Kaiser Permanente Georgia 1

u Formulary additions . . . . . .1

ISSUE 2 VOLUME 7 APRIL 2013

FormularyUpdate

u new standing order . . . . . 2

u medications reviewed at P&t, But not added to the

Formulary . . . . . . . . . . . . 3

Ipratropium bromide (generic Atrovent) 0.03% nasal spray is currently available on the National Medicare Part D (MPD) Formulary as Tier 2, generic, and was added to the Commercial Formulary effective April 18, 2013. Ipratropium bromide 0.03% nasal spray, an anticholinergic agent, is indicated for the symptomatic relief of rhinorrhea associated with allergic perennial rhinitis and nonallergic perennial rhinitis. Ipratropium 0.03% nasal spray provides an alternative therapy for the treatment of rhinorrhea associated with allergic and nonallergic perennial rhinitis for patients who have inadequate control of rhinorrhea on conventional therapy. Ipratropium bromide provides an alternative therapy for the treatment of rhinorrhea associated with allergic and nonallergic perennial rhinitis for patients who have inadequate control of rhinorrhea on conventional therapy. Inhaled corticosteroids, flunisolide (generic Nasarel) or fluticasone (generic Flonase), remain the first line option with greatest efficacy in managing rhinitis.

Ambrisenten (Letairis) 5 mg and 10 mg tablets are currently available on the National MPD Formulary as Tier 5, specialty, and were added to the Commercial Formulary effective April 18, 2013. Ambrisentan is an oral endothelin receptor antagonist FDA-approved for the

treatment of pulmonary arterial hypertension (PAH) in patients with WHO Group 1 PAH with Functional Class II or III disease to improve exercise capacity and delay clinical worsening. Due the serious risk of birth defects with ambrisentan, it is only available to prescribers and patients enrolled in the Letairis Education and Access Program [LEAP]. The KP Specialty Pharmacy (KPSP) is an authorized pharmacy for LEAP and helps to coordinate prescriber and patient enrollment. Prescriptions dispensed through KPSP can be seen in the KP electronic medical record. Letairis shoud be considered after therapy with sildenafil (generic Revatio).

Ethinyl estradiol and norgestrel (generic Cryselle) 0.03 mg/0.3 mg tablets are currently available on the National MPD Formulary as Tier 2, generic, and were added to the Commercial Formulary effective April 18, 2013. Cryselle is a monophasic prescription estrogen and progestin combination oral contraceptive indicated for the prevention of pregnancy. The safety and efficacy

u national medicare Part d Formulary . . . . . . . . . . . . . . 2

Formulary Additions

A PUBL ICAT ION OF THE GEORGIA PHARMACY AND THERAPEUT ICS (P&T) COMMITTEE . The Formulary Update contains information regarding formulary additions, deletions, exclusions, brief descriptions of products, and current drug related news. It also lists items to be discussed at upcoming P&T meetings. Please refer to the web site http://kpnet.kp.org:81/ga/healthcare/formularies.html or providers.kp.org for the full KP GA Drug Formulary. If you have Lexi-Comp PDA access to the KPGA Online Formulary, remember to sync your device for the most current information.

u Quantity limits . . . . . . . . . 3 u Floorstock additions . . . . . 3

u clinical uPdate . . . . . . . . . 3

u aPPendix a: dePartment Floorstock list additions . . . 4 u aPPendix B: Quantity limits . 6

2 Kaiser Permanente Georgia

uPcoming Formulary decisions

An important aspect of the formulary process is the involvement of all practitioners. So that each of you has an opportunity to participate in the process, upcoming P&T agenda items are listed below. Please contact your P&T Committee representative or your clinical service chief by May 15, 2013 if you wish to comment on any of the medications, class reviews, or other agenda items under consideration. To make formulary addition requests, you must submit a Formulary Additions/Deletions Form and Conflict of Interest Form to Drug Information Services or call (404) 949-5331.

Formulary Reviews (June 2013):

medication class reviews

Dermatological

Penicillins

Cephalosporins

Macrolides

Tetracyclines

Floroquinolones

Aminoglycosides

Gastrointestinal Agents, Misc

Sulfonamides

Anitmycobacterial

Antifungals

Antivirals

Antimalarials

Amebicides

Anthelmintics

Anti-Infectives-Misc.

