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Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Comments Acanya (Clindamycin/Benzoyl Peroxide) 1.2/2.5% Gel AAA BID 1) Clindamycin 1% Gel AAA BID AND OTC Benzoyl Peroxide 5% Gel AAA BID 2) Erythromycin/Benzoyl Peroxide 3/5% Gel AAA BID Dispense Clindamycin as 1 copay and purchase OTC Benzoyl Peroxide Accolate (Zafirlukast) 10, 20mg Tablet BID 1) Montelukast 10mg QHS 2) Qvar 40-80mcg 1-2 PUFFS QD-BID 3) Flovent HFA 44mcg 2 PUFFS BID NOTE: Flovent HFA 44mcg for patients 4-11 years of age 4) Zafirlukast 10-20mg BID NF Document adequate therapeutic trial or intolerance to Montelukast, Zafirlukast, and an Inhaled Corticosteroid within the past 3 months *Patients should have prescription for a ShortActing Beta 2 Agonist (e.g. Proair) for asthma exacerbations Accu-Check Glucometer and Test Strips One Touch Ultra 2 Glucometer and One Touch Ultra Test Strips 1) Lisinopril 20-40mg QD 2) Benazepril 20-40mg QD Dose Conversion 3) Enalapril 10-40mg QD 4) Captopril 25-100mg TID Quinapril 5mg=Lisinopril 5mg / Quinapril 10mg=Lisinopril 10mg / Quinapril 20mg=Lisinopril 5) Ramipril 2.5-20mg QD 20mg / Quinapril 40mg=Lisinopril 40mg Accupril (Quinapril) 5, 10, 20, 40mg Tablet QD Accuretic (Quinapril/HCTZ) 20/12.5, 20/25mg Tablet 2 Separate Medications QD HCTZ QD AND 1) Lisinopril 20-40mg QD 2) Benazepril 20-40mg QD 3) Enalapril 10-40mg QD 4) Captopril 25-100mg TID 5) Ramipril 2.5-20mg QD Dose Conversion Quinapril 20mg=Lisinopril 20mg NOTE: Consider Lisinopril/HCTZ 20/12.5, 20/25mg Aceon (Perindopril) 4, 8mg Tablet QD Dose Conversion Aceon 4mg=Lisinopril10mg / Aceon 8mg=Lisinopril 40mg 1) Lisinopril 10-40mg QD 2) Benazepril 20-40mg QD 3) Enalapril 10-40mg QD 4) Captopril 25-100mg TID 5) Ramipril 2.5-20mg QD Acetasol HC (Acetic Acid/Hydrocortisone) 2/1% Otic 1) Neomycin/Polymyxin/Hydrocortisone 1% Solution 3-5 GTTS Q4-6H Suspension 1-2 GTTS Q4 HOURS 2) Neomycin/Polymyxin/Dexamethasone 0.1% Ophthalmic Suspension 1-2 GTTS Q4 HOURS 3) Acetic Acid 2% Solution 1-2 GTTS Q4-6 HOURS Aciphex (Rabeprazole) 20mg Tablet QD 1) Pantoprazole 40mg QD 2) OTC Omeprazole 20mg QD 3) OTC Zegerid 20/1100mg QD 4) OTC Prevacid 15mg QD Aclovate (Alclometasone Dipropionate) 0.05% Low Potency Cream, Ointment AAA BID-TID Low Potency 1) Betamethasone Valerate 0.1% Lotion AAA QD-BID 2) Desonide 0.05% Cream, Ointment AAA BID-TID 3) Fluocinolone Acetonide 0.01% Solution AAA QD 4) Derma-Smoothe/FS 0.01% Oil AAA QD Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BIDQID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Actemra (Tocilizumab) 80mg/4ml, 200mg/10ml, 1) Humira 40mg QOW 2) Enbrel 50mg QW 400mg/20ml Intravenous Solution 8mg/kg Q4W Actiq (Fentanyl) 0.2, 0.4, 0.6, 0.8, 1.2, 1.6mg Buccal 1) Oxycodone/Acetaminophen 5/325mg Q6H 2) Lozenge PRN (Maximum 4 units per day) Morphine 15-30mg Q4H 3) Hydromorphone 2-8mg Q4-6H 4) Oxycodone 5-30mg Q4-6H 5) Morphine Solution 20mg/ml 0.5-1.5ml Q4H 6) Meperidine 50150mg Q3-4H Activella (Etradiol/Norethindrone Acetate) 0.5/0.1, 2 Separate Medications 1/0.5mg Tablet QD Estradiol QD AND Nora-BE 0.35mg QD Actonel (Risedronate) 5mg Tablet QD, 35mg Tablet 1) Alendronate 5, 10mg QD 2) Alendronate 70mg QW, 150mg Tablet QM QW 3) Alendronate 35mg QW 4) Fortical 200IU QD Alternate nostrils 5) Ibandronate 150mg QM NF 6) Actonel 5mg QD NF 7) Actonel 150mg QM NF 8) Evista 60mg QD 9) Actonel 35mg QW NF Actonel (Risedronate) 30mg Tablet QD X2M Alendronate 40mg QD X6M Page 1 Last Updated: 8/27/2012 Excluded Medication Actiq is contraindicated in the management of acute or postoperative pain including headache/migrane Dose Conversion Norethindrone Acetate 0.5mg=Norethindrone 0.35mg Osteoporosis Prophylaxis Alendronate 35mg QW or Alendronate 5mg QD Osteoporosis Treatment Alendronate 70mg QW or Alendronate 10mg QD Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Comments Actoplus Met (Metformin/Pioglitazone) 500/15, 850/15mg Tablet QD 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin 500-1000mg (Maximum 2550mg QD) 3) Metformin ER 500-750mg (Maximum 2000mg QD) 4) Novolin R (Insulin Regular) SC 30 minutes AC 5) Novolin N (NPH) SC 15-30 minutes AC 6) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos 15mg (Maximum 45mg QD) Adjust based on patient response American Diabetes Association Recommendations -Patient uncontrolled on maximum Metformin and maximum Sulfonylurea=Do not initiate Actos and initiate Novolin N -Patient on Actos and Insulin=Discontinue Actos and maximize Novolin N Actoplus Met XR (Metformin/Pioglitazone) 1000/15, 1000/30mg Extended Release Tablet QD 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin 500-1000mg (Maximum 2550mg QD) 3) Metformin ER 500-750mg (Maximum 2000mg QD) 4) Novolin R (Insulin Regular) SC 30 minutes AC 5) Novolin N (NPH) SC 15-30 minutes AC 6) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos 15mg (Maximum 45mg QD) Adjust based on patient response American Diabetes Association Recommendations -Patient uncontrolled on maximum Metformin and maximum Sulfonylurea=Do not initiate Actos and initiate Novolin N -Patient on Actos and Insulin=Discontinue Actos and maximize Novolin N Acuvail (Ketorolac) 0.45% Ophthalmic Solution 1 GTT BID 1) Diclofenac 0.1% 1GTT QID 2) Ketorolac 0.5% 1 GTT QID 3) Prednisolone 1% 1-2 GTTS BID-QID 4) Fluorometholone 0.1% 1-2 GTTS BID-QID 5) Dexamethasone 0.1% 1-2 GTTS BID-QID 6) Ketorolac 0.4% 1 GTT QID 7) Flurbiprofen 0.03% 1 GTT QID NF 8) Vexol 1% 1-2 GTT QID NF 9) Bromfenac 0.09% 1 GTT QD-BID NF 10) Lotemax 0.5% 1-2 GTT QID NF 11) Nevanac 0.1% 1 GTT TID NF 12) Zylet 0.5/0.3% 1-2 GTT Q4-6H NF 1) Clindamycin 1% Gel AAA BID AND OTC Benzoyl Dispense Clindamycin or Erythromycin as 1 copay and purchase OTC Benzoyl Peroxide Peroxide 5% Gel AAA BID 2) Sodium Sulfacetamide/Sulfur 10/5% Lotion AAA BID 3) Erythromycin/Benzoyl Peroxide 3/5% Gel AAA BID Aczone (Dapsone) 5% Gel AAA BID Adcirca (Tadalafil) 20mg Tablet 2T QD Pulmonary Hypertension 1) Viagra 50mg 0.5T TID 2) Cialis 20mg 2T QD Adipex-P (Phentermine) 37.5mg Tablet QD Excluded Medication (Exception: Obesity Rider) 1) Doxycycline Hyclate 50-100mg BID 2) Minocycline Dose Conversion Adoxa 50mg=Doxycycline Hyclate 50mg / Adoxa 50-100mg BID 3) Tetracycline 250-500mg BID 100mg=Doxycycline Hyclate 100mg Document adequate trial or intolerance to Qvar 1) Qvar 40-80mcg 1-2 PUFFS QD-BID 2) Flovent 80mcg 2 PUFFS BID or Asmanex 220mcg 2 PUFFS HFA 44mcg 2 PUFFS BID NOTE: Flovent HFA QD within the past 3 months 44mcg for patients 4-11 years of age 3) Asmanex *Patients should have prescription for a Short110-220mcg 1-2 PUFFS QD 4) Dulera 100/5Acting Beta 2 Agonist (e.g. Proair) for asthma 200/5mcg 2 PUFFS BID NF exacerbations Dose Conversion Advair 100/50mcg 1 PUFF BID=Albuterol Q4H PRN + Qvar 80mcg 1PUFF BID =Albuterol Q4H PRN + Flovent 44mcg 2 PUFFS BID Adoxa (Doxycycline Monohydrate) 150mg Capsule; 50, 75, 100mg Tablet BID Advair Diskus (Fluticasone/Salmeterol) 100/50, 250/50, 500/50mcg Inhalation Disk 1 PUFF BID Advair 250/50mcg 1 PUFF BID=Albuterol Q4H PRN + Qvar 80mcg 2 PUFFS BID=Albuterol Q4H PRN + Asmanex 220mcg 2 PUFFS QD=Dulera 100/5mcg 2 PUFFS BID NF Advair 500/50mcg 1 PUFF BID=Dulera 200/5mcg 2 PUFFS BID NF Page 2 Last Updated: 8/27/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Advair HFA (Fluticasone/Salmeterol) 45/21, 115/21, 1) Qvar 40-80mcg 1-2 PUFFS QD-BID 2) Flovent 230/21mcg/Actuation Inhalation Aerosol Liquid 2 HFA 44mcg 2 PUFFS BID NOTE: Flovent HFA PUFFS BID 44mcg for patients 4-11 years of age 3) Asmanex 110-220mcg 1-2 PUFFS QD 4) Dulera 100/5200/5mcg 2 PUFFS BID NF Comments Document adequate trial or intolerance to Qvar 80mcg 2 PUFFS BID or Asmanex 220mcg 2 PUFFS QD within the past 3 months *Patients should have prescription for a ShortActing Beta 2 Agonist (e.g. Proair) for asthma exacerbations Dose Conversion Advair HFA 45/21mcg 2 PUFFS BID=Albuterol Q4H PRN + Qvar 80mcg 1PUFF BID=Albuterol Q4H PRN + Flovent 44mcg 2 PUFFS BID Advair HFA 115/21mcg 2 PUFFS BID=Albuterol Q4H PRN + Qvar 80mcg 2 PUFFS BID=Albuterol Q4H PRN + Asmanex 220mcg 2 PUFFS QD=Dulera 100/5mcg 2 PUFFS BID NF Advair HFA 230/21mcg 2 PUFFS BID=Dulera 200/5mcg 2 PUFFS BID NF Advicor (Lovastatin/Niacin) 20/500mg, 20/750mg, 20/1000mg, 40/1000mg Extended Release Tablet QD Aerobid (Flunisolide) 0.25mg Inhalation Aerosol Powder 2 PUFFS BID 2 Separate Medications OTC Slo-Niacin 500mg QD (Titrate to 2000mg/day as tolerated using .PITTTSLONIACIN) AND Lovastatin 20-40mg QD 1) Qvar 40-80mcg 1-2 PUFFS QD-BID 2) Flovent HFA 44mcg 2 PUFFS BID NOTE: Flovent HFA 44mcg for patients 4-11 years of age 3) Asmanex 110-220mcg 1-2 PUFFS QD Document adequate therapeutic trial or intolerance to Qvar 80mcg 2 PUFFS BID or Asmanex 220mcg 2 PUFFS QD within the past 3 months Dose Conversion Aerobid 0.25mg 2 PUFFS BID=Qvar 80mcg 2 PUFFS BID=Asmanex 220mcg 2 PUFFS QD Afinitor (Everolimus) 2.5, 5, 10mg Tablet QD 1) Torisel 25mg IV QW 2) Sutent 50mg QD NOTE: 4 Sutent preferred when initiating therapy weeks on then 2 weeks off Alamast (Pemirolast) 0.1% Ophthalmic Solution 1-2 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q3GTTS QID 4 HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID 4) Crolom 4% 1-2 GTTS Q4-6 HOURS NF 5) Emadine 0.05% 1 GTT QID NF 6) Alocril 2% 1-2 GTTS BID NF 7) Optivar 0.05% 1 GTT BID NF 8) Alomide 0.1% 1-2 GTTS QID NF 9) Lastacaft 0.25% 1 GTT QD NF 10) Pataday 0.2% 1 GTT QD NF 11) Alrex 0.2% 1 GTT QID NF 12) Patanol 0.1% 1 GTT BID NF 13) Elestat 0.05 % 1 GTT BID NF Alesse (20mcg Ethinyl Estradiol/0.1mg 1) Aviane (20mcg Ethinyl Estradiol/0.1mg Equivalent Brand and Generic Products Levonorgestrel) Tablet QD Alesse=Aviane Levonorgestrel) QD 2) Microgestin Fe 1/20 (20mcg Document adequate therapeutic trial or intolerance Ethinyl Estradiol/1mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD to at least 3 formulary oral contraceptives Alinia (Nitazoxanide) 100mg/5ml Powder for Suspension; 500mg Tablet Q12H X3D Allegra (Fexofenadine) 30, 60, 180mg Tablet QDBID Cryptosporidiosis No formulary alternative Giardiasis 1) Metronidazole 250mg TID X5-7D 2) Tindamax 2gm Single dose NF 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) Excluded Medication OTC Allegra 60mg BID 4) Fluticasone 2 SPRAYS IEN QD 5) Flunisolide 2 SPRAYS IEN BID Allegra D (Fexofenadine/Pseudoephedrine) 60/120, 1) OTC Claritin D 5/120, 10/240mg QD-BID 2) OTC 180/240mg Tablet QD-BID Zyrtec D 5/120mg BID 3) OTC Allegra D 60/120, 180/240mg QD-BID 4) Fluticasone 2 SPRAYS IEN QD 5) Flunisolide 2 SPRAYS IEN BID Page 3 Last Updated: 8/27/2012 Excluded Medication Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Comments Alocril (Nedocromil) 2% Ophthalmic Solution 1-2 GTTS BID 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q34 HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID 4) Crolom 4% 1-2 GTTS Q4-6 HOURS NF 5) Emadine 0.05% 1 GTT QID NF Alomide (Lodoxamide) 0.1% Ophthalmic Solution 1- 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q32 GTTS QID 4 HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID 4) Crolom 4% 1-2 GTTS Q4-6 HOURS NF 5) Emadine 0.05% 1 GTT QID NF 6) Alocril 2% 1-2 GTTS BID NF 7) Optivar 0.05% 1 GTT BID NF Alora (Estradiol) 0.025, 0.05, 0.075, 0.1mg/24 hr Adjust to the lowest dose needed to control Vasomotor Symtoms Transdermal Patch Apply twice weekly 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.025- symptoms based on patient response 0.1mg/24hr Apply weekly Vaginal/Vulvar Atrophy 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.0250.1mg/24hr Apply weekly 3) Premarin Vaginal 1gm Apply three times a week 4) Vagifem 10mcg Insert twice weekly 5) Estring 2mg Insert for 90 days Alphagan P (Brimonidine) 0.1, 0.15% Ophthalmic Solution 1 GTT TID Alrex (Loteprednol) 0.2% Ophthalmic Suspension 1 GTT QID Altavera (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) Tablet QD Alvesco (Ciclesonide) 80, 160mcg Inhalation Aerosol Liquid 1-2 PUFFS BID 1) Brimonidine 0.2% 1 GTT TID 2) Brimonidine 0.15% 1 GTT TID 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q34 HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID 4) Crolom 4% 1-2 GTTS Q4-6 HOURS NF 5) Emadine 0.05% 1 GTT QID NF 6) Alocril 2% 1-2 GTTS BID NF 7) Optivar 0.05% 1 GTT BID NF 8) Alomide 0.1% 1-2 GTTS QID NF 9) Lastacaft 0.25% 1 GTT QD NF 10) Pataday 0.2% 1 GTT QD NF 1) Reclipsen (30mcg Ethinyl Estradiol/0.15mg Equivalent Brand and Generic Products Altavera=Levora Desogestrel) QD 2) Microgestin Fe 1.5/30 (30mcg Ethinyl Estradiol/1.5mg Norethindrone) QD 3) Levora Document adequate therapeutic trial or intolerance (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD to at least 3 formulary oral contraceptives 1) Qvar 40-80mcg 1-2 PUFFS QD-BID 2) Flovent HFA 44mcg 2 PUFFS BID NOTE: Flovent HFA 44mcg for patients 4-11 years of age 3) Asmanex 110-220mcg 1-2 PUFFS QD 4) Aerobid 0.25mg 2 PUFFS BID NF 5) Pulmicort Flexhaler 90-180mcg 2 PUFFS BID NF 6) Flovent HFA 110-220mcg 1-2 PUFFS BID NF Document adequate trial or intolerance to Qvar 80mcg 2 PUFFS BID and Asmanex 220mcg 2 PUFFS QD within the past 3 months Dose Conversion Alvesco 80mcg 1 PUFF QD=Qvar 40mcg 1 PUFF QD=Flovent 44mcg 1 PUFF BID Alvesco 160mcg 1 PUFF QD=Qvar 80mcg 1 PUFF QD=Flovent 44mcg 2 PUFFS BID Amaryl (Glimepiride) 1, 2, 4mg Tablet QD Adjust based on patient response 1) Glipizide 5-15mg QD 2) Glyburide 2.5-10mg QD Glipizide preferred if 65 years of age and older due to prolonged half life of Glyburide Amaryl (Glimepiride) 4mg Tablet BID 1) Glipizide 10-20mg BID 2) Glyburide 7.5-10mg BID Adjust based on patient response Glipizide preferred if 65 years of age and older due to prolonged half life of Glyburide Ambien CR (Zolpidem) 6.25, 12.5mg Extended Document adequate therapeutic trial or intolerance 1) Trazodone 50-100mg QHS 2) Temazepam 15Release Tablet QHS 30mg QHS 3) Zolpidem 5-10mg QHS 4) Zaleplon 5- to Trazodone, Zolpidem, and at least 1 Benzodiazepine 10mg QHS Amevive (Alefacept) 15mg Intramuscular Powder for Administered in a healthcare setting by healthcare Solution QW providers Amitiza (Lubiprostone) 8, 24mcg Liquid Filled 1) OTC Citrucel 1 TBSP in 8oz water QD-TID 2) OTC Capsule BID Benefiber 3T TID 3) OTC Metamucil 1 TBSP in 8oz water QD-TID 4) OTC Docusate 50mg QD 5) OTC Dulcolax 5-15mg QD 6) OTC Miralax 1 TBSP in 8oz water 7) Lactulose 15-30ml QD Amoxil (Amoxicillin) 875mg Tablet BID 1) Amoxicillin 500mg TID 2) Amoxicillin/Clavulanate 875/125mg BID Page 4 Last Updated: 8/27/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Ampyra (Dalfampridine) 10mg Tablet BID Amrix (Cyclobenzaprine) 15, 30mg Extended Release Capsule QD Analpram-HC (Hydrocortisone Acetate/Pramoxine) 1/1% Cream QD-BID Comments Ampyra is delivered directly to patient via KP CA Specialty Pharmacy Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. KP CA Specialty Pharmacy MD Line 650-301-5799 / Patient Line 1-877-4045777 / Fax Line 650-301-5790 1) Cyclobenzaprine 10mg TID 2) Chlorzoxazone 250- Dose Conversion 500mg TID 3) Carisoprodol 350mg TID 4) Tizanidine Amrix 15mg QD=Cyclobenzaprine 10mg 0.5T TID / Amrix 30mg QD=Cyclobenzaprine 10mg TID 4mg TID 5) Methocarbamol 500-750mg QID 6) Baclofen 10-20mg TID 1) OTC Hydrocortisone 0.5-1% Cream, Ointment AAA BID-QID 2) OTC Prax 1% Cream, Lotion AAA BID-QID 3) Hydrocortisone 2.5% Cream, Lotion, Ointment AAA BID-QID 4) Hydrocortisone 25mg Suppository BID 5) Hydrocortisone 100mg/60ml Enema QD-BID 6) Proctofoam-HC 1/1% QD-BID AndroGel 1% (Testosterone) 25mg/2.5gm, 50mg/5gm Gel Apply QAM 1) Testosterone Cypionate 200mg/ml IM Q2-4W 2) Androderm Patch 2-4mg/24hr Apply QPM 3) AndroGel Pump 1.62% Apply 2 pumps QAM NF 4) AndrogGel Pump 1% Apply 4 pumps QAM NF AndroGel Pump 1% (Testosterone) 1) Testosterone Cypionate 200mg/ml IM Q2-4W 2) 1.25gm/Actuation Gel Apply 4 pumps QAM Androderm Patch 2-4mg/24hr Apply QPM 3) AndroGel Pump 1.62% Apply 2 pumps QAM NF AndroGel Pump 1.62% (Testosterone) 1) Testosterone Cypionate 200mg/ml IM Q2-4W 2) 20.25mg/Actuation Gel Apply 2 pumps QAM Androderm Patch 2-4mg/24hr Apply QPM Angeliq (Drospirenone/Estradiol) 0.5/1mg Tablet QD 2 Separate Medications Estradiol Tablet 1mg QD AND 1) Medroxyprogesterone 2.5-5mg QD 2) Nora-BE 0.35mg QD 3) Norethindrone 5mg QD Ansaid (Flurbiprofen) 50, 100mg Tablet BID-TID 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg BID 3) Ibuprofen 400-800mg TID-QID Antara (Fenofibrate Micronized) 43, 130mg Capsule 1) Gemfibrozil 600mg BID 2) Fenofibrate 54-160mg QD QD Adjust to the lowest dose needed to control symptoms based on patient response Dose Conversion Antara 43mg=Fenofibrate 54mg / Antara 130mg=Fenofibrate 160mg Fenofibrate preferred if current statin therapy Gemfibrozil preferred if reduced renal function Anzemet (Dolasetron) 50, 100mg Tablet 1 hour prior 1) Metoclopramide 1-2mg/kg 30 minutes prior to to chemotherapy chemotherapy 2) Prochlorperazine 5-10mg Q6H 3) Dexamethasone 20mg 30 minutes prior to chemotherapy 4) Ondansetron 4-8mg 30 minutes prior to chemotherapy 5) Ondansetron 4-8mg ODT 30 minutes prior to chemotherapy 6) Transderm Scop 1.5mg Apply Q72H NF 7) Granisetron 2mg 1 hour prior to chemotherapy NF Apidra (Insulin Glulisine) 100U/ml Injection Solution 1) Novolin R (Insulin Regular) SC 30 minutes AC 2) Adjust based on patient response SC 15 minutes AC NovoLog (Insulin Aspart) SC 5-10 minutes AC NF Aplenzin (Bupropion Hydrobromide) 174, 348, 522mg Extended Release Tablet QD 1) Citalopram 20-40mg QD 2) Fluoxetine 20-40mg QD 3) Sertraline 50-100mg QD 4) Mirtazapine 30mg QHS 5) Bupropion SR/XL 300mg QD 6) Venlafaxine ER 225mg QD 7) Fluvoxamine 50-300mg QD NF 8) Escitalopram 10-20mg QD NF 9) Paxil CR 12.537.5mg QD NF 10) Viibryd 10-40mg QD 11) Pristiq 50-100mg QD NF 12) Cymbalta 30-60mg BID NF Page 5 Last Updated: 8/27/2012 Dose Conversion Aplenzin 174mg=Bupropion HCL SR/XL 150mg / Aplenzin 348mg=Bupropion HCL SR/XL 300mg Document adequate therapeutic trial or intolerance to 2 SSRIs, Venlafaxine, and Bupropion HCL SR/XL Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Comments Apri (30mcg Ethinyl Estradiol/0.15mg Desogestrel) Tablet QD 1) Reclipsen (30mcg Ethinyl Estradiol/0.15mg Desogestrel) QD 2) Microgestin Fe 1.5/30 (30mcg Ethinyl Estradiol/1.5mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD Apriso (Mesalamine) 0.375gm Extended Release Capsule 1.5gm QAM 1) Sulfasalazine 500mg (2-4gm QD) 2) Colazal 750mg (2.25gm TID for 8-12 weeks) 3) Asacol 400mg (800mg TID) 4) Dipentum 550mg BID NF 5) Pentasa 250, 500mg (1gm QID) 1) Anastrozole 1mg QD 2) Letrozole 2.5mg QD Document adequate therapeutic trial or intolerance 1) Galantamine 4-12mg BID, Galantamine ER 824mg QD 2) Namenda 5-10mg BID 3) Rivastigmine to Aricept, Exelon Solution, and Razadyne Solution 6mg BID 4) Aricept 5-10mg QD 5) Exelon 2mg/ml Solution 3ml BID 6) Exelon 4.5-9.6mg/24hr Patch QD NF 7) Razadyne 4mg/ml 1-3 ml BID NF Aromasin (Exemestane) 25mg Tablet QD Aricept ODT (Donepezil) 5, 10mg Orally Disintegrating Tablet QD Equivalent Brand and Generic Products Apri=Reclipsen Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Arixtra (Fondaparinux) 2.5/0.5, 7.5/0.6, 10/0.8, 5/0.4mg/ml Subcutaneous Solution QD Arthrotec (Diclofenac/Misoprostol) 50/0.2, 75/0.2mg Enteric Coated Tablet BID-TID Ascensia Breeze Glucometer and Test Strips Enoxaparin 1.5 mg/kg QD or 1mg/kg BID Asendin (Amoxapine) 25, 50, 100, 150mg Tablet BID-TID 1) Nortriptyline 25-150mg QHS 2) Amitriptyline 50150mg QD 3) Doxepin 25-150mg QD 4) Imipramine 50-150mg QD 5) Desipramine 50-150mg QD Astelin (Azelastine) 137mcg/Actuation Nasal Spray 2 SPRAYS IEN BID 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) Document adequate therapeutic trial or intolerance to Claritin, Zyrtec, or Allegra and at least 1 Nasal OTC Allegra 60mg BID 4) Fluticasone 2 SPRAYS Steroid IEN QD 5) Flunisolide 2 SPRAYS IEN BID Azelastine is indicated for the treatment of vasomotor rhinitis Dose Conversion 1) Lisinopril QD NOTE: If Angiotensin Converting Enzyme Inhibitor allergy or contraindication consider Atacand 4mg=Lisinopril 10mg=Losartan 25mg / Atacand 8mg=Lisinopril 20mg=Losartan 50mg / Angiotensin Receptor Blocker 2) Losartan QD Atacand 16mg=Lisinopril 40mg=Losartan 100mg / Atacand 32mg=No Formulary Alternative 2 Separate Medications Dose Conversion HCTZ QD AND 1) Lisinopril QD NOTE: If Angiotensin Atacand 16mg=Lisinopril 40mg=Losartan 100mg / Atacand 32mg=No Formulary Alternative Converting Enzyme Inhibitor allergy or NOTE: Consider Losartan/HCTZ 100/12.5mg contraindication consider Angiotensin Receptor Blocker 2) Losartan QD 1) Alendronate 10mg QD 2) Alendronate 70mg QW 3) Fortical 200IU QD Alternate nostrils 4) Ibandronate 150mg QM NF 5) Actonel 5mg QD NF 6) Actonel 150mg QM NF 7) Evista 60mg QD 8) Actonel 35mg QW NF 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) Document adequate therapeutic trial or intolerance to Claritin, Zyrtec, or Allegra and at least 1 Nasal OTC Allegra 60mg BID 4) Fluticasone 2 SPRAYS Steroid IEN QD 5) Flunisolide 2 SPRAYS IEN BID Atacand (Candesartan) 4, 8, 16, 32mg Tablet QD Atacand HCT (Candesartan/HCTZ) 16/12.5, 32/12.5mg Tablet QD Atelvia (Risedronate Sodium) 35mg Delayed Release Tablet QW Atrovent (Ipratropium) 0.03, 0.06% Nasal Spray 2 SPRAYS IEN BID-QID Augmentin (Amoxicillin/Clavulanate) 125mg/31.25mg/5ml Powder for Suspension BID Augmentin (Amoxicillin/Clavulanate) 250mg/62.5mg/5ml Powder for Suspension BID Augmentin XR (Amoxicillin/Clavulanate) 1000/62.5mg Extended Release Tablet 2T BID 2 Separate Medications Diclofenac BID-TID AND Misoprostol BID-TID One Touch Ultra 2 Glucometer and One Touch Ultra Test Strips 1) Amoxicillin 125mg/5ml Suspension BID 2) Amoxicillin/Clavulanate 200mg/28.5mg/5ml Suspension BID 3) Amoxicillin 125mg Chew Tablet BID 4) Amoxicillin/Clavulanate 125/31.25mg Chew Tablet BID 1) Amoxicillin 250mg Capsule 2) Amoxicillin 250mg Chew Tablet BID 3) Amoxicillin 250mg/5ml Suspension BID 4) Amoxicillin/Clavulanate 200mg/28.5mg/5ml Suspension BID 2 Separate Medications Amoxicillin/Clavulanate 875/125mg BID AND Amoxicillin 250mg BID Page 6 Last Updated: 8/27/2012 Arixtra preferred if history of Heparin-Induced Thrombocytopenia (HIT) Document member is unable to accurately use One Touch Ultra 2 Glucometer and One Touch Ultra Test Strips due to impaired dexterity Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Avalide (Irbesartan/HCTZ) 150/12.5, 300/12.5, 300/25mg Tablet QD Comments 2 Separate Medications HCTZ QD AND 1) Lisinopril QD NOTE: If Angiotensin Converting Enzyme Inhibitor allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan QD Avandamet (Metformin/Rosiglitazone) 500/2, 500/4, 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin 1000/2, 1000/4mg Tablet QD-BID 500-1000mg (Maximum 2550mg QD) 3) Metformin ER 500-750mg (Maximum 2000mg QD) 4) Novolin R (Insulin Regular) SC 30 minutes AC 5) Novolin N (NPH) SC 15-30 minutes AC 6) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos 15mg (Maximum 45mg QD) Avandia (Rosiglitazone) 2, 4, 8mg Tablet QD-BID Avapro (Irbesartan) 75, 150, 300mg Tablet QD AVC Vaginal (Sulfanilamide) 15% Vaginal Cream QD-BID Dose Conversion Avapro 150mg=Lisinopril 20mg=Losartan 50mg / Avapro 300mg=Lisinopril 40mg=Losartan 100mg NOTE: Consider Lisinopril/HCTZ 20/12.5mg or Losartan/HCTZ 50/12.5, 100/12.5, 100/25mg Adjust based on patient response American Diabetes Association Recommendations -Patient uncontrolled on maximum Metformin and maximum Sulfonylurea=Do not initiate Actos and initiate Novolin N -Patient on Actos and Insulin=Discontinue Actos and maximize Novolin N Dose Conversion Avandia 2mg=Actos 15mg / Avandia 4mg=Actos 30mg / Avandia 8mg=Actos 45mg 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin Adjust based on patient response 500-1000mg (Maximum 2550mg QD) 3) Metformin American Diabetes Association ER 500-750mg (Maximum 2000mg QD) 4) Novolin R Recommendations -Patient uncontrolled on maximum Metformin and (Insulin Regular) SC 30 minutes AC 5) Novolin N maximum Sulfonylurea=Do not initiate Actos and (NPH) SC 15-30 minutes AC 6) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog initiate Novolin N -Patient on Actos and Insulin=Discontinue Actos (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos and maximize Novolin N 15mg (Maximum 45mg QD) Dose Conversion Avandia 2mg=Actos 15mg / Avandia 4mg=Actos 30mg / Avandia 8mg=Actos 45mg 1) Lisinopril QD NOTE: If Angiotensin Converting Dose Conversion Enzyme Inhibitor allergy or contraindication consider Avapro 75mg=Lisinopril 10mg=Losartan 25mg / Avapro 150mg=Lisinopril 20mg=Losartan 50mg / Angiotensin Receptor Blocker 2) Losartan QD Avapro 300mg=Lisinopril 40mg=Losartan 100mg 1) OTC Mycelex (Clotrimazole 1%) QHS 2) OTC Monistat (Miconazole) QHS 3) OTC Vagistat (Tioconazole 6.5%) QHS 4) Fluconazole 150mg QD Avelox (Moxifloxacin) 400mg Tablet QD X7-14D Community Acquired Pneumonia 1) Levofloxacin 750mg QD X5D 2) Levofloxacin 500mg QD X10D 3) Azithromycin 500mg QD X5D 4) Cefuroxime 500mg BID X10D Sinusitis 1) SMZ-TMP DS BID X7D 2) Doxycycline 100mg BID X7D 3) Amoxicillin 1000mg BID X7D 4) Azithromycin 500mg QD X3D Avinza (Morphine Sulfate) 30, 45, 60, 75, 90, 120mg 1) Morphine ER 60-100mg BID 2) Fentanyl 25Dose Conversion Extended Release Capsule QD 100mcg/hr Q72H Morphine 30mg=Oxycodone 20mg=Oxymorphone 10mg / Morphine 90mg=Fentanyl 25mcg/hr Document adequate therapeutic trial or intolerance to Morphine ER and Fentanyl Avodart (Dutasteride) 0.5mg Capsule QD Axert (Almotriptan) 6.25, 12.5mg Tablet PRN Finasteride 5mg QD 1) Sumatriptan 25-100mg PRN 2) Sumatriptan 20mg Nasal Spray PRN 3) Naratriptan 1-2.5mg PRN 4) Sumatriptan 6mg/ml Subcutaneous Solution PRN 5) Maxalt MLT 5-10mg PRN NF 6) Zomig 5mg PRN NF 7) Zomig 2.5mg PRN NF 8) Relpax 20-40mg PRN NF Axid Pulvules (Nizatidine) 150, 300mg Capsule QD- 1) OTC Famotidine 10-20mg QD-BID 2) OTC BID Ranitidine 75-150mg QD-BID 3) Cimetidine 400800mg QD-BID Page 7 Last Updated: 8/27/2012 Quantity Limit Axert 6.25-12.5mg=6 Tablets