ 50mcg Mestranol), or NORQD
(0.35 NE only) Document diagnosis (If PCOS is
the reason for the request then benefit
coverage may be extended).
Zaditor (ketotifen) .025% ophth soln
For allergic conjunctivitis: OTC Opcon-A
(Pheniramine & Naphazoline) or OTC
Zaditor 0.25% [NOTE: OTC products are
not a covered benefit]
OTC Zaditor 0.25% and Patanol are both dual
action antihistamine/mast cell stabilizers, are
dosed twice daily, and have the same FDA
approved indications. If treating steroid
responsive inflammatory condition consider at
least 2 formulary products before
prescribing/authorizing a NF product :
Dexamethasone 0.1% ophth soln or Prednisolone
0.12%-1% ophth soln or Flarex, FML
(Fluorometholone) ophth soln 0.1% i-ii drops in
affected eye(s) QID
Zegerid (Omeprazole) powder for oral suspension
20mg
Prilosec OTC
OTC Prilosec 20mg tablet. (If cannot
swallow tablet, OTC prilosec will disperse in
5cc of water in less than 60 seconds with
gentle agitation. Dose should be taken
immediately after dispersal in liquid.)
Zelnorm (Tegaserod) 2mg BID 5HT4 agonist [also
branded zelmac]
Lactulose 3 tablespoonsful QD to TID OR
OTC Miralax (Polyethylene glycol powder
for oral solution) 17gm in 8 ounces of water
QD OR other OTC bulk forming laxatives
for constipation
Zestril (Lisinopril)
Lisinopril (generic prinivil)
Page 72
Miralax is now available OTC. OTC products are
not a covered benefit. Prescribers are encouraged
to to consider OTC options if appropriate. Zelnorm
used for shortterm treatment of women with
irritable bowel syndrome and primary symptom
constipation. (Zelnorm available MMA group)
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Comments
Zetia (Ezetimibe) 10mg QD tablet
OTC Slo-Niacin/ Time Release niacin
500mg OR cholestyramine powder 4 - 8gm
BID OR Colestid (colestipol) 1gm tablets 24gm BID OR if a statin is not already being
used, consider Lovastatin 20-40mg QPM
OR Simvastatin 20mg QHS
Zetia monotherapy may be appropriate only if
pt has intolerance to MULTIPLE statins. Note
that zetia is not recommended to use in
combination with gemfibrozil. The effects of
Ezetimibe on cardiovascular morbidity and
mortality have not been established. Zetia is
expected to lower LDL 15 -20% compared to
statins that can lower LDL 30-60%. Zetia is no
more effective than BAS therapy in lowering
cholesterol. Adding Zetia to statin therapy may be
appropriate if max dose statin plus niacin or BAS
was ineffective OR if pt is not appropriate
candidate for niacin or BAS OR if pt has
intolerance to simvastatin or Vytorin. Vytorin is
preferred over use of zetia plus statin as separate
prescriptions. All other Vytorin doses other than
10/80 mg are non-formulary. For questions,
consider calling Pharmacy Cardiac Risk Service
at 770-496-3560 between 830AM and 530PM.
Zoloft (Sertraline) tab 25-100 mg QD
Prozac caps 10-40 mg QD or Celexa
(Citalopram) 20-40mg QD or Sertraline 25 100mg QD (added to formulary Mar 8th
2007)
Prozac is the preferred agent. Initiation of lowdose Prozac with dosage titration to desired
response is suggested. Document response to
all formulary SSRI alternatives before
prescribing a NF SSRI. Document reason,
when patient is medically unable to convert to
Formulary alternative.
Zofran (Ondansetron) tabs 4mg-8mg BID & Zofran
(ondansetron) ODT 4mg-8mg
Limited to 14 day supply per prescription,
per 30 days
Zofran oral liquid & IV available via pediatric
floorstock for in office dose to break pediatric n/v
cycle & allow hydration in children unable to use
phenergan safely (</= 2 yoa)
Zomig (Zolmitriptan) 2.5-5 mg tab prn for migraine
headache
Maxalt (Rizatriptan) MLT 10mg tablet
(Maxalt MLT 5mg tablet is also available)
Maxalt MLT 10 mg is preferred, Maxalt MLT QTY
limit of 9 tablets/copay. If failed a trial on Maxalt
MLT consider formulary alternative Imitrex 50 mg
tablets (qty limit of 9 tablets/copay), nasal, or
injectable dosage forms. Quantity limit for Nonformulary Zomig 5mg is 3 tablets per copay; for
Zomig 2.5mg it's 6 tablets per copay.