Approved standing orders are written instructions issued by medical practitioners, in ac-cordance with the regulations, authorizing pharmacy personnel at pharmacies owned or operated by Kaiser Foundation Health Plan to supply and administer specified medica-tions under circumstances specified in the order. Asacol/Asacol HD to Lialda: Mesalamine delayed-release 400 mg tablets (Asacol) have been discontinued by the manufacturer because the product contins pthalate. Lialda con-tains the same active ingredients as Asacol and does not contain phthalate. In response to the change in the market, a standing order has been approved for the conversion of Asacol to Lialda. Patients should be counseled to take Lialda once daily with food.

New Standing Order

National Medicare Part D FormularyKaiser Permanente has a National Medicare Part D (MPD) Formulary. Each regional P&T Committee reviews drugs and decides on tier status. The National Medicare Part D Pharmacy and Therapeutics Committee is charged with reconciling regional differences in MPD Formulary recommendations through consensus building in order to maintain one National MPD Formulary for Kaiser Permanente. National MPD Formulary tier placement and changes are listed below with the corresponding effective date:

medication name tiereFFective

date

Mesalamine (Lialda) 1.2 gm 3 4/18/2013

Linaclotide (Linzess) 145 mcg, 290 mcg 4 2/5/2013

Apixaban (Eliquis) 2.5 mg, 5 mg 4 3/5/2013

Alogliptan (Nesina) 6.25 mg, 12.5 mg, 25 mg 4 3/5/2013

Alogliptin and pioglitazone (Oseni) 12.5 mg-15 mg, 12.5 mg-30 mg, 12.5 mg-45 mg, 25 mg -15 mg, 25mg -30 mg, 25-45 mg

4 3/5/2013

Alogliptin and metformin (Kazano) 500 mg, 1000 mg 4 3/5/2013

Budesonide (Uceris) 9 mg 5 2/12/3013

Tier 1 = Value Generic Tier 3 = Brand Tier 5 = Specialty Tier 2 = Generic Tier 4 = Non-Preferred Brand Tier 6 = Injectable Part D Vaccine

Formulary Additions, Continuedof Cryselle is similar to other available combination oral contraceptives. It is similar in cost to other combination oral contraceptives available on the formulary. Cryselle provides a low-cost oral contraceptive option on the formulary containing a second generation progestin.

Ipratropium bromide-albuterol (generic Duoneb) nebulizer solution is currently available on the National MPD Formulary as Tier 2, generic, and was added to the Commercial Formulary effective April 18, 2013. Ipratropium bromide-albuterol solution is a combination nebulizer solution for the treatment of bronchospasm associated with chronic obstructive pulmonary disease in patients requiring more than one bronchodilator. Nebulized medications

may be indicated in patients unable to effectively use MDIs with spacers.

Mesalamine (Lialda) 1.2 gm delayed-release tablets were added to the Commercial Formulary and placed on Brand Tier 3 on the National MPD Formulary effective April 18, 2013. Lialda is a locally acting 5-aminosalicylic acid (5-ASA) indicated for the induction of remission and maintenance of remission of mildly- to moderately-active ulcerative colitis. Lialda is dosed once daily and is recommended to be taken with food. Lialda replaces Asacol as the mesalamine containing product on our formulary. Please see standing order article below.

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Kaiser Permanente Georgia 3

Questions and concerns?

If you have any questions or concerns, please contact any of the following P&T Committee members and designated alternates:

P&T Chair:Daniel Lee, MD, FACS

Physician Program Director of Pharmacy

P&T Committee Members:Seeme Ahmad, MD*

Behavioral Health

Debbi Baker, PharmD, BCPSClinical Pharmacy

Gary Beals, RPhDirector of Pharmacy

Karen Bolden, RN, BSNClinical Services

Deborah Burzotta, PharmDPharmacy Operations

Alyssa Dayton, MDObstetrics and Gynecology

Carole Gardner, MDElder Care

Patrice Gaspard, MDPediatrics

Marcus Griffith, MD*Behavioral Health

Donald Hanchett, MDAmbulatory Medicine

David Jones, MDPediatrics

Felecia Martin, PharmDPharmacy/Geriatrics

LaJune Oliver, MDAmbulatory Medicine

Rachel Robins, MDHospitalist

Designated Alternates:Jacqueline Anglade, MD

Obstetrics and Gynecology

Lesia Jackson, RNClinical Services

*Attend alternating meetings

Clinical Updates

Medications Reviewed, but Not Added to the Formulary• Taliglucerase alpha (Elelyso) 200 units for injection, decision pending for the National MPD Formulary• Ponatinib (Iclusig) 15 mg & 45 mg tablets, decision pending for the National MPD Formulary• Sodium picosulfate, magnesium oxide and anhydrous citric acid for oral solution (Prepopik), not

added to the Commercial Formulary; decision pending for the National MPD Formulary• Tofacitinib (Xeljanz) 5 mg tablet, not added to the Commercial Formulary; decision pending for the