Maxalt MLT 5-10mg=9 Tablets Naratriptan 1-2.5mg=9 Tablets Relpax 20-40mg=6 Tablets Sumatriptan 25-100mg=9 Tablets Zomig 2.5mg=6 Tablets Zomig 5mg=3 Tablets Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Axiron (Testosterone) 30mg/1.5ml Topical Solution Apply 1 pump to each axilla QAM AzaSite (Azithromycin) 1% Ophthalmic Solution 1 GTT BID 1) Testosterone Cypionate 200mg/ml IM Q2-4W 2) Androderm Patch 2-4mg/24hr Apply QPM 3) AndroGel Pump 1.62% Apply 2 pumps QAM NF 4) AndrogGel Pump 1% Apply 4 pumps QAM NF 5) AndroGel 1% (25mg/2.5gm-50mg/5gm) Apply QAM NF 6) Testim 1% Gel Apply QAM NF Blepharitis 1) Neomycin/Polymyxin/Hydrocortisone 1% Suspension 1-2 GTTS Q4H 2) Neomycin/Polymyxin/Dexamethasone 0.1% Suspension 1-2 GTTS Q4H 3) Sulfacetamide/Prednisolone 10/0.25% Solution 1-2 GTTS Q2-3H 4) Erythromycin 0.5% Ointment APPLY RIBBON Q4H 5) Tobramycin/Dexamethasone 0.3/0.1% 1-2 GTTS Q4-6H 6) Neomycin/Polymyxin/Bacitracin Ointment APPLY RIBBON Q4H 7) Restasis 0.05% 1 GTT BID Conjunctivitis 1) Ofloxacin 0.3% Solution 1-2 GTTS QID 2) Ciprofloxacin 0.3% Solution 1-2 GTTS Q4HS NF 3) Sodium Sulfacetamide 10% Solution 1-3 GTTS Q23H 4) Gentamicin 0.3% Solution 1-2 GTTS QID 5) Erythromycin 0.5% Ointment APPLY RIBBON Q4H 6) Vigamox Solution 0.5% 1 GTT BID NF 7) Ciloxan 0.3% Ointment APPLY RIBBON BID-TID NF 8) Zymaxid 0.5% Solution 1 GTT QID 9) Quixin 0.5% Solution 1-2 GTTS Q4H NF Azelex (Azelaic Acid) 20 % Cream AAA BID 1) Clindamycin 1% Gel AAA BID AND OTC Benzoyl Peroxide 5% Gel AAA BID 2) Sodium Sulfacetamide/Sulfur 10/5% Lotion AAA BID 3) Erythromycin/Benzoyl Peroxide 3/5% Gel AAA BID Azilect (Rasagiline) 0.5, 1mg Tablet QD 1) Carbidopa/Levodopa ER 25/100mg BID 2) Bromocriptine 2.5mg QD 3) Amantadine 100mg BID 4) Selegiline 5mg QD 1) Methazolamide 50-100mg BID-TID 2) Dorzolamide 2% 1 GTT TID 3) Dorzolamide/Timolol 2/0.5% 1 GTT BID 4) Acetazolamide 250mg QD-QID Azopt (Brinzolamide) 1% Ophthalmic Suspension 1 GTT TID Azor (Amlodipine/Olmesartan) 5/20, 5/40, 10/20, 10/40mg Tablet QD 2 Separate Medications Amlodipine QD AND 1) Lisinopril QD NOTE: If Angiotensin Converting Enzyme Inhibitor allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan QD B12 Vitamins (Cyanocobalamin, Hydroxocobalamin, OTC Vitamin B12 (Cyanocobalamin) 50, 100, 250, Metanx) QD 500, 1000mcg QD Bactroban (Mupirocin) 2% Cream, Ointment AAA Mupirocin 2% Ointment AAA TID TID Bactroban Nasal (Mupirocin) 2% Nasal Ointment Mupirocin 2% Ointment Apply IEN BID Apply 1/2 tube IEN BID Balziva (35mcg Ethinyl Estradiol/0.4mgNorethindrone) Tablet QD Comments 1) Sprintec (35mcg Ethinyl Estradiol/0.25mg Norgestimate) QD 2) Necon 1/35 (35mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Necon 0.5/35 (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD 4) Zovia 1/35 (35mcg Ethinyl Estradiol/1mg Ethynodiol diacetate) QD 5) Brevicon (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD Page 8 Last Updated: 8/27/2012 Dispense Clindamycin or Erythromycin as 1 copay and purchase OTC Benzoyl Peroxide Dose Conversion Benicar 20mg=Lisinopril 20mg=Losartan 50mg / Benicar 40mg=Lisinopril 40mg=Losartan 100mg Excluded Medication Available OTC MRSA Colonization Mupirocin 2% Ointment may be administered with a cotton swab to the anterior nares Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Banzel (Rufinamide) 40mg/ml Suspension; 200, 400mg Tablet BID Beconase (Beclomethasone) 0.042mg/Actuation Nasal Aerosol Powder 1-2 SPRAYS IEN BID Benicar (Olmesartan) 5, 20, 40mg Tablet QD Benicar HCT (Olmesartan/HCTZ) 20/12.5, 40/12.5, 40/25mg Tablet QD Comments 1) Lamotrigine 100-200mg BID 2) Carbamazepine 800-1600mg QD 3) Topiramate 200mg BID 4) Phenytoin 100mg TID 5) Levetiracetam 500-1500mg BID 6) Zonisamide 100mg TID NF 7) Gabapentin 300600mg TID 8) Levetiracetam ER 1000mg QD 9) Oxcarbazepine 600mg BID NF 10) Divalproex 250500mg TID 11) Lyrica 50-200mg TID NF 12) Vimpat 100-200mg BID NF 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) Age Recommendations Fluticasone=4 years of age and older / OTC Allegra 60mg BID 4) Fluticasone 2 SPRAYS Flunisolide=6 years of age and older / IEN QD 5) Flunisolide 2 SPRAYS IEN BID 6) Triamcinolone 2 SPRAYS IEN QD NF 7) Nasonex 2 Triamcinolone=2 years of age and older / Nasonex=2 years of age and older / Veramyst=2 SPRAYS IEN QD NF 8) Veramyst 2 SPRAYS IEN years of age and older / Omnaris=6 years of age QD NF 9) Omnaris 2 SPRAYS IEN QD NF 10) and older / Rhinocort Aqua=6 years of age and Rhinocort AQ 2 SPRAYS IEN BID NF older / Beconase=5 years of age and older 1) Lisinopril QD NOTE: If Angiotensin Converting Dose Conversion Enzyme Inhibitor allergy or contraindication consider Benicar 20mg=Lisinopril 20mg=Losartan 50mg / Benicar 40mg=Lisinopril 40mg= Losartan 100mg Angiotensin Receptor Blocker 2) Losartan QD 2 Separate Medications HCTZ QD AND 1) Lisinopril QD NOTE: If Angiotensin Converting Enzyme Inhibitor allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan QD OTC Benzoyl Peroxide 5-10% Liquid AAA QD-BID Benzac AC (Benzoyl Peroxide) 5, 10% Liquid AAA QD-BID BenzaClin (Clindamycin/Benzoyl Peroxide) 1/5% Gel 1) Clindamycin 1% Gel AAA BID AND OTC Benzoyl AAA BID Peroxide 5% Gel AAA BID 2) Erythromycin/Benzoyl Peroxide 3/5% Gel AAA BID Dose Conversion Benicar 20mg=Lisinopril 20mg=Losartan 50mg / Benicar 40mg=Lisinopril 40mg= Losartan 100mg NOTE: Consider Lisinopril/HCTZ 20/12.5mg or Losartan/HCTZ 50/12.5, 100/12.5, 100/25mg Excluded Medication Dispense Clindamycin as 1 copay and purchase OTC Benzoyl Peroxide Bepreve (Bepotastine) 1.5% Ophthalmic Solution 1 GTT BID 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q34 HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID 4) Crolom 4% 1-2 GTTS Q4-6 HOURS NF 5) Emadine 0.05% 1 GTT QID NF 6) Alocril 2% 1-2 GTTS BID NF 7) Optivar 0.05% 1 GTT BID NF 8) Alomide 0.1% 1-2 GTTS QID NF 9) Lastacaft 0.25% 1 GTT QD NF 10) Pataday 0.2% 1 GTT QD NF 11) Alrex 0.2% 1 GTT QID NF 12) Patanol 0.1% 1 GTT BID NF 13) Elestat 0.05 % 1 GTT BID NF 14) Alamast 0.1% 1-2 GTTS QID NF Berinert (C1 Esterase Inhibitor) 500U Intravenous Powder for Solution 20U/kg Q3-4D 1) Danazol 200mg BID-TID 2) Oxandrolone 2.5-20mg Criteria Restricted Medication QRM approval required prior to being dispensed for BID-QID NF Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Sotalol 80mg BID Betapace AF (Sotalol AF) 80, 120, 160mg Tablet QD-BID Betaseron (Interferon Beta-1b) 0.3mg Subcutaneous Extavia 0.25mg QOD Powder for Solution 0.25mg QOD Beyaz (20mcg Ethinyl Estradiol/3mg Drospirenone) 1) Reclipsen (30mcg Ethinyl Estradiol/0.15 Tablet QD Desogestrel) QD 2) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Aviane (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel) QD Biaxin XL (Clarithromycin) 500mg Extended Release 1) Clarithromycin 500mg BID 2) Azithromycin Day 1: Tablet 2T QD 500mg Day 2-5: 250mg QD 3) Erythromycin 333mg EC Q8H 4) Erythromycin 250mg EC Q6H Page 9 Last Updated: 8/27/2012 Equivalent Brand and Generic Products Betaseron=Extavia Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Biaxin XL to Clarithromycin is a 1:1 Conversion Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Comments BiDil (Isosorbide Dinitrate/Hydralazine) 20/37.5mg Tablet TID 2 Separate Medications Isosorbide Dinitrate 20mg TID AND Hydralazine 25mg 1.5T TID Biltricide (Praziquantel) 600mg Tablet 25mg/kg TID 1) Paromomycin 250mg 25-35mg/kg/day divided TID X1D X5-10D 2) Albenza 400mg Single dose Boniva (Ibandronate) 150mg Tablet QM 1) Alendronate 10mg QD 2) Alendronate 70mg QW 3) Fortical 200IU QD Alternate nostrils 4) Ibandronate 150mg QM NF Botox (Onabotulinumtoxin A) 200U Injection Powder Administered in a healthcare setting by healthcare Criteria Restricted Medication for Solution; 100U Intramuscular Powder for Solution providers QRM approval required prior to being dispensed for Q12-16W Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Brilinta (Ticagrelor) 90mg Tablet BID Clopidogrel 75mg QD Bromday (Bromfenac) 0.09% Ophthalmic Solution 1 1) Diclofenac 0.1% 1GTT QID 2) Ketorolac 0.5% 1 GTT QD GTT QID 3) Prednisolone 1% 1-2 GTTS BID-QID 4) Fluorometholone 0.1% 1-2 GTTS BID-QID 5) Dexamethasone 0.1% 1-2 GTTS BID-QID 6) Ketorolac 0.4% 1 GTT QID 7) Flurbiprofen 0.03% 1 GTT QID NF 8) Vexol 1% 1-2 GTT QID NF 9) Bromfenac 0.09% 1 GTT QD-BID NF Bumex (Bumetanide) 0.5, 1, 2mg Tablet QD 1) Bumetanide 0.5-1mg QD 2) Furosemide 20-80mg QD Butrans (Buprenorphine) 5, 10, 20mcg/hr Transdermal Patch Apply QW Byetta (Exenatide) 250mcg/ml Subcutaneous Solution BID Dose Conversion Bumetanide 0.5mg=Furosemide 20mg / Bumetanide 1mg=Furosemide 40mg / Bumetanide 2mg=Furosemide 80mg 1) Morphine ER 60-100mg BID 2) Fentanyl 25Dose Conversion 100mcg/hr Q72H Morphine 30mg=Butrans 5mcg/hr / Morphine 90mg=Fentanyl 25mcg/hr Document adequate therapeutic trial or intolerance to Morphine ER and Fentanyl 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin Criteria Restricted Medication QRM approval required prior to being dispensed for 500-1000mg (Maximum 2550mg QD) 3) Metformin ER 500-750mg (Maximum 2000mg QD) 4) Novolin R Commercial, Multi-Choice, Self-Funded, and Triple Tier members. (Insulin Regular) SC 30 minutes AC 5) Novolin N Provider must call 404-364-7320 (Option 2) to (NPH) SC 15-30 minutes AC 6) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog initiate review by QRM department. (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos 15mg (Maximum 45mg QD) Bystolic (Nebivolol) 2.5, 5, 10, 20mg Tablet QD 1) Atenolol 50-100mg QD 2) Metoprolol 100-450mg QD 3) Acebutolol 400-800mg QD 4) Bisoprolol 2.520mg QD 5) Carvedilol 12.5-25mg BID 6) Labetalol 200-400mg BID Caduet (Amlodipine/Atorvastatin) 2.5/10, 2.5/20, 2.5/40, 5/10, 5/20, 5/40, 5/80, 10/10, 10/20, 10/40, 10/80mg Tablet QD Atorvastatin to minimize drug interactions and risk 2 Separate Medications Amlodipine 2.5-10mg QD AND Atorvastatin 10-80mg of myalgias if current therapy with: -Amlodipine (Maximum Simvastatin 20mg) QD Campral (Acamprosate) 333mg Enteric Coated Tablet 2T TID Capex (Fluocinolone Acetonide) 0.01% Shampoo QD Low Potency 1) Naltrexone 50mg QD 2) Disulfiram 250-500mg QD Low Potency 1) Betamethasone Valerate 0.1% Lotion AAA QD-BID 2) Desonide 0.05% Cream, Ointment AAA BID-TID 3) Fluocinolone Acetonide 0.01% Solution AAA QD 4) Derma-Smoothe/FS 0.01% Oil AAA QD Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BIDQID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Page 10 Last Updated: 8/27/2012 Dose Conversion Bystolic 2.5mg QD=Metoprolol Tartrate 12.5mg BID / Bystolic 5mg QD=Metoprolol Tartrate 25mg BID / Bystolic 10mg=Metoprolol Tartrate 50mg BID / Bystolic 20mg QD=Metoprolol Tartrate 100mg BID Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Carac (Fluorouracil) 0.5% Cream AAA BID 1) Fluorouracil 5% Solution AAA BID 2) Efudex 5% Cream AAA BID 3) Fluoroplex 1% Cream AAA BID Cardene SR (Nicardipine) 30, 45, 60mg Extended Release Capsule BID 1) Amlodipine 5-10mg QD 2) Verapamil SR 180240mg BID 3) Diltiazem ER 240-360mg QD 4) Nifedipine ER 30-60mg QD 5) Felodipine 2.5-20mg QD 2 Separate Medications OTC Hydrocortisone 1% Cream AAA BID-QID AND OTC Carmol 10 (Urea 10%) Cream AAA BID Clonidine 0.1-0.3mg BID Carmol HC (Hydrocortisone/Urea) 1/10% Cream AAA BID Catapres TTS-1,TTS-2, TTS-3 Transdermal Patch Apply QW Caverject (Alprostadil) 10, 20, 40mcg Intracavernosal Powder for Solution; 0.02mg/ml Intracavernosal Solution PRN Cayston (Aztreonam) 75mg/vial Inhalation Powder for Solution TID Comments Dose Conversion Cardene SR 30mg BID=Nifedipine ER 30mg QD / Cardene SR 45mg BID=Nifedipine ER 60 QD / Cardene SR 60mg BID=Nifedipine ER 90mg QD Dose Conversion Catapres TTS-1=Clonidine 0.1mg BID / Catapres TTS-2=Clonidine 0.2mg BID / Catapres TTS3=Clonidine 0.3mg BID Excluded Medication (Exception: Sexual Dysfunction Rider) 1) Tobi 300mg/5ml BID NF 2) Colistimethate 150mg/ml BID NF Cayston is delivered directly to patient via Foundation Care Pharmacy Cedax (Ceftibuten) 400mg Capsule; 90mg/5ml, 1) Cefdinir 125mg/5ml-250mg/5ml 7mg/kg BID 3rd 180mg/5ml Powder for Suspension QD 3rd Generation 2) Pediazole (Erythromycin Generation Ethylsuccinate/Sulfisoxazole) 50mg/kg divided TIDQID Ceftin (Cefuroxime) 125mg/5ml, 250mg/5ml Powder 1) Cefuroxime 250-500mg BID 2nd Generation 2) for Suspension BID 2nd Generation Cefdinir 125mg/5ml-250mg/5ml BID 3rd Generation 3) Ceflacor 250-500mg BID-TID 2nd Generation Cefzil (Cefprozil) 125mg/5ml, 250mg/5ml Powder for 1) Cefuroxime 250-500mg BID 2nd Generation 2) Suspension; 250, 500mg Tablet BID 2nd Cefdinir 125mg/5ml-250mg/5ml BID 3rd Generation Generation 3) Ceflacor 250-500mg BID-TID 2nd Generation Celebrex (Celecoxib) 50, 100, 200, 400mg Capsule BID Cenestin (Conjugated Estrogen Synthetic A) 0.3, 0.45, 0.625, 0.9, 1.25mg Tablet QD Chantix (Varenicline) 0.5, 1mg Tablet 1mg BID 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg BID 3) Ibuprofen 400-800mg TID-QID 4) Sulindac 150-200mg BID 5) Etodolac 200-500mg BID-TID 6) Nabumetone 500-750mg BID 7) Lidocaine 5% Ointment AAA Q4H 8) Diclofenac 25-100mg BID-TID 9) Indomethacin 25-75mg QD-BID 10) Tolmetin 200600mg TID Vasomotor Symtoms 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.0250.1mg/24hr Apply weekly Vaginal/Vulvar Atrophy 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.0250.1mg/24hr Apply weekly 3) Premarin Vaginal 1gm Apply three times a week 4) Vagifem 10mcg Insert twice weekly 5) Estring 2mg Insert for 90 days Document NSAID GI Risk Score > 21 and adequate therapeutic trial or intolerance to Etodolac, Meloxicam, and Nabumetone Adjust to the lowest dose needed to control symptoms based on patient response Dose Conversion Cenestin 0.3mg=Estradiol 0.5mg / Cenestin 0.45mg=Estradiol 0.75mg / Cenestin 0.625mg=Estradiol 1mg / Cenestin 0.9mg=Estradiol 1.5mg / Cenestin 1.25mg=Estradiol 2mg 1) OTC Nicoderm 7, 14, 21mg/day Patch Apply QD 2) Document adequate therapeutic trial or intolerance to Nicotine Replacement Therapy and/or Bupropion OTC Nicorette 2, 4mg Gum Chew 3-24 QD 3) SR Bupropion SR 150mg QD-BID Cialis (Tadalafil) 2.5, 5mg Tablet QD; 10, 20mg Excluded Medication Tablet PRN (Exception: Sexual Dysfunction Rider) Ciloxan (Ciprofloxacin) 0.3% Ophthalmic Ointment 1) Ofloxacin 0.3% Solution 1-2 GTTS QID 2) APPLY RIBBON BID-TID; 0.3% Ophthalmic Solution Ciprofloxacin 0.3% Solution 1-2 GTTS Q4HS NF 3) 1-2 GTTS Q4H Sodium Sulfacetamide 10% Solution 1-3 GTTS Q23H 4) Gentamicin 0.3% Solution 1-2 GTTS QID 5) Erythromycin 0.5% Ointment APPLY RIBBON Q4H 6) Vigamox Solution 0.5% 1 GTT BID NF 7) Ciloxan 0.3% Ointment APPLY RIBBON BID-TID NF Page 11 Last Updated: 8/27/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Cimzia (Certolizumab Pegol) 200mg Subcutaneous Powder for Solution, 200mg/ml Subcutaneous Solution 400mg Q4W (CD/RA) 1) Humira 40mg QOW (CD/RA) 2) Enbrel 50mg QW (RA) 3) Remicade 5mg/kg Q8W NF (CD/RA) Cinryze (C1 Esterase Inhibitor) 500 U Intravenous Powder for Solution Q3-4D Administered in a healthcare setting by healthcare providers Comments Crohns Disease (CD) Document adequate therapeutic trial or intolerance to Humira and Remicade Rheumatoid Arthritis (RA) Document adequate therapeutic trial or intolerance to Humira, Enbrel, and Remicade Remicade Infusion KP GI or Rheumatology Contact CU Infusion Center 770-431-4367 or SW Infusion Center 770-603-3663 Network GI or Rheumatology Contact Provider Relations 404-364-4934 Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Cipro Hc (Ciprofloxacin/Hydrocortisone) 0.2/1% Otic 1) Ofloxacin 0.3% Solution 10 GTTS QD 2) Suspension 3 GTTS BID Neomycin/Polymyxin/Hydrocortisone 1% Suspension 1-2 GTTS Q4 HOURS 3) Neomycin/Polymyxin/Dexamethasone 0.1% Ophthalmic Suspension 1-2 GTTS Q4 HOURS 4) Acetic Acid 2% Solution 1-2 GTTS Q4-6 HOURS 5) Ciprodex 0.3/0.1% Suspension 4 GTTS BID Clarinex (Desloratadine) 5mg Tablet; 5mg Orally 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) Excluded Medication Disintegrating Tablet; 0.5mg/ml Syrup QD OTC Allegra 60mg BID 4) Fluticasone 2 SPRAYS IEN QD 5) Flunisolide 2 SPRAYS IEN BID Cleocin Vaginal (Clindamycin) 2% Cream; 100mg Suppository QHS 1) Clindamycin 300mg BID 2) Metronidazole 500mg BID 3) Metronidazole 0.75% Vaginal Gel QHS NF Adjust to the lowest dose needed to control 2 Separate Medications 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.025- symptoms based on patient response 0.1mg/24hr Apply weekly AND 1) Medroxyprogesterone 2.5-5mg QD 2) Nora-BE 0.35mg QD 3) Norethindrone 5mg QD Clobex (Clobetasol) 0.05% Lotion, Shampoo, Spray Very High Potency AAA BID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID Climara Pro (Estradiol/Levonorgestrel) 0.045/0.015mg/24hr Transdermal Patch Apply weekly Cloderm (Clocortolone Pivalate) 0.1% Cream AAA TID Medium-High Potency Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BIDQID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BIDQID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QDBID Coartem (Artemether/Lumefantrine) 20/120mg 1) Aralen 500mg (Day 1: 1gm, 500mg 6-8 hours later Tablet Day1: 80/480mg, 80/480mg 8 hours later Day Day 2: 500mg Day 3: 500mg) NF 2) Lariam 1250mg 2: 80/480mg BID Day 3: 80/480mg BID (Single dose) NF Page 12 Last Updated: 8/27/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Colcrys (Colchicine) 0.6mg Tablet QD-BID Comments Gout Prophylaxis Quantity Limit Gout Prophylaxis (30 Day Supply)=60 Tablets 1) Allopurinol 100-800mg QD 2) Probenecid 250Gout Treatment=9 Tablets 1000mg BID Gout Treatment 1) Prednisone 40mg X3D decreased by 10mg Q3D to 5mg X3D 2) Ibuprofen 400mg TID-QID 3) Etodolac 400mg BID-TID 4) Indomethacin 25mg QD-BID Colestid (Colestipol) 5gm Powder for Suspension 5- 1) Cholestyramine 4gm 8-16gm QD 2) 30gm QD Cholestyramine Light 4gm 8-16gm QD 3) Colestipol 1gm 2-16gm QD Combigan (Brimonidine/Timolol) 0.2/0.5% 2 Separate Medications Ophthalmic Solution 1 GTT BID Brimonidine 0.2% 1 GTT BID AND Timolol 0.5% 1 GTT BID Combipatch (Estradiol/Norethindrone Acetate) Adjust to the lowest dose needed to control 2 Separate Medications 0.05/0.14mg/24hr, 0.05/0.25mg/24hr Transdermal symptoms based on patient response Vasomotor Symtoms Patch Apply twice weekly 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.0250.1mg/24hr Apply weekly AND 1) Medroxyprogesterone 2.5-5mg QD 2) Nora-BE 0.35mg QD 3) Norethindrone 5mg QD Vaginal/Vulvar Atrophy 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.0250.1mg/24hr Apply weekly 3) Premarin Vaginal 1gm Apply three times a week 4) Vagifem 10mcg Insert twice weekly 5) Estring 2mg Insert for 90 days AND 1) Medroxyprogesterone 2.5-5mg QD 2) Nora-BE 0.35mg QD 3) Norethindrone 5mg QD Combunox (Ibuprofen/Oxycodone) 400/5mgTablet QID Complera (Rilpivirine Hydrochloride/Emtricitabine/Tenofovir Disoproxil Fumarate) 25/200/300mg Tablet QD Condylox (Podofilox) 0.5% Solution AAA BID ConZip (Tramadol) 100, 200, 300mg Variable Release Capsule QD 2 Separate Medications Ibuprofen 400mg QID AND Oxycodone 5mg QID Atripla (Efavirenz/Emtricitabine/Tenofovir Disoproxil Fumarate) Tablet 600/200/300mg QD Condylox 0.5% Gel AAA BID 1) Tramadol 50mg Q4-6H PRN 2) Hydrocodone/Acetaminophen 5/325mg Q4-6H 3) Codeine/APAP 15/300, 30/300, 60/300mg Q4H Cordran (Flurandrenolide) 0.05% Lotion AAA BIDTID Medium Potency ConZip 100mg=Tramadol 25mg Immediate Release + Tramadol 75mg Extended Release / ConZip 200mg=Tramadol 50mg Immediate Release + Tramadol 150mg Extended Release / ConZip 300mg=Tramadol 50mg Immediate Release + Tramadol 250mg Extended Release Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BIDQID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BIDQID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID Cordran (Flurandrenolide) 4mcg/cm Tape Apply Q12- Medium-High Potency 24H Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BIDQID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BIDQID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QDBID Coreg CR (Carvedilol Phosphate) 10, 20, 40, 80mg 1) Propranolol 120-240mg QD 2) Nadolol 240-320mg Dose Conversion Extended Release Capsule QD Coreg CR 10mg QD=Carvedilol 3.125mg BID / QD 3) Carvedilol 12.5-25mg BID 4) Labetalol 200Coreg CR 20mg QD=Carvedilol 6.25mg BID / Coreg 400mg BID CR 40mg QD=Carvedilol 12.5mg BID / Coreg CR 80mg QD=Carvedilol 25mg BID Page 13 Last Updated: 8/27/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Cortisporin (Hydrocortisone Acetate/Neomycin Sulfate/Polymyxin B Sulfate) Cream AAA BID-QID Lowest Potency Corzide (Nadolol/Bendroflumethiazide) 40/5, 80/5mg Tablet QD Cosopt PF (Dorzolamide Hydrochloride/Timolol Maleate) 2/0.5% Ophthalmic Solution 1 GTT BID Creon (Pancrelipase Enzyme) 5, 6, 10, 12, 20, 24 Unit Delayed Release Capsule 10000 Lipase Units/kg QD Crestor (Rosuvastatin) 5, 10, 20, 40mg Tablet QD Comments 2 Separate Medications OTC Hydrocortisone 0.5% Cream AND OTC Neosporin (Neomycin/Polymixin B/Bacitracin) 2 Separate Medications Nadolol QD AND 1) HCTZ 25mg QD 2) Chlorthalidone 50mg QD Dorzolamide/Timolol 2/0.5% 1 GTT BID 1) Pancrelipase 5 Unit 10000 Lipase Units/kg QD 2) Zenpep 5-20 Unit 10000 Lipase Units/kg QD 1) Simvastatin 20-40mg QD 2) Pravastatin 40-80mg QD 3) Atorvastatin 10-80mg QD Crestor to minimize drug interactions and risk of myalgias if current therapy with: -Clarithromycin, Cyclosporine, Danazol, Erythromycin, Gemfibrozil, HIV Protease Inhibitors, Itraconazole, Ketoconazole, Nefazodone, Posaconazole,Telithromycin -Diltiazem, Verapamil (Maximum Lovastatin 40mg, Pravastatin 40mg, or Simvastatin 10mg) -Amiodarone, Amlodipine, Ranolazine (Maximum Simvastatin 20mg) Dose Conversion Crestor 5mg=Atorvastatin 10mg=Pravastatin 40mg=Simvastatin 20mg / Crestor 10mg=Atorvastatin 20mg=Pravastatin 80mg=Simvastatin 40mg / Crestor 20mg=Atorvastatin 40mg / Crestor 40mg=Atorvastatin 80mg Crinone (Progesterone) 4% Vaginal Gel QOD Medroxyprogesterone 5-10mg QD Crolom (Cromolyn) 4% Ophthalmic Solution 1-2GTT 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q3Q4-6 HOURS 4 HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID Cryselle (30mcg Ethinyl Estradiol/0.3 Norgestrel) Document adequate therapeutic trial or intolerance 1) Reclipsen (30mcg Ethinyl Estradiol/0.15mg Tablet QD to at least 3 formulary oral contraceptives Desogestrel) QD 2) Microgestin Fe 1.5/30 (30mcg Ethinyl Estradiol/1.5mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD Cutivate (Fluticasone Propionate) 0.005% Ointment High Potency AAA BID High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BIDQID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QDBID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Cutivate (Fluticasone Propionate) 0.05% Cream, Medium Potency Lotion AAA BID Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BIDQID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BIDQID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID Cuvposa (Glycopyrrolate) 1mg/5ml Oral Solution 1) Benztropine 2mg TID-QID 2) Trihexphenidyl 2mg BID-TID TID 3) Trihexphenidyl 0.4mg/ml NF 4) Glycopyrrolate 1mg TID-QID 5) Atrovent 1-2 PUFFS TID 6) Transderm Scop 1.5mg Patch Apply Q72H NF Page 14 Last Updated: 8/27/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Comments Cyclessa (25 mcg Ethinyl Estradiol/0.1mg Desogestrel x 7days, 25 mcg EE/0.125mg Desogestrel x 7 days, 25 mcg EE/0.15mg Desogestrel x 7 days) Tablet QD Document adequate therapeutic trial or intolerance 1) Tri-Sprintec (35mcg Ethinyl Estradiol/0.18mg to at least 3 formulary oral contraceptives Norgestimate x 7 days, 35mcg EE/0.215mg NG x 7 days, 35mcg EE/0.25mg NGx 7 days) QD 2) Reclipsen (30mcg Ethinyl Estradiol/0.15 Desogestrel) QD 3) Trivora (30mcg Ethinyl Estradiol/0.05mg Levonorgestrel x 6 days, 40mcg EE/0.075mg LVNGL x 5 days, 30mcg EE/0.125mg LVNGL x 10 days) QD 4) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) QD 5) Leena (35mcg Ethinyl Estradiol/0.5mg Norethindrone x 7 days, 35mcg EE/1mg NE x 9 days, 35mcg EE/0.5mg NE x 5 days) QD Cyclocort (Amcinonide) 0.1% Cream, Lotion AAA BID-TID High Potency High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BIDQID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QDBID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID Cyclocort (Amcinonide) 0.1% Ointment AAA BID TID Very High Potency Page 15 Last Updated: 8/27/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Cymbalta (Duloxetine) 20, 30, 60mg Delayed Release Capsule QD Cytovene (Ganciclovir) 250, 500mg Capsule 1000mg TID Daliresp (Roflumilast) 500mcg Tablet QD Dalmane (Flurazepam) 15, 30mg Capsule QHS Dantrium (Dantrolene) 25, 50, 100mg Capsule TID Daytrana (Methylphenidate) 10mg/9hr, 15mg/9hr, 20mg/9hr, 30mg/9hr Transdermal Patch Apply 1 patch up to 9 hours Major Depressive Disorder or Generalized Anxiety Disorder 1) Citalopram 20-40mg QD 2) Fluoxetine 20-40mg QD 3) Sertraline 50-100mg QD 4) Mirtazapine 30mg QHS 5) Bupropion SR/XL 300mg QD 6) Venlafaxine ER 225mg QD 7) Fluvoxamine 50-300mg QD NF 8) Escitalopram 10-20mg QD NF 9) Paxil CR 12.537.5mg QD NF 10) Viibryd 10-40mg QD NF 11) Pristiq 50-100mg QD NF Diabetic Peripheral Neuropathic Pain 1) Amitriptyline (AMT)* 50mg QHS 2) Nortriptyline (NRT)* (<65 YOA: 25mg/>65 YOA: 10mg) QHS 3) Cyclobenzaprine* 10mg TID 4) Tramadol* 50mg BID 5) Venlafaxine ER 225mg QD Non-Diabetic Peripheral Neuropathic Pain 1) AMT* 50mg QHS 2) NRT* (<65 YOA: 25mg/>65 YOA: 10mg) QHS 3) Cyclobenzaprine* 10mg TID 4) Tramadol* 50mg BID Fibromyalgia 1) AMT* 50mg QHS 2) NRT* (<65 YOA: 25mg/>65 YOA: 10mg) QHS 3) Cyclobenzaprine* 10mg TID 4) Tramadol* 50mg BID Post Herpetic Neuralgia 1) NRT* (<65 YOA: 25mg/>65 YOA: 10mg) QHS 2) Gabapentin 600mg TID 3) Lidocaine 5% Ointment AAA HIV Associated Polyneuropathy 1) Lamotrigine 200-400mg QD Trigeminal Neuralgia 1) Carbamazepine 200-1200mg QD 2) Oxcarbazepine 600-1800mg QD NF Mi P h l i CMV Retinitis Prophylaxis 1) Valcyte 450mg 2T QD 2) Valcyte 50mg/ml 18ml QD CMV Retinitis Treatment 1) Valcyte 450mg 2T BID 2) Valcyte 50mg/ml 18ml BID 1) Ipratropium 