Zomig (Zolmitriptan) 5mg Nasal Spray
Maxalt (Rizatriptan) MLT 10mg orally
disintegrating tablet (Maxalt MLT 5mg
tablet is also available) QTY limit of 9
tablets/copay
OR, if
nasal spray required, Imitrex 20mg Nasal
Spray
Neurontin (gabapentin), Topamax
(topiramate), Tranxene (clorazepate),
Tegretol (carbamazepine), Lamotrigine 525mg chews and Lamictal 100mg-200mg
oral tablets
Imitrex 20 mg nasal spray is significantly more
effective than Imitrex 5 mg nasal spray. The
same precautions and contraindications apply for
both strengths of nasal spray. Maximum
prescription quantity for Imitrex 20 mg spray is 6
bottles/prescription.
Adjunctive therapy for partial seizures in adults >
16 yrs of age. Lamictal 25mg oral tablets are nonformulary as of 3/22/07; if a 25mg dose is
required, Lamotrigine chewables are preferred.
Zonegran (Zonisamide) tab
Page 73
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
Zovirax 5% ointment 6 times per day x 7 days
Zyban (Bupropion SR) 150mg
TSPMG clinical practice resource
encourages treatment with oral Acyclovir
(generic Zovirax) tab. 1st episode Herpes
simplex: 400mg TID x 7-10 days,
recurrence 800mg BID x 5 days,
suppression 400mg BID titrate to lowest
effective dose. Herpes Zoster: acyclovir
800mg 5 times per day x 7-10 days.
Principles and Practice of Infectious Disease
"discourages use of topical acyclovir" stating that
it "offers no significant clinical benefit in HSV
infections" Acyclovir ointment is ineffective in
treatment or prevention of herpes labialis.
Consider OTC Abreva ( shortened the course by
18 hours) or Carmex or Orabase for herpes
labialis to prevent drying and fissuring. Domoboro
soaks may relieve itching and dry blisters.
Consider OTC Capsaicin cream for pain
associated with shingles.
OTC Nicotrol (Nicotine transdermal system) Smoking cessation products are non formulary
5, 10, 15mg/day
Zyflo tab 600 mg QID
ICS inhaler (QVAR or *Flovent or
Asmanex) plus a long acting B2-agonist
(Serevent) OR an ICS and B2 agonist
Zylet (loteprednol etabonate 0.5% / tobramycin 0.3%) Tobramycin 0.3% ophth drops PLUS either:
ophthalmic suspension
Dexamethasone 0.1% ophth soln or
Prednisolone 0.12%-1% ophth soln or
Flarex, FML (Fluorometholone) ophth soln
0.1% i-ii drops in affected eye(s) QID
Zyprexa zydis (Olanzapine) orally disintegrating tabs
5, 10, 15, 20mg
Zyrtec tab 5 -10 mg QD
Comments
*Flovent 110mcg/puff & 220mcg/puff are nonformulary .
Post op inflammation (when steroids not desired):
Voltaren 0.1% ophth soln [Loteprednol 0.5%
(Lotemax) less effective than Prednisolone
Acetate 1% in treatment of acute anterior uveitis]
Seroquel (quetiapine) or Zyprexa
(olanzapine) 2.5, 5, 7.5, 10, 15mg tabs or
Risperdal (risperidone)
Consider using 1/2 tablet dosing whenever
appropriate (eg. Seroquel 200mg 1/2 tablet for
Seroquel 100mg dose or Risperdal 1mg 1/2 tablet
for Risperdal 0.5mg dose.)
Claritin and Zyrtec available OTC. Nasarel ii Intranasal steroids (Nasarel or Flonase) more
effective than nonsedating antihistamines for
spray per nostril BID or generic Flonase
allergic rhinitis.
(fluticasone) 1SP EN QD
Zyrtec-D 5/120MG
Claritin D and Zyrtec D available OTC.
Nasarel ii spray per nostril BID or generic
Flonase (fluticasone) 1SP EN QD
Intranasal steroids (Nasarel or Flonase) more
effective than nonsedating antihistamines for
allergic rhinitis. Zyrtec-D is excluded from the
benefit because pseudoephedrine is available
OTC.
Zyrtec syrup
Claritin and Zyrtec syrups available OTC.