National MPD Formulary• Teriflunomide (Aubagio) 7 mg and 14 mg film coated tablets, not added to the Commercial

Formulary; decision pending for the National MPD Formulary• Elvitegravir 150 mg, cobicistat 150 mg, emtricitabine 200 mg, tenofovir disoproxil fumarate 300 mg

(Stribild), not added to the Commercial Formulary• Azelastine (generic Astelin) 0.1% nasal spray, not added to the Commercial Formulary

MedSafety Alert: Azithromycin (Zithromax or Zmax) - Risk of Potentially Fatal Heart Arrhythmias. The FDA is warning the public that azithromycin (Zithromax or Zmax) can cause abnormal changes in the electrical activity of the heart that may lead to a potentially fatal irregular heart rhythm.

Patients at particular risk for developing this condition include those with known risk factors such as existing QT interval prolongation, low blood levels of potassium or magnesium, a slower than normal heart rate, or use of certain drugs used to treat abnormal heart rhythms, or arrhythmias.

The FDA recommends health care professionals should consider the risk of torsades de pointes and fatal heart rhythms with azithromycin when considering treatment options for patients who are already at risk for cardiovascular events. The FDA notes that the potential risk of QT prolongation with azithromycin should be placed in appropriate context when choosing an antibacterial drug: Alternative drugs in the macrolide class, or non-macrolides such as the fluoroquinolones, also have the potential for QT prolongation or other signifi-cant side effects that should be considered when choosing an antibacterial drug.

MedSafety Alert: Incretin Mimetic Drugs - Reports of Possible Risk of Pancreatitis and Pre-cancerous Findings of the Pancreas. The FDA is evaluating new unpublished findings that suggest an increased risk of pancre-atitis and pre-cancerous cellular changes in type-2 diabetic patients treated with incretin mimetics (e.g, exenatide (Byetta) and liraglutide (Victoza)). The FDA has formally issued this alert as an “early communication,” meaning additional stud-

ies and results are pending. The FDA is evaluating new unpublished findings by a group of academic researchers that suggest an increased risk of pancreatitis and pre-cancerous cellular changes (called pancreatic duct metaplasia) in patients with type 2 diabetes treated with incretin mimetics. These findings were based on examination of a small number of pancreatic tissue specimens taken from patients after they died from unspecified causes. The FDA has not made any conclusions about the risk for these drugs to cause or contrib-ute to the development of pancreatic cancer.

The FDA recommends that patients continue to take their medicine as directed and to dis-cuss this issue with their health care professional. Health care professionals should continue to follow the prescribing recommendations in each drug’s product labeling. Incretin mimet-ics (Byetta, Bydureon and Victoza) remain non-formulary prior authorization on the KPGA Commercial Formulary.

Quantity LimitsIn order to encourage appropriate drug utilization and contain medication cost, quantity limits will be implemented on certain medication beginning May 1, 2013. The quantity limit identifies the maximum quantity of medication that can be dispensed over a specific period of time at the applicable benefit co-pay for the patient. Quantity limits may not ap-ply to all strengths or formulations of a medication. APPENDIX B CONTAINS A DETAILED LIST OF ALL MEDICATIONS THAT WILL BE AFFECTED BY THE QUANTITY LIMITS.

Medical Office Floorstock AdditionsP&T committee annually reviews all of the departmental floorstock lists. All medications on the department floorstock lists have been changed to single dose or unit-of-use when available. APPENDIX A CONTAINS A DETAILED LIST OF ADDITIONS TO THE DEPART-MENT FLOORSTOCK LISTS.