0.02% Inhalation Solution QID 2) Aminophylline 100-200mg BID-TID 3) Proair HFA (Albuterol) 0.09mg Inhalation Aerosol Powder Q4H PRN 4) Theophylline 100-300 TID-QID 5) Albuterol 0.5% Inhalation Solution QID 6) Combivent (Albuterol Sulfate/Ipratropium Bromide) 0.09mg-0.018mg Inhalation Aerosol Powder QID 7) Spiriva 18mcg QD Comments Major Depressive Disorder or Generalized Anxiety Disorder Document adequate therapeutic trial or intolerance to 2 SSRIs and Venlafaxine Diabetic Peripheral Neuropathic Pain Document adequate therapeutic trial or intolerance to 1 TCA*, Tramadol*; and Venlafaxine Non-Diabetic Peripheral Neuropathic Pain Document adequate therapeutic trial or intolerance to 1 TCA*, Tramadol*, and Cyclobenzaprine Fibromyalgia Document adequate therapeutic trial or intolerance to 1 TCA*, Tramadol*, and Cyclobenzaprine Post Herpetic Neuralgia Document adequate therapeutic trial or intolerance to1 TCA* and Gabapentin HIV Associated Polyneuropathy Document adequate therapeutic trial or intolerance to Lamotrigine Trigeminal Neuralgia Document adequate therapeutic trial or intolerance to Carbamazepine and Oxcarbazepine NF Migrane Prophylaxis Document adequate therapeutic trial or intolerance to Topiramate, Divalproex, 1 Beta Blocker, and 1 TCA* *Not recommended in the elderly and not a required medication for patients over 65 years old 1) Temazepam 15mg QHS 2) Lorazepam 0.5mg QHS 3) Oxazepam 10-30mg QHS 4) Trazodone 50-100mg QHS 5) Zolpidem 5-10mg QHS 6) Hydroxyzine 1025mg QHS 1) Cyclobenzaprine 10mg TID 2) Chlorzoxazone 250500mg TID 3) Carisoprodol 350mg TID 4) Tizanidine 4mg TID 5) Methocarbamol 500-750mg QID 6) Baclofen 10-20mg TID 1) Methylin 5-20mg BID-TID 2) Adderall 5-30mg QD- Document adequate therapeutic trial or intolerance to at least 3 formulary alternatives BID 3) Methylin ER 10-20mg BID-TID 4) Dextroamphetamine CR 5-15mg QD-BID 5) Adderall XR 5-30mg QAM 6) Methylphenidate ER 18-72mg QAM Page 16 Last Updated: 8/27/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Daypro (Oxaprozin) 600mg Tablet BID-TID Demadex (Torsemide) 5, 10, 20, 100mg Tablet QD Denavir (Penciclovir) 1% Cream AAA Q2H Depo-Testosterone (Testosterone Cypionate) 100mg/ml Intramuscular Suspension Q2-4W Dermatop (Prednicarbate) 0.1% Cream, Ointment AAA BID Medium Potency Desonate (Desonide) 0.05% Gel AAA BID Low Potency Detrol (Tolterodine) 1, 2mg Tablet BID Detrol LA (Tolterodine) 2, 4mg Extended Release Capsule QD Dexilant (Dexlansoprazole) 30, 60mg Capsule QD Didrex (Benzphetamine) 50mg Tablet QD-TID Differin (Adapalene) 0.1% Cream, Gel, Lotion AAA QHS Dificid (Fidaxomicin) 200mg Tablet BID X10D Comments 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg BID 3) Ibuprofen 400-800mg TID-QID 4) Sulindac 150-200mg BID 5) Etodolac 200-500mg BID-TID 6) Nabumetone 500-750mg BID 7) Lidocaine 5% Ointment AAA Q4H 8) Diclofenac 25-100mg BID-TID 9) Indomethacin 25-75mg QD-BID 10) Tolmetin 200600mg TID 1) Bumetanide 0.5-1mg QD 2) Furosemide 20-80mg Dose Conversion QD Torsemide 10mg=Bumetanide 0.5mg=Furosemide 20mg / Torsemide 20mg=Bumetanide 1mg=Furosemide 40mg / Torsemide 40mg=Bumetanide 2mg=Furosemide 80mg 1) OTC Abreva 10% Cream AAA Q4H 2) Acyclovir 400mg BID 1) Testosterone Cypionate 200mg/ml IM Q2-4W 2) Androderm Patch 2-4mg/24hr Apply QPM Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BIDQID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BIDQID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID Low Potency 1) Betamethasone Valerate 0.1% Lotion AAA QD-BID 2) Desonide 0.05% Cream, Ointment AAA BID-TID 3) Fluocinolone Acetonide 0.01% Solution AAA QD 4) Derma-Smoothe/FS 0.01% Oil AAA QD Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BIDQID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID 1) Oxybutinin 5mg BID-TID 2) Oxybutynin XL 5-15mg QD 3) Oxytrol 3.9mg/day Patch Apply twice weekly 4) Trospium 20mg BID NF 5) Detrol LA 2-4mg QD NF 6) Toviaz 4-8mg QD NF 7) Enablex 7.5-15mg QD NF 8) Vesicare 5-10mg QD NF 1) Oxybutinin 5mg BID-TID 2) Oxybutynin XL 5-15mg QD 3) Oxytrol 3.9mg/day Patch Apply twice weekly 4) Trospium 20mg BID NF 1) Pantoprazole 40mg QD 2) OTC Omeprazole 20mg Excluded Medication QD 3) OTC Zegerid 20/1100mg QD 4) OTC Prevacid 15mg QD Excluded Medication (Exception: Obesity Rider) Retin-A 0.025-0.1% Cream, Gel AAA QHS Excluded Medication for patients > 36 YOA 1) Metronidazole 500mg TID X10-14D 2) Vancomycin KPGA Approved Compound 50mg/ml Solution 125mg QID X10-14D Diflucan (Fluconazole) 10, 40mg/ml Oral Powder for 1) Nystatin 100000 Suspension 4-6ml QID 2) Suspension QD Clotrimazole 10mg Troche QID Diovan (Valsartan) 80, 160, 320mg Tablet QD 1) Lisinopril QD NOTE: If Angiotensin Converting Enzyme Inhibitor allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan QD Page 17 Last Updated: 8/27/2012 Dose Conversion Diovan 80mg=Lisinopril 10mg=Losartan 25mg / Diovan 160mg=Lisinopril 20mg=Losartan 50mg / Diovan 320mg=Lisinopril 40mg=Losartan 100mg Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Diovan HCT (Valsartan/HCTZ) 80/12.5, 160/12.5, 320/12.5, 160/25, 320/25mg Tablet QD 2 Separate Medications HCTZ QD AND 1) Lisinopril QD NOTE: If Angiotensin Converting Enzyme Inhibitor allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan QD Dipentum (Olsalazine) 250mg Capsule 2T BID 1) Sulfasalazine 500mg (2-4gm QD) 2) Colazal 750mg (2.25gm TID for 8-12 weeks) 3) Asacol 400mg (800mg TID) 4) Dipentum 550mg BID NF 5) Pentasa 250, 500mg (1gm QID) Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID Diprolene (Betamethasone Dipropionate Augmented) 0.05% Lotion, Ointment AAA QD-BID Ultra High Potency Comments Dose Conversion Diovan 80mg=Lisinopril 10mg=Losartan 25mg / Diovan 160mg=Lisinopril 20mg=Losartan 50mg / Diovan 320mg=Lisinopril 40mg=Losartan 100mg NOTE: Consider Lisinopril/HCTZ 10/12.5, 20/12.5, 20/25mg or Losartan/HCTZ 50/12.5, 100/12.5, 100/25mg Diprolene AF (Betamethasone Dipropionate Very High Potency Augmented) 0.05% Cream AAA QD- BID Ultra High 1) Betamethasone Dipropionate Augmented 0.05% Potency Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID Diprosone (Betamethasone Dipropionate) 0.05% Ointment AAA QD-BID Very High Potency Divigel (Estradiol) 0.25, 0.5, 1mg Gel Apply QD alternating right or left upper thigh Dolobid (Diflunisal) 250, 500mg Tablet BID-TID Doral (Quazepam) 15mg Tablet QHS Doryx (Doxycycline Hyclate) 75, 100, 150mg Delayed Release Tablet QD-BID Duac (Clindamycin/Benzoyl Peroxide) 1/5% Gel AAA BID High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BIDQID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QDBID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.025- Adjust to the lowest dose needed to control symptoms based on patient response 0.1mg/24hr Apply weekly 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg BID 3) Ibuprofen 400-800mg TID-QID 4) Sulindac 150-200mg BID 5) Etodolac 200-500mg BID-TID 6) Nabumetone 500-750mg BID 7) Lidocaine 5% Ointment AAA Q4H 8) Diclofenac 25-100mg BID-TID 1) Temazepam 15mg QHS 2) Lorazepam 0.5mg QHS 3) Oxazepam 10-30mg QHS 4)Trazodone 50-100mg QHS 5) Zolpidem 5-10mg QHS 6) Hydroxyzine 1025mg QHS 1) Doxycycline Hyclate 50-100mg BID 2) Minocycline 50-100mg BID 3) Tetracycline 250500mg BID 1) Clindamycin 1% Gel AAA BID AND OTC Benzoyl Peroxide 5% Gel AAA BID 2) Erythromycin/Benzoyl Peroxide 3/5% Gel AAA BID Page 18 Last Updated: 8/27/2012 Dose Conversion Doryx 100mg QD=Doxycycline 50mg BID Dispense Clindamycin as 1 copay and purchase OTC Benzoyl Peroxide Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Duetact (Glimepiride/Pioglitazone) 2/30, 4/30mg Tablet QD 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin 500-1000mg (Maximum 2550mg QD) 3) Metformin ER 500-750mg (Maximum 2000mg QD) 4) Novolin R (Insulin Regular) SC 30 minutes AC 5) Novolin N (NPH) SC 15-30 minutes AC 6) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos 15mg (Maximum 45mg QD) Duexis (Ibuprofen/Famotidine) 800/26.6mg Tablet TID 2 Separate Medications Ibuprofen 800mg TID AND OTC Famotidine 20mg TID 1) Qvar 40-80mcg 1-2 PUFFS QD-BID 2) Asmanex 110-220mcg 1-2 PUFFS QD Dulera (Mometasone/Formoterol) 100/5, 200/5mcg Inhalation Aerosol Powder 2 PUFFS BID Comments Adjust based on patient response American Diabetes Association Recommendations -Patient uncontrolled on maximum Metformin and maximum Sulfonylurea=Do not initiate Actos and initiate Novolin N -Patient on Actos and Insulin=Discontinue Actos and maximize Novolin N Glipizide preferred if 65 years of age and older due to prolonged half life of Glyburide Document adequate trial or intolerance to Qvar 80mcg 2 PUFFS BID or Asmanex 220mcg 2 PUFFS QD within the past 3 months *Patients should have prescription for a ShortActing Beta 2 Agonist (e.g. Proair) for asthma exacerbations Dose Conversion Dulera 100/5mcg 2 PUFFS BID=Albuterol Q4H PRN + Qvar 80mcg 2 PUFFS BID=Albuterol Q4H PRN + Asmanex 220mcg 2 PUFFS QD Dulera 200/5 2 PUFFS BID=No formulary alternative DuoNeb (Albuterol Sulfate/Ipratropium Bromide) 3mg/3 ml-0.5mg/3ml Inhalation Solution QID 1) Albuterol 0.5% Inhalation Solution QID AND Ipratropium 0.02% Inhalation Solution QID 2) Combivent (Albuterol Sulfate/Ipratropium Bromide) 0.09mg-0.018mg Inhalation Aerosol Powder QID Durezol (Difluprednate) 0.05% Ophthalmic Emulsion 1) Prednisolone 1% 1-2 GTTS BID-QID 2) 1GTT BID-QID Fluorometholone 0.1% 1-2 GTTS BID-QID 3) Dexamethasone 0.1% 1-2 GTTS BID-QID Duricef (Cefadroxil) 500mg Capsule; 250mg/5ml, 1) Cephalexin 250-500mg BID 1st Generation 500mg/5ml Powder for Suspension; 1gm Tablet QD- 2)Cefuroxime 250-500mg BID 2nd Generation 3) BID 1st Generation Cefdinir 125mg/5ml-250mg/5ml BID 3rd Generation 4) Ceflacor 250-500mg BID-TID 2nd Generation Dynacin (Minocycline) 75mg Tablet BID DynaCirc CR (Isradipine) 5, 10mg Extended Release Tablet QD Edarbi (Azilsartan Medoxomil) 40, 80mg Tablet QD 1) Doxycycline 50-100mg BID 2) Minocycline 50100mg BID 3)Tetracycline 250-500mg BID 1) Amlodipine 5-10mg QD 2) Verapamil SR 180240mg BID 3) Diltiazem ER 240-360mg QD 4) Nifedipine ER 30-60mg QD 5) Felodipine 2.5-20mg QD 1) Lisinopril QD NOTE: If Angiotensin Converting Enzyme Inhibitor allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan QD Edecrin (Ethacrynic acid) 25mg Tablet QD 1) Bumetanide 0.5-1mg QD 2) Furosemide 20-80mg QD Edluar (Zolpidem) 5, 10mg Sublingual Tablet QHS 1) Trazodone 50-100mg QHS 2) Temazepam 1530mg QHS 3) Zolpidem 5-10mg QHS 4) Zaleplon 510mg QHS 5) Ambien CR 6.25-12.5mg QHS NF Intelence 200mg BID Clopidogrel 75mg QD 1) Fluorouracil 5% Solution AAA BID 2) Efudex 5% Cream AAA BID 3) Carac 0.5% Cream AAA BID NF 4) Fluoroplex 1% Cream AAA BID Edurant (Rilpivirine) 25mg Tablet QD Effient (Prasugrel) 5, 10mg Tablet QD Efudex (Fluorouracil) 2% Solution AAA BID Page 19 Last Updated: 8/27/2012 Dose Conversion DynaCirc CR 5mg=Nifedipine ER 30mg QD / DynaCirc CR 10mg=Nifedipine ER 60mg QD Dose Conversion Edarbi 40mg=Lisinopril 40mg=Losartan 100mg / Edarbi 80mg=No formulary alternative (Consider combination therapy)=Lisinopril/HCTZ 20/12.5mg 2T QD=Losartan/HCTZ 100/25mg Dose Conversion Ethacrynic Acid 25mg=Bumetanide 0.5mg=Furosemide 20mg Document adequate therapeutic trial or intolerance to Trazodone, Zolpidem, and at least 1 Benzodiazepine Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Egrifta (Tesamorelin) 1mg Subcutaneous Powder for Egrifta is delivered directly to patient via KP CA Solution 2mg SQ QD Specialty Pharmacy Elestat (Epinastine) 0.05 % Ophthalmic Solution 1 GTT BID Comments Excluded Medication KP CA Specialty Pharmacy MD Line 650-301-5799 / Patient Line 1-877-4045777 / Fax Line 650-301-5790 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q34 HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID 4) Crolom 4% 1-2 GTTS Q4-6 HOURS NF 5) Emadine 0.05% 1 GTT QID NF 6) Alocril 2% 1-2 GTTS BID NF 7) Optivar 0.05% 1 GTT BID NF 8) Alomide 0.1% 1-2 GTTS QID NF 9) Lastacaft 0.25% 1 GTT QD NF 10) Pataday 0.2% 1 GTT QD NF 11) Alrex 0.2% 1 GTT QID NF 12) Patanol 0.1% 1 GTT BID NF Eldoquin Forte (Hydroquinone) 4% Cream AAA BID Excluded Medication Elestrin (Estradiol) 0.06% Gel Apply 1-2 pumps to upper arm QD 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.025- Adjust to the lowest dose needed to control symptoms based on patient response 0.1mg/24hr Apply weekly Eligard (Leuprolide Acetate) 7.5 (1 Month), 22.5 (3 Month), 30 (4 Month), 45mg (6 Month) Subcutaneous Powder for Suspension UAD Administered in a healthcare setting by healthcare providers Lupron Depot available via KP Oncology Floorstock Elocon (Mometasone Furoate ) 0.1% Solution AAA QD High Potency High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BIDQID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QDBID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Emadine (Emedastine) 0.05% Ophthalmic Solution 1 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q3GTT QID 4 HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID 4) Crolom 4% 1-2 GTTS Q4-6 HOURS NF Emend (Aprepitant) 80, 125mg Capsule Day 1: 1) Metoclopramide 1-2mg/kg 30 minutes prior to Document current treatment with a) Cisplatin > 125mg 1 hour prior to chemotherapy Day 2-3: 80mg chemotherapy 2) Prochlorperazine 5-10mg Q6H 3) 50mg/m2 b) AC (Doxorubicin/Cyclophosphamide) c) QAM Dexamethasone 20mg 30 minutes prior to other highly emetogenic chemotherapy chemotherapy 4) Ondansetron 4-8mg 30 minutes prior to chemotherapy 5) Ondansetron 4-8mg ODT 30 minutes prior to chemotherapy Emsam (Selegiline) 6, 9, 12mg/24hr Transdermal 1) Citalopram 20-40mg QD 2) Fluoxetine 20-40mg Patch QD QD 3) Sertraline 50-100mg QD 4) Mirtazapine 30mg QHS 5) Bupropion SR/XL 300mg QD 6) Venlafaxine ER 225mg QD 7) Fluvoxamine 50-300mg QD NF 8) Escitalopram 10-20mg QD NF 9) Paxil CR 12.537.5mg QD NF 10) Viibryd 10-40mg QD NF 11) Pristiq 50-100mg QD NF 12) Cymbalta 30-60mg BID NF Enablex (Darifenacin) 7.5, 15mg Extended Release 1) Oxybutinin 5mg BID-TID 2) Oxybutynin XL 5-15mg Tablet QD QD 3) Oxytrol 3.9mg/day Patch Apply twice weekly 4) Trospium 20mg BID NF 5) Detrol LA 2-4mg QD NF 6) Toviaz 4-8mg QD NF Page 20 Last Updated: 8/27/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Comments Enjuvia (Conjugated Estrogen Synthetic B) 0.3, 0.45, 0.625, 0.9, 1.25mg Tablet QD Vasomotor Symtoms 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.0250.1mg/24hr Apply weekly Vaginal/Vulvar Atrophy 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.0250.1mg/24hr Apply weekly 3) Premarin Vaginal 1gm Apply three times a week 4) Vagifem 10mcg Insert twice weekly 5) Estring 2mg Insert for 90 days Adjust to the lowest dose needed to control symptoms based on patient response Dose Conversion Enjuvia 0.3mg=Estradiol 0.5mg / Enjuvia 0.45mg=Estradiol 0.75mg / Enjuvia 0.625mg=Estradiol 1mg / Enjuvia 0.9mg=Estradiol 1.5mg / Enjuvia 1.25mg=Estradiol 2mg Enpresse (30mcg Ethinyl Estradiol/0.05mg Levonorgestrel x 6 days, 40 mcg EE/0.075mg LVNGL x 5 days, 30mcg EE/0.125mg LVNGL x 10 days) Tablet QD 1) Tri-Sprintec (35mcg Ethinyl Estradiol/0.18mg Norgestimate x 7 days, 35mcg EE/0.215mg NG x 7 days, 35mcg EE/0.25mg NGx 7 days) QD 2) Trivora (30mcg Ethinyl Estradiol/0.05mg Levonorgestrel x 6 days, 40mcg EE/0.075mg LVNGL x 5 days, 30mcg EE/0.125mg LVNGL x 10 days) QD 3) Leena (35mcg Ethinyl Estradiol/0.5mg Norethindrone x 7 days, 35mcg EE/1mg NE x 9 days, 35mcg EE/0.5mg NE x 5 days) QD Equivalent Brand and Generic Products Enpresse=Trivora Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Entocort (Budesonide) 3mg Delayed Release Capsule 2-3T QD 1) Prednisone 5-60mg QD 2) Sulfasalazine 500mg (2- Budesonide is indicated for the treatment of severe microscopic colitis 4gm QD) 3) Hydrocortisone 100mg Enema QHS 4) Mesalamine 4gm Enema QHS 5) Colazal 750mg (2.25gm TID for 8-12 weeks) 6) Asacol 400mg (800mg TID) 7) Dipentum 550mg BID NF 8) Pentasa 250, 500mg (1gm QID) 9) Budesonide 3mg 2-3T QD NF 1) OTC Hydrocortisone 0.5-1% Cream, Ointment AAA BID-QID 2) OTC Prax 1% Cream, Lotion AAA BID-QID 3) Hydrocortisone 2.5% Cream, Lotion, Ointment AAA BID-QID 4) Hydrocortisone 25mg Suppository BID 5) Hydrocortisone 100mg/60ml Enema QD-BID 6) Proctofoam-HC 1/1% QD-BID Enzone (Hydrocortisone Acetate/Pramoxine) 1/1% Cream QD-BID Epiduo (Adapalene/Benzoyl Peroxide) 0.1/2.5% Gel 2 Separate Medications AAA QD OTC Benzoyl Peroxide 2.5% AAA QD AND 1) RetinA 0.025-0.1% Cream, Gel AAA QHS 2) Differin 0.1% Cream AAA QD NF Epifoam (Hydrocortisone Acetate/Pramoxine) 1/1% 1) OTC Hydrocortisone 0.5-1% Cream, Ointment Foam QD-BID AAA BID-QID 2) OTC ProctoFoam 1% QD-BID 3) Hydrocortisone 2.5% Cream, Lotion, Ointment AAA BID-QID 4) Hydrocortisone 25mg Suppository BID 5) Hydrocortisone 100mg/60ml Enema QD-BID 6) Proctofoam-HC 1/1% QD-BID EpiPen (Epinephrine) 0.3mg/0.3ml Injection Device Epinephrine 0.3mg/0.3ml Injection Device PRN PRN EpiPen Jr (Epinephrine) 0.15mg/0.3ml Injection Epinephrine 0.15mg/0.3ml Injection Device PRN Device PRN Epivir HBV (Lamivudine) 5mg/ml Solution; 100mg 1) Epivir 10mg/ml 10ml QD 2) Epivir 150mg QD Tablet QD Epogen (Epoetin Alfa) 2000, 3000, 4000, 10000, Procrit (Epoetin Alfa) 2000, 3000, 4000, 10000, 20000U/ml Injection Solution QW 20000, 40000U/ml QW Estrace (Estradiol) 0.1mg/gm Vaginal Cream 1gm 1) Estradiol QD 2) Climara Patch 0.025-0.1mg/24hr Apply three times a week Apply weekly 3) Premarin Vaginal 1gm Apply three times a week 4) Vagifem 10mcg Insert twice weekly 5) Estring 2mg Insert for 90 days Page 21 Last Updated: 8/27/2012 Excluded Medication for patients > 36 YOA Dispense Retin-A or Differin as 1 copay and purchase OTC Benzoyl Peroxide EpiPen to Epinephrine 0.3mg/0.3ml is a 1:1 Conversion EpiPen Jr to Epinephrine 0.15mg/0.3ml is a 1:1 Conversion Epogen to Procrit is a 1:1 Conversion Adjust to the lowest dose needed to control symptoms based on patient response Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Comments Estraderm (Estradiol) 0.05, 0.1mg/24hr Transdermal Vasomotor Symtoms Adjust to the lowest dose needed to control Patch Apply twice weekly 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.025- symptoms based on patient response 0.1mg/24hr Apply weekly Vaginal/Vulvar Atrophy 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.0250.1mg/24hr Apply weekly 3) Premarin Vaginal 1gm Apply three times a week 4) Vagifem 10mcg Insert twice weekly 5) Estring 2mg Insert for 90 days Estrasorb (Estradiol) 2.5mg/gm Transdermal Emulsion Apply QD to each thigh EstroGel (Estradiol) 0.06% Gel Apply 1.25gm QD on the arm from wrist to shoulder 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.0250.1mg/24hr Apply weekly Vasomotor Symtoms 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.0250.1mg/24hr Apply weekly Vaginal/Vulvar Atrophy 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.0250.1mg/24hr Apply weekly 3) Premarin Vaginal 1gm Apply three times a week 4) Vagifem 10mcg Insert twice weekly 5) Estring 2mg Insert for 90 days EstroStep Fe (20 mcg Ethinyl Estradiol/1mg Norethindrone x 5 days, 30mcg EE/1mg NE x 7 days, 35mcg EE/1mg NE x 9 days) Tablet QD 1) Tri-Sprintec (35mcg Ethinyl Estradiol/0.18mg Norgestimate x 7 days, 35mcg EE/0.215mg NG x 7 days, 35mcg EE/0.25mg NGx 7 days) QD 2) Trivora (30mcg Ethinyl Estradiol/0.05mg Levonorgestrel x 6 days, 40mcg EE/0.075mg LVNGL x 5 days, 30mcg EE/0.125mg LVNGL x 10 days) QD 3) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) QD 4) Necon 1/35 (35mcg Ethinyl Estradiol/1mg Norethindrone) QD 5) Leena (35mcg Ethinyl Estradiol/0.5mg Norethindrone x 7 days, 35mcg EE/1mg NE x 9 days, 35mcg EE/0.5mg NE x 5 days) QD Evamist (Estradiol) 1.53mg/Actuation Transdermal 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.025Spray Apply 1-3 sprays to adjacent, non-overlapping 0.1mg/24hr Apply weekly area on the inner surface of the forearm Adjust to the lowest dose needed to control symptoms based on patient response Adjust to the lowest dose needed to control symptoms based on patient response Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Adjust to the lowest dose needed to control symptoms based on patient response Evoclin (Clindamycin) 1% Foam AAA QD 1) Clindamycin 1% Solution AAA BID 2) Clindamycin 1% Gel AAA BID 3) Clindamycin 1% Lotion AAA BID Evoxac (Cevimeline) 30mg Capsule TID 1) Pilocarpine 0.5, 1, 2, 3, 4, 6% Ophthalmic Solution Ophthalmic Solution may be administered orally 5-10 GTTS PO TID 2) Pilocarpine 5mg TID-QID NF Exalgo (Hydromorphone) 8, 12, 16mg Extended Release Tablet QD 1) Morphine ER 60-100mg BID 2) Fentanyl 25100mcg/hr Q72H 3) Avinza 30-120mg QD NF 4) Opana ER 5-40mg BID NF 5) Kadian 10-200mg QD NF Exelderm (Sulconazole) 1% Cream, Solution QDBID 1) OTC Lamisil Ultra (Butenafine 1%) QD-BID 2) OTC Lotrimin AF (Clotrimazole 1%) BID 3) OTC Micatin (Miconazole 1%) BID 4) Ketoconazole 2% Cream QD Exelon (Rivastigmine) 4.6mg/24hr, 9.5mg/24 hr Patch QD 1) Galantamine 4-12mg BID, Galantamine ER 824mg QD 2) Aricept 5-10mg QD 3) Namenda 5-10mg QD-BID 4) Exelon Capsule 1.5-6mg BID 5) Exelon Solution 2mg/ml 3ml BID 2 Separate Medications Amlodipine QD AND 1) Lisinopril QD NOTE: If Angiotensin Converting Enzyme Inhibitor allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan QD Exforge (Amlodipine/Valsartan) 5/160, 5/320, 10/160, 10/320mg Tablet QD Page 22 Last Updated: 8/27/2012 Dose Conversion Hydromorphone 7.5mg=Morphine 30mg=Oxycodone 20mg=Oxymorphone 10mg / Morphine 90mg=Fentanyl 25mcg/hr Document adequate therapeutic trial or intolerance to Morphine ER and Fentanyl Document adequate therapeutic trial or intolerance to Galantamine, Aricept, Namenda, and Exelon Capsule or Solution Dose Conversion Diovan 80mg=Lisinopril 10mg=Losartan 25mg / Diovan 160mg=Lisinopril 20mg=Losartan 50mg / Diovan 320mg=Lisinopril 40mg=Losartan 100mg Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Comments Exforge HCT (Amlodipine/Valsartan/HCTZ) 5/160/12.5, 5/160/25, 10/160/12.5, 10/160/25, 10/320/25mg Tablet QD 3 Separate Medications Dose Conversion Amlodipine QD AND HCTZ QD AND 1) Lisinopril QD Diovan 160mg=Lisinopril 20mg=Losartan 50mg / Diovan 320mg=Lisinopril 40mg=Losartan 100mg NOTE: If Angiotensin Converting Enzyme Inhibitor NOTE: Consider Lisinopril/HCTZ 20/12.5mg or allergy or contraindication consider Angiotensin Losartan/HCTZ 50/12.5, 100/25mg Receptor Blocker 2) Losartan QD Famvir (Famcyclovir) 125, 250, 500mg Tablet BID- Genital Herpes Episodic Treatment TID 1) Acyclovir 200mg Q4H 2) Acyclovir 400mg TID 3) Acyclovir 800mg BID 4) Valacyclovir 1gm BID X7D NF Genital Herpes Suppressive Treatment 1) Acyclovir 400mg BID 2) Valacyclovir 500mg QD NF Herpes Zoster Treatment 1) Acyclovir 800mg Q4H 2) Valacyclovir 1gm TID X7D NF Fanapt (Iloperidone) 1, 2, 4, 6, 8, 10, 12mg Tablet 1) Risperidone 4mg QD 2) Haloperidol 0.5-5mg BIDBID TID 3) Thiothixene 2mg TID 4) Quetiapine 400800mg QD 5) Ziprasidone 20-80mg BID 6) Olanzapine 10mg QD 7) Olanzapine ODT 10mg QD 8) Latuda 40-80mg QD NF 9) Abilify 10-15mg QD 10) Saphris 5-10mg BID NF Fareston (Toremifene Citrate) 60mg Tablet QD 1) Tamoxifen 20-40mg QD 2) Faslodex 50mg/ml IM QM Felbatol (Felbamate) 600mg/5mL Suspension; 400, 1) Lamotrigine 100-200mg BID 2) Carbamazepine 600mg Tablet TID-QID 800-1600mg QD 3) Topiramate 200mg BID 4) Phenytoin 100mg TID 5) Levetiracetam 500-1500mg BID 6) Zonisamide 100mg TID NF 7) Gabapentin 300600mg TID 8) Levetiracetam ER 1000mg QD 9) Oxcarbazepine 600mg BID NF 10) Divalproex 250500mg TID 11) Lyrica 50-200mg TID NF 12) Vimpat 100-200mg BID NF 13) Banzel 400mg BID NF 14) Gabitril 16 mg BID-TID NF Feldene (Piroxicam) 10, 20mg Capsule QD Meloxicam 7.5-15mg QD Femcon Fe (35mcg Ethinyl Estradiol/0.4mg Document adequate therapeutic trial or intolerance 1) Sprintec (35mcg Ethinyl Estradiol/0.25mg Norethindrone) Tablet QD to at least 3 formulary oral contraceptives Norgestimate) QD 2) Necon 1/35 (35mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Necon 0.5/35 (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD 4) Zovia 1/35 (35mcg Ethinyl Estradiol/1mg Ethynodiol diacetate) QD 5) Brevicon (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD Femhrt 1/5 (Ethinyl Estradiol/Norethindrone Acetate) 2 Separate Medications Adjust to the lowest dose needed to control 5mcg/1mg Tablet QD 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.025- symptoms based on patient response Dose Conversion 0.1mg/24hr Apply weekly AND 1) Ethinyl Estradiol 5mcg=Estradiol 1mg Medroxyprogesterone 2.5-5mg QD 2) Nora-BE 0.35mg QD 3) Norethindrone 5mg QD Femring (Estradiol Acetate) 0.05, 0.1mg/24hr Adjust to the lowest dose needed to control Vasomotor Symtoms Vaginal Insert Insert for 90 days 1) Estradiol QD 2) Climara Patch 0.025-0.1mg/24hr symptoms based on patient response Apply weekly Vaginal/Vulvar Atrophy 1) Estradiol QD 2) Climara Patch 0.025-0.1mg/24hr Apply weekly 3) Premarin Vaginal 1gm Apply three times a week 4) Vagifem 10mcg Insert twice weekly 5) Estring 2mg Insert for 90 days Fentora (Fentanyl) 100, 200, 300, 400, 600, 800mg Buccal Tablet PRN Finacea (Azelaic Acid) 15% Gel AAA BID 1) Oxycodone/Acetaminophen 5/325mg Q6H 2) Morphine 15-30mg Q4H 3) Hydromorphone 2-8mg Q4-6H 4) Oxycodone 5-30mg Q4-6H 5) Morphine Solution 20mg/ml 0.5-1.5ml Q4H 6) Meperidine 50150mg Q3-4H 1) Tetracycline 250ā1000mg QD 2) Doxycycline 50ā200mg QD 3) Minocycline 50ā200mg QD 4) Metronidazole 0.75% Cream, Gel AAA BID Page 23 Last Updated: 8/27/2012 Fentora is only approved for management of breakthrough cancer pain in patients tolerant to opioid therapy Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Firazyr (Icatibant Acetate) 10mg/ml Subcutaneous Solution 3ml SC Comments Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Flector (Diclofenac Epolamine) 1.3% Topical Patch AAA BID 1) OTC Aspercreme AAA BID-QID 2) Meloxicam 7.515mg QD 3) Naproxen 250-550mg BID 4) Ibuprofen 400-800mg TID-QID 5) Sulindac 150-200mg BID 6) Etodolac 200-500mg BID-TID 7) Nabumetone 500750mg BID 8) Lidocaine 5% Ointment AAA Q4H 9) Diclofenac 25-100mg BID-TID 