Intranasal steroids (Nasarel or Flonase) more
effective than nonsedating antihistamines for
allergic rhinitis.
zzPrepared: February 8, 1998
zzUpdated: April 10, 2000
zzUpdated: August 18, 1999
zzUpdated: August 18, 1999
zzUpdated: December 7, 1999
zzUpdated: July 25, 2001
zzUpdated: August 14, 2001
zzUpdated: September 13, 2001
zzUpdated: October 31, 2001
zzUpdated: November 21, 2001
zzUpdated: January 8, 2002
zzUpdated: April 10, 2002
zzUpdated: April 22, 2002
zzUpdated: June 19, 2002
zzUpdated: July 22, 2002
zzUpdated: September 13, 2001
zzupdated: December 11, 2002
zzUpdated: January 8, 2003
zzUpdated: March 26, 2003
Beth Barham, Pharm.D.
Theresa Betteker, Pharm.D
Beth Barham, Pharm.D.
Beth Barham, Pharm.D.
Beth Barham, Pharm.D.
Debbi Baker, Pharm. D.
Debbi Baker, Pharm. D.
Debbi Baker, Pharm. D.
Debbi Baker, Pharm. D.
Debbi Baker, Pharm. D.
Beth Barham, Pharm.D.
Debbi Baker, Pharm. D.
Debbi Baker, Pharm. D.
Debbi Baker, Pharm. D.
Debbi Baker, Pharm. D.
Debbi Baker, Pharm. D.
Debbi Baker, Pharm. D.
Debbi Baker, Pharm. D.
Debbi Baker, Pharm. D.
Page 74
Non-formulary conversion document 02.08.xls
Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List
Non-Formulary, Restricted Formulary, NF Formulary Alternative(s)
No Initial Fill & Criteria Restricted
Medications (CRMs require QRM review)
zzUpdated: July 11, 2003
zzUpdated: July 18, 2003
zzUpdated: September 26, 2003
zzUpdated: October 22, 2003
zzUpdated: November 12, 2003
zzUpdated: December 2, 2003
zzUpdated: February 10, 2004
zzUpdated: February 27, 2004
zzUpdated: March 15, 2004
zzUpdated: April 19, 2004
zzUpdated: May 14,2004
zzUpdated: July 13, 2004
zzUpdated: September 15, 2004
zzUpdated: October 19, 2004
zzUpdated: November 12, 2004
zzUpdated: December 20, 2004
zzUpdated: January 25, 2005
zzUpdated: February 15, 2005
zzUpdated: March 31, 2005
zzUpdated: May 20,2005
zzUpdated: June 7, 2005
zzUpdated: July 7, 2005
zzUpdated: July 11, 2005
zzUpdated: July 21, 2005
zzUpdated: August 15,2005
zzUpdated: August 25, 2005
zzUpdated: September 14,2005
zzUpdated: September 21,2005
zzUpdated: September 27,2005
zzUpdaated: January 25, 2006
zzUpdated: March 1, 2006
zzUpdated: June ***, 2006
zzUpdated: August 21, 2006
zzUpdated: December 7, 2006
zzUpdated: February 21, 2007
zzUpdated: March 16, 2007
zzUpdated: May 29, 2007
zzUpdated: August 22, 2007
zzUpdated: December 5, 2007
zzUpdated: February 25, 2008
Comments
Debbi Baker, Pharm. D.
Debbi Baker, Pharm. D.
Debbi Baker, Pharm. D.
Debbi Baker, Pharm. D.
Debbi Baker, Pharm. D.
Debbi Baker, Pharm. D.
Debbi Baker, Pharm. D.
Debbi Baker, Pharm. D.
Debbi Baker, Pharm. D.
Debbi Baker, Pharm. D.
Debbi Baker, Pharm. D.
Debbi Baker, Pharm. D.
Debbi Baker, Pharm. D.
Debbi Baker, Pharm. D.
Debbi Baker, Pharm. D.
Debbi Baker, Pharm. D.
Debbi Baker, Pharm. D.
Debbi Baker, Pharm. D.
Debbi Baker, Pharm. D.
Debbi Baker, Pharm. D.
Debbi Baker, Pharm. D.
Debbi Baker, Pharm. D.
Elizabeth Flores, Pharm.D.
Elizabeth Flores, Pharm.D.
Phyllis Lockridge, Pharm.D.
Jacinda Byrd-Smith, Pharm. D.
Debbi Baker, Pharm. D.
Phyllis Lockridge, Pharm.D.
Phyllis Lockridge, Pharm.D.
Phyllis Lockridge, Pharm.D.
Phyllis Lockridge, Pharm.D.
Pat daCosta, Pharm.D.
Pat daCosta, Pharm.D.
Pat daCosta, Pharm.D.
Pat daCosta, Pharm.D.
Pat daCosta, Pharm.D.
Pat daCosta, Pharm.D.
Charnelda Gray, Pharm.D., BCPS
Charnelda Gray, Pharm.D., BCPS
Dionne Maddox, Pharm.D.
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