KPGA Medical Office Floorstock AdditionsAppendix A

Kaiser Pharmacy Services, Georgia RegionLast Revised: 04/09/2013

DEPARTMENT NAME MEDICATION ADDED

Cardiology Clonidine 0.1 mg UD tab (Catapress), #100

D5W 1000 mL bag

Dobutamine 250 mg bag (Dobutrex)

Flumazenil 0.1 mg/mL, 10 mL vial (Romazicom)

Hydocortisone-sodium succinate 250 mg/2 ml vial (Solu-Cortef)

Hydralazine 25 mg UD tab (Apresoline)

Lidocaine-D5W 0.4% (4 mg/ml), 250 ml bag

MI-Acid 30 ml UD cup (Maalox)

Norepinephrine 1 mg/ml, 4 ml vial (Levophed)

Phenytoin 250 mg, 5 ml vial (Dilantin)

Sodium Chloride 0.9%, 10 ml in 12 ml syringe

Vasopressin 20 units/ml, 1 ml vial (Pitressin)

Dermatology Acetaminophen 325 mg UD tab (Tylenol)

Epinephrine 0.15 mg kit (EpiPen Jr)

Epinephrine 0.3 mg kit (EpiPen)

PPD (tuberculin purified protein derivative) 1 ml vial

Triple antibiotic ointment UD packs (Neosporin)

Endocrinology Ocreotide Acetate 10 mg injection kit (Sandostatin LAR)

Gastroenterology D5W 1000 ml bag

Diphenhydramine 50 mg/ml, 1 ml vial (Benadryl)

Dobutamine 250 mg bag (Dobutrex)

Flumazenil 0.1 mg/ml, 10 ml vial (Romazicom)

Insulin Regular 100 units/ml, 3 ml MDV (Humulin R)

Lidocaine-D5W 0.4% (4 mg/ml), 250 ml bag

Norepinephrine 1 mg/ml, 4 ml vial (Levophed)

One Touch Suresoft Lancets

Phenytoin 250 mg, 5 ml vial (Dilantin)

Simethicone 40 mg/0.6 ml, 30 ml bottle (Gas Relief Drops)

Sure Step Pro high control solution

Sure Step Pro #50 test stips

Sure Step Pro low control solution

General Surgery Heparin lock flush units/ml, 5ml vial

Sodium Chloride 0.9% irrigation solution 500 ml bottle

Sterile water for irrigation , 500 ml bottle

Triamcinolone acetonide 40 mg/ml, 1 ml vial (Kenalog)

Infusion Center Lactated ringers 500 ml bag

Lidocaine 1% (10 mg/ml), 20 ml vial

Lidocaine 2% (20 mg/ml), 20 ml vial

Lidocaine-Prilocaine 2.5%-2.5% cream, 5 gm UD (EMLA), #5

KPGA Medical Office Floorstock AdditionsAppendix A

Kaiser Pharmacy Services, Georgia RegionLast Revised: 04/09/2013

DEPARTMENT NAME MEDICATION ADDED

Internal Medicine Fluorescen 1 mg ophthalmic strips (Flu-Glo)

Ketorolac 30 mg/ml, 1 ml vial (Toradol)

Ondansetron 4 mg ODT tab (Zofran), #30

Sodium Chloride 0.9% 10 ml vial

Sodium Chloride 0.9% 10 ml syringe

Interventional Radiology D5W 1000 ml bag

Dobutamine 250 mg bag (Dobutrex)

Hydocortisone-sodium succinate 250 mg/2 ml vial (Solu-Cortef)

Lidocaine-D5W 0.4% (4 mg/ml), 250 ml bag

OB GYN Mepivacaine 1%, 30 ml vial (Carbocaine)

Monsel’s Solution 8 ml

Oncology Clonidine 0.1 mg UD tab (Catapress), #100

Ketorolac 15 mg/ml SDV (Toradol)

Ophthalmology Genteal Eye Gel Drop 15 ml

Prednisolone Acetate 1% O/S, 1 ml bottle

Optometry Genteal Eye Gel Drop 15 ml

Otolaryngology Sulfacetamide and prednisolone

Plastic Surgery Eucerin Cream Original 2 oz

Sodium Chloride 0.9% 100 ml bag

Podiatry Povidone-iodine10% soln, 16 oz bottle (Betadine)

Pulmonology Acetaminophen 325 mg UD tab (Tylenol), #100

Rheumatology Lidocaine 2% (20 mg/ml), 20 ml vial

Urgent Care Acetaminophen 160 mg/5ml suspension, 5 ml UD cup (Tylenol), #30

Bacitracin 500 units/gm ointment UD

Bupivicaine 0.5%, 50 ml vial (Marcaine)