10) Indomethacin 2575mg QD-BID 11) Tolmetin 200-600mg TID Flovent HFA (Fluticasone) 110, 220mcg Inhalation Aerosol Powder 1-2 PUFFS BID 1) Qvar 40-80mcg 1-2 PUFFS QD-BID 2) Flovent HFA 44mcg 2 PUFFS BID NOTE: Flovent HFA 44mcg for patients 4-11 years of age 3) Asmanex 110-220mcg 1-2 PUFFS QD 4) Aerobid 0.25mg 2 PUFFS BID NF 5) Pulmicort Flexhaler 90-180mcg 2 PUFFS BID NF Document adequate therapeutic trial or intolerance to Qvar 80mcg 2 PUFFS BID and Asmanex 220mcg 2 PUFFS QD within the past 3 months Flovent is swallowed for the treatment of eosinophilic esophagitis Dose Conversion Flovent 110mcg 1-2 PUFFS BID=Qvar 80mcg 2 PUFFS BID=Asmanex 110mcg 1-2 PUFFS BID Flovent 220mcg 1-2 PUFFS BID=Asmanex 220mcg 1-2 PUFFS BID Florone (Diflorasone Diacetate) 0.05% Ointment AAA QD-QID High Potency High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BIDQID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QDBID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID FML Forte (Fluorometholone) 0.25% Ophthalmic 1) Prednisolone 1% 1-2 GTTS BID-QID 2) Suspension 1 GTT BID-QID Fluorometholone 0.1% 1-2 GTTS BID-QID 3) Dexamethasone 0.1% 1-2 GTTS BID-QID Focalin (Dexmethylphenidate) 2.5, 5, 10mg Tablet 1) Methylin 5-20mg BID-TID 2) Adderall 5-30mg QDBID BID 3) Methylin ER 10-20mg BID-TID 4) Dextroamphetamine CR 5-15mg QD-BID 5) Adderall XR 5-30mg QAM 6) Methylphenidate ER 18-72mg QAM Focalin XR (Dexmethylphenidate) 5, 10, 15, 20, 1) Methylin 5-20mg BID-TID 2) Adderall 5-30mg QD30mg Extended Release Capsule QD BID 3) Methylin ER 10-20mg BID-TID 4) Dextroamphetamine CR 5-15mg QD-BID 5) Adderall XR 5-30mg QAM 6) Methylphenidate ER 18-72mg QAM Folic Acid Vitamins (Deplin, Folvite, Folacin-800, FA- OTC Folic Acid 0.4, 0.8,1mg QD 8) QD Foradil Aerolizer (Formoterol) 12mcg Inhalation 1) Albuterol Q4H PRN 2) Serevent 50mcg 1 PUFF Capsule BID BID Fortamet (Metformin) 500, 1000mg Extended Release Tablet QD Forteo (Teriparatide) 250mcg/ml Subcutaneous Solution 20mcg QD Document adequate therapeutic trial or intolerance to at least 3 formulary alternatives Focalin to Methylphenidate is a 1:2 Conversion Document adequate therapeutic trial or intolerance to at least 3 formulary alternatives Focalin to Methylphenidate is a 1:2 Conversion Excluded Medication Available OTC Dose Conversion Foradil 12mcg 1 PUFF BID=Albuterol 1 PUFF BID=Serevent 50mcg 1 PUFF BID 1) Metformin 500-1000mg (Maximum 2550mg QD) 2) Adjust based on patient response Metformin ER 500-750mg (Maximum 2000mg QD) 1) Alendronate 10mg QD 2) Alendronate 70mg QW 3) Fortical 200IU QD Alternate nostrils 4) Ibandronate 150mg QM NF 5) Actonel 5mg QD NF 6) Actonel 150mg QM NF 7) Evista 60mg QD 8) Actonel 35mg QW NF Page 24 Last Updated: 8/27/2012 Document a) diagnosis of osteoporosis (T-Score ā¤ 2.5) b) adequate therapeutic trial or intolerance to Bisphosphonate or SERM c) vertebral or fragility fracture prior to approval of Forteo for a total of 24 months with no renewal Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Comments Fosamax Plus D (Alendronate/Cholecalciferol) Alendronate 70 mg Tablet QW 70mg/2800 IU, 70mg/5600 IU Tablet QW Fosrenol (Lanthanum Carbonate) 500, 750, 1000mg 1) Phoslyra 667mg/5ml 15ml with meals 2) Eliphos Chewable Tablet 1T with meals 667mg 3C with meals 3) Renvela 800mg 3T with meals Fragmin (Dalteparin) 10000/1, 2500/0.2, 15000/0.6, Enoxaparin 1.5 mg/kg QD or 1mg/kg BID 5000/0.2, 7500/0.3, 18000/0.72, 12500/0.5, 25000IU/ml Subcutaneous Solution QD Freestyle Glucometer and Test Strips Frova (Frovatriptan) 2.5mg Tablet PRN One Touch Ultra 2 Glucometer and One Touch Ultra Test Strips 1) Sumatriptan 25-100mg PRN 2) Sumatriptan 20mg Nasal Spray PRN 3) Naratriptan 1-2.5mg PRN 4) Sumatriptan 6mg/ml Subcutaneous Solution PRN 5) Maxalt MLT 5-10mg PRN NF 6) Zomig 5mg PRN NF 7) Zomig 2.5mg PRN NF 8) Relpax 20-40mg PRN NF 9) Axert 6.25-12.5mg PRN NF 10) Treximet 500/85mg PRN NF Gabitril (Tiagabine) 2, 4, 12, 16mg Tablet QD 1) Lamotrigine 100-200mg BID 2) Carbamazepine 800-1600mg QD 3) Topiramate 200mg BID 4) Phenytoin 100mg TID 5) Levetiracetam 500-1500mg BID 6) Zonisamide 100mg TID NF 7) Gabapentin 300600mg TID 8) Levetiracetam ER 1000mg QD 9) Oxcarbazepine 600mg BID NF 10) Divalproex 250500mg TID 11) Lyrica 50-200mg TID NF 12) Vimpat 100-200mg BID NF 13) Banzel 400mg BID NF Gebauer Ethyl Chloride (Ethyl Chloride) 100% Topical Spray AAA PRN OTC Aerofreeze (Trichloromonofluoromethane/Dichlorodifluoromethan e) AAA PRN Gilenya (Fingolimod) 0.5mg Capsule QD Glucotrol XL (Glipizide) 5, 10, 20mg Extended Release Tablet QD Glipizide 5-10mg QD-BID Glucovance (Glyburide/Metformin) 1.25/250, 2 Separate Medications 2.5/500, 5/500mg Tablet BID Glyburide BID AND Metformin BID Glynase PresTab (Micronized Glyburide) 1.5, 3, 6mg 1) Glipizide QD 2) Glyburide QD Tablet QD Glyset (Miglitol) 25, 50, 100mg Tablet TID 1) Glipizide 5-15mg QD 2) Glyburide 2.5-10mg QD Golytely (Polyethylene Glycol 3350/Potassium Chloride/Sodium Bicarbonate/Sodium Chloride/Sodium Sulfate) 236/2.97/6.74/5.86/22.74gm Powder for Solution Polyethylene Glycol 3350/Potassium Chloride/Sodium Bicarbonate/Sodium Chloride/Sodium Sulfate Powder for Solution Page 25 Last Updated: 8/27/2012 Quantity Limit Axert 6.25-12.5mg=6 Tablets Frova 2.5mg=9 Tablets Maxalt MLT 5-10mg=9 Tablets Naratriptan 1-2.5mg=9 Tablets Relpax 20-40mg=6 Tablets Sumatriptan 25-100mg=9 Tablets Treximet 500/85mg=9 Tablets Zomig 2.5mg=6 Tablets Zomig 5mg=3 Tablets Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Adjust based on patient response Glipizide preferred if 65 years of age and older due to prolonged half life of Glyburide Dose Conversion Glynase 1.5mg=Glipizide 5mg=Glyburide 2.5mg / Glynase 3mg=Glipizide 10mg=Glyburide 5mg / Glynase 6mg=Glipizide 20mg=Glyburide 10mg Adjust based on patient response Glipizide preferred if 65 years of age and older due to prolonged half life of Glyburide Adjust based on patient response Glipizide preferred if 65 years of age and older due to prolonged half life of Glyburide -Fill to 4L mark with water and shake vigorously to dissolve -Chill prior to administration to improve palatability -Refrigerate and use within 48 hours -Drink 240mL every 10 minutes until rectal effluent is clear or 4L are consumed Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Comments Gralise (Gabapentin) 300, 600mg Tablet 1800mg QD 1) Nortriptyline (<65 YOA: 25mg/>65 YOA: 10mg) QHS 2) Gabapentin 600mg TID 3) Lidocaine 5% Ointment AAA Gris-PEG 250mg TID Gris-PEG (Griseofulvin) 125mg Tablet QD-TID Halcion (Triazolam) 0.125, 0.25mg Tablet QHS 1) Temazepam 15mg QHS 2) Lorazepam 0.5mg QHS 3) Oxazepam 10-30mg QHS 4) Trazodone 50-100mg QHS 5) Zolpidem 5-10mg QHS Halog (Halcinonide) 0.1% Cream AAA BID-TID High High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BIDPotency QID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QDBID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Halog (Halcinonide) 0.1% Ointment AAA BID-TID Very High Potency Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID Hectorol (Doxercalciferol) 0.5, 1, 2.5mcg Capsule QD Helidac Therapy (Bismuth Subsalicylate, Metronidazole, Tetracycline) 262.4mg 2T QID, 250mg QID, 500mg QID X14D Hizentra (Immune Globulin) 20% Subcutaneous Solution SC QW Horizant (Gabapentin Enacarbil) 600mg Extended Release Tablet QD Humalog (Insulin Lispro) 100U/ml Injection Solution SC 15 minutes AC Calcitriol 0.25-1mcg QD First Line Tetracycline Hydrochloride 500mg QID, Metronidazole 250mg QID, OTC Omeprazole 20mg BID, OTC Bismuth Subsalicylate 262.4mg 2T QID X14D Second Line Clarithromycin 500mg BID or Amoxicillin 500mg 2C BID, Metronidazole 250mg QID, OTC Omeprazole 20mg BID, OTC Bismuth Subsalicylate 262.4mg 2T QID X14D IVIG Q4W Dispense Antibiotics for copays and purchase OTC Bismuth Subsalicylate and OTC Omeprazole IVIG Infusion KP Hematology Contact CU Infusion Center 770-431-4367 or SW Infusion Center 770-603-3663 Network Hematology Contact Provider Relations 404-364-4934 1) Pramipexole 0.125mg QHS 2) Ropinirole 0.25-4mg QHS 1) Novolin R (Insulin Regular) SC 30 minutes AC 2) Adjust based on patient response NovoLog (Insulin Aspart) SC 5-10 minutes AC NF Humalog Mix 50/50 (Insulin Lispro Protamine/Insulin 2 Separate Medications Lispro) 100U/ml Injection Solution SC 15 minutes Novolin N (NPH) SC 15-30 minutes AC AND 1) AC Novolin R (Insulin Regular) SC 30 minutes AC 2) NovoLog (Insulin Aspart) SC 5-10 minutes AC NF Humalog Mix 75/25 (Insulin Lispro Protamine/Insulin Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes Lispro) 100U/ml Injection Solution SC 15 minutes AC OR AC 2 Separate Medications Novolin N (NPH) SC 15-30 minutes AC AND 1) Novolin R (Insulin Regular) SC 30 minutes AC 2) NovoLog (Insulin Aspart) SC 5-10 minutes AC NF Page 26 Last Updated: 8/27/2012 Adjust based on patient response Dose Conversion Humalog Mix 50/50 20U=NPH 10U+Novolin R 10U Adjust based on patient response Dose Conversion Humalog Mix 75/25 20U=Novolin 70/30 20U=NPH 15U+Novolin R 5U Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Comments Humalog KwikPen (Insulin Lispro) 100U/ml Injection 1) Novolin R (Insulin Regular) SC 30 minutes AC 2) Solution SC 15 minutes AC NovoLog (Insulin Aspart) SC 5-10 minutes AC NF Adjust based on patient response Insulin Administration Device Document a) member is unable to accurately draw up insulin due to upper extremity amputation, visual impairment, young age, Parkinson's Disease, Rheumatoid Arthritis b) member administers doses < 5U c) school or day care requires insulin cartridge device for insulin administration while member is outside of primary caretaker's care Humatrope (Somatropin) 6, 12, 24mg Injection Omnitrope (Somatropin) 5/1.5, 10/1.5mg/ml QW NF Powder for Solution; 5mg Subcutaneous Powder for Solution QW Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Adjust based on patient response Humulin R (Insulin Regular) 500U/ml Injection Solution SC 15 minutes AC 1) Novolin R (Insulin Regular) SC 30 minutes AC 2) Novolin N (NPH) SC 15-30 minutes AC 3) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 4) NovoLog (Insulin Aspart) SC 5-10 minutes AC NF Hycamtin (Topotecan) Capsule 0.25, 1mg 2.3mg/m2/day PO X5D Q21D FDA approved for treatment of relapsed small cell 1) Platinum-based Chemotherapy 2) Etoposide 2 2 50mg/m /day X5D Q21D 3) Topotecan 1.5 mg/m /day lung cancer (SCLC) IV X5D Q21D 1) Cheratussin AC (Codeine/Guaifenesin) 10mg/100mg/5ml Q4-6H PRN 2) Promethazine/Codeine 6.25mg/10mg/5ml Q4-6H PRN 3) Promethazine VC/Codeine (Promethazine/Codeine/Phenylephrine) 6.25mg/10mg/5mg/5ml Q4-6H PRN 4) Benzonatate 100-200mg TID PRN 5) Tussigon (Hydrocodone Bitartrate/Homatropine Methylbromide) 5/1.5mg Q46H PRN Lowest Potency 1) OTC Hydrocortisone 0.5-1% Cream, Ointment AAA BID-QID 2) Hydrocortisone 2.5% Cream, Lotion, Ointment AAA BID-QID Low Potency 1) Betamethasone Valerate 0.1% Lotion AAA QD-BID 2) Desonide 0.05% Cream, Ointment AAA BID-TID 3) Fluocinolone Acetonide 0.01% Solution AAA QD 4) Derma-Smoothe/FS 0.01% Oil AAA QD Hycodan (Hydrocodone Bitartrate/Homatropine Methylbromide) 5mg/1.5mg/5ml Syrup 5ml Q4-6H PRN Hydrocortisone Acetate/Aloe 2% Cream, Gel AAA BID-QID Lowest Potency HyoMax SR (Hyoscyamine) 0.375mg Extended Release Tablet BID Imitrex (Sumatriptan) 5mg Nasal Spray PRN Imitrex (Sumatriptan) 4mg/0.5ml Subcutaneous Solution PRN Incivek (Telaprevir) 375mg Tablet 2T TID 1) OTC Imodium A-D 4mg after first loose stool then 2mg after each subsequent loose stool 2) Dicyclomine 20mg QID 3) Belladonna Alkaloids/Phenobarbital 1-2T TID-QID 4) Diphenoxylate/Atropine 2.5/0.025mg/5ml 10ml QID 5) Diphenoxylate/Atropine 2.5/0.025mg 2T QID 6) Hyoscyamine SL 0.125mg 1-2T Q4H 7) Hyoscyamine 0.125mg 1-2T Q4H 8) Hyoscyamine Solution 0.125mg/ml 5-10ml Q4H Sumatriptan 20mg Nasal Spray PRN Sumatriptan 6mg/0.5ml Subcutaneous Solution PRN 2 Separate Medications Peg-Intron 1.5mcg/kg QW AND Ribavirin 8001400mg QD Page 27 Last Updated: 8/27/2012 No initial fill Document a) chronic Hepatitis C genotype 1 b) prescription from Gastroenterologist or Infectious Disease Specialist c) compensated liver disease d) active prescriptions for Interferon Alfa and Ribavirin Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Inderal LA (Propranolol) 60, 80, 120, 160mg Extended Release Capsule QD Infergen (Interferon Alfacon-1) 30mcg/ml Subcutaneous Solution QD Inspra (Eplerenone) 25, 50mg Tablet QD Intuniv (Guanfacine ER) 1, 2, 3, 4mg Tablet QD Invega (Paliperidone) 1.5, 3, 6, 9mg Extended Release Tablet QD Iressa (Gefitinib) 250mg Tablet QD 1) Propranolol 120-240mg QD 2) Nadolol 240-320mg Dose Conversion Propanolol ER 60mg=Propranolol 20mg 1.5T BID / QD 3) Carvedilol 12.5-25mg BID 4) Labetalol 200Propanolol ER 80mg=Propanolol 40mg BID / 400mg BID Propranolol ER 120mg=Propranolol 60mg BID / Propanolol ER 160mg=Propranolol 80mg BID 1) Pegasys 180mcg QW 2) PEG-Intron 150mcg QW 1) Amiloride/HCTZ 5/50mg QD 2) Triamterene/HCTZ 37.5/25-75/50mg QD 3) Spironolactone 50-100mg Tablet QD 1) Guanfacine 1-4mg QD 2) Methylin 5-20mg BIDTID 3) Adderall 5-30mg QD-BID 4) Methylin ER 1020mg BID-TID 5) Dextroamphetamine CR 5-15mg QD-BID 6) Adderall XR 5-30mg QAM 7) Methylphenidate ER 18-72mg QAM 1) Risperidone 4mg QD 2) Haloperidol 0.5-5mg BIDTID 3) Thiothixene 2mg TID 4) Quetiapine 400800mg QD 5) Ziprasidone 20-80mg BID 6) Olanzapine 10mg QD 7) Olanzapine ODT 10mg QD 8) Latuda 40-80mg QD NF 9) Abilify 10-15mg QD 10) Saphris 5-10mg BID NF 11) Fanapt 6-12mg BID NF 1) Platinum-based Chemotherapy 2) Docetaxel 75mg/m2 IV Q21D Iron Vitamins (Ferrex Forte, Niferex, Niferex Forte) OTC Ferrex 150 QD QD Ismo (Isosorbide Mononitrate) 10, 20mg Tablet BID Isosorbide Mononitrate ER 30-120mg QD Jalyn (Dutasteride/Tamsulosin) 0.5/0.4mg Capsule QD Januvia (Sitagliptin) 25, 50, 100mg Tablet QD 2 Separate Medications Finasteride 5mg QD and 1) Terazosin 1-10mg QD 2) Doxazosin 1-8mg QD 3) Tamsulosin 0.4mg QD 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin 500-1000mg (Maximum 2550mg QD) 3) Metformin ER 500-750mg (Maximum 2000mg QD) 4) Novolin R (Insulin Regular) SC 30 minutes AC 5) Novolin N (NPH) SC 15-30 minutes AC 6) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos 15mg (Maximum 45mg QD) Janumet (Metformin/Sitagliptin) 500/50, 1000/50mg 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin Tablet QD 500-1000mg (Maximum 2550mg QD) 3) Metformin ER 500-750mg (Maximum 2000mg QD) 4) Novolin R (Insulin Regular) SC 30 minutes AC 5) Novolin N (NPH) SC 15-30 minutes AC 6) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos 15mg (Maximum 45mg QD) Junel 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) Tablet QD Comments Document adequate therapeutic trial or intolerance to 2 formulary alternatives and Guanfacine FDA approved for treatment of locally advanced or metastatic nonsmall cell lung cancer (NSCLC) who have failed both Platinum and Docetaxel-based Chemotherapy Excluded Medication Available OTC Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. 1) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Norethindrone) QD 2) Aviane (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD Page 28 Last Updated: 8/27/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Juvisync (Simvastatin/Sitagliptin) 10/100, 20/100, 40/100mg Tablet QD Kadian (Morphine Sulfate) 10, 20, 30, 50, 60, 80, 100, 200mg Extended Release Capsule QD 2 Separate Medications Simvastatin 10-40mg QD AND 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin 500-1000mg (Maximum 2550mg QD) 3) Metformin ER 500-750mg (Maximum 2000mg QD) 4) Novolin R (Insulin Regular) SC 30 minutes AC 5) Novolin N (NPH) SC 15-30 minutes AC 6) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos 15mg (Maximum 45mg QD) 1) Morphine ER 60-100mg BID 2) Fentanyl 25100mcg/hr Q72H 3) Avinza 30-120mg QD NF 4) Opana ER 5-40mg BID NF Comments Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Dose Conversion Morphine 30mg=Oxycodone 20mg=Oxymorphone 10mg / Morphine 90mg=Fentanyl 25mcg/hr Document adequate therapeutic trial or intolerance to Morphine ER and Fentanyl Kalbitor (Ecallantide) 10mg/ml Subcutaneous Solution 3ml SC 1) Danazol 200mg BID-TID 2) Oxandrolone 2.5-20mg Criteria Restricted Medication QRM approval required prior to being dispensed for BID-QID NF 3) Berinert 20U/kg IV NF Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Kapvay (Clonidine) 0.1mg Extended Release Tablet 1) Clonidine 0.1mg QD-TID 2) Methylin 5-20mg BID- Document adequate therapeutic trial or intolerance QHS-BID to 2 formulary alternatives and Clonidine TID 3) Adderall 5-30mg QD-BID 4) Methylin ER 1020mg BID-TID 5) Dextroamphetamine CR 5-15mg QD-BID 6) Adderall XR 5-30mg QAM 7) Concerta 1872mg QAM 8) Guanfacine 1-4mg QD Kariva (20mcg Ethinyl Estradiol/0.15mg Desogestrel 1) Reclipsen 0.25 (30mcg Ethinyl Estradiol/0.15 Document adequate therapeutic trial or intolerance x 21 days, 10mcg EE x 5 days) Tablet QD to at least 3 formulary oral contraceptives Desogestrel) QD 2) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Aviane (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel) QD Kenalog (Triamcinolone Acetonide) 0.5% Cream, Ointment AAA BID-QID Very High Potency Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID Keppra XR 500, 750mg Extended Release Tablet QD-BID 1) Lamotrigine 100-200mg BID 2) Carbamazepine 800-1600mg QD 3) Topiramate 200mg BID 4) Phenytoin 100mg TID 5) Levetiracetam 500-1500mg BID 6) Zonisamide 100mg TID NF 7) Gabapentin 300600mg TID 8) Levetiracetam ER 1000mg QD Kerlone (Betaxolol) 10, 20mg Tablet QD 1) Atenolol 50-100mg QD 2) Metoprolol 100-450mg QD 3) Acebutolol 400-800mg QD 4) Bisoprolol 2.520mg QD 5) Carvedilol 12.5-25mg BID 6) Labetalol 200-400mg BID Community Acquired Pneumonia 1) Levofloxacin 750mg QD X5D 2) Levofloxacin 500mg QD X10D 3) Azithromycin 500mg QD X5D 4) Cefuroxime 500mg BID X10D 1) Humira 40mg QOW 2) Enbrel 50mg QW 3) Remicade 5mg/kg Q8W NF Ketek (Telithromycin) 300, 400mg Tablet 2T QD Kineret (Anakinra) 100mg/0.67ml Subcutaneous Solution QD Page 29 Last Updated: 8/27/2012 Dose Conversion Betaxolol 10mg QD=Atenolol 50mg QD / Betaxolol 20mg QD=Atenolol 100mg QD Remicade Infusion KP Rheumatology Contact CU Infusion Center 770-431-4367 or SW Infusion Center 770-603-3663 Network Rheumatology Contact Provider Relations 404-364-4934 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Comments Klaron (Sodium Sulfacetamide) 10% Lotion AAA BID 1) Sodium Sulfacetamide/Sulfur 10/5% Lotion AAA BID 2) Sodium Sulfacetamide/Sulfur 10/5% Solution AAA BID Klor-Con 25 (Potassium Chloride) 25mEq Powder 1) K-Tab 10mEq Extended Release 2T QD 2) Klorfor Solution QD Con 20mEq Powder for Solution QD Klor-Con M20 (Potassium Chloride) 20mEq Extended Release Tablet QD 1) K-Tab 10mEq Extended Release 2T QD 2) KlorCon 20mEq Powder for Solution QD Kombiglyze (Metformin/Saxagliptin) 500/5, 1000/2.5, 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin 1000/5mg Extended Release Tablet QD 500-1000mg (Maximum 2550mg QD) 3) Metformin ER 500-750mg (Maximum 2000mg QD) 4) Novolin R (Insulin Regular) SC 30 minutes AC 5) Novolin N (NPH) SC 15-30 minutes AC 6) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos 15mg (Maximum 45mg QD) Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Kytril (Granisetron) 1mg Tablet 2T 1 hour prior to chemotherapy 1) Metoclopramide 1-2mg/kg 30 minutes prior to chemotherapy 2) Prochlorperazine 5-10mg Q6H 3) Dexamethasone 20mg 30 minutes prior to chemotherapy 4) Ondansetron 4-8mg 30 minutes prior to chemotherapy 5) Ondansetron 4-8mg ODT 30 minutes prior to chemotherapy 6) Transderm Scop 1.5mg Apply Q72H NF Lac-Hydrin (Ammonium Lactate) 12% Cream AAA OTC AmLactin (Ammonium Lactate) 12% Cream Excluded Medication BID AAA BID Available OTC Lacrisert (Hydroxypropyl Cellulose) 5mg Artificial 1) OTC GenTeal, Tears Again, Tears Naturale Free Tear Insert Insert QD-BID (Hydroxypropyl Methylcelluclose 0.3%) 1-2 GTT TIDQID 2) OTC Isopto Plain (Hydroxypropyl Methylcelluclose 0.5%) 1-2 GTT TID-QID 3) OTC Murocel (Methylcellulose 3%) 1-2 GTT TID-QID Lamisil (Terbinafine) 250mg Tablet QD-BID Thymol/Isopropyl Alcohol 4/99% Solution QD KPGA Approved Compound Finger Onychomycosis Document positive fungal culture prior to approval of one 6 week treatment Toe Onychomycosis Document a) positive fungal culture b) DM or Vascular Disease prior to approval one 12 week treatment Lantus (Insulin Glargine) 100U/ml Injection Solution 1) Novolin N (NPH) SC 15-30 minutes AC 2) Novolin -Lantus (< 30U QD) to Novolin N (QD dosing) is a SC QD 1:1 Conversion 70/30 (NPH/Insulin Regular) SC 30 minutes AC -Lantus (>30U QD) to Novlin N (BID dosing) is a 0.8:1 Conversion Document a) member with DM1 b) member undergoing dialysis c) adequate therapeutic trial or intolerance (Hypoglycemia) to NPH Lantus Solostar (Insulin Glargine) 100U/ml Injection 1) Novolin N (NPH) SC 15-30 minutes AC 2) Novolin -Lantus (< 30U QD) to Novolin N (QD dosing) is a Solution SC QD 1:1 Conversion 70/30 (NPH/Insulin Regular) SC 30 minutes AC -Lantus (>30U QD) to Novlin N (BID dosing) is a 0.8:1 Conversion Document a) member with DM1 b) member undergoing dialysis c) adequate therapeutic trial or intolerance (Hypoglycemia) to NPH Insulin Administration Device Document a) member is unable to accurately draw up insulin due to upper extremity amputation, visual impairment, young age, Parkinson's Disease, Rheumatoid Arthritis b) member is administers doses < 5U Page 30 Last Updated: 8/27/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Comments Lastacaft (Alcaftadine) 0.25% Ophthalmic Solution 1 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q3GTT QD 4 HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID 4) Crolom 4% 1-2 GTTS Q4-6 HOURS NF 5) Emadine 0.05% 1 GTT QID NF 6) Alocril 2% 1-2 GTTS BID NF 7) Optivar 0.05% 1 GTT BID NF 8) Alomide 0.1% 1-2 GTTS QID NF Latisse (Bimatoprost) 0.03% Ophthalmic Solution Excluded Medication Apply QHS to upper eyelid margin Latuda (Lurasidone) 40, 80mg Tablet QD 1) Risperidone 4mg QD 2) Haloperidol 0.5-5mg BIDTID 3) Thiothixene 2mg TID 4) Quetiapine 400800mg QD 5) Ziprasidone 20-80mg BID 6) Olanzapine 10mg QD 7) Olanzapine ODT 10mg QD Lescol (Fluvastatin) 20, 40mg Capsule QHS Lescol XL (Fluvastatin) 80mg Extended Release Tablet QHS Lessina (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel) Tablet QD 1) Simvastatin 5-10mg QD 2) Pravastatin 10-20mg QD Dose Conversion Fluvastatin 20mg=Pravastatin 10mg=Simvastatin 5mg / Fluvastatin 40mg=Pravastatin 20mg=Simvastatin 10mg 1) Simvastatin 20mg QD 2) Pravastatin 40mg QD 3) Dose Conversion Fluvastatin 80mg=Atorvastatin 10mg=Pravastatin Atorvastatin 10mg QD 40mg=Simvastatin 20mg Equivalent Brand and Generic Products 1) Aviane (20mcg Ethinyl Estradiol/0.1mg Lessina=Aviane Levonorgestrel) QD 2) Microgestin Fe 1/20 (20mcg Document adequate therapeutic trial or intolerance Ethinyl Estradiol/1mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD to at least 3 formulary oral contraceptives Letairis (Ambrisentan) 5, 10mg Tablet QD 1) Tracleer 62.5-125mg BID 2) Flolan 2ng/kg/min 3) Remodulin 1.25-2.5ng/kg/min QW Prescribing Physician must call Letairis Education Access Program 866-664-LEAP Letairis is delivered directly to patient via KP CA Specialty Pharmacy Levaquin (Levofloxacin) 25mg/ml Solution QD Community Acquired Pneumonia 1) Levofloxacin 750mg QD X5D 2) Levofloxacin 500mg QD X10D 3) Azithromycin 500mg QD X5D 4) Cefuroxime 500mg BID X10D Sinusitis 1) SMZ-TMP DS BID X7D 2) Doxycycline 100mg BID X7D 3) Amoxicillin 1000mg BID X7D 4) Azithromycin 500mg QD X3D Urinary Tract Infection 1) SMZ-TMP DS BID X3D 2) Ciprofloxacin 250mg BID X3D 3) Levofloxacin 250mg QD X3D 4) Nitrofurantoin Monohydrate 100mg BID X7D Levemir (Insulin Detemir) 100U/ml Injection Solution 1) Novolin N (NPH) SC 15-30 minutes AC 2) Novolin SC QD-BID 70/30 (NPH/Insulin Regular) SC 30 minutes AC KP CA Specialty Pharmacy MD Line 650-301-5799 / Patient Line 1-877-4045777 / Fax Line 650-301-5790 Levitra (Vardenafil) 2.5, 5, 10, 20mg Tablet PRN Excluded Medication (Exception: Sexual Dysfunction Rider) Document adequate trial or intolerance to all formulary SSRIs Lexapro (Escitalopram) 5mg/5ml Solution; 5, 10, 20mg Tablet QD 1) Citalopram 20-40mg QD 2) Fluoxetine 20-40mg QD 3) Sertraline 50-100mg QD 4) Mirtazapine 30mg QHS 5) Bupropion SR/XL 300mg QD 6) Venlafaxine ER 225mg QD 7) Fluvoxamine 50-300mg QD NF Document adequate therapeutic trial or intolerance (Hypoglycemia) to NPH Lialda (Mesalamine) 1.2gm Delayed Release Tablet 1) Sulfasalazine 500mg (2-4gm QD) 2) Colazal 2.4-4.8gm QD 750mg (2.25gm TID for 8-12 weeks) 3) Asacol 400mg (800mg TID) 4) Dipentum 550mg BID NF 5) Pentasa 250, 500mg (1gm QID) Lidoderm (Lidocaine) 5% Topical Patch Apply 1-3 Lidoderm is only indicated for postherpetic neuralgia 1) OTC LMX 4 (Lidocaine 4% Cream) AAA QID 2) patches up to 12 hours OTC Axsain cream (Lidocaine 4%/Capsaicin 0.25% Cream) AAA QID 3) Lidocaine 2% Gel AAA QID 4) Lidocaine 5% Ointment AAA 5G QID Page 31 Last Updated: 8/27/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Comments Lipofen (Fenofibrate) 50, 150mg Capsule QD 1) Gemfibrozil 600mg BID 2) Fenofibrate 54-160mg QD Livalo (Pitavastatin) 1, 2, 4mg Tablet QD 1) Simvastatin 10-40mg QD 2) Pravastatin 20-80mg QD 3) Atorvastatin 10-20mg QD Locoid (Hydrocortisone Butyrate) 0.1% Cream, Ointment, Solution AAA BID-TID Medium Potency Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BIDQID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BIDQID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BIDQID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BIDQID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg BID 3) Ibuprofen 400-800mg TID-QID 4) Sulindac 150-200mg BID 5) Etodolac 200-500mg BID-TID 6) Nabumetone 500-750mg BID Document adequate therapeutic trial or intolerance 1) Aviane (20mcg Ethinyl Estradiol/0.1mg to at least 3 formulary oral contraceptives Levonorgestrel) QD 2) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD Locoid Lipocream (Hydrocortisone Butyrate) 0.1% Cream AAA BID-TID Medium Potency Lodine XL (Etodolac) 400, 500, 600mg Extended Release Tablet QD Loestrin 21 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) Tablet QD Dose Conversion Lipofen 50mg=Fenofibrate 54mg / Lipofen 150mg=Fenofibrate 160mg Fenofibrate preferred if current statin therapy Gemfibrozil preferred if reduced renal function Dose Conversion Pitavastatin 1mg=Pravastatin 20mg=Simvastatin 10mg / Pitavastatin 2mg=Atorvastatin 10mg=Pravastatin 40mg=Simvastatin 20mg / Pitavastatin 4mg=Atorvastatin 20mg=Pravastatin 80mg=Simvastatin 40mg Loestrin 24 Fe (20mcg Ethinyl Estradiol/1mg Norethindrone x 24 days) Tablet QD Document adequate therapeutic trial or intolerance 1) Aviane (20mcg Ethinyl Estradiol/0.1mg to at least 3 formulary oral contraceptives Levonorgestrel) QD 2) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD Lo Loestrin Fe (10mcg Ethinyl Estradiol/1mg Norethindrone x 24 days, 10mcg EE x 2 days) Tablet QD Document adequate therapeutic trial or intolerance 1) Aviane (20mcg Ethinyl Estradiol/0.1mg to at least 3 formulary oral contraceptives Levonorgestrel) QD 2) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD Lo/Ovral (30mcg Ethinyl Estradiol/0.3 Norgestrel) Tablet QD Equivalent Brand and Generic Products 1) Reclipsen (30mcg Ethinyl Estradiol/0.15mg Lo/Ovral=Cryselle Desogestrel) QD 2) Microgestin Fe 1.5/30 (30mcg Ethinyl Estradiol/1.5mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD Loprox (Ciclopirox) 0.77% Cream; 0.77% Gel; 1% Shampoo BID 1) OTC Lamisil Ultra (Butenafine 1%) QD-BID 2) OTC Lotrimin AF (Clotrimazole 1%) BID 3) OTC Micatin (Miconazole 1%) BID 4) Ketoconazole 2% Cream QD LoSeasonique (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel x 84 days, 10mcg EE x 7 days) Tablet QD 1) Aviane (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel) QD 2) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD 3) Jolessa (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel x 84 days) QD NF 4) Amethia Lo (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel x 84 days, 10mcg EE x 7 days) QD NF Page 32 Last Updated: 8/27/2012 Equivalent Brand and Generic Products LoSeasonique=Amethia Lo Levora Dose Recommendation Day 1-84: Take 1 active tablet QD (Discard placebo tablets from first 3 packets) Day 85-91: Take 1 placebo tablet QD Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Lotemax (Loteprednol) 0.5% Ophthalmic Suspension 1-2 GTT QID Lotrel (Amlodipine/Benazepril) 2.5/10, 5/10, 5/20, 10/20mg Tablet QD Lotrisone (Betamethasone Dipropionate/Clotrimazole) 0.05/1% Cream, Lotion AAA BID Lotronex (Alosetron) 0.5, 1mg Tablet BID Comments 1) Diclofenac 0.1% 1GTT QID 2) Ketorolac 0.5% 1 GTT QID 3) Prednisolone 1% 1-2 GTTS BID-QID 4) Fluorometholone 0.1% 1-2 GTTS BID-QID 5) Dexamethasone 0.1% 1-2 GTTS BID-QID 6) Ketorolac 0.4% 1 GTT QID 7) Flurbiprofen 0.03% 1 GTT QID NF 8) Vexol 1% 1-2 GTT QID NF 9) Bromfenac 0.09% 1 GTT QD-BID NF 2 Separate Medications Amlodipine QD AND Benazapril QD Dispense Betamethasone Dipropionate as 1 copay 2 Separate Medications Betamethasone Dipropionate 0.05% Cream AAA BID and purchase OTC Clotrimazole AND OTC Clotrimazole 1% Gel AAA BID 1) OTC Imodium A-D 4mg after first loose stool then 2mg after each subsequent loose stool 2) Dicyclomine 20mg QID 3) Belladonna Alkaloids/Phenobarbital 1-2T TID-QID 4) Diphenoxylate/Atropine 2.5/0.025mg/5ml 10ml QID 5) Diphenoxylate/Atropine 2.5/0.025mg 2T QID 6) Hyoscyamine SL 0.125mg 1-2T Q4H 7) Hyoscyamine 0.125mg 1-2T Q4H 8) Hyoscyamine Solution 0.125mg/ml 5-10ml Q4H 9) Hyoscyamine SR 0.375mg BID NF Prescribing Physician must call Prometheus Prescribing 888-423-5227 Lovaza (Omega-3-Acid Ethyl Esters) 1gm Liquid Filled Capsule QD 1) OTC Omega-3 Fish Oil QD 2) Gemfibrozil 600mg BID 3) Fenofibrate 54-160mg QD Low-Ogestrel (30mcg Ethinyl Estradiol/0.3 Norgestrel) Tablet QD 1) Reclipsen (30mcg Ethinyl Estradiol/0.15mg Desogestrel) QD 2) Microgestin Fe 1.5/30 (30mcg Ethinyl Estradiol/1.5mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD Lumigan (Bimatoprost) 0.01, 0.03% Ophthalmic Solution 1 GTT QPM Lunesta (Eszopiclone) 1, 2, 3mg Tablet QHS 1) Latanoprost 0.005% 1 GTT QPM 1) Trazodone 50-100mg QHS 2) Temazepam 1530mg QHS 3) Zolpidem 5-10mg QHS 4) Zaleplon 510mg QHS 5) Ambien CR 6.25-12.5mg QHS NF 6) Rozerem 8mg QHS NF Dose Conversion Lovaza 1gm= EPA 465mg and DHA 375mg Lovaza is only FDA approved for TG > 500mg/dL Fenofibrate preferred if current statin therapy Gemfibrozil preferred if reduced renal function Equivalent Brand and Generic Products Low-Ogestrel=Cryselle Document adequate therapeutic trial or intolerance to Trazodone, Zolpidem, and at least 1 Benzodiazepine Lustra (Hydroquinone) 4% Cream AAA BID Luvox CR (Fluvoxamine) 100, 150mg Extended Release Capsule QHS Excluded Medication Document adequate trial or intolerance to all 1) Citalopram 20-40mg QD 2) Fluoxetine 20-40mg QD 3) Sertraline 50-100mg QD 4) Mirtazapine 30mg formulary SSRIs QHS 5) Bupropion SR/XL 300mg QD 6) Venlafaxine ER 225mg QD 7) Fluvoxamine 50-300mg QD NF Luxiq (Betamethasone Valerate) 0.12% Foam AAA BID Medium-High Potency Low Potency Fluocinolone 0.01% Solution Medium-High Potency Betamethasone Valerate 0.1% Ointment AAA QDBID Very High Potency Flucinonide 0.05% Gel, Ointment, Solution AAA BIDQID Ultra High Potency 1) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 2) Clobetasol Propionate 0.05% Solution AAA BID 3) Clobetasol 0.05% Aerosol AAA BID NF Page 33 Last Updated: 8/27/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Comments Lybrel (20mcg Ethinyl Estradiol/0.09mg Levonorgestrel) Tablet QD Document adequate therapeutic trial or intolerance 1) Aviane (20mcg Ethinyl Estradiol/0.1mg to at least 3 formulary oral contraceptives Levonorgestrel) QD 2) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD Lyrica (Pregabalin) 25, 50, 75, 100, 150, 200, 225, 300mg Capsule BID-TID Diabetic Peripheral Neuropathic Pain 1) Amitriptyline* 50mg QHS 2) Nortriptyline* (<65 YOA: 25mg QHS / > 65 YOA: 10mg QHS) 3) Cyclobenzaprine* 10mg TID 4) Tramadol* 50mg BID 5) Venlafaxine ER 150 ā 225mg QD Non-Diabetic Peripheral Neuropathic Pain 1) Amitriptyline* 50mg QHS 2) Nortriptyline* (<65 YOA: 25mg QHS / > 65 YOA: 10mg QHS) 3) Cyclobenzaprine* 10mg TID 4) Tramadol* 50mg BID Fibromyalgia 1) Amitriptyline* 50mg QHS 2) Nortriptyline* (<65 YOA: 25mg QHS / > 65 YOA: 10mg QHS) 3) Cyclobenzaprine* 10mg TID 4) Tramadol* 50mg BID Post Herpetic Neuralgia 1) Nortriptyline* (<65 YOA: 25mg QHS / > 65 YOA: 10mg QHS) 2) Gabapentin 600mg TID 3) Lidocaine 5% Ointment AAA of allodynia and localized pain Lysteda (Tranexamic Acid) 650mg Tablet 2T TID X5D 1) Combination Oral Contraceptive 2) Medroxyprogesterone 5-10mg QD 3) Norethindrone 5mg QD Macrodantin (Nitrofurantoin Macrocrystal) 100mg UTI Prophylaxis Capsule QD-BID Nitrofurantoin Monohydrate 100mg QD UTI Treatment 1) SMZ-TMP DS BID X3D 2) Ciprofloxacin 250mg BID X3D 3) Levofloxacin 250mg QD X3D 4) Nitrofurantoin Monohydrate 100mg BID X7D Makena (Hydroxyprogesterone Caproate) 250mg/ml Preservative Free Hydroxyprogesterone 250mg/ml Intramuscular Solution QW QW Hydroxyprogesterone compounded by PharMerica is delivered directly to patient via Alere Obstetrical Homecare Administered by Alere Obstetrical Homecare Nurse Mavik (Trandolapril) 1, 2, 4mg Tablet QD Maxair Autohaler (Pirbuterol) 200mcg Inhalation Aerosol Powder Q4H PRN Maxalt (Rizatriptan) 5, 10mg Tablet PRN Maxalt MLT (Rizatriptan) 5, 10mg Orally Disintegrating Tablet PRN Diabetic Peripheral Neuropathic Pain Document adequate therapeutic trial or intolerance to 1 TCA*, Tramadol*; and Venlafaxine Non-Diabetic Peripheral Neuropathic Pain Document adequate therapeutic trial or intolerance to 1 TCA*, Tramadol*, and Cyclobenzaprine Fibromyalgia Document adequate therapeutic trial or intolerance to 1 TCA*, Tramadol*, and Cyclobenzaprine Post Herpetic Neuralgia Document adequate therapeutic trial or intolerance to 1 TCA* and Gabapentin *Not recommended in the elderly and not a required medication for patients over 65 years old Quantity Limit Lysteda 650mg (30 Day Supply)=30 Tablets Alere Obstetrical Homecare MD Line 404-316-2013 1) Lisinopril 20-40mg QD 2) Benazepril 20-40mg QD Dose Conversion 3) Enalapril 10-40mg QD 4) Captopril 25-100mg TID Trandolapril 1mg=Lisinopril 10mg / Trandolapril 2mg=Lisinopril 20mg / Trandolapril 4mg=Lisinopril 5) Ramipril 2.5-20mg QD 40mg Proair HFA (Albuterol) 0.09mg Inhalation Aerosol Maxair Autohaler to Proair HFA is a 1:1 Conversion Powder Q4H PRN 1) Sumatriptan 25-100mg PRN 2) Sumatriptan 20mg Quantity Limit Maxalt MLT 5-10mg=9 Tablets Nasal Spray PRN 3) Naratriptan 1-2.5mg PRN 4) Sumatriptan 6mg/ml Subcutaneous Solution PRN 5) Naratriptan 1-2.5mg=9 Tablets Sumatriptan 25-100mg=9 Tablets Maxalt MLT 5-10mg PRN NF 1) Sumatriptan 25-100mg PRN 2) Sumatriptan 20mg Quantity Limit Maxalt MLT 5-10mg=9 Tablets Nasal Spray PRN 3) Naratriptan 1-2.5mg PRN 4) Naratriptan 1-2.5mg=9 Tablets Sumatriptan 6mg/ml Subcutaneous Solution PRN Sumatriptan 25-100mg=9 Tablets Page 34 Last Updated: 8/27/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Maxiflor (Diflorasone Diacetate) 0.05% Ointment AAA QD-QID High Potency Maxivate (Betamethasone Dipropionate) 0.05% Lotion AAA QD-BID Medium Potency Medrol (Methylprednisolone) 2, 8, 16, 32mg Tablet QD Melanex (Hydroquinone) 3% Solution AAA BID Mentax (Butenafine) 1% Cream AAA QD-BID Meridia (Sibutramine) 5, 10, 15mg Capsule QD Metadate CD (Methylphenidate) 10, 20, 30, 40, 50, 60mg Extended Release Capsule QAM Metadate ER (Methylphenidate) 20mg Extended Release Tablet QD MetroGel Vaginal (Metronidazole) 0.75% Gel QD Micardis (Telmisartan) 20, 40, 80mg Tablet QD Comments High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BIDQID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QDBID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BIDQID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BIDQID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID Methylprednisolone 4mg QD Excluded Medication 1) OTC Lamisil Ultra (Butenafine 1%) QD-BID 2) OTC Lotrimin AF (Clotrimazole 1%) BID 3) OTC Micatin (Miconazole 1%) BID 4) Ketoconazole 2% Cream QD Excluded Medication (Exception: Obesity Rider) 1) Methylin 5-20mg BID-TID 2) Adderall 5-30mg QD- Document adequate therapeutic trial or intolerance to at least 3 formulary alternatives BID 3) Methylin ER 10-20mg BID-TID 4) Dextroamphetamine CR 5-15mg QD-BID 5) Adderall XR 5-30mg QAM 6) Methylphenidate ER 18-72mg QAM 1) Methylin 5-20mg BID-TID 2) Adderall 5-30mg QD- Document adequate therapeutic trial or intolerance to at least 3 formulary alternatives BID 3) Methylin ER 10-20mg BID-TID 4) Dextroamphetamine CR 5-15mg QD-BID 5) Adderall XR 5-30mg QAM 6) Methylphenidate ER 18-72mg QAM 1) Clindamycin 300mg BID 2) Metronidazole 500mg BID 1) Lisinopril QD NOTE: If Angiotensin Converting Dose Conversion Enzyme Inhibitor allergy or contraindication consider Micardis 40mg=Lisinopril 10mg=Losartan 25mg / Micardis 80mg=Lisinopril 20mg=Losartan 50mg Angiotensin Receptor Blocker 2) Losartan QD Micardis HCT (Telmisartan/HCTZ) 40/12.5, 80/12.5, 2 Separate Medications 80/25mg Tablet QD HCTZ QD AND 1) Lisinopril QD NOTE: If Angiotensin Converting Enzyme Inhibitor allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan QD Microgestin 1/20 (20mcg Ethinyl Estradiol/1mg 1) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) Tablet QD Norethindrone) QD 2) Aviane (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD Dose Conversion Micardis 40mg=Lisinopril 10mg=Losartan 25mg / Micardis 80mg=Lisinopril 20mg=Losartan 50mg NOTE: Consider Lisinopril/HCTZ 10/12.5, 20/12.5, 20/25mg or Losartan/HCTZ 50/12.5mg Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Micronor (Norethindrone) 0.35mg Tablet QD Nora-BE (Norethindrone) 0.35mg QD Equivalent Brand and Generic Products Micronor=Nora-BE Midamor (Amiloride) 5mg Tablet QD 1) Amiloride/HCTZ 5/50mg QD 2) Triamterene/HCTZ 37.5/25-75/50mg QD 3) Spironolactone 50-100mg Tablet QD Page 35 Last Updated: 8/27/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Mirapex ER (Pramipexole) 0.375, 0.75, 1.5, 3, 4.5mg Extended Release Tablet QD Mircette (20mcg Ethinyl Estradiol/0.15mg Desogestrel x 21 days, 10mcg EE x 5 days) Tablet QD Comments Parkinson's Disease 1) Carbidopa/Levodopa ER 25/100mg BID 2) Bromocriptine 2.5mg QD 3) Amantadine 100mg BID 4) Pramipexole 0.125-1.5mg TID 5) Ropinirole 2-8mg QD 6) Selegiline 5mg QD 7) Carbidopa/Levodopa/Entacapone 12.5/50/200mg TID 8) Ropinrole ER 2-12mg QD NF 9) Zelapar 1.25mg QD NF Restless Leg Syndrome 1) Pramipexole 0.125mg QHS 2) Ropinirole 0.25-4mg QHS Document adequate therapeutic trial or intolerance 1) Reclipsen 0.25 (30mcg Ethinyl Estradiol/0.15 to at least 3 formulary oral contraceptives Desogestrel) QD 2) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Aviane (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel) QD Modicon (35mcg Ethinyl Estradiol/0.5mg Norethindrone) Tablet QD 1) Necon 0.5/35 (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD 2) Necon 1/35 (35mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Brevicon (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD Equivalent Brand and Generic Products Modicon=Necon 0.5/35=Brevicon Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives MonoNessa (35mcg Ethinyl Estradiol/0.25mg Norgestimate) Tablet QD 1) Sprintec (35mcg Ethinyl Estradiol/0.25mg Norgestimate) QD 2) Necon 1/35 (35mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Necon 0.5/35 (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD 4) Zovia 1/35 (35mcg Ethinyl Estradiol/1mg Ethynodiol diacetate) QD 5) Brevicon (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD 1) Lisinopril 20-40mg QD 2) Benazepril 20-40mg QD 3) Enalapril 10-40mg QD 4) Captopril 25-100mg TID 5) Ramipril 2.5-20mg QD Equivalent Brand and Generic Products MonoNessa=Sprintec Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Monopril (Fosinopril) 10, 20, 40mg Tablet QD Mozobil (Plerixafor) 20mg/ml Subcutaneous Solution Mozobil is dispensed via KP Glenlake Pharmacy X4D Dose Conversion Fosinopril 10mg=Lisinopril 10mg / Fosinopril 20mg=Lisinopril 20mg / Fosinopril 40mg=Lisinopril 40mg Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Multaq (Dronedarone) 400mg Tablet BID Muse (Alprostadil) 125, 250, 500, 1000mcg Intraurethral Suppository PRN Myobloc (Rimabotulinumtoxin B) 2500/0.5, 5000/1, 10000/2U/ml Intramuscular Solution Q12-16W Amiodarone 200-400mg QD Naftin (Naftifine) 1% Cream AAA QD; 1% Gel AAA BID 1) OTC Lamisil Ultra (Butenafine 1%) QD-BID 2) OTC Lotrimin AF (Clotrimazole 1%) BID 3) OTC Micatin (Miconazole 1%) BID 4) Ketoconazole 2% Cream QD Nalfon (Fenoprofen) 200, 400mg Capsule; 600mg Tablet TID-QID 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg BID 3) Ibuprofen 400-800mg TID-QID 4) Sulindac 150-200mg BID 5) Etodolac 200-500mg BID-TID 6) Nabumetone 500-750mg BID 7) Lidocaine 5% Ointment AAA Q4H 8) Diclofenac 25-100mg BID-TID Namenda (Memantine) 10mg/5ml Solution QD Document adequate therapeutic trial or intolerance 1) Galantamine 4-12mg BID, Galantamine ER 824mg QD 2) Namenda 5-10mg BID 3) Rivastigmine to Galantamine, Aricept, Namenda, and Rivastigmine Capsule or Exelon Solution 6mg BID 4) Aricept 5-10mg QD 5) Exelon 2mg/ml Solution 3ml BID 6) Exelon 4.5-9.6mg/24hr Patch QD NF 7) Razadyne 4mg/ml 1-3 ml BID NF 8) Aricept ODT 5-10mg QD NF Administered in a healthcare setting by healthcare providers Page 36 Last Updated: 8/27/2012 Excluded Medication (Exception: Sexual Dysfunction Rider) Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Nasacort AQ (Triamcinolone) 55mcg/Actuation Nasal Spray 2 SPRAYS IEN QD Nasonex (Mometasone) 0.05mg/Actuation Nasal 2 SPRAYS IEN QD 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) OTC Allegra 60mg BID 4) Fluticasone 2 SPRAYS IEN QD 5) Flunisolide 2 SPRAYS IEN BID 6) Triamcinolone 2 SPRAYS IEN QD NF 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) OTC Allegra 60mg BID 4) Fluticasone 2 SPRAYS IEN QD 5) Flunisolide 2 SPRAYS IEN BID 6) Triamcinolone 2 SPRAYS IEN QD NF Comments Age Recommendations Fluticasone=4 years of age and older / Flunisolide=6 years of age and older / Triamcinolone=2 years of age and older Age Recommendations Fluticasone=4 years of age and older / Flunisolide=6 years of age and older / Triamcinolone=2 years of age and older / Nasonex=2 years of age and older Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Natazia (3mg Estradiol Valerate x 2 days, 2mg EV/2mg Dienogest x 5 days, 2mg EV/3mg Dienogest x 17 days, 1mg EV x 2 days) Tablet QD 1) Tri-Sprintec (35mcg Ethinyl Estradiol/0.18mg Norgestimate x 7 days, 35mcg EE/0.215mg NG x 7 days, 35mcg EE/0.25mg NGx 7 days) QD 2) Trivora (30mcg Ethinyl Estradiol/0.05mg Levonorgestrel x 6 days, 40mcg EE/0.075mg LVNGL x 5 days, 30mcg EE/0.125mg LVNGL x 10 days) QD 3) Leena (35mcg Ethinyl Estradiol/0.5mg Norethindrone x 7 days, 35mcg EE/1mg NE x 9 days, 35mcg EE/0.5mg NE x 5 days) QD Necon 10/11 (35mcg Ethinyl Estradiol/0.5mg Norethindrone x 10 days, 35mcg EE/1mg NE x 11 days) Tablet QD Document adequate therapeutic trial or intolerance 1) Necon 0.5/35 (35mcg Ethinyl Estradiol/0.5mg to at least 3 formulary oral contraceptives Norethindrone) QD 2) Necon 1/35 (35mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Leena (35mcg Ethinyl Estradiol/0.5mg Norethindrone x 7 days, 35mcg EE/1mg NE x 9 days, 35mcg EE/0.5mg NE x 5 days) QD 4) Brevicon (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD Neupogen (Filgrastim) 5mg/kg/day QD 24 hours after chemotherapy Neulasta (Pegfilgrastim) 6mg/0.6ml Subcutaneous Solution 24 hours after chemotherapy Neupro (Rotigotine) Transdermal Patch 1, 2, 3, 4, 6, Parkinson's Disease 8mg/24hr QD 1) Carbidopa/Levodopa ER 25/100mg BID 2) Bromocriptine 2.5mg QD 3) Amantadine 100mg BID 4) Pramipexole 0.125-1.5mg TID 5) Ropinirole 2-8mg QD 6) Selegiline 5mg QD 7) Carbidopa/Levodopa/Entacapone 12.5/50/200mg TID 8) Ropinrole ER 2-12mg QD NF 9) Zelapar 1.25mg QD NF 10) Mirapex ER 0.75-4.5mg QD NF Restless Leg Syndrome 1) Pramipexole 0.125mg QHS 2) Ropinirole 0.25-4mg QHS Nevanac (Nepafenac) 0.1% Ophthalmic Suspension 1) Diclofenac 0.1% 1GTT QID 2) Ketorolac 0.5% 1 1 GTT TID GTT QID 3) Prednisolone 1% 1-2 GTTS BID-QID 4) Fluorometholone 0.1% 1-2 GTTS BID-QID 5) Dexamethasone 0.1% 1-2 GTTS BID-QID 6) Ketorolac 0.4% 1 GTT QID 7) Flurbiprofen 0.03% 1 GTT QID NF 8) Vexol 1% 1-2 GTT QID NF 9) Bromfenac 0.09% 1 GTT QD-BID NF 10) Lotemax 0.5% 1-2 GTT QID NF Nexavar (Sorafenib) 200mg Tablet 2T BID 1) Torisel 25mg IV QW 2) Sutent 50mg QD NOTE: 4 Sutent preferred when initiating therapy weeks on then 2 weeks off FDA approved for treatment of advanced renal cell cancer (RCC) or unresectable hepatocellular cancer (HCC) Nexium (Esomeprazole) 20, 40mg Capsule QD-BID 1) Pantoprazole 40mg QD 2) OTC Omeprazole 20mg Excluded Medication QD 3) OTC Zegerid 20/1100mg QD 4) OTC Prevacid 15mg QD Niaspan (Niacin) 500, 750, 1000mg Extended OTC Slo-Niacin 500mg QD (Titrate to 2000mg/day as Release Tablet QD tolerated using .PITTTSLONIACIN) Nitro-Dur (Nitroglycerin) 0.1, 0.2, 0.3, 0.4, 0.6, 1) Minitran 0.1-0.6mg/hr Patch Apply 12-14 hours 0.8mg/hr Transdermal Patch then remove 10-12 hours 2) Nitro-Dur 0.8mg/hr Patch Apply 12-14 hours then remove 10-12 hours Apply 12-14 hours then remove 10-12 hours Page 37 Last Updated: 8/27/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Nordette (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) Tablet QD Norflex (Orphenadrine Citrate) 100mg Extended Release Tablet BID Norgesic (Orphenadrine Citrate/Aspirin/Caffeine) 25/385/30mg Tablet TID-QID Noritate (Metronidazole) 1% Cream AAA QD Noroxin (Norfloxacin) 400mg Tablet BID NovoLog (Insulin Aspart) 100U/ml Subcutaneous Solution SC 5-10 minutes AC NovoLog 70/30 (Insulin Aspart Protamine/Insulin Aspart) 100U/ml Injection Solution SC 15 minutes AC 1) Reclipsen (30mcg Ethinyl Estradiol/0.15mg Desogestrel) QD 2) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD 3) Microgestin Fe 1.5/30 (30mcg Ethinyl Estradioll/1.5mg Norethindrone) QD 1) Cyclobenzaprine 10mg TID 2) Chlorzoxazone 250500mg TID 3) Carisoprodol 350mg TID 4) Tizanidine 4mg TID 5) Methocarbamol 500-750mg QID 6) Baclofen 10-20mg TID 2 Separate Medications OTC Aspirin 325mg TID-QID AND 1) Cyclobenzaprine 10mg TID 2) Chlorzoxazone 250500mg TID 3) Carisoprodol 350mg TID 4) Tizanidine 4mg TID 5) Methocarbamol 500-750mg QID 6) Baclofen 10-20mg TID Metronidazole 0.75% Cream, Gel AAA BID Prostatitis 1) SMZ-TMP DS BID X14D 2) Ciprofloxacin 500mg BID X14D Urinary Tract Infection 1) SMZ-TMP DS BID X3D 2) Ciprofloxacin 250mg BID X3D 3) Levofloxacin 250mg QD X3D 4) Nitrofurantoin Monohydrate 100mg BID X7D Novolin R (Insulin Regular) SC 30 minutes AC Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC OR 2 Separate Medications Novolin N (NPH) SC 15-30 minutes AC AND 1) Novolin R (Insulin Regular) SC 30 minutes AC 2) NovoLog (Insulin Aspart) SC 5-10 minutes AC NF NovoLog FlexPen (Insulin Aspart) 100U/ml Injection 1) Novolin R (Insulin Regular) SC 30 minutes AC 2) Solution SC 15 minutes AC NovoLog (Insulin Aspart) SC 5-10 minutes AC NF Noxafil (Posaconazole) 40mg/ml Suspension QDQID 1) Fluconazole 50-200mg QD 2) Itraconazole 100mg QD-BID 3) Sporanox 10mg/ml QD-BID Nucynta (Tapentadol) 50, 75, 100mg Tablet TID-QID 1) Oxycodone/Acetaminophen 5/325mg Q6H 2) Morphine 15-30mg Q4H 3) Hydromorphone 2-8mg Q4-6H 4) Oxycodone 5-30mg Q4-6H 5) Morphine Solution 20mg/ml 0.5-1.5ml Q4H 6) Meperidine 50150mg Q3-4H Page 38 Last Updated: 8/27/2012 Comments Equivalent Brand and Generic Products Nordette=Levora Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives NovoLog to Novolin R is a 1:1 Conversion Document a) member with DM1 b) adequate therapeutic trial or intolerance (Persistent hypoglycemia) to Novolin R c) member using NovoLog via Insulin Pump d) member using Humulin R (Insulin Regular) 500U/ml e) Isolated post-prandial hyperglycemia despite titration and A1c within 0.5% of goal Dose Conversion NovoLog 70/30 20U=Novolin 70/30 20U=Novolin N (NPH) 14U+Novolin R (Insulin Regular) 6U Insulin Administration Device Document a) member is unable to accurately draw up insulin due to upper extremity amputation, visual impairment, young age, Parkinson's Disease, Rheumatoid Arthritis b) member administers doses < 5U c) school or day care requires insulin cartridge device for insulin administration while member is outside of primary caretaker's care Adjust based on patient response Insulin Administration Device Document a) member is unable to accurately draw up insulin due to upper extremity amputation, visual impairment, young age, Parkinson's Disease, Rheumatoid Arthritis b) member administers doses < 5U c) school or day care requires insulin cartridge device for insulin administration while member is outside of primary caretaker's care Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Nuedexta (Dextromethorphan 1) Amitriptyline 50-75mg QD 2) Citalopram 10-30mg Hydrobromide/Quinidine Sulfate) 20/10mg Capsule QD 3) Nortriptyline 50-100mg QD 4) Imipramine 10BID 20mg QD Nuquin HP (Hydroquinone) 4% Cream, Gel AAA BID NuvaRing (15mcg Ethinyl Estradiol/0.12mg Etonogestrel) Vaginal Insert Insert for 3 weeks and remove for 1 week Comments Excluded Medication Document adequate therapeutic trial or intolerance 1) Aviane (20mcg Ethinyl Estradiol/0.1mg to at least 3 formulary oral contraceptives Levonorgestrel) QD 2) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD Nuvigil (Armodafinil) 50, 150, 250mg Tablet QAM Narcolepsy 1) OTC Caffeine 100-200mg Q3-4H 2) Methylin 1060mg Divided BID-TID 3) Adderall 5-60mg Divided dose 4) Dextroamphetamine CR 5-60mg QD Obstructive Sleep Apnea Modafinil 100-200mg QAM NF Ocella (30mcg Ethinyl Estradiol/3mg Drospirenone) 1) Reclipsen (30mcg Ethinyl Estradiol/0.15mg Tablet QD Desogestrel) QD 2) Microgestin Fe 1.5/30 (30mcg Ethinyl Estradiol/1.5mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD Dose Conversion Modafinil 50mg=Nuvigil 50mg / Modafinil100mg=Nuvigil 150mg 0.5T / Modafinil 200mg=Nuvigil 250mg 0.5T / Modafinil 300mg=Nuvigil 250mg Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Ocufen (Flurbiprofen) 0.03% Ophthalmic Solution 1 GTT QID 1) Diclofenac 0.1% 1GTT QID 2) Ketorolac 0.5% 1 GTT QID 3) Prednisolone 1% 1-2 GTTS BID-QID 4) Fluorometholone 0.1% 1-2 GTTS BID-QID 5) Dexamethasone 0.1% 1-2 GTTS BID-QID 6) Ketorolac 0.4% 1 GTT QID Ocupress (Carteolol) 1% Ophthalmic Solution 1 GTT 1) Timolol 0.25-0.5% 1 GTT QD-BID 2) Levobunolol BID 0.25-0.5% 1-2 GTT QD-BID 3) Betaxolol 0.5% 1-2 GTT BID Oforta (Fludarabine) 10mg Tablet 40mg/m2 QD X5D Fludara 25mg/m2 X5D Q28D NF Q28D Ogestrel (50mcg Ethinyl Estradiol/0.5mg Norgestrel) 1) Zovia 1/50 (50mcg Ethinyl Estradiol/1mg Tablet QD Ethynodiol Diacetate) QD 2) Necon 1/50 (50mcg Mestranol/1mg Norethindrone) QD Oleptro (Trazodone) 150, 300mg Extended Release 1) Citalopram 20-40mg QD 2) Fluoxetine 20-40mg Tablet QPM QD 3) Trazodone 150-400mg QD 4) Sertraline 50100mg QD 5) Mirtazapine 30mg QHS 6) Bupropion SR/XL 300mg QD 7) Venlafaxine ER 225mg QD Dose Conversion Oleptro 150mg=Trazodone 150mg 0.5T BID / Oleptro 300mg=Trazodone 150mg BID Olux (Clobetasol Propionate) 0.05% Foam AAA BID Very High Potency Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID Omnaris (Ciclesonide) 50mcg/Actuation Nasal Spray 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) 2 SPRAYS IEN QD OTC Allegra 60mg BID 4) Fluticasone 2 SPRAYS IEN QD 5) Flunisolide 2 SPRAYS IEN BID 6) Triamcinolone 2 SPRAYS IEN QD NF 7) Nasonex 2 SPRAYS IEN QD NF 8) Veramyst 2 SPRAYS IEN QD NF Omnicef (Cefdinir) 300mg Capsule BID 3rd Generation 1) Cefdinir 125mg/5ml-250mg/5ml 7mg/kg BID 3rd Generation Page 39 Last Updated: 8/27/2012 Age Recommendations Fluticasone=4 years of age and older / Flunisolide=6 