Enema 4.5 oz

Ethyl chloride spray, 3.5 oz bottle (Chloroethane)

Sodium Chloride 0.9% 10 ml syringe

Triamcinolone acetonide 40 mg/ml, 1 ml vial (Kenalog)

Urology Chlorhexidine topical 4 oz bottle (Hibiclens)

Promethazine 25 mg/ml, 1 ml amp (Phenergan)

Sodium bicarbonate 8.4%, 30 ml vial

Vascular Surgery Sodium Chloride 0.9% 1000 ml bag

Heparin 5,000 units/ml, 1 ml vial

Wound Care Enema 4.5 oz

KPGA Quantity Limits

Kaiser Pharmacy Services, Georgia RegionLast Revised: 04/09/2013

Oral Contraceptives

Medication NameFormulary Status Strength

Quantity LimitCOM MPD Estrogen Progestin

Angeliq 0.25/0.5 NF T4 0.5 mg Estradiol 0.25 mg Drospirenone 16 packs/365 days

Angeliq 0.5/1 NF T4 1 mg Estradiol 0.5 mg Drospirenone 16 packs/365 days

Aviane & Lessina F T2 0.02 mg EE 0.1 mg Levonorgestrel 16 packs/365 days

Beyaz NF T4 0.02 mg EE 3 mg Drospirenone 16 packs/365 days

Camila F T2 --- 0.035 mg Norethindrone 16 packs/365 days

Cryselle F T2 0.03 mg EE 0.3 mg Norgestrel 16 packs/365 days

Gianvi NF T2 0.02 mg EE 3 mg Drospirenone 16 packs/365 days

Leena F T20.035 mg EE 0.035 mg EE 0.035 mg EE

0.05 mg Norethindrone 1 mg Norethindrone 0.5 mg Norethindrone

16 packs/365 days

Levora F T2 0.03 mg EE 0.15 mg Levonorgestrel 16 packs/365 days

Loryna NF T2 0.02 mg EE 3 mg Drospirenone 16 packs/365 days

Microgestin FE 1.5/30 F T2 0.03 mg EE 1 mg Norethindrone 16 packs/365 days

Microgestin FE 1/20 F T2 0.02 mg EE 1 mg Norethindrone 16 packs/365 days

Necon 1/35 F T2 0.035 mg EE 1 mg Norethindrone 16 packs/365 days

Necon 1/50 F T2 0.05 mg Mestranol 1 mg Norethindrone 16 packs/365 days

Nortrel 0.5/35 F T2 0.035 mg EE 0.5 mg Norethindrone 16 packs/365 days

Nortrel 7/7/7 F T20.035 mg EE 0.035 mg EE 0.035 mg EE

0.5 mg Norethindrone 0.75 mg Norethindrone 1 mg Norethindrone

16 packs/365 days

NuvaRing NF T3 0.015 mg EE 0.12 mg Etonogestrel 13 Rings/365 days

Ocella NF T2 0.03 mg EE 3 mg Drospirenone 16 packs/365 days

Ortho Evra NF T4 0.75 mg EE 6 mg Norelgestromin 13 patches/365 days

Reclipsen F T2 0.03 mg EE 0.15 mg Desogestrel 16 packs/365 days

Safyral NF T4 0.03 mg EE 3 mg Drospirenone 16 packs/365 days

Seasonique NF T4 0.15 EE 0.03 EE

0.03 mg Levonorgestrel -- 4 packs/365 days

Sprintec F T2 0.035 mg EE 0.25 mg Norgestimate 16 packs/365 days

Syeda NF T2 0.03 mg EE 3 mg Drospirenone 16 packs/365 days

Trisprintec F T20.035 mg EE 0.035 mg EE 0.035 mg EE

0.18 mg Norgestimate 0.215 mg Norgestimate 0.25 mg Norgestimate

16 packs/365 days

Trivora F T20.03 mg EE 0.04 mg EE 0.03 mg EE

0.05 mg Levonorgestrel 0.075 mg Levonorgestrel 0.125 mg Levonorgestrel

16 packs/365 days

Vestura NF T2 0.02 mg EE 3 mg Drospirenone 16 packs/365 days

Yasmin NF T4 0.03 mg EE 3 mg Drospirenone 16 packs/365 days

Yaz NF T4 0.02 mg EE 3 mg Drospirenone 16 packs/365 days

Zarah NF T2 0.03 mg EE 3 mg Drospirenone 16 packs/365 days

Zovia 1/35 F T2 0.035 mg EE 1 mg Ethynodiol Diacetate 16 packs/365 days

Zovia 1/50 F T2 0.05 mg EE 1 mg Ethynodiol Diacetate 16 packs/365 days

NOTE: Quantity limit applies to all brand and generic equivalents for the medications listed in the table above.

Appendix B

KPGA Quantity Limits

Kaiser Pharmacy Services, Georgia RegionLast Revised: 04/09/2013

All Other Medications

Generic Name Brand NameFormulary Status Affected Strengths

(NOTE: Not all strengths of a medication may have a qty limit)

Quantity LimitCOM MPD

Abacavir Ziagen F T2 300 mg 60 tabs/30 days

Abacavir-Lamivudine Epzicom F T5 600-300 mg 30 tabs/30 days

Abacavir-Lamivudine-Zidovudine Trizivir F T5 300-150-300 mg 60 tabs/30 days

Abiraterone Zytiga F T5 250 mg 120 tabs/30 days

Adefovir Hepsera F T5 10 mg 30 tabs/30 days

Armodafinil Nuvigil NF T4 50 mg, 150 mg, 250 mg 30 tabs/30 days

Atazanavir Reyataz F T3 T5

100 mg 150 mg, 300 mg 30 tabs/30 days

Atazanavir Reyataz F T5 200 mg 60 tabs/30 days

Boceprevir Victrelis NF T5 200 mg 3696 caps/308 days

Buprenorphine Butrans NF T4 5 mcg/hr, 10 mcg/hr, 20 mcg/hr 4 patches/28 days

Buprenorphine-Naloxone Suboxone Film NF T4 8-2 mg 120 fims/month

Buprenorphine-Naloxone Suboxone F T3 8-2 mg, 2-0.5 mg 120 tabs/30 days

Dabigatran Pradaxa NF T4 75 mg, 150 mg 60 caps/30 days

Darunavir Prezista F T3 T5

75 mg 150 mg, 400 mg, 600 mg 60 tabs/30 days

Delavirdine Rescriptor F T3 200 mg 180 tabs/30 days

Delavirdine Rescriptor F T3 100 mg 60 tabs/30 days

Dexmethylphenidate immediate-release Focalin NF T2 2.5 mg, 5 mg, 10 mg 60 tabs/30 days

Dexmethylphenidate extended-release Focalin XR NF T4 5 mg, 10 mg, 15mg, 20mg, 25

mg, 30 mg, 35 mg, 40mg 30 caps/30 days

Dextroamphetamine Sulfate Dexedrine F T2 5 mg, 10 mg 120 tabs/30 days

Dextroamphetamine Sulfate extend-ed-release Dexedrine F T2 5 mg, 10 mg, 15 mg 30 caps/30 days

Didanosine Videx EC F T2 125 mg, 200 mg, 250 mg 60 caps/30 days

Didanosine Videx EC F T2 400 mg 30 caps/30 days

Efavirenz Sustiva NF T3 50 mg, 200 mg 120 caps/30 days

Efavirenz Sustiva F T3 600 mg 30 caps/30 days

Efavirenz-Emtricitabine-Tenofovir Atripla F T5 600-200-300 mg 30 tabs/30 days

Elvitegravir-Cobicistat-Emtricitabine-Tenofovir Stribild NF T5 150-150-200-300 mg 30 tabs/30 days

Emtricitabine Emtriva F T3 200 mg 30 caps/30 days

Emtricitabine-Tenofovir Truvada F T5 200-300 mg 30 tabs/30 days

Enfurvitide Fuzeon F T5 90 mg/ml 60 injections/30 days

Entecavir Baraclude F T5 0.5 mg, 1 mg 30 tabs/30 days

Etravirine Intelence F T5 100 mg, 200 mg 60 tabs/30 days

Fentanyl Duragesic F T2 12 mcg, 25 mcg, 50 mcg, 75 mcg, 100 mcg 30 patches/30 days