years of age and older / Triamcinolone=2 years of age and older / Nasonex=2 years of age and older / Veramyst=2 years of age and older / Omnaris=6 years of age and older Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Omnitrope (Somatropin) 5/1.5, 10/1.5mg/ml Subcutaneous Solution QW Onglyza (Saxagliptin) 2.5, 5mg Tablet QD Comments Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin Criteria Restricted Medication QRM approval required prior to being dispensed for 500-1000mg (Maximum 2550mg QD) 3) Metformin ER 500-750mg (Maximum 2000mg QD) 4) Novolin R Commercial, Multi-Choice, Self-Funded, and Triple Tier members. (Insulin Regular) SC 30 minutes AC 5) Novolin N Provider must call 404-364-7320 (Option 2) to (NPH) SC 15-30 minutes AC 6) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog initiate review by QRM department. (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos 15mg (Maximum 45mg QD) Opana ER (Oxymorphone) 5, 7.5, 10, 15, 20, 30, 40mg Extended Release Tablet BID 1) Morphine ER 60-100mg BID 2) Fentanyl 25100mcg/hr Q72H 3) Avinza 30-120mg QD NF Optivar (Azelastine) 0.05% Ophthalmic Solution 1 GTT BID 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q34 HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID 4) Crolom 4% 1-2 GTTS Q4-6 HOURS NF 5) Emadine 0.05% 1 GTT QID NF 6) Alocril 2% 1-2 GTTS BID NF Oracea (Doxycycline) 40mg Extended Release Capsule QD 1) Doxycycline 50-100mg BID 2) Minocycline 50100mg BID 3) Tetracycline 250-500mg BID 4) Metronidazole 0.75% Gel/Cream AAA BID 1) Reclipsen (30mcg Ethinyl Estradiol/0.15mg Desogestrel) QD 2) Microgestin Fe 1.5/30 (30mcg Ethinyl Estradioll/1.5mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD Oracea 40mg=Doxycyline 30mg Immediate Release + Doxycycline 10mg Delayed Release 1) Sprintec (35mcg Ethinyl Estradiol/0.25mg Norgestimate) QD 2) Necon 1/35 (35mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Necon 0.5/35 (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD 4) Zovia 1/35 (35mcg Ethinyl Estradiol/1mg Ethynodiol diacetate) QD 5) Brevicon (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD 1) Sprintec (35mcg Ethinyl Estradiol/0.25mg Norgestimate) QD 2) Aviane (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel) QD 3) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) QD 1) Sprintec (35mcg Ethinyl Estradiol/0.25mg Norgestimate) QD 2) Necon 1/35 (35mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Necon 0.5/35 (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD 4) Zovia 1/35 (35mcg Ethinyl Estradiol/1mg Ethynodiol diacetate) QD 5) Brevicon (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD 1) Necon 1/50 (50mcg Mestranol/1mg Norethindrone) QD 2) Zovia 1/50 (50mcg Ethinyl Estradiol/1mg Ethynodiol Diacetate) QD Equivalent Brand and Generic Products Ortho-Cyclen=Sprintec Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Ortho-Cept 28 (30mcg Ethinyl Estradiol/0.15mg Desogestrel) Tablet QD Ortho-Cyclen (35mcg Ethinyl Estradiol/0.25mg Norgestimate) Tablet QD Ortho Evra (20mcg Ethinyl Estradiol/0.15mg Norelgestromin) Transdermal Patch Apply QW Ortho-Novum 1/35 (35mcg Ethinyl Estradiol/1mg Norethindrone) Tablet QD Ortho-Novum 1/50 (50mcg Mestranol/1mg Norethindrone) Tablet QD Page 40 Last Updated: 8/27/2012 Dose Conversion Morphine 30mg=Oxycodone 20mg=Oxymorphone 10mg / Morphine 90mg=Fentanyl 25mcg/hr Document adequate therapeutic trial or intolerance to Morphine ER and Fentanyl Equivalent Brand and Generic Products Ortho-Cept=Reclipsen Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Equivalent Brand and Generic Products Ortho-Novum 1/35=Necon 1/35 Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Equivalent Brand and Generic Products Ortho-Novum 1/50=Necon 1/50 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Ortho-Novum 7/7/7 (35mcg Ethinyl Estradiol/0.5mg Norethindrone x 7 days, 35mcg EE/0.75mg NE x 7 days, 35mcg EE/1mg NE x 7 days) Tablet QD 1) Nortrel 7/7/7 (35mcg Ethinyl Estradiol/ 0.5mg Norethindrone x 7 days, 35mcg EE/0.75mg NE x 7 days, 35mcg EE/1mg NE x 7 days) QD 2) TriSprintec (35mcg Ethinyl Estradiol/0.18mg Norgestimate x 7 days, 35mcg EE/0.215mg NG x 7 days, 35mcg EE/0.25mg NGx 7 days) QD 3) Trivora (30mcg Ethinyl Estradiol/0.05mg Levonorgestrel x 6 days, 40mcg EE/0.075mg LVNGL x 5 days, 30mcg EE/0.125mg LVNGL x 10 days) QD 4) Leena (35mcg Ethinyl Estradiol/0.5mg Norethindrone x 7 days, 35mcg EE/1mg NE x 9 days, 35mcg EE/0.5mg NE x 5 days) QD Ortho-Novum 10/11 (35mcg Ethinyl Estradiol/0.5mg 1) Necon 0.5/35 (35mcg Ethinyl Estradiol/0.5mg Norethindrone x 10 days, 35mcg EE/1mg NE x Norethindrone) QD 2) Necon 1/35 (35mcg Ethinyl 11days) Tablet QD Estradiol/1mg Norethindrone) QD 3) Leena (35mcg Ethinyl Estradiol/0.5mg Norethindrone x 7 days, 35mcg EE/1mg NE x 9 days, 35mcg EE/0.5mg NE x 5 days) QD 4) Brevicon (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD Ortho Tri-Cyclen (35mcg Ethinyl Estradiol/0.18mg 1) Tri-Sprintec (35mcg Ethinyl Estradiol/0.18mg Norgestimate x 7 days, 35mcg EE/0.215mg NG x 7 Norgestimate x 7 days, 35mcg EE/0.215mg NG x 7 days, 35mcg EE/0.25mg NG x 7 days) Tablet QD days, 35mcg EE/0.25mg NGx 7 days) QD 2) Sprintec (35mcg Ethinyl Estradiol/0.25mg Norgestimate) Tablet QD 3) Trivora (30mcg Ethinyl Estradiol/0.05mg Levonorgestrel x 6 days, 40mcg EE/0.075mg LVNGL x 5 days, 30mcg EE/0.125mg LVNGL x 10 days) QD 4) Leena (35mcg Ethinyl Estradiol/0.5mg Norethindrone x 7 days, 35mcg EE/1mg NE x 9 days, 35mcg EE/0.5mg NE x 5 days) QD Comments Equivalent Brand and Generic Products Ortho-Novum 7/7/7=Nortrel 7/7/7 Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Equivalent Brand and Generic Products Ortho-Novum 10/11=Necon 10/11 Equivalent Brand and Generic Products Ortho Tri-Cyclen=Tri-Sprintec Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Ortho Tri-Cyclen Lo (25mcg Ethinyl Estradiol/0.18mg Norgestimate x 7 days, 25mcg EE/0.215mg NG x 7 days, 25mcg EE/ 0.25mg NG x 7 days) Tablet QD Document adequate therapeutic trial or intolerance 1) Tri-Sprintec (35mcg Ethinyl Estradiol/0.18mg to at least 3 formulary oral contraceptives Norgestimate x 7 days, 35mcg EE/0.215mg NG x 7 days, 35mcg EE/0.25mg NGx 7 days) QD 2) Sprintec (35mcg Ethinyl Estradiol/0.25mg Norgestimate) Tablet QD 3) Aviane (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel) QD 4) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) QD Orudis (Ketoprofen) 50, 75mg Capsule TID-QID 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg BID 3) Ibuprofen 400-800mg TID-QID 4) Sulindac 150-200mg BID 5) Etodolac 200-500mg BID-TID 6) Nabumetone 500-750mg BID 7) Lidocaine 5% Ointment AAA Q4H 8) Diclofenac 25-100mg BID-TID Oruvail (Ketoprofen) 150, 200mg Extended Release 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg Capsule QD BID 3) Ibuprofen 400-800mg TID-QID 4) Sulindac 150-200mg BID 5) Etodolac 200-500mg BID-TID Ovcon 35 (35mcg Ethinyl Estradiol/0.4mg Norethindrone) Tablet QD 1) Sprintec (35mcg Ethinyl Estradiol/0.25mg Norgestimate) QD 2) Necon 1/35 (35mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Necon 0.5/35 (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD 4) Zovia 1/35 (35mcg Ethinyl Estradiol/1mg Ethynodiol diacetate) QD 5) Brevicon (35mcg Ethinyl Estradiol/0.5mg Norethindrone) QD Ovcon 50 (50mcg Ethinyl Estradiol/1mg 1) Zovia 1/50 (50mcg Ethinyl Estradiol/1mg Norethindrone) Tablet QD Ethynodiol Diacetate) QD 2) Necon 1/50 (50mcg Mestranol/1mg Norethindrone) QD Ovide (Malathion) 0.5% Lotion Apply to scalp, 1) OTC Nix (Permethrin 1%) 2) OTC Rid, Pronto Plus Shampoo hair after 8-12 hours, Repeat application if (Pyrethrins 0.33%/Piperonyl Butoxide 4%) 3) OTC lice present 7 days after initial treatment Cetaphil Cleanser Lotion 4) Ulesfia 5% Lotion NF Page 41 Last Updated: 8/27/2012 Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Apply to scalp, Leave on for 10 minutes, Rinse, Repeat application if lice present 7 days after initial treatment Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Oxistat (Oxiconazole) 1% Cream, Lotion BID Comments 1) OTC Lamisil Ultra (Butenafine 1%) QD-BID 2) OTC Lotrimin AF (Clotrimazole 1%) BID 3) OTC Micatin (Miconazole 1%) BID 4) Ketoconazole 2% Cream QD Oxycontin (Oxycodone) 10, 15, 20, 30, 40, 60, 80mg 1) Morphine ER 60-100mg BID 2) Fentanyl 25Extended Release Tablet QD-BID 100mcg/hr Q72H 3) Avinza 30-120mg QD NF 4) Opana ER 5-40mg BID NF 5) Kadian 10-200mg QD NF 6) Exalgo 8-16mg QD NF Pamine (Methscopolamine) 2.5mg Tablet BID Allergic Rhinitis 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) OTC Allegra 60mg BID 4) Fluticasone 2 SPRAYS IEN QD 5) Flunisolide 2 SPRAYS IEN BID 6) Ipratropium 0.03-0.06% 2 SPRAYS IEN BID-QID NF Peptic Ulcer 1) Pantoprazole 40mg QD 2) OTC Omeprazole 20mg QD 3) OTC Zegerid 20/1100mg QD 4) OTC Prevacid 15mg QD Pandel (Hydrocortisone Probutate) 0.1% Cream AAA QD-BID Medium Potency Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BIDQID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BIDQID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID Panretin (Alitretinoin) 0.1% Gel AAA BID-QID Quantity Limit Oxycontin 10-80mg (30 Day Supply)=60 Tablets Dose Conversion Hydromorphone 7.5mg=Morphine 30mg=Oxycodone 20mg=Oxymorphone 10mg / Morphine 90mg=Fentanyl 25mcg/hr Document adequate therapeutic trial or intolerance to Morphine ER and Fentanyl Document a) AIDS-related Kaposi's Sarcoma b) less than 10 new Kaposi's Sarcoma lesions in the prior month c) adequate therapeutic trial or intolerance to cryotherapy Parlodel (Bromocriptine) 5mg Capsule QD-BID Pataday (Olopatadine) 0.2% Ophthalmic Solution 1 GTT QD Bromocritpine 2.5mg QD-BID 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q34 HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID 4) Crolom 4% 1-2 GTTS Q4-6 HOURS NF 5) Emadine 0.05% 1 GTT QID NF 6) Alocril 2% 1-2 GTTS BID NF 7) Optivar 0.05% 1 GTT BID NF 8) Alomide 0.1% 1-2 GTTS QID NF 9) Lastacaft 0.25% 1 GTT QD NF Patanase (Olopatadine) 0.6% Nasal Spray 2 SPRAYS IEN BID 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) Document adequate therapeutic trial or intolerance to Claritin, Zyrtec, or Allegra, at least 1 Nasal OTC Allegra 60mg BID 4) Fluticasone 2 SPRAYS Steroid, and Azelastine IEN QD 5) Flunisolide 2 SPRAYS IEN BID 6) Azelastine 2 SPRAYS IEN BID NF 1) OTC Naphcon-A, Opcon-A, Visine-A 1-2 GTTS Q34 HOURS 2) OTC Zaditor (Ketotifen 0.025%) 1 GTT BID 3) Ketorolac 0.5% 1 GTT QID 4) Crolom 4% 1-2 GTTS Q4-6 HOURS NF 5) Emadine 0.05% 1 GTT QID NF 6) Alocril 2% 1-2 GTTS BID NF 7) Optivar 0.05% 1 GTT BID NF 8) Alomide 0.1% 1-2 GTTS QID NF 9) Lastacaft 0.25% 1 GTT QD NF 10) Pataday 0.2% 1 GTT QD NF 11) Alrex 0.2% 1 GTT QID NF Patanol (Olopatadine) 0.1% Ophthalmic Solution 1 GTT BID Paxil CR (Paroxetine) 12.5, 25, 37.5mg Extended Release Tablet QD 1) Citalopram 20-40mg QD 2) Fluoxetine 20-40mg QD 3) Sertraline 50-100mg QD 4) Mirtazapine 30mg QHS 5) Bupropion SR/XL 300mg QD 6) Venlafaxine ER 225mg QD 7) Paroxetine 10-40mg QD 8) Fluvoxamine 50-300mg QD NF 9) Escitalopram 1020mg QD NF Page 42 Last Updated: 8/27/2012 Document adequate trial or intolerance to all formulary SSRIs Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Paxil CR (Paroxetine) 12.5, 25, 37.5mg Extended Release Tablet QD Pediapred (Prednisolone Sodium Phosphate) 5mg/5ml Solution 5-60mg QD Penlac (Ciclopirox) 8% Solution QD 1) Citalopram 20-40mg QD 2) Fluoxetine 20-40mg QD 3) Sertraline 50-100mg QD 4) Mirtazapine 30mg QHS 5) Bupropion SR/XL 300mg QD 6) Venlafaxine ER 225mg QD 7) Paroxetine 10-40mg QD 8) Fluvoxamine 50-300mg QD NF 9) Lexapro 10-20mg QD NF Prednisolone Sodium Phosphate 15mg/5ml 5-60mg QD Thymol/Isopropyl Alcohol 4/99% Solution QD Comments Document adequate trial or intolerance to all formulary SSRIs KPGA Approved Compound Finger Onychomycosis Document positive fungal culture prior to approval of one 6 week treatment Toe Onychomycosis Document a) positive fungal culture b) DM or Vascular Disease prior to approval one 12 week treatment Pennsaid (Voltaren) 1.5% Topical Solution Apply 10 1) OTC Aspercreme AAA BID-QID 2) Meloxicam 7.5GTTS QID 15mg QD 3) Naproxen 250-550mg BID 4) Ibuprofen 400-800mg TID-QID 5) Sulindac 150-200mg BID 6) Etodolac 200-500mg BID-TID 7) Nabumetone 500750mg BID 8) Lidocaine 5% Ointment AAA Q4H 9) Diclofenac 25-100mg BID-TID Pepcid (Famotidine) 40mg Tablet QD-BID Percocet (Oxycodone/Acetaminophen) 7.5/325, 10/325, 7.5/500, 10/650mg Tablet Q6H Periostat (Doxycycline) 20mg Tablet BID 1) OTC Famotidine 10-20mg QD-BID 2) OTC Excluded Medication Ranitidine 75-150mg QD-BID 3) Cimetidine 400800mg QD-BID Oxycodone/Acetaminophen 5/325mg Q6H OR 2 Separate Medications OTC Acetaminophen 325-650mg Q6H AND Oxycodone 5-10mg Q6H 1) Doxycycline Hyclate 50-100mg BID 2) Minocycline 50-100mg BID 3) Tetracycline 250-500mg BID Phendiet (Phendimetrazine) 35mg Tablet BID-TID Excluded Medication (Exception: Obesity Rider) Poly-Pred (Neomycin/Polymyxin/Prednisolone) Ophthalmic Solution 1-2 GTTS Q4 HOURS 1) Neomycin/Polymyxin/Hydrocortisone 1% Suspension 1-2 GTTS Q4 HOURS 2) Neomycin/Polymyxin/Dexamethasone 0.1% Suspension 1-2 GTTS Q4 HOURS 3) Tobramycin/Dexamethasone 0.3/0.1% 1-2 GTTS Q46 HOURS Ponstel (Mefenamic Acid) 250mg Capsule QID 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg BID 3) Ibuprofen 400-800mg TID-QID 4) Sulindac 150-200mg BID 5) Etodolac 200-500mg BID-TID 6) Nabumetone 500-750mg BID 7) Lidocaine 5% Ointment AAA Q4H 8) Diclofenac 25-100mg BID-TID 9) Indomethacin 25-75mg QD-BID 10) Tolmetin 200600mg TID Portia (30mcg Ethinyl Estradiol/0.15 Levonorgestrel) 1) Reclipsen (30mcg Ethinyl Estradiol/0.15 Tablet QD Desogestrel) Tablet QD 2) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) Tablet QD 3) Microgestin Fe 1.5/30 (30mcg Ethinyl Estradiol/1.5mg Norethindrone) QD Page 43 Last Updated: 8/27/2012 Equivalent Brand and Generic Products Portia=Levora Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Pradaxa (Dabigatran) 75, 150mg Capsule 150mg BID Warfarin 1-10mg QD (Tiitrate to target INR) Pramosone (Hydrocortisone Acetate/Pramoxine) 1/1% Cream, Lotion, Ointment QD-BID 1) OTC Hydrocortisone 0.5-1% Cream, Ointment AAA BID-QID 2) OTC Prax 1% Cream, Lotion AAA BID-QID 3) Hydrocortisone 2.5% Cream, Lotion, Ointment AAA BID-QID 4) Hydrocortisone 25mg Suppository BID 5) Hydrocortisone 100mg/60ml Enema QD-BID 6) Proctofoam-HC 1/1% QD-BID Prandin (Repaglinide) 0.5, 1mg Tablet TID-QID 1) Glipizide 5-15mg QD 2) Glyburide 2.5-10mg QD Prandin (Repaglinide) 2mg Tablet TID-QID Premarin (Conjugated Estrogen) 0.3, 0.45, 0.625, 0.9, 1.25, 2.5mg Tablet QD Comments Document inclusion of: a) Irreversible atrial fibrillation If CHADS2 Score=1 b) Identified as an anticoagulation candidate (not ASA) c) Uninterrupted Warfarin therapy for at least 22 weeks d) TTR < 54% If CHADS2 Scoreā„2 b) Uninterrupted Warfarin therapy for at least 22 weeks c) TTR < 54% AND exclusion of: a) CHADS2 Score=0 b) TTR ā„ 67% c) History of heart valve disorder d) Severe, disabling stroke within the last 6 months e) Stroke within the previous 14 days f) Increased risk for bleeding g) CrCl<30mL/min h) Active liver disease i) Active infective endocarditis j) Anemia or thrombocytopenia k) Malignancy l) Reversible causes of atrial fibrillation m) Pregnancy n) Women of childbearing potential who refuse to use a form of contraception o) Contraindication to warfarin treatment p) Need for anticoagulant treatment of disorders other than atrial fibrillation Adjust based on patient response Glipizide preferred if 65 years of age and older due to prolonged half life of Glyburide 1) Glipizide 10-20mg BID 2) Glyburide 7.5-10mg BID Adjust based on patient response Glipizide preferred if 65 years of age and older due to prolonged half life of Glyburide Adjust to the lowest dose needed to control Vasomotor Symtoms 1) Estradiol QD 2) Climara Patch 0.025-0.1mg/24hr symptoms based on patient response Dose Conversion Apply weekly Premarin 0.3mg=Estradiol 0.5mg / Premarin Vaginal/Vulvar Atrophy 1) Estradiol QD 2) Climara Patch 0.025-0.1mg/24hr 0.45mg=Estradiol 0.75mg / Premarin 0.625mg=Estradiol 1mg / Premarin 0.9mg=Estradiol Apply weekly 3) Premarin Vaginal 1gm Apply three times a week 4) Vagifem 10mcg Insert twice weekly 1.5mg / Premarin 1.25mg=Estradiol 2mg / Premarin 2.5mg=No Formulary Alternative 5) Estring 2mg Insert for 90 days Premphase (Conjugated Estrogen/Medroxyprogesterone) 0.625/5mg Tablet Day 1-14: Conjugated Estrogen QD Day 15-28: Conjugated Estrogen/Medroxyprogesterone QD 2 Separate Medications Day 1-14: Estradiol 1mg QD Day 15-28: Estradiol 1mg QD AND Medroxyprogesterone 5mg QD Dose Conversion Premarin 0.625mg=Estradiol 1mg Prempro (Conjugated Estrogen/Medroxyprogesterone) 0.3/1.5, 0.45/1.5mg, 0.625/2.5, 0.625/5mg Tablet QD 2 Separate Medications Vasomotor Symtoms 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.0250.1mg/24hr Apply weekly AND 1) Medroxyprogesterone 2.5-5mg QD 2) Nora-BE 0.35mg QD 3) Norethindrone 5mg QD Vaginal/Vulvar Atrophy 1) Estradiol Tablet 1-2mg QD 2) Climara Patch 0.0250.1mg/24hr Apply weekly 3) Premarin Vaginal 1gm Apply three times a week 4) Vagifem 10mcg Insert twice weekly 5) Estring 2mg Insert for 90 days AND 1) Medroxyprogesterone 2.5-5mg QD 2) Nora-BE 0.35mg QD 3) Norethindrone 5mg QD Adjust to the lowest dose needed to control symptoms based on patient response Dose Conversion Premarin 0.3mg=Estradiol 0.5mg / Premarin 0.45mg=Estradiol 0.75mg / Premarin 0.625mg=Estradiol 1mg Page 44 Last Updated: 8/27/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Prenatal Vitamins (Citranatal DHA, Generet, Prenate OTC Natures Best Prenatal QD Elite) QD Prevacid (Lansoprazole) 15, 30mg Capsule QD-BID 1) Pantoprazole 40mg QD 2) OTC Omeprazole 20mg QD 3) OTC Zegerid 20/1100mg QD 4) OTC Prevacid 15mg QD Prevacid Solutab (Lansoprazole) 15, 30mg Orally 1) Pantoprazole 40mg QD 2) OTC Omeprazole 20mg Disintegrating Tablet QD-BID QD 3) Omeprazole 2mg/ml Liquid 10ml QD 4) Lansoprazole 3mg/ml Liquid 10ml QD 5) OTC Zegerid 20/1100mg QD 6) OTC Prevacid 15mg QD Prevpac (Lansoprazole, Amoxicillin, Clarithromycin) First Line 30mg Delayed Release Capsule BID, 500mg Tetracycline Hydrochloride 500mg QID, Capsule 2C BID, 500mg Tablet BID X14D Metronidazole 250mg QID, OTC Omeprazole 20mg BID, OTC Bismuth Subsalicylate 262.4mg 2T QID X14D Second Line Clarithromycin 500mg BID or Amoxicillin 500mg 2C BID, Metronidazole 250mg QID, OTC Omeprazole 20mg BID, OTC Bismuth Subsalicylate 262.4mg 2T QID X14D Prilosec (Omeprazole) 10, 20mg Capsule QD-TID 1) Pantoprazole 40mg QD 2) OTC Omeprazole 20mg QD Pristiq (Desvenlafaxine) 50,100mg Tablet QD 1) Citalopram 20-40mg QD 2) Fluoxetine 20-40mg QD 3) Sertraline 50-100mg QD 4) Mirtazapine 30mg QHS 5) Bupropion SR/XL 300mg QD 6) Venlafaxine ER 225mg QD 7) Fluvoxamine 50-300mg QD NF 8) Escitalopram 10-20mg QD NF 9) Paxil CR 12.537.5mg QD NF 10) Viibryd 10-40mg QD NF Proamatine (Midodrine) 2.5, 5, 10mg Tablet TID Procardia (NIfedipine) 10, 20mg Tablet TID Proctosol HC (Hydrocortisone) 2.5% Cream AAA BID-QID Prodigy Glucometer and Test Strips Fludrocortisone 0.1-0.2mg QD Nifedipine ER 30-60mg QD Hydrocortisone 2.5% Cream, Lotion, Ointment AAA BID-QID One Touch Ultra 2 Glucometer and One Touch Ultra Test Strips Prolia (Denosumab) 60mg/ml Subcutaneous Solution Q6M Administered in a healthcare setting by healthcare providers 1) Alendronate 10mg QD 2) Alendronate 70mg QW 3) Fortical 200IU QD Alternate nostrils 4) Ibandronate 150mg QM NF 5) Actonel 5mg QD NF 6) Actonel 150mg QM NF 7) Evista 60mg QD 8) Actonel 35mg QW NF Prescribing Physician must call Promacta Cares Distribution Program 877-9-PROMACTA Promacta is delivered directly to patient via KP CA Specialty Pharmacy 1) Medroxyprogesterone 2.5-5mg QD 2) Nora-BE 0.35mg QD 3) Norethindrone 5mg QD OTC Rogaine (Minoxidil) BID 1) Temazepam 15mg QHS 2) Lorazepam 0.5mg QHS 3) Oxazepam 10-30mg QHS 4) Trazodone 50-100mg QHS 5) Zolpidem 5-10mg QHS Pantoprazole 40mg QD Promacta (Eltrombopag Olamine) 25, 50, 75mg Tablet QD Prometrium (Progesterone) 100, 200mg Tablet QD Propecia (Finasteride) 1mg Tablet QD Prosom (Estazolam) 1, 2mg Tablet QHS Protonix (Pantoprazole) 20, 40mg Tablet QD-BID Page 45 Last Updated: 8/27/2012 Comments Excluded Medication Available OTC Excluded Medication Excluded Medication Dispense Antibiotics for copays and purchase OTC Bismuth Subsalicylate and OTC Omeprazole Excluded Medication Document adequate therapeutic trial or intolerance to 2 SSRIs and Venlafaxine Document member is unable to accurately use One Touch Ultra 2 Glucometer and One Touch Ultra Test Strips due to visual impairment KP CA Specialty Pharmacy MD Line 650-301-5799 / Patient Line 1-877-4045777 / Fax Line 650-301-5790 Excluded Medication Document adequate therapeutic trial or intolerance to Trazodone, Zolpidem, and at least 1 Benzodiazepine Excluded Medication Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Protopic (Tacrolimus) 0.03, 0.1% Ointment AAA BID Comments Protopic preferred over Elidel if Vitiligo Atopic Dermatitis Elidel 1% Cream AAA BID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BIDQID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BIDQID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QDBID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID Proventil HFA (Albuterol) 0.09mg Inhalation Aerosol Proair HFA (Albuterol) 0.09mg Inhalation Aerosol Powder Q4H PRN Powder Q4H PRN Provigil (Modafinil) 100, 200mg Tablet QAM Narcolepsy 1) OTC Caffeine 100-200mg Q3-4H 2) Methylin 1060mg Divided BID-TID 3) Adderall 5-60mg Divided dose 4) Dextroamphetamine CR 5-60mg QD Obstructive Sleep Apnea Modafinil 100-200mg QAM NF Prozac Weekly (Fluoxetine) 90mg Delayed Release 1) Citalopram 20-40mg QD 2) Fluoxetine 20-40mg Capsule QW QD 3) Sertraline 50-100mg QD 4) Mirtazapine 30mg QHS 5) Bupropion SR/XL 300mg QD 6) Venlafaxine ER 225mg QD 7) Fluvoxamine 50-300mg QD NF 8) Escitalopram 10-20mg QD NF 9) Paxil CR 12.537.5mg QD NF 10) Viibryd 10-40mg QD NF 11) Pristiq 50-100mg QD NF Psorcon (Diflorasone Diacetate) 0.05% Cream AAA High Potency QD-QID High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BIDQID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QDBID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Psorcon (Diflorasone Diacetate) 0.05% Ointment Very High Potency AAA QD-QID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID Page 46 Last Updated: 8/27/2012 Proventil HFA to Proair HFA is a 1:1 Conversion Dose Conversion Modafinil 50mg=Nuvigil 50mg / Modafinil100mg=Nuvigil 150mg 0.5T / Modafinil 200mg=Nuvigil 250mg 0.5T / Modafinil 300mg=Nuvigil 250mg Document adequate trial or intolerance to all formulary SSRIs Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Pulmicort Flexhaler (Budesonide) 90, 180mcg Inhalation Powder 2 PUFFS BID 1) Qvar 40-80mcg 1-2 PUFFS QD-BID 2) Flovent HFA 44mcg 2 PUFFS BID NOTE: Flovent HFA 44mcg for patients 4-11 years of age 3) Asmanex 110-220mcg 1-2 PUFFS QD 4) Aerobid 0.25mg 2 PUFFS BID NF Comments Document adequate trial or intolerance to Qvar 80mcg 2 PUFFS BID and Asmanex 220mcg 2 PUFFS QD within the past 3 months Pulmicort is the preferred Inhaled Corticosteroid during pregnancy Dose Conversion Pulmicort Flexhaler 90mcg 2 PUFFS BID=Qvar 80mcg 1PUFF BID=Flovent 44mcg 2 PUFFS BID Pulmicort 180mcg 2 PUFFS BID=Qvar 80mcg 2 PUFFS BID=Asmanex 220mcg 2 PUFFS QD Pylera (Tetracycline Hydrochloride/Metronidazole/Bismuth Subcitrate Potassium) 125/125/140mg Capsule 3C QID with OTC Omeprazole 20mg BID X10D Dispense Antibiotics for copays and purchase OTC First Line Bismuth Subsalicylate and OTC Omeprazole Tetracycline Hydrochloride 500mg QID, Metronidazole 250mg QID, OTC Omeprazole 20mg BID, OTC Bismuth Subsalicylate 262.4mg 2T QID X14D Second Line Clarithromycin 500mg BID or Amoxicillin 500mg 2C BID, Metronidazole 250mg QID, OTC Omeprazole 20mg BID, OTC Bismuth Subsalicylate 262.4mg 2T QID X14D Quixin (Levofloxacin) 0.5% Ophthalmic Solution 1-2 1) Ofloxacin 0.3% Solution 1-2 GTTS QID 2) GTTS Q4H Ciprofloxacin 0.3% Solution 1-2 GTTS Q4HS NF 3) Sodium Sulfacetamide 10% Solution 1-3 GTTS Q23H 4) Gentamicin 0.3% Solution 1-2 GTTS QID 5) Erythromycin 0.5% Ointment APPLY RIBBON Q4H 6) Vigamox Solution 0.5% 1 GTT BID NF 7) Ciloxan 0.3% Ointment APPLY RIBBON BID-TID NF 8) Zymaxid 0.5% Solution 1 GTT QID Qutenza (Capsaicin) 8% Patch Apply up to 4 patches for 60 mintues every 3 months Ranexa (Ranolazine) 500, 1000mg Extended Release Tablet BID Rapaflo (Silodosin) 4, 8mg Capsule QD Razadyne (Galantamine) 4mg/ml Solution 3ml BID Rectiv (Nitroglycerin) 0.4% Ointment Apply intraanally Q12H Relpax (Eletriptan) 20, 40mg Tablet PRN Remeron Soltab (Mirtazapine) 15, 30, 45mg Orally Disintegrating Tablet QD 1) OTC LMX 4 (Lidocaine 4% Cream) AAA QID 2) OTC Axsain cream (Lidocaine 4%/Capsaicin 0.25% Cream) AAA QID 3) Lidocaine 2% Gel AAA QID 4) Lidocaine 5% Ointment AAA 5G QID 1) Atenolol 50-100mg QD 2) Nitroglycerin CR 6.5mg BID-TID 3) Isosorbide Mononitrate ER 30-60mg QD 4) Isosorbide Dinitrate 5-40mg TID 5) Metoprolol Tartrate 50-100mg BID 6) Verapamil SR 240mg QD 7) Diltiazem ER 240mg QD 8) Nifedipine ER 30690mg QD 1) Terazosin 1-10mg QD 2) Doxazosin 1-8mg QD 3) Tamsulosin 0.4mg QD 1) Galantamine 4-12mg BID, Galantamine ER 824mg QD 2) Namenda 5-10mg BID 3) Rivastigmine 6mg BID 4) Aricept 5-10mg QD 5) Exelon 2mg/ml Solution 3ml BID 6) Exelon 4.5-9.6mg/24hr Patch QD NF Nitroglycerin 0.2% Ointment Apply intra-anally Q12H Qutenza is only indicated for postherpetic neuralgia 1) Sumatriptan 25-100mg PRN 2) Sumatriptan 20mg Nasal Spray PRN 3) Naratriptan 1-2.5mg PRN 4) Sumatriptan 6mg/ml Subcutaneous Solution PRN 5) Maxalt MLT 5-10mg PRN NF 6) Zomig 5mg PRN NF 7) Zomig 2.5mg PRN NF Quantity Limit Maxalt MLT 5-10mg=9 Tablets Naratriptan 1-2.5mg=9 Tablets Relpax 20-40mg=6 Tablets Sumatriptan 25-100mg=9 Tablets Zomig 2.5mg=6 Tablets Zomig 5mg=3 Tablets Document adequate therapeutic trial or intolerance to 2 SSRIs and Venlafaxine 1) Citalopram 