Fosamprenavir Lexiva F T5 700 mg 120 tabs/30 days

Ketorolac Toradol NF T2 10 mg 20 tabs/30 days

Lamivudine Epivir F T2 300 mg 30 tabs/30 days

Lamivudine Epivir HBV NF T4 100 mg 30 tabs/30 days

Lamivudine Epivir F T2 150 mg 60 tabs/30 days

Lamivudine-Zidovudine Combivir F T2 150-300 mg 60 tabs/30 days

Lopinavir-Ritonavir Kaletra F T3 100-25 mg 300 tabs/30 days

KPGA Quantity Limits

Kaiser Pharmacy Services, Georgia RegionLast Revised: 04/09/2013

Generic Name Brand NameFormulary Status Affected Strengths

(NOTE: Not all strengths of a medication may have a qty limit)

Quantity LimitCOM MPD

Lopinavir-Ritonavir Kaletra F T5 200-50 mg 180 tabs/30 days

Maraviroc Selzentry NF T5 150 mg 60 tabs/30 days

Maraviroc Selzentry NF T5 300 mg 120 tabs/30 days

Mefenamic acid Ponstel NF T2 250 mg 28 caps/30 days

Methylphenidate extended-release Concerta F T2 36 mg 60 tabs/30 days

Methylphenidate extended-release Daytrana NF T4 10 mg, 15 mg, 20 mg, 30 mg 30 patches/30 days

Methylphenidate extended-release Metadate ER F T2 20 mg 90 tabs/30 days

Methylphenidate extended-release Ritalin LA NF T4 30 mg 60 caps/30 days

Methylphenidate sustained-release Ritalin SR NF T4 20 mg 90 tabs/30 days

Milnacipran Savella NF T3 12.5 mg, 25 mg, 50 mg, 100 mg 60 tabs/30 days

Modafinil Provigil NF T4 100 mg, 200 mg 60 tabs/30 days

Nelfinavir Viracept F T2 625 mg 120 tabs/30 days

Nelfinavir Viracept F T2 250 mg 90 tabs/30 days

Nevirapine Viramune F T3 50 mg/5 ml 1200 mls/30 days

Nevirapine extended-release Viramune XR NF T4 400 mg 30 tabs/30 days

Nevirapine immediate-release Viramune IR F T3 200 mg 30 tabs/30 days

Oseltamvir Tamiflu F T3 T4

75 mg 30 mg, 45 mg 20 caps/365 days

Oseltamvir Tamiflu F T3 6 mg/ml 480 mls/365 days

Oxycodone controlled-release Oxycontin NF T4 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg 60 tabs/30 days

Oxycodone-Ibuprofen Combunox NF T2 5-400 mg 28 tabs/30 days

Peginterferon alpha-2A Pegasys F T5 180 mcg/ml 4 vials/28 days

Ranolazine Ranexa NF T4 1000 mg 60 tabs/30 days

Rilpivirine Edurant NF T5 25 mg 30 caps/30 days

Rimantadine Flumadine F T2 100 mg 30 tabs/30 days

Ritonavir Norvir F T3 100 mg 180 tabs & caps/30 days

Rivaroxaban Xarelto NF T4 10 mg 35 tabs/365 days

Rivaroxaban Xarelto NF T4 15 mg, 20 mg 30 tabs/30 days

Saquinavir Invirase F T3 200 mg 300 caps/30 days

Saquinavir Invirase F T5 500 mg 120 tabs/30 days

Sodium Oxybate Xyrem NF T5 500 mg/ml 540 mls/30 days

Stavudine Zerit F T2 15 mg, 20 mg, 30 mg, 40 mg 60 caps/30 days

Tapentadol Nucynta NF T4 50 mg, 75 mg, 100 mg 180 tabs/30 days

Telaprevir Incivek NF T5 375 mg 504 tabs/84 days

Tenofovir Viread FNF

T5T5

300 mg150 mg, 200 mg, 250 mg 30 tabs/30 days

Tesamorelin Egrifta Excluded T4 1 mg 60 mls/30 days

Tipranavir Aptivus F T5 250 mg 60 caps/30 days

Zanamivir Relezna F T3 5 mg 56 blisters/28 days

Zidovudine Retrovir F T2 100 mg 180 caps/30 days

Zidovudine Retrovir F T2 300 mg 60 caps/30 days

COM = Commercial FormularyT1 = Value Generic TierT5 = Specialty Tier

MPD = Medicare Part DT2 = Generic TierT6 = Injectable Part D Vaccine

F = FormularyT3 = Brand Tier

NF = Non-FormularyT4 = Non-Preferred Brand Tier