20-40mg QD 2) Fluoxetine 20-40mg QD 3) Sertraline 50-100mg QD 4) Mirtazapine 1545mg QHS 5) Bupropion SR/XL 300mg QD 6) Venlafaxine ER 225mg QD Page 47 Last Updated: 8/27/2012 Document adequate trial or intolerance to Beta Blocker (NOTE: If Beta Blocker allergy or contraindication consider Verapamil ER or Diltiazem ER) and Long-Acting Nitrate (NOTE: If patient is hypertensive consider Nifedipine ER) Document adequate therapeutic trial or intolerance to Galantamine, Aricept, Namenda, and Exelon Capsule or Solution KPGA Approved Compound Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Remicade (Infliximab) 100mg Intravenous Powder for Solution 5mg/kg Q8W 1) Humira 40mg QOW 2) Enbrel 50mg QW Renal Vitamins (Nephrocaps, Nephronex, Nephrotrans) QD Renova (Tretinoin) 0.02, 0.05% Cream AAA QHS Renvela (Sevelamer Carbonate) 0.8, 2.4gm/Packet Powder for Suspension 1 Packet with meals OTC Full Spectrum B with Vitamin C QD Requip XL (Ropinirole) 2, 4, 6, 8, 12mg Extended Release Tablet QD Restoril (Temazepam) 7.5, 22.5mg Capsule QHS Retin-A Micro (Tretinoin) 0.04, 0.1% Gel AAA QHS Revatio (Sildenafil) 20mg Tablet TID Revlimid (Lenalidomide) 5, 10, 15, 25mg Capsule QD Rhinocort Aqua (Budesonide) 0.032mg/Actuation Nasal Spray 2 SPRAYS IEN BID Riomet (Metformin) 500mg/5ml Solution QD-BID Ritalin LA (Methylphenidate) 10, 20, 30, 40mg Extended Release Capsule QAM Rozerem (Ramelteon) 8mg Tablet QHS Sabril (Vigabatrin) 500mg Tablet BID Salagen (Pilocarpine) 5mg Tablet TID-QID Samsca (Tolvaptan) 15, 30mg Tablet QD Sanctura (Trospium) 20mg Tablet BID Comments KP Dermatology, GI, or Rheumatology Contact CU Infusion Center 770-431-4367 or SW Infusion Center 770-603-3663 Network Dermatology, GI, or Rheumatology Contact Provider Relations 404-364-4934 Excluded Medication Available OTC Excluded Medication for patients > 36 YOA Retin-A 0.025-0.1% Cream, Gel AAA QHS 1) Phoslyra 667mg/5ml 15ml with meals 2) Eliphos 667mg 3C with meals 3) Renvela 800mg 3T with meals Parkinson's Disease 1) Carbidopa/Levodopa ER 25/100mg BID 2) Bromocriptine 2.5mg QD 3) Amantadine 100mg BID 4) Pramipexole 0.125-1.5mg TID 5) Ropinirole 2-8mg QD 6) Selegiline 5mg QD 7) Carbidopa/Levodopa/Entacapone 12.5/50/200mg TID 8) Ropinrole ER 2-12mg QD NF Restless Leg Syndrome 1) Pramipexole 0.125mg QHS 2) Ropinirole 0.25-4mg QHS Temazepam 15, 30mg QHS Retin-A 0.025-0.1% Cream, Gel AAA QHS Excluded Medication for patients > 36 YOA Pulmonary Hypertension 1) Viagra 50mg 0.5T TID 2) Cialis 20mg 2T QD 3) Adcirca 20mg 2T QD Prescribing Physician must call RevAssist Program 888-423-5436 Revlimid is delivered directly to patient via KP CA Specialty Pharmacy 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) OTC Allegra 60mg BID 4) Fluticasone 2 SPRAYS IEN QD 5) Flunisolide 2 SPRAYS IEN BID 6) Triamcinolone 2 SPRAYS IEN QD NF 7) Nasonex 2 SPRAYS IEN QD NF 8) Veramyst 2 SPRAYS IEN QD NF 9) Omnaris 2 SPRAYS IEN QD NF KP CA Specialty Pharmacy MD Line 650-301-5799 / Patient Line 1-877-4045777 / Fax Line 650-301-5790 Age Recommendations Fluticasone=4 years of age and older / Flunisolide=6 years of age and older / Triamcinolone=2 years of age and older / Nasonex=2 years of age and older / Veramyst=2 years of age and older / Omnaris=6 years of age and older / Rhinocort Aqua=6 years of age and older 1) Metformin 500-1000mg (Maximum 2550mg QD) 2) Adjust based on patient response Metformin ER 500-750mg (Maximum 2000mg QD) 1) Methylin 5-20mg BID-TID 2) Adderall 5-30mg QDBID 3) Methylin ER 10-20mg BID-TID 4) Dextroamphetamine CR 5-15mg QD-BID 5) Adderall XR 5-30mg QAM 6) Methylphenidate ER 18-72mg QAM 1) Trazodone 50-100mg QHS 2) Temazepam 1530mg QHS 3) Zolpidem 5-10mg QHS 4) Zaleplon 510mg QHS 5) Ambien CR 6.25-12.5mg QHS NF Precribing Physician must call SHARE Distribution Program 888-45-SHARE Sabril is delivered directly to patient via CuraScript Specialty Pharmacy Document adequate therapeutic trial or intolerance to at least 3 formulary alternatives Document adequate therapeutic trial or intolerance to Trazodone, Zolpidem, and at least 1 Benzodiazepine Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Pilocarpine 0.5, 1, 2, 3, 4, 6% Ophthalmic Solution 5- Ophthalmic Solution may be administered orally 10 GTTS PO TID 1) OTC Sodium Chloride 1gm QD 2) Demeclocycline Quantity Limit Samsca 15-30mg=10 Tablets 300mg BID-TID NF 1) Oxybutinin 5mg BID-TID 2) Oxybutynin XL 5-15mg QD 3) Oxytrol 3.9mg/day Patch Apply twice weekly Page 48 Last Updated: 8/27/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Sanctura XR (Trospium) 60mg Extended Release Capsule QD Sancuso (Granisetron) 3.1mg/24hr Transdermal Patch Apply 24-48 hours prior to chemotherapy Comments 1) Oxybutinin 5mg BID-TID 2) Oxybutynin XL 5-15mg QD 3) Oxytrol 3.9mg/day Patch Apply twice weekly 4) Trospium 20mg BID NF 5) Detrol LA 2-4mg QD NF 6) Toviaz 4-8mg QD NF 7) Enablex 7.5-15mg QD NF 8) Vesicare 5-10mg QD NF 1) Metoclopramide 1-2mg/kg 30 minutes prior to chemotherapy 2) Prochlorperazine 5-10mg Q6H 3) Dexamethasone 20mg 30 minutes prior to chemotherapy 4) Ondansetron 4-8mg 30 minutes prior to chemotherapy 5) Ondansetron 4-8mg ODT 30 minutes prior to chemotherapy 6) Transderm Scop 1.5mg Apply Q72H NF 7) Granisetron 2mg 1 hour prior to chemotherapy NF Sandostatin (Octreotide) 50, 100, 200, 500, 1000mcg/ml Injection Solution TID Document Acromegaly, Metastatic carcinoid tumor, or Vasoactive intestinal peptide secreting tumor Sandostatin LAR Depot (Octreotide) 10, 20, 30mg Intramuscular Powder for Suspension Q4W Octreotide 50mcg TID NF Santyl (Collagenase) 250U/gm Ointment AAA QD Urea 40% Cream AAA BID Document Acromegaly, Metastatic carcinoid tumor, or Vasoactive intestinal peptide secreting tumor Saphris (Asenapine) 5, 10mg Sublingual Tablet BID 1) Risperidone 4mg QD 2) Haloperidol 0.5-5mg BIDTID 3) Thiothixene 2mg TID 4) Quetiapine 400800mg QD 5) Ziprasidone 20-80mg BID 6) Olanzapine 10mg QD 7) Olanzapine ODT 10mg QD 8) Latuda 40-80mg QD NF 9) Abilify 10-15mg QD Sarafem (Fluoxetine) 10mg Capsule; 10, 15, 20mg 1) Citalopram 20-40mg QD 2) Fluoxetine 20-40mg Tablet QD QD 3) Sertraline 50-100mg QD 4) Mirtazapine 30mg QHS 5) Bupropion SR/XL 300mg QD 6) Venlafaxine ER 225mg QD 7) Fluvoxamine 50-300mg QD NF 8) Escitalopram 10-20mg QD NF 9) Paxil CR 12.537.5mg QD NF 10) Viibryd 10-40mg QD NF 11) Pristiq 50-100mg QD NF 12) Cymbalta 30-60mg BID NF Savella (Milnacipran) 12.5, 25, 50, 100mg Tablet 1) Amitriptyline* 50mg QHS 2) Nortriptyline* (<65 BID YOA: 25mg QHS / > 65 YOA: 10mg QHS) 3) Cyclobenzaprine* 10mg TID 4) Tramadol* 50mg BID Document adequate trial or intolerance to all formulary SSRIs Document adequate therapeutic trial or intolerance to 1 TCA*, Tramadol*, and Cyclobenzaprine *Not recommended in the elderly and not a required medication for patients over 65 years old Seasonale (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel x 84 days) Tablet QD 1) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD 2) Jolessa (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel x 84 days) QD NF 3) Quasense (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel x 84 days) QD NF Seasonique (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel x 84 days, 10mcg EE x 7 days) Tablet QD 1) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD 2) Jolessa (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel x 84 days) QD NF 3) Amethia Lo (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel x 84 days, 10mcg EE x 7 days) QD NF 4) Amethia (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel x 84 days, 10mcg EE x 7 days) QD NF 1) Citalopram 20-40mg QD 2) Fluoxetine 20-40mg QD 3) Sertraline 50-100mg QD 4) Mirtazapine 1545mg QHS 5) Bupropion SR/XL 300mg QD 6) Venlafaxine ER 225mg QD Serzone (Nefazodone) 50, 100, 150, 200, 250mg Tablet BID Page 49 Last Updated: 8/27/2012 Equivalent Brand and Generic Products Seasonale=Jolessa=Quasense Levora Dose Recommendation Day 1-84: Take 1 active tablet QD (Discard placebo tablets from first 3 packets) Day 85-91: Take 1 placebo tablet QD Equivalent Brand and Generic Products Seasonique=Amethia Levora Dose Recommendation Day 1-84: Take 1 active tablet QD (Discard placebo tablets from first 3 packets) Day 85-91: Take 1 placebo tablet QD Document adequate therapeutic trial or intolerance to 2 SSRIs and Venlafaxine Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Comments Silenor (Doxepin) 3, 6mg Tablet QHS 1) Trazodone 50-100mg QHS 2) Temazepam 1530mg QHS 3) Zolpidem 5-10mg QHS 4) Zaleplon 510mg QHS 5) Ambien CR 6.25-12.5mg QHS NF 6) Rozerem 8mg QHS NF 7) Lunesta 1-3mg QHS NF Document adequate therapeutic trial or intolerance to Trazodone, Zolpidem, and at least 1 Benzodiazepine Simponi (Golimumab) 50mg/0.5ml Subcutaneous Solution Q4W 1) Humira 40mg QOW 2) Enbrel 50mg QW 3) Remicade 5mg/kg Q8W NF Document adequate therapeutic trial or intolerance to Humira, Enbrel, and Remicade Remicade Infusion KP Rheumatology Contact CU Infusion Center 770-431-4367 or SW Infusion Center 770-603-3663 Network Rheumatology Contact Provider Relations 404-364-4934 Skelaxin (Metaxalone) 400, 800mg Tablet TID-QID 1) Cyclobenzaprine 10mg TID 2) Chlorzoxazone 250500mg TID 3) Carisoprodol 350mg TID 4) Tizanidine 4mg TID 5) Methocarbamol 500-750mg QID 6) Baclofen 10-20mg TID Solage (Mequinol/Tretinoin) 2/0.01% Cream AAA BID Solaquin Forte (Hydroquinone) 4% Cream AAA BID Excluded Medication Excluded Medication Solodyn (Minocycline) 45, 55, 65, 80, 90, 105, 115, 135mg Extended Release Tablet QD 1) Doxycycline Hyclate 50-100mg BID 2) Minocycline Dose Conversion Solodyn 45mg QD=Minocycline 50mg QD / Solodyn 50-100mg BID 3) Tetracycline 250-500mg BID 135mg=Minocycline 100mg QD Soma Compound (Carisoprodol/Aspirin) 200/325mg 2 Separate Medications Tablet QID OTC Aspirin 325mg TID-QID AND 1) Cyclobenzaprine 10mg TID 2) Chlorzoxazone 250500mg TID 3) Carisoprodol 350mg TID 4) Tizanidine 4mg TID 5) Methocarbamol 500-750mg QID 6) Baclofen 10-20mg TID Somatuline Depot (Lanreotide) 120/0.5, 90/0.3, Document Acromegaly, Metastatic carcinoid tumor, Octreotide 50mcg TID NF 60/0.2mg/ml Subcutaneous Solution Q4W or Vasoactive intestinal peptide secreting tumor Soriatane (Acitretin) 10, 17.5, 22.5, 25mg Capsule QD 1) Vectical 3mcg/gm (Calcitriol) AAA BID 2) Calcipotriene 0.005% Solution AAA QD-BID NF 3) Tazorac 0.05, 0.1% Cream, Gel AAA QHS NF 4) Calcipotriene 0.005% Ointment AAA QD-BID NF 5) Taclonex 0.005/0.064% Ointment, Suspension AAA QD NF OR Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID Spectazole (Econazole) 1% Cream AAA QD-BID 1) OTC Lamisil Ultra (Butenafine 1%) QD-BID 2) OTC Lotrimin AF (Clotrimazole 1%) BID 3) OTC Micatin (Miconazole 1%) BID 4) Ketoconazole 2% Cream QD Page 50 Last Updated: 8/27/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Sprix (Ketorolac) 15.75mg/Actuation Nasal Spray 1 SPRAY IEN Q6-8H Stadol (Butorphanol) 10mg/ml Nasal Spray 1 SPRAY IN 1 NOSTRIL Q3-4H PRN 1) Sumatriptan 25-100mg PRN 2) Sumatriptan 20mg Nasal Spray PRN 3) Naratriptan 1-2.5mg PRN 4) Sumatriptan 6mg/ml Subcutaneous Solution PRN 5) Maxalt MLT 5-10mg PRN NF 6) Zomig 5mg PRN NF 7) Zomig 2.5mg PRN NF 8) Relpax 20-40mg PRN NF 9) Axert 6.25-12.5mg PRN NF 10) Treximet 500/85mg PRN NF Quantity Limit Axert 6.25-12.5mg=6 Tablets Frova 2.5mg=9 Tablets Maxalt MLT 5-10mg=9 Tablets Naratriptan 1-2.5mg=9 Tablets Relpax 20-40mg=6 Tablets Sumatriptan 25-100mg=9 Tablets Treximet 500/85mg=9 Tablets Zomig 2.5mg=6 Tablets Zomig 5mg=3 Tablets Migraine Treatment Quantity Limit 1) Sumatriptan 25-100mg PRN 2) Sumatriptan 20mg Naratriptan 1-2.5mg=9 Tablets Sumatriptan 25-100mg=9 Tablets Nasal Spray PRN 3) Naratriptan 1-2.5mg PRN 4) Sumatriptan 6mg/ml Subcutaneous Solution PRN Pain 1) Oxycodone/Acetaminophen 5/325mg Q6H 2) Morphine 15-30mg Q4H 3) Hydromorphone 2-8mg Q4-6H 4) Oxycodone 5-30mg Q4-6H 5) Morphine Solution 20mg/ml 0.5-1.5ml Q4H 6) Meperidine 50150mg Q3-4H Starlix (Nateglinide) 60, 120mg Tablet TID 1) Glipizide 5-15mg QD 2) Glyburide 2.5-10mg QD Stavzor (Valproic Acid) 125, 250, 500mg Delayed Release Capsule BID-TID Epilepsy 1) Lamotrigine 100-200mg BID 2) Carbamazepine 800-1600mg QD 3) Topiramate 200mg BID 4) Phenytoin 100mg TID 5) Levetiracetam 500-1500mg BID 6) Gabapentin 300-600mg TID 7) Levetiracetam ER 1000mg QD 8) Divalproex 250-500mg TID Migraine Prophylaxis 1) Amitriptyline 10-25mg QHS 2) Propranolol 2040mg BID-TID 3) Topiramate 25-100mg QHS 4) Divalproex 250-1000mg BID 5) Propranolol ER 80mg QD NF 6) Divalproex ER 500-1000mg QD Staxyn (Vardenafil) 10mg Orally Disintegrating Tablet PRN Stelara (Ustekinumab) 90mg/ml, 45mg/0.5ml Subcutaneous Solution Q12W Strattera (Atomoxetine) 10, 18, 25, 40, 60, 80, 100mg Capsule QD Stromectol (Ivermectin) 3mg Tablet 3mg Single dose Suboxone (Buprenorphine/Naloxone) 2/0.5, 8/2mg Sublingual Film QD Comments 1) Humira 40mg QOW 2) Enbrel 50mg QW 3) Remicade 5mg/kg Q8W NF 1) Guanfacine 1-4mg QD 2) Methylin 5-20mg BIDTID 3) Adderall 5-30mg QD-BID 4) Methylin ER 1020mg BID-TID 5) Dextroamphetamine CR 5-15mg QD-BID 6) Adderall XR 5-30mg QAM 7) Methylphenidate ER 18-72mg QAM Scabies Permethrim 5% Cream Apply from head to toe, Wash off after 8-14 hours, Repeat application if live mites present 7 days after initial treatment Tissue Nematodes Albenza 400mg Single dose Buprenorpine/Naloxone 2/0.5-8/2mg QD Page 51 Last Updated: 8/27/2012 Adjust based on patient response Glipizide preferred if 65 years of age and older due to prolonged half life of Glyburide Excluded Medication (Exception: Sexual Dysfunction Rider) Document adequate therapeutic trial or intolerance to Humira, Enbrel, and Remicade Remicade Infusion KP Dermatology Contact CU Infusion Center 770-431-4367 or SW Infusion Center 770-603-3663 Network Dermatology Contact Provider Relations 404-364-4934 Document adequate therapeutic trial or intolerance to at least 3 formulary alternatives Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Sular (Nisoldipine) 8.5, 10, 17, 20, 25.5, 34, 40mg Extended Release Tablet QD 1) Amlodipine 5-10mg QD 2) Verapamil SR 180240mg BID 3) Diltiazem ER 240-360mg QD 4) Nifedipine ER 30-60mg QD 5) Felodipine 2.5-20mg QD Supartz (Hyaluronate Sodium) 25mg/2.5ml Injection Administered in a healthcare setting by healthcare Solution QW providers Suprax (Cefixime) 100mg/5ml, 200mg/5ml Powder for Suspension; 400mg Tablet QD 3rd Generation Sylatron (Peginterferon Alfa-2b) 296, 444, 888mcg Subcutaneous Powder for Solution 1.5mcg/kg QW Symbicort (Budesonide/Formoterol) 80/4.5, 160/4.5mcg Inhalation Aerosol Liquid 2 PUFFS BID Comments Dose Conversion Nislodipine 10mg=Nifedipine ER 30mg / Nislodipine 20mg=Nifedipine ER 60mg / Nislodipine 40mg=Nifedipine ER 90mg Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. 1) Cefdinir 125mg/5ml-250mg/5ml 7mg/kg BID 3rd Generation 2) Pediazole (Erythromycin Ethylsuccinate/Sulfisoxazole) 50mg/kg divided TIDQID 1) Pegasys 180mcg QW 2) PEG-Intron 150mcg QW 1) Qvar 40-80mcg 1-2 PUFFS QD-BID 2) Flovent HFA 44mcg 2 PUFFS BID NOTE: Flovent HFA 44mcg for patients 4-11 years of age 3) Asmanex 110-220mcg 1-2 PUFFS QD 4) Dulera 200/5mcg 2 PUFFS BID NF Document adequate trial or intolerance to Qvar 80mcg 2 PUFFS BID or Asmanex 220mcg 2 PUFFS QD within the past 3 months *Patients should have prescription for a ShortActing Beta 2 Agonist (e.g. Proair) for asthma exacerbations Dose Conversion Symbicort 80/4.5mcg 2 PUFFS BID=Albuterol Q4H PRN + Qvar 80mcg 1PUFF BID =Albuterol Q4H PRN + Flovent 44mcg 2 PUFFS BID Symbicort 160/4.5mcg 2 PUFFS BID=Albuterol Q4H PRN + Qvar 80mcg 2 PUFFS BID=Albuterol Q4H PRN + Asmanex 220mcg 2 PUFFS QD=Dulera 200/5mcg 2 PUFFS BID NF Symbyax (Fluoxetine/Olanzapine) 25/3, 25/6, 25/12, 2 Separate Medications 50/6, 50/12mg Capsule QD Fluoxetine 20-40mg QD AND Olanzapine 2.5-15mg QD Symlin (Pramlintide) 0.6mg/ml Subcutaneous DM1 Solution AC 1) Novolin R (Insulin Regular) SC 30 minutes AC 2) Novolin N (NPH) SC 15-30 minutes AC 3) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 4) NovoLog (Insulin Aspart) SC 5-10 minutes AC DM2 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin 500-1000mg (Maximum 2550mg QD) 3) Metformin ER 500-750mg (Maximum 2000mg QD) 4) Novolin R (Insulin Regular) SC 30 minutes AC 5) Novolin N (NPH) SC 15-30 minutes AC 6) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos 15mg (Maximum 45mg QD) Synagis (Palivizumab) 50/0.5, 100mg/ml Intramuscular Solution 15mg/kg QM Synalar (Fluocinolone) 0.01% Cream AAA BID-QID Low Potency Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Administered in a healthcare setting by healthcare Contact GW Synagis Clinic 770-931-6010 providers Low Potency 1) Betamethasone Valerate 0.1% Lotion AAA QD-BID 2) Desonide 0.05% Cream, Ointment AAA BID-TID 3) Fluocinolone Acetonide 0.01% Solution AAA QD 4) Derma-Smoothe/FS 0.01% Oil AAA QD Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BIDQID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Page 52 Last Updated: 8/27/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Comments Synalar (Fluocinolone Acetonide) 0.025% Cream AAA BID-QID Medium Potency Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BIDQID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BIDQID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID Synalar (Fluocinolone Acetonide) 0.025% Ointment Medium-High Potency AAA BID-QID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BIDQID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BIDQID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QDBID Synthroid (Levothyroxine) 0.025, 0.05, 0.075, 0.088, Levothroid 0.025-0.3mg QD Synthroid to Levothroid is a 1:1 Conversion 0.1, 0.112, 0.125, 0.137, 0.15, 0.175, 0.2, 0.3mg Tablet QD Synvisc (Hylan Polymers A and B) 8mg/ml Injection Administered in a healthcare setting by healthcare Criteria Restricted Medication Solution QW providers QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Taclonex (Calcipotriene/Betamethasone 2 Separate Medications Dipropionate) 0.005/0.064% 1) Vectical 3mcg/gm (Calcitriol) AAA BID 2) Ointment, Suspension AAA QD Very High Potency Calcipotriene 0.005% Solution AAA QD-BID NF 3) Tazorac 0.05, 0.1% Cream, Gel AAA QHS NF 4) Calcipotriene 0.005% Ointment AAA QD-BID NF AND Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID Talwin NX (Pentazocine/Naloxone) 50/0.5mg Tablet 1) Tramadol 50mg Q4-6H PRN 2) Q3-4H Hydrocodone/Acetaminophen 5/325mg Q4-6H 3) Codeine/APAP 15/300, 30/300, 60/300mg Q4H Tarceva (Erlotinib) 25, 100, 150mg Tablet QD 1) Platinum-based Chemotherapy 2) Docetaxel 75mg/m2 IV Q21D FDA approved for locally advanced or metastatic nonsmall cell lung cancer (NSCLC) failed at least one Chemotherapy Tarka (Trandolapril/Verapamil) 1/240, 2/180, 2/240, 2 Separate Medications Dose Conversion 4/240mg Tablet QD-BID Lisinopril QD AND Verapamil SR 180-240mg QD-BID Trandolapril 1mg=Lisinopril 10mg / Trandolapril 2mg=Lisinopril 20mg / Trandolapril 4mg=Lisinopril 40mg Tasigna (Nilotinib) 150, 200mg Capsule 400mg BID Sprycel 100-180mg QD Page 53 Last Updated: 8/27/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Comments Tazorac (Tazarotene) 0.05, 0.1% Cream, Gel AAA QHS Acne Excluded medication for patients > 36 YOA 1) Retin-A 0.025-0.1% Cream, Gel AAA QHS Psoriasis 1) Vectical 3mcg/gm (Calcitriol) AAA BID 2) Calcipotriene 0.005% Solution AAA QD-BID NF OR Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID Tegretol-XR (Carbamazepine) 100, 200, 400mg Extended Release Tablet BID Tekamlo (Aliskiren/Amlodipine) 150/5, 150/10, 300/5, 300/10mg Tablet QD Carbatrol 100, 200, 300mg BID Tegretol-XR to Carbatrol is a 1:1 Conversion 2 Separate Medications Amlodipine 5-10mg QD AND Renin-Angiotensin System/Diuretic 1) Lisinopril/HCTZ 10/12.5, 20/12.5, 20/25mg QD NOTE: If Angiotensin Converting Enzyme Inhibitor allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan/HCTZ 50/12.5, 100/12.5, 100/25mg QD Beta Blocker Metoprolol 100-450mg QD Renin-Angiotensin System/Diuretic 1) Lisinopril/HCTZ 10/12.5, 20/12.5, 20/25mg QD NOTE: If Angiotensin Converting Enzyme Inhibitor allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan/HCTZ 50/12.5, 100/12.5, 100/25mg QD Calcium Channel Blocker Amlodipine 5-10mg QD Beta Blocker Metoprolol 100-450mg QD Renin-Angiotensin System/Diuretic 1) Lisinopril/HCTZ 10/12.5, 20/12.5, 20/25mg QD NOTE: If Angiotensin Converting Enzyme Inhibitor allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan/HCTZ 50/12.5, 100/12.5, 100/25mg QD Calcium Channel Blocker Amlodipine 5-10mg QD Beta Blocker Metoprolol 100-450mg QD Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID Document adequate therapeutic trial or intolerance to maximum tolerated doses of at least 4 Blood Pressure medications Tekturna (Aliskiren) 150, 300mg Tablet QD Tekturna HCT (Aliskiren/HCTZ) 150/12.5, 150/25, 300/12.5, 300/25mg Tablet QD Temovate E (Clobetasol Propionate) 0.05% Emollient Cream AAA BID Ultra High Potency Tenex (Guanfacine) 1, 2mg Tablet QHS Guanfacine 1mg QHS Page 54 Last Updated: 8/27/2012 Document adequate therapeutic trial or intolerance to maximum tolerated doses of at least 3 Blood Pressure medications Document adequate therapeutic trial or intolerance to maximum tolerated doses of at least 4 Blood Pressure medications Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Terazol (Terconazole) 0.4, 0.8% Cream; 80mg Vaginal Suppository QHS 1) OTC Mycelex (Clotrimazole 1%) QHS 2) OTC Monistat (Miconazole) QHS 3) OTC Vagistat (Tioconazole 6.5%) QHS 4) Fluconazole 150mg QD Testim 1% (Testosterone) 50mg/5gm Gel Apply QAM 1) Testosterone Cypionate 200mg/ml IM Q2-4W 2) Androderm Patch 2-4mg/24hr Apply QPM 3) AndroGel Pump 1.62% Apply 2 pumps QAM NF 4) AndrogGel Pump 1% Apply 4 pumps QAM NF 5) AndroGel 1% (25mg/2.5gm-50mg/5gm) Apply QAM NF Levothroid QD Thyroid (Thyroid) 1/4(15mg), 1/2(30mg), 1(60mg), 1&1/2(90mg), 2(120mg), 3(180mg), 4(240mg), 5(300mg) Grain Tablet QD Comments Dose Conversion Thyroid 15mg=Levothroid 25mcg / Thyroid 30mg=Levothroid 50mcg / Thyroid 60mg =Levothroid 100mcg / Thyroid 90mg =Levothroid 150mcg / Thyroid 120mg =Levothroid 200mcg / Thyroid 180mg =Levothroid 300mcg / Thyroid 240mg =Levothroid 400mcg / Thyroid 300mg =Levothroid 500mcg Ticlid (Ticlopidine) 250mg Tablet BID (CVA/CABG) 1) Clopidogrel 75mg QD (CVA/CABG) 2) Aggrenox 25/200mg BID (CVA) Tikosyn (Dofetilide) 125, 250, 500mcg Capsule BID Prescribing Physician must call Tikosyn Education Distribution Program 877-TIKOSYN Timoptic-XE (Timolol) 0.25, 0.5% Ophthalmic Gel1) Timolol 0.25-0.5% 1 GTT QD-BID 2) Levobunolol Forming Solution 1 GTT QD 0.25-0.5% 1-2 GTT QD-BID 3) Betaxolol 0.5% 1-2 GTT BID Tindamax (Tinidazole) 250, 500mg Tablet 2gm Bacterial Vaginosis Single dose 1) Metronidazole 500mg BID X7D 2) Clindamycin 300mg BID X7D Giardiasis Metronidazole 250mg TID X5-7D Trichomoniasis Metronidazole 500mg BID X7D Tirosint (Levothyroxine) 13, 25, 50, 75, 88, 100, 112, Levothroid 0.025-0.15mg QD 125, 137, 150mcg Liquid Filled Capsule QAM TOBI (Tobramycin) 300mg/5ml Inhalation Solution BID TobraDex ST (Tobramycin/Dexamethasone) 0.3/0.05% Ophthalmic Suspension 1-2 GTTS Q4-6 HOURS Topamax (Topiramate) 15, 25mg Capsule; 25, 50, 100, 200mg Tablet QD-BID Tirosint to Levothroid is a 1:1 Conversion Document cystic fibrosis patient requiring treatment of Pseudomonas aeruginosa Tobramycin/Dexamethasone 0.3/0.1% 1-2 GTTS Q46 HOURS Epilepsy 1) Lamotrigine 100-200mg BID 2) Carbamazepine 800-1600mg QD 3) Topiramate 200mg BID 4) Phenytoin 100mg TID 5) Levetiracetam 500-1500mg BID 6) Gabapentin 300-600mg TID 7) Levetiracetam ER 1000mg QD 8) Divalproex 250-500mg TID Migraine Prophylaxis 1) Amitriptyline 10-25mg QHS 2) Propranolol 2040mg BID-TID 3) Topiramate 25-100mg QHS 4) Divalproex 250-1000mg BID 5) Propranolol ER 80mg QD NF 6) Divalproex ER 500-1000mg QD Page 55 Last Updated: 8/27/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Topicort (Desoximetasone) 0.05% Gel; 0.25% Cream, Ointment AAA BID Very High Potency Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID Topicort LP (Desoximetasone) 0.05% Cream AAA BID High Potency High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BIDQID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QDBID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg BID 3) Ibuprofen 400-800mg TID-QID 4) Sulindac 150-200mg BID 5) Etodolac 200-500mg BID-TID 6) Nabumetone 500-750mg BID 7) Lidocaine 5% Ointment AAA Q4H 1) Oxybutinin 5mg BID-TID 2) Oxybutynin XL 5-15mg QD 3) Oxytrol 3.9mg/day Patch Apply twice weekly 4) Trospium 20mg BID NF 5) Detrol LA 2-4mg QD NF Toradol (Ketorolac) 10mg Tablet Q4-6H X5D Toviaz (Fesoterodine) 4, 8mg Extended ReleaseTablet QD Tradjenta (Linagliptin) 5mg Tablet QD 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin 500-1000mg (Maximum 2550mg QD) 3) Metformin ER 500-750mg (Maximum 2000mg QD) 4) Novolin R (Insulin Regular) SC 30 minutes AC 5) Novolin N (NPH) SC 15-30 minutes AC 6) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos 15mg (Maximum 45mg QD) Comments Black Box Warning Ketorolac is only indicated for short-term (up to 5 days) management of moderatley severe acute pain. Ketorolac is not indicated for minor or chronic painful conditions. Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Transderm Scop (Scopolamine) 1.5mg Transdermal Vertigo Excluded Medication for Travel Patch Apply Q72H 1) OTC Benadryl (Diphenhydramine) 25-50mg Q4-6H 2) OTC Dramamine (Dimenhydrinate) 50mg Q4-6H 3) OTC Antivert (Meclizine) 25-50mg QD-QID 4) OTC Bonine (Cyclizine) 50mg Q4-6H 5) Clonazepam 0.5mg TID 6) Diazepam 5mg BID-QID 7) Lorazepam 1-2mg TID 8) Promethazine 25mg Q6H Sialorrhea 1) Benztropine 2mg TID-QID 2) Trihexphenidyl 2mg TID 3) Trihexphenidyl 0.4mg/ml NF 4) Glycopyrrolate 1mg TID-QID 5) Atrovent 1-2 PUFFS TID Tranxene-SD (Clorazepate) 11.25, 22.5mg Extended Release Tablet QD Travatan Z (Travoprost) 0.004% Ophthalmic Solution 1 GTT QPM 1) Clonazepam 0.25-0.5mg BID 2) Alprazolam 0.250.5mg TID 3) Diazepam 2-10mg BID-QID 4) Lorazepam 1mg BID-TID 5) Clorazepate 3.75-15mg TID 6) Chlordiazepoxide 5-10mg TID-QID 7) Oxazepam 10-15mg TID-QID 1) Latanoprost 0.005% 1 GTT QPM 2) Lumigan 0.010.03% 1 GTT QPM NF Page 56 Last Updated: 8/27/2012 Dose Conversion Tranxene-SD 11.25mg QD=Clorazepate 3.75mg TID / Tranxene-SD 22.5mg QD=Clorazepate 7.5mg TID Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Comments Treximet (Naproxen/Sumatriptan) 500/85mg Tablet PRN 2 Separate Medications Naproxen 500mg AND 1) Sumatriptan 25-100mg PRN 2) Sumatriptan 20mg Nasal Spray PRN 3) Naratriptan 1-2.5mg PRN 4) Sumatriptan 6mg/ml Subcutaneous Solution PRN 5) Maxalt MLT 5-10mg PRN NF 6) Zomig 5mg PRN NF 7) Zomig 2.5mg PRN NF 8) Relpax 20-40mg PRN NF 9) Axert 6.25-12.5mg PRN NF Triaz (Benzoyl Peroxide) 3, 6, 9% Gel; 6% Foaming Cloth; 3, 6, 9% Pad QD-BID Tribenzor (Amlodipine/Hydrochlorothiazide/Olmesartan) 5/12.5/20, 5/12.5/40, 10/12.5/40, 5/25/40, 10/25/40mg Tablet QD 1) OTC Benzoyl Peroxide 2.5-10% AAA QD 2) OTC Benzoyl Peroxide 5-10% Liquid AAA QD-BID 3 Separate Medications Amlodipine 5-10mg QD AND HCTZ QD AND 1) Lisinopril QD NOTE: If Angiotensin Converting Enzyme Inhibitor allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan QD Tricor (Fenofibrate) 48, 145, 160mg Tablet QD 1) Gemfibrozil 600mg BID 2) Fenofibrate 54-160mg QD Trileptal (Oxcarbazepine) 300mg/5ml Suspension; 150, 300, 600mg Tablet BID 1) Lamotrigine 100-200mg BID 2) Carbamazepine 800-1600mg QD 3) Topiramate 200mg BID 4) Phenytoin 100mg TID 5) Levetiracetam 500-1500mg BID 6) Zonisamide 100mg TID NF 7) Gabapentin 300600mg TID 8) Levetiracetam ER 1000mg QD 9) Oxcarbazepine 600mg BID NF 1) Gemfibrozil 600mg BID 2) Fenofibrate 54-160mg Dose Conversion QD Trilipix 45mg=Fenofibrate 54mg / Trilipix 135mg=Fenofibrate 160mg Fenofibric Acid is the active metabolite of Fenofibrate Fenofibrate preferred if current statin therapy Gemfibrozil preferred if reduced renal function Excluded Medication Trilipix (Fenofibric Acid) 45, 135mg Capsule QD Tri-Luma (Fluocinolone/Hydroquinone/Tretinoin) 0.01/4/0.05% Cream AAA BID Triphasil (30mcg Ethinyl Estradiol/0.05mg Levonorgestrel x 6 days, 40mcg EE/0.075mg LVNGL x 5 days, 30mcg EE/0.125mg LVNGL x 10 days) Tablet QD 1) Tri-Sprintec (35mcg Ethinyl Estradiol/0.18mg Norgestimate x 7 days, 35mcg EE/0.215mg NG x 7 days, 35mcg EE/0.25mg NGx 7 days) QD 2) Trivora (30mcg Ethinyl Estradiol/0.05mg Levonorgestrel x 6 days, 40mcg EE/0.075mg LVNGL x 5 days, 30mcg EE/0.125mg LVNGL x 10 days) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD 4) Leena (35mcg Ethinyl Estradiol/0.5mg Norethindrone x 7 days, 35mcg EE/1mg NE x 9 days, 35mcg EE/0.5mg NE x 5 days) QD Tussionex Pennkinetic (Hydrocodone 1) Cheratussin AC (Codeine/Guaifenesin) Bitartrate/Chlorpheniramine Maleate) 10mg/8mg/5ml 10mg/100mg/5ml Q4-6H PRN 2) Extended-Release Suspension Q12H Promethazine/Codeine 6.25mg/10mg/5ml Q4-6H PRN 3) Promethazine VC/Codeine (Promethazine/Codeine/Phenylephrine) 6.25mg/10mg/5mg/5ml Q4-6H PRN 4) Benzonatate 100-200mg TID PRN 5) Tussigon (Hydrocodone Bitartrate/Homatropine Methylbromide) 5/1.5mg Q46H PRN Tysabri (Natalizumab) 20mg/ml Solution 300mg Precribing Physician must call TOUCH Prescribing Q4W Program 800-456-2255 (Option 2) Tysabri is delivered directly to MD office via Tysabri Direct Administered in a healthcare setting by healthcare providers Page 57 Last Updated: 8/27/2012 Quantity Limit Axert 6.25-12.5mg=6 Tablets Maxalt MLT 5-10mg=9 Tablets Naratriptan 1-2.5mg=9 Tablets Relpax 20-40mg=6 Tablets Sumatriptan 25-100mg=9 Tablets Treximet 500/85mg=9 Tablets Zomig 2.5mg=6 Tablets Zomig 5mg=3 Tablets Excluded Medication Dose Conversion Benicar 20mg=Lisinopril 20mg=Losartan 50mg / Benicar 40mg=Lisinopril 40mg= Losartan 100mg NOTE: Consider Lisinopril/HCTZ 20/12.5mg or Losartan/HCTZ 50/12.5, 100/12.5, 100/25mg Dose Conversion Tricor 48mg=Fenofibrate 54mg / Tricor 145,160mg=Fenofibrate 160mg Fenofibrate preferred if current statin therapy Gemfibrozil preferred if reduced renal function Equivalent Brand and Generic Products Triphasil=Trivora Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy U-Cort (Hydrocortisone/Urea) 1/10% Cream AAA BID-QID Lowest Potency Comments Lowest Potency 1) OTC Hydrocortisone 0.5-1% Cream, Ointment AAA BID-QID 2) Hydrocortisone 2.5% Cream, Lotion, Ointment AAA BID-QID Low Potency 1) Betamethasone Valerate 0.1% Lotion AAA QD-BID 2) Desonide 0.05% Cream, Ointment AAA BID-TID 3) Fluocinolone Acetonide 0.01% Solution AAA QD 4) Derma-Smoothe/FS 0.01% Oil AAA QD Ulesfia (Benzyl Alcohol) 5% Lotion Apply to scalp, 1) OTC Nix (Permethrin 1%) 2) OTC Rid, Pronto Plus Apply to scalp, Leave on for 10 minutes, Rinse, Leave on for 10 minutes, Rinse, Repeat application (Pyrethrins 0.33%/Piperonyl Butoxide 4%) 3) OTC Repeat application if lice present 7 days after initial if lice present 7 days after initial treatment treatment Cetaphil Cleanser Lotion Uloric (Febuxostat) 40, 80mg Tablet QD Allopurinol 300mg BID Ultracet (Acetaminopen/Tramadol) 325/37.5mg Tablet Q4-6H PRN 2 Separate Medications OTC Aspirin 325mg Q4-6H PRN AND Tramadol 50mg Q4-6H PRN Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Ultra High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream, Gel, Lotion AAA QD-BID 2) Clobetasol Propionate 0.05% Cream, Gel, Ointment AAA BID 3) Clobetasol Propionate 0.05% Solution AAA BID Ultravate (Halobetasol Propionate) 0.05% Cream, Ointment AAA QD-BID Ultra High Potency Uniretic (Moexipril/HCTZ) 7.5/12.5, 15/25mg Tablet QD 2 Separate Medications HCTZ QD AND 1) Lisinopril 10-40mg QD 2) Benazepril 20-40mg QD 3) Enalapril 10-40mg QD 4) Captopril 25-100mg TID 5) Ramipril 2.5-20mg QD Document adequate therapeutic trial or intolerance to maximum tolerated dose of Allopurinol Dose Conversion Moexipril 7.5mg=Lisinopril 10mg / Moexipril 15mg=Lisinopril 20mg NOTE: Consider Lisinopril/HCTZ 10/12.5, 20/25mg Univasc (Moexipril) 7.5, 15mg Tablet QD 1) Lisinopril 10-40mg QD 2) Benazepril 20-40mg QD Dose Conversion 3) Enalapril 10-40mg QD 4) Captopril 25-100mg TID Moexipril 7.5mg=Lisinopril 10mg / Moexipril 15mg=Lisinopril 20mg 5) Ramipril 2.5-20mg QD Uroxatral (Alfuzosin) 10mg Extended Release Tablet 1) Terazosin 1-10mg QD 2) Doxazosin 1-8mg QD 3) QD Tamsulosin 0.4mg QD UTA (Methenamine Sodium, Phosphate Monobasic, 1) OTC Azo-Standard (Phenazopyridine) 95mg TID 2) Phenyl Salicylate, Methylene Blue, Hyoscyamine Hyoscyamine SL 0.125mg 1-2T Q4H 3) Hyoscyamine Sulfate) 120/40.8/36/10/0.12mg Capsule QID 0.125mg 1-2T Q4H 4) Hyoscyamine Solution 0.125mg/ml 5-10ml Q4H 5) Elmiron 100mg TID Valtrex (Valacyclovir) 1gm, 500mg Tablet QD-BID Valturna (Aliskiren/Valsartan) 150/160, 300/320mg Tablet QD Genital Herpes Episodic Treatment 1) Acyclovir 200mg Q4H 2) Acyclovir 400mg TID 3) Acyclovir 800mg BID Genital Herpes Suppressive Treatment Acyclovir 400mg BID Herpes Zoster Treatment Acyclovir 800mg Q4H Renin-Angiotensin System/Diuretic 1) Lisinopril/HCTZ 10/12.5, 20/12.5, 20/25mg QD NOTE: If Angiotensin Converting Enzyme Inhibitor allergy or contraindication consider Angiotensin Receptor Blocker 2) Losartan/HCTZ 50/12.5, 100/12.5, 100/25mg QD Calcium Channel Blocker Amlodipine 5-10mg QD Beta Blocker Metoprolol 100-450mg QD Page 58 Last Updated: 8/27/2012 Document adequate therapeutic trial or intolerance to maximum tolerated doses of at least 4 Blood Pressure medications Dose Conversion Diovan 80mg=Lisinopril 10mg=Losartan 25mg / Diovan 160mg=Lisinopril 20mg=Losartan 50mg / Diovan 320mg=Lisinopril 40mg=Losartan 100mg Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Vaniqa (Eflornithine) 13.9% Cream AAA BID Comments Excluded Medication Vanos (Flucinonide) 0.1% Cream AAA QD Ultra High Potency High Potency 1) Triamcinolone Acetonide 0.1% Ointment AAA BIDQID 2) Fluocinonide 0.05% Cream AAA BID-QID 3) Mometastone 0.1% Cream AAA QD 4) Betamethasone Dipropionate 0.05% Cream AAA QDBID Very High Potency 1) Betamethasone Dipropionate Augmented 0.05% Cream AAA QD-BID 2) Mometasone 0.1% Ointment AAA QD 3) Flucinonide 0.05% Gel, Ointment, Solution AAA BID-QID Vantin (Cefpodoxime) 50mg/5ml, 100mg/5ml 1) Cefdinir 125mg/5ml-250mg/5ml 7mg/kg BID 3rd Powder for Suspension; 100, 200mg Tablet BID 3rd Generation 2) Pediazole (Erythromycin Generation Ethylsuccinate/Sulfisoxazole) 50mg/kg divided TIDQID Vaseretic (Enalapril/HCTZ) 5/12.5, 10/25mg Tablet 2 Separate Medications QD Enalapril QD AND HCTZ QD Veltin (Clindamycin/Tretinoin) 1.2/0.025% Gel AAA 2 Separate Medications QHS Clindamycin 1% Gel AAA QHS AND Retin-A 0.025% Cream, Gel AAA QHS Ventolin HFA (Albuterol) 0.09mg Inhalation Aerosol Proair HFA (Albuterol) 0.09mg Inhalation Aerosol Powder Q4H PRN Powder Q4H PRN Veramyst (Fluticasone Furoate) 27.5mcg/Actuation 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) Nasal Spray 2 SPRAYS IEN QD OTC Allegra 60mg BID 4) Fluticasone 2 SPRAYS IEN QD 5) Flunisolide 2 SPRAYS IEN BID 6) Triamcinolone 2 SPRAYS IEN QD NF 7) Nasonex 2 SPRAYS IEN QD NF Verdeso (Desonide) 0.05% Foam AAA BID Low Potency Low Potency 1) Betamethasone Valerate 0.1% Lotion AAA QD-BID 2) Desonide 0.05% Cream, Ointment AAA BID-TID 3) Fluocinolone Acetonide 0.01% Solution AAA QD 4) Derma-Smoothe/FS 0.01% Oil AAA QD Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BIDQID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Veregen (Sinecatechins) 15% Ointment AAA TID X16W 1) Condylox 0.5% Gel AAA BID X3D 2) Imiquimod 5% Cream AAA three times a week X16W Verelan PM (Verapamil) 100, 200, 300mg Extended Verapamil SR QD-BID Release Capsule QHS Vesicare (Solifenacin) 5, 10mg Tablet QD Excluded Medication for patients > 36 YOA Ventolin HFA to Proair HFA is a 1:1 Conversion Age Recommendations Fluticasone=4 years of age and older / Flunisolide=6 years of age and older / Triamcinolone=2 years of age and older / Nasonex=2 years of age and older / Veramyst=2 years of age and older Document a) biopsy confirming external genical or perianal warts b) adequate trial or intolerance to Condylox Gel and Imiquimod Cream prior to approval one 16 week treatment Dose Conversion Verelan PM 100mg=Verapamil SR 120mg / Verelan PM 200mg=Verapamil SR 180mg / Verelan PM 300mg=Verapamil SR 240mg 1) Oxybutinin 5mg BID-TID 2) Oxybutynin XL 5-15mg QD 3) Oxytrol 3.9mg/day Patch Apply twice weekly 4) Trospium 20mg BID NF 5) Detrol LA 2-4mg QD NF 6) Toviaz 4-8mg QD NF 7) Enablex 7.5-15mg QD NF Vexol (Rimexolone) 1% Ophthalmic Suspension 1-2 1) Prednisolone 1% 1-2 GTTS BID-QID 2) GTT QID Fluorometholone 0.1% 1-2 GTTS BID-QID 3) Dexamethasone 0.1% 1-2 GTTS BID-QID Vfend (Voriconazole) 40mg/ml Powder for 1) Fluconazole 50-200mg QD 2) Itraconazole 100mg Suspension; 50, 200mg Tablet BID QD-BID 3) Sporanox 10mg/ml QD-BID Viagra (Sildenafil) 25, 50, 100mg Tablet PRN Excluded Medication (Exception: Sexual Dysfunction Rider) Page 59 Last Updated: 8/27/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Vicoprofen (Hydrocodone/Ibuprofen) 7.5/200mg Tablet Q4-6H PRN Comments 1) Tramadol 50mg Q4-6H PRN 2) Hydrocodone/Acetaminophen 7.5/325mg Q6H 3) Oxycodone/Acetaminophen 5/325mg Q6H 4) Morphine 15-30mg Q4H 5) Oxycodone 5-30mg Q46H Victoza (Liraglutide) 6mg/ml Subcutaneous Solution 1) Glipizide 10mg (Maximum 40mg QD) 2) Metformin QD 500-1000mg (Maximum 2550mg QD) 3) Metformin ER 500-750mg (Maximum 2000mg QD) 4) Novolin R (Insulin Regular) SC 30 minutes AC 5) Novolin N (NPH) SC 15-30 minutes AC 6) Novolin 70/30 (NPH/Insulin Regular) SC 30 minutes AC 7) NovoLog (Insulin Aspart) SC 5-10 minutes AC NF 8) Actos 15mg (Maximum 45mg QD) Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Victrelis (Boceprevir) 200mg Capsule 4T TID No initial fill Document a) chronic Hepatitis C genotype 1 b) prescription from Gastroenterologist or Infectious Disease Specialist c) compensated liver disease d) completion of 4 week lead-in with Interferon Alfa and Ribavirin 2 Separate Medications Peg-Intron 1.5mcg/kg QW AND Ribavirin 8001400mg QD Vigamox (Moxifloxacin) 0.5% Ophthalmic Solution 1 1) Ofloxacin 0.3% Solution 1-2 GTTS QID 2) GTT BID Ciprofloxacin 0.3% Solution 1-2 GTTS Q4HS NF 3) Sodium Sulfacetamide 10% Solution 1-3 GTTS Q23H 4) Gentamicin 0.3% Solution 1-2 GTTS QID 5) Erythromycin 0.5% Ointment APPLY RIBBON Q4H Viibryd (Vilazodone) 10, 20, 40mg Tablet QD Vimovo (Esomeprazole/Naproxen) 20/375, 20/500mg Delayed Release Tablet BID Vimpat (Lacosamide) 50, 100, 150, 200mg Tablet BID Viquin Forte (Hydroquinone/Sunscreen) 4% Cream AAA BID Viramune XR (Nevirapine) 400mg Extended Release Tablet QD Vistaril (Hydroxyzine Pamoate) 25, 50, 100mg Capsule; 25mg/5ml Suspension TID-QID Vivactil (Protriptyline) 5, 10mg Tablet TID-QID Document adequate therapeutic trial or intolerance 1) Citalopram 20-40mg QD 2) Fluoxetine 20-40mg QD 3) Sertraline 50-100mg QD 4) Mirtazapine 30mg to 2 SSRIs and Venlafaxine QHS 5) Bupropion SR/XL 300mg QD 6) Venlafaxine ER 225mg QD 7) Fluvoxamine 50-300mg QD NF 8) Escitalopram 10-20mg QD NF 9) Paxil CR 12.537.5mg QD NF 2 Separate Medications Excluded Medication Naproxen 375-500mg BID AND 1) Pantoprazole 40mg QD 2) OTC Omeprazole 20mg QD 3) OTC Zegerid 20/1100mg QD 4) OTC Prevacid 15mg QD 1) Lamotrigine 100-200mg BID 2) Carbamazepine 800-1600mg QD 3) Topiramate 200mg BID 4) Phenytoin 100mg TID 5) Levetiracetam 500-1500mg BID 6) Zonisamide 100mg TID NF 7) Gabapentin 300600mg TID 8) Levetiracetam ER 1000mg QD 9) Oxcarbazepine 600mg BID NF 10) Divalproex 250500mg TID 11) Lyrica 50-200mg TID NF Excluded Medication 1) Nevirapine 200mg BID 2) Viramune 50mg/5ml 20ml BID Vistaril to Hydroxyzine HCl is a 1:1 Conversion 1) Hydroxyzine HCl 10, 25, 50mg TID-QID 2) Hydroxyzine HCl 10mg/5ml Syrup TID-QID 1) Amitriptyline 50-100mg QHS 2) Nortriptyline 25mg TID 3) Imipramine 75mg QHS 4) Clomipramine 25mg TID 5) Desipramine 100-200mg QD Page 60 Last Updated: 8/27/2012 Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Comments Vivelle-DOT (Estradiol) 0.025, 0.0375, 0.05, 0.075, 0.1mg/24hr Transdermal Patch Apply twice weekly Vasomotor Symtoms 1) Estradiol QD 2) Climara Patch 0.025-0.1mg/24hr Apply weekly Vaginal/Vulvar Atrophy 1) Estradiol QD 2) Climara Patch 0.025-0.1mg/24hr Apply weekly 3) Premarin Vaginal 1gm Apply three times a week 4) Vagifem 10mcg Insert twice weekly 5) Estring 2mg Insert for 90 days Adjust to the lowest dose needed to control symptoms based on patient response Voltaren Gel (Diclofenac Sodium) 1% Gel AAA 24gm QID 1) OTC Aspercreme AAA BID-QID 2) Meloxicam 7.515mg QD 3) Naproxen 250-550mg BID 4) Ibuprofen 400-800mg TID-QID 5) Sulindac 150-200mg BID 6) Etodolac 200-500mg BID-TID 7) Nabumetone 500750mg BID 8) Lidocaine 5% Ointment AAA Q4H 9) Diclofenac 25-100mg BID-TID Lower Extremity Application Voltaren Gel 1% AAA 4gm QID Upper Extremity Application Voltaren Gel 1% AAA 2gm QID Votrient (Pazopanib) 200mg Tablet 4T QD 1) Torisel 25mg IV QW 2) Sutent 50mg QD NOTE: 4 Sutent preferred when initiating therapy weeks on then 2 weeks off FDA approved for treatment of advanced renal cell cancer (RCC) 1) Zavesca 100mg TID NF 2) Cerezyme 60U/kg Q2W NF 3) Ceredase 60 U/kg Q2W NF VPRIV (Velaglucerase Alfa) 400U Powder for Solution 60U/kg QOW Vytorin (Ezetimibe/Simvastatin) 10/10, 10/20, 10/40mg, 10/80mg Tablet QD 2 Separate Medications OTC Slo-Niacin 500mg QD (Titrate to 2000mg/day as tolerated using .PITTTSLONIACIN) AND 1) Simvastatin 10-40mg QD 2) Pravastatin 20-80mg QD 3) Atorvastatin 10-80mg QD Vyvanse (Lisdexamfetamine) 20, 30, 40, 50, 60, 1) Methylin 5-20mg BID-TID 2) Adderall 5-30mg QD70mg Capsule QD BID 3) Methylin ER 10-20mg BID-TID 4) Dextroamphetamine CR 5-15mg QD-BID 5) Adderall XR 5-30mg QAM 6) Methylphenidate ER 18-72mg QAM Welchol (Colesevelam) 3.75gm Powder for 1) Cholestyramine 4gm 8-16gm QD 2) Suspension QD; 625mg Tablet 3T BID Cholestyramine Light 4gm 8-16gm QD 3) Colestipol 1gm 2-16gm QD Westcort (Hydrocortisone Valerate) 0.2% Cream, Medium Potency Ointment BID-TID Medium Potency 1) Triamcinolone Acetonide 0.1% Lotion AAA BIDQID 2) Betamethasone Valerate 0.1% Cream AAA QD-BID Medium-High Potency 1) Triamcinolone Acetonide 0.1% Cream AAA BIDQID 2) Betamethasone Valerate 0.1% Ointment AAA QD-BID Xalatan (Latanoprost) 0.005% Ophthalmic Solution 1 1) Latanoprost 0.005% 1 GTT QPM 2) Lumigan 0.01GTT QPM 0.03% 1 GTT QPM NF 3) Travatan Z 0.004% 1 GTT QPM NF Xanax XR (Alprazolam) 0.5, 1, 2, 3mg Extended 1) Clonazepam 0.25-0.5mg BID 2) Alprazolam 0.25Release Tablet QAM 0.5mg TID 3) Diazepam 2-10mg BID-QID 4) Lorazepam 1mg BID-TID 5) Clorazepate 3.75-15mg TID 6) Chlordiazepoxide 5-10mg TID-QID 7) Oxazepam 10-15mg TID-QID Xarelto (Rivaroxaban) 10, 15, 20mg Tablet QD Hip or Knee Replacement Enoxaparin 40mg QD or 30mg BID Atrial Fibrillation 1) Warfarin 1-10mg QD (Tiitrate to target INR) 2) Pradaxa 150mg BID NF Page 61 Last Updated: 8/27/2012 NOTE: Zetia 5mg (25.8%) is expected to give the same LDL reduction as 10mg (26%) Document adequate therapeutic trial or intolerance to at least 3 formulary alternatives Dose Conversion Xanax XR 0.5mg QAM=Alprazolam 0.25mg BID / Xanax XR 1mg QAM=Alprazolam 0.25mg QID / Xanax XR 2mg QAM=Alprazolam 0.5mg QID / Xanax XR 3mg=Alprazolam 1mg TID Quantity Limit Xarelto 10mg (30 Day Supply)=35 Tablets No initial fill of Xarelto 15, 20mg Document a) Irreversible atrial fibrillation If CHADS2 Score=1 b) Identified as an anticoagulation candidate (not ASA) c) Uninterrupted Warfarin therapy for at least 22 weeks If CHADS2 Scoreā„2 b) Uninterrupted Warfarin therapy for at least 22 weeks Arixtra preferred if history of Heparin-Induced Thrombocytopenia (HIT) Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Xenazine (Tetrabenazine) 12.5, 25mg Tablet BIDTID Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Excluded Medication (Exception: Obesity Rider) Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Xenical (Orlistat) 120mg Capsule TID Xgeva (Denosumab) 120/1.7mg/ml Subcutaneous Solution Q4W Xiaflex (Collagenase, Clostridium histolyticum) 0.9mg Powder for Solution Q4W Xibrom (Bromfenac) 0.09% Ophthalmic Solution 1 GTT BID Xifaxan (Rifaximin) 200, 550mg Tablet BID-TID Xolair (Omalizumab) 150mg Subcutaneous Powder for Solution Q2-4W Comments 1) Diclofenac 0.1% 1GTT QID 2) Ketorolac 0.5% 1 GTT QID 3) Prednisolone 1% 1-2 GTTS BID-QID 4) Fluorometholone 0.1% 1-2 GTTS BID-QID 5) Dexamethasone 0.1% 1-2 GTTS BID-QID 6) Ketorolac 0.4% 1 GTT QID 7) Flurbiprofen 0.03% 1 GTT QID NF 8) Vexol 1% 1-2 GTT QID NF 9) Bromfenac 0.09% 1 GTT QD-BID NF Hepatic Encephalopathy Lactulose 10gm/15ml Solution 30-45ml TID-QID Traveler's Diarrhea Ciprofloxacin 500mg BID Xolair is delivered directly to MD office via CuraScript Specialty Pharmacy Administered in a healthcare setting by healthcare providers Hepatic Encephalopathy Xifaxan 550mg BID Traveler's Diarrhea Xifaxan 200mg TID X3D Criteria Restricted Medication QRM approval required prior to being dispensed for Commercial, Multi-Choice, Self-Funded, and Triple Tier members. Provider must call 404-364-7320 (Option 2) to initiate review by QRM department. Xopenex (Levalbuterol Hydrochloride) 0.31mg/3ml, 0.63mg/3ml, 1.25mg/3ml Inhalation Solution Q4H PRN 1) Albuterol 0.5% Inhalation Solution Q4H PRN 2) Albuterol 0.083% Inhalation Solution Q4H PRN 3) Proair HFA (Albuterol) 0.09mg Inhalation Aerosol Powder Q4H PRN 4) Xopenex HFA Q4H PRN NF Xopenex HFA (Levalbuterol Tartrate) 0.045mg Proair HFA (Albuterol) 0.09mg Inhalation Aerosol Inhalation Aerosol Powder Q4H PRN Powder Q4H PRN Xyzal (Levocetirizine) 5mg Tablet, 0.5mg/ml Solution 1) OTC Claritin 10mg QD 2) OTC Zyrtec 10mg QD 3) Excluded Medication QPM OTC Allegra 60mg BID 4) Fluticasone 2 SPRAYS IEN QD 5) Flunisolide 2 SPRAYS IEN BID Yasmin (30mcg Ethinyl Estradiol/3mg Drospirenone) 1) Reclipsen (30mcg Ethinyl Estradiol/0.15mg Document adequate therapeutic trial or intolerance Tablet QD to at least 3 formulary oral contraceptives Desogestrel) QD 2) Microgestin Fe 1.5/30 (30mcg Ethinyl Estradiol/1.5mg Norethindrone) QD 3) Levora (30mcg Ethinyl Estradiol/0.15mg Levonorgestrel) QD Yaz (20mcg Ethinyl Estradiol/3mg Drospirenone) Tablet QD 1) Reclipsen (30mcg Ethinyl Estradiol/0.15 Desogestrel) QD 2) Microgestin Fe 1/20 (20mcg Ethinyl Estradiol/1mg Norethindrone) QD 3) Aviane (20mcg Ethinyl Estradiol/0.1mg Levonorgestrel) QD Zanaflex (Tizanidine) 2mg Tablet TID 1) Cyclobenzaprine 10mg TID 2) Chlorzoxazone 250500mg TID 3) Carisoprodol 350mg TID 4) Tizanidine 4mg 0.5T TID 5) Methocarbamol 500-750mg QID 6) Baclofen 10-20mg TID Page 62 Last Updated: 8/27/2012 Document adequate therapeutic trial or intolerance to at least 3 formulary oral contraceptives Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Zantac 300 (Ranitidine) 300mg Tablet QD Zegerid (Omeprazole/Sodium Bicarbonate) 40/1100mg Capsule; 20/1680, 40/1680mg Packet QD Zelapar (Selegiline) 1.25mg Orally Disintegrating Tablet QD Zelboraf (Vemurafenib) 240mg Tablet 4T BID Zemplar (Paricalcitol) 1, 2, 4mcg Capsule QD Zetia (Ezetimibe) 10mg Tablet QD Comments 1) OTC Famotidine 10-20mg QD-BID 2) OTC Excluded Medication Ranitidine 75-150mg QD-BID 3) Cimetidine 400800mg QD-BID 1) Pantoprazole 40mg QD 2) OTC Omeprazole 20mg Excluded Medication QD 3) Omeprazole 2mg/ml Liquid 10ml QD 4) Lansoprazole 3mg/ml Liquid 10ml QD 5) OTC Zegerid 20/1100mg QD 6) OTC Prevacid 15mg QD 1) Carbidopa/Levodopa ER 25/100mg BID 2) Bromocriptine 2.5mg QD 3) Amantadine 100mg BID 4) Pramipexole 0.125-1.5mg TID 5) Ropinirole 2-8mg QD 6) Selegiline 5mg QD 7) Carbidopa/Levodopa/Entacapone 12.5/50/200mg TID 8) Ropinrole ER 2-12mg QD NF FDA approved for treatment of unresectable, Stage IIIC or metastatic, BRAF V6003 mutation positive malignant melanoma Calcitriol 0.25-1mcg QD Adjunctive Therapy NOTE: Zetia 5mg (25.8%) is expected to give the 1) OTC Slo-Niacin 500mg QD (Titrate to 2000mg/day same LDL reduction as 10mg (26%) as tolerated using .PITTTSLONIACIN) 2) Cholestyramine 4gm 8-16gm QD 3) Cholestyramine Light 4gm 8-16gm QD 4) Colestipol 1gm 2-16gm QD Monotherapy 1) Simvastatin 5-40mg QD 2) Pravastatin 10-80mg QD 3) Atorvastatin 10-80mg QD Ziana (Clindamycin/Tretinoin) 1.2/0.025% Gel AAA QHS 2 Separate Medications Clindamycin 1% Gel AAA QHS AND Retin-A 0.025% Cream, Gel AAA QHS Zipsor (Diclofenac Potassium) 25mg Liquid Filled 1) Meloxicam 7.5-15mg QD 2) Naproxen 250-550mg Capsule 2C BID-TID BID 3) Ibuprofen 400-800mg TID-QID 4) Sulindac 150-200mg BID 5) Etodolac 200-500mg BID-TID 6) Nabumetone 500-750mg BID 7) Lidocaine 5% Ointment AAA Q4H 8) Diclofenac 25-100mg BID-TID 9) Indomethacin 25-75mg QD-BID 10) Tolmetin 200600mg TID Zirgan (Ganciclovir) 0.15% Ophthalmic Gel 1 GTT 5 Trifluridine 1% 1 GTT Q2H until healed then 1 GTT times daily until healed then 1 GTT TID X7D Q4H X7D Zofran (Ondansetron) 4mg/5ml Solution 30 minutes 1) Ondansetron 4-8mg 30 minutes prior to prior to chemotherapy chemotherapy 2) Ondansetron 4-8mg ODT 30 minutes prior to chemotherapy Zomig (Zolmitriptan) 5mg Nasal Spray; 2.5, 5mg 1) Sumatriptan 25-100mg PRN 2) Sumatriptan 20mg Tablet PRN Nasal Spray PRN 3) Naratriptan 1-2.5mg PRN 4) Sumatriptan 6mg/ml Subcutaneous Solution PRN 5) Maxalt MLT 5-10mg PRN NF Zonegran (Zonisamide) 25, 50, 100mg Capsule QD 1) Lamotrigine 100-200mg BID 2) Carbamazepine 800-1600mg QD 3) Topiramate 200mg BID 4) Phenytoin 100mg TID 5) Levetiracetam 500-1500mg BID 6) Zonisamide 100mg TID NF Zovirax (Acyclovir) 5% Ointment AAA Q4H 1) OTC Abreva 10% Cream AAA Q4H 2) Acyclovir 400mg BID Zyban (Bupropion) 150mg Extended Release Tablet 1) OTC Nicoderm 7, 14, 21mg/day Patch Apply QD 2) BID OTC Nicorette 2, 4mg Gum Chew 3-24 QD 3) Bupropion SR 150mg QD-BID Zyflo CR (Zileuton) 600mg Extended Release Tablet 1) Montelukast 10mg QHS 2) Qvar 40-80mcg 1-2 2T BID PUFFS QD-BID 3) Flovent HFA 44mcg 2 PUFFS BID NOTE: Flovent HFA 44mcg for patients 4-11 years of age 4) Zafirlukast 10-20mg BID NF 5) Asmanex 110220mcg 1-2 PUFFS QD 6) Budesonide 0.250.5mg/2ml QD-BID Page 63 Last Updated: 8/27/2012 Excluded Medication for patients > 36 YOA Quantity Limit Maxalt MLT 5-10mg=9 Tablets Naratriptan 1-2.5mg=9 Tablets Sumatriptan 25-100mg=9 Tablets Zomig 2.5mg=6 Tablets Zomig 5mg=3 Tablets Document adequate therapeutic trial or intolerance to Montelukast, Zafirlukast, and an Inhaled Corticosteroid within the past 3 months *Patients should have prescription for a ShortActing Beta 2 Agonist (e.g. Proair) for asthma exacerbations Kaiser Permanente NF, Restricted Formulary and Criteria Restricted Medication Conversion List Non-Formulary, Restricted Formulary, NF No Formulary Alternative(s) Initial Fill & Criteria Restricted Medications NOTE: Options are numbered in the order of (CRMs require QRM review) cost efficacy Zylet (Loteprednol/Tobramycin) 0.5/0.3% Ophthalmic Suspension 1-2 GTT Q4-6H Zytiga (Abiraterone Acetate) 250mg Tablet 4T QD zzUpdated: January 7, 2011 zzUpdated: February 15, 2011 zzUpdated: April 12, 2011 zzUpdated: June 10, 2011 zzUpdated: June 23, 2011 zzUpdated: August 19, 2011 zzUpdated: October 20, 2011 zzUpdated: December 21, 2011 zzUpdated: February 20, 2012 zzUpdated: April 24, 2012 zzUpdated: June 20, 2012 zzUpdated: August 17, 2012 Comments 2 Separate Medications NOTE: Consider Tobramycin/Dexamethasone 0.3/0.1% 1-2 GTTS Q4-6 HOURS Tobramycin 0.3% 1-2 GTT Q4H AND 1) Diclofenac 0.1% 1GTT QID 2) Ketorolac 0.5% 1 GTT QID 3) Prednisolone 1% 1-2 GTTS BID-QID 4) Fluorometholone 0.1% 1-2 GTTS BID-QID 5) Dexamethasone 0.1% 1-2 GTTS BID-QID 6) Ketorolac 0.4% 1 GTT QID 7) Flurbiprofen 0.03% 1 GTT QID NF 8) Vexol 1% 1-2 GTT QID NF 9) Bromfenac 0.09% 1 GTT QD-BID NF 10) Lotemax 0.5% 1-2 GTT QID NF 11) Nevanac 0.1% 1 GTT TID NF Docetaxel-based Chemotherapy FDA approved for treatment of castration-resistant metastatic prostate cancer who have failed Docetaxel-based Chemotherapy Diana Diaz, Pharm.D. Diana Diaz, Pharm.D. Diana Diaz, Pharm.D. Diana Diaz, Pharm.D. Diana Diaz, Pharm.D. Diana Diaz, Pharm.D. Diana Diaz, Pharm.D. Diana Diaz, Pharm.D. Diana Diaz, Pharm.D. Christine Lord, PharmD Diana Diaz, Pharm.D. Diana Diaz, Pharm.D. Page 64 Last Updated: 8/27/2012
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