1. Anti-Infectives
1.1 Penicillins
TIER 1
Amoxicillin Trihydrate Capsule, Chewable Tablet,
1.1 Penicillins
TIER 1
Amoxicillin Trihydrate Capsule, Chewable Tablet,
Drops, Suspension, Tablet (Amoxil)
Amoxicillin Trihydrate/Potassium Clavulanate
(Augmentin 200, 400 mg Susp .; 200, 400 mg
Chewable Tablet; 500, 875 mg Tablet)
Amoxicillin Trihydrate/Potassium Clavulanate
(Augmentin ES 600 mg Suspension)
Amoxicillin Trihydrate/Potassium Clavulanate Suspension
(Augmentin 250-62 .5 mg/5 ml)
Dicloxacillin Sodium Capsule (Dynapen)
Penicillin V Potassium (Pen-Vee K)
TIER 2
Augmentin (Amoxicillin Trihydrate/
Potassium Clavulanate)
TIER 3
Amoxicillin Clavulanate ER Tablet,
Sustained-Release 12 Hour (Augmentin XR)
AMOXICILLIN TABLETS - FOR ORAL SUSPENSION (DisperMox)
1.2 Tetracyclines
TIER 1
Doxycycline Hyclate (Vibra-Tabs, Vibramycin, Periostat)
Doxycycline Monohydrate Capsule (Monodox)
Minocycline HCl (Dynacin, Minocin)
Tetracycline HCl (Achromycin V)
TIER 3
Doxycyline Capsules (Adoxa)
Doxycycline Hyclate Tablet, Enteric-Coated (Doryx)
Doxycycline Monohydrate Capsule (Adoxa 150 mg)
Minocycline Hydrochloride (Solodyn)
Vibramycin Suspension
1.3 Cephalosporins
1.3.1 FIRST GENERATION CEPHALOSPORINS
TIER 1
Cefadroxil Hydrate (Duricef)
Cephalexin Monohydrate (Keflex)
Cephradine Capsule (Velosef)
TIER 2
Velosef 250 mg Suspension (Cephradine)
1.3.2 SECOND GENERATION CEPHALOSPORINS
TIER 1
Cefaclor (Ceclor, Ceclor CD)
Cefpodoxime Tablet (Vantin)
Cefprozil (Cefzil)
Cefuroxime Axetil Tablet (Ceftin)
TIER 3
CEFUROXIME SUSPENSION (Ceftin Suspension)
Cefaclor (Raniclor Tablet, Chewable)
1.3.3 THIRD GENERATION CEPHALOSPORINS
TIER 1
Cefditoren Pivoxil (Spectracef)
TIER 2
Cefdinir (Omnicef)
TIER 3
Ceftibuten (Cedax)
Cefixime (Suprax)
Amoxicillin Trihydrate/Potassium Clavulanate
(Augmentin 200, 400 mg Susp .; 200, 400 mg
Chewable Tablet; 500, 875 mg Tablet)
Amoxicillin Trihydrate/Potassium Clavulanate
(Augmentin ES 600 mg Suspension)
Amoxicillin Trihydrate/Potassium Clavulanate Suspension
(Augmentin 250-62 .5 mg/5 ml)
Dicloxacillin Sodium Capsule (Dynapen)
Penicillin V Potassium (Pen-Vee K)
TIER 2
Augmentin (Amoxicillin Trihydrate/
Potassium Clavulanate)
TIER 3
Amoxicillin Clavulanate ER Tablet,
Sustained-Release 12 Hour (Augmentin XR)
AMOXICILLIN TABLETS - FOR ORAL SUSPENSION (DisperMox)
1.2 Tetracyclines
TIER 1
Doxycycline Hyclate (Vibra-Tabs, Vibramycin, Periostat)
Doxycycline Monohydrate Capsule (Monodox)
Minocycline HCl (Dynacin, Minocin)
Tetracycline HCl (Achromycin V)
TIER 3
Doxycyline Capsules (Adoxa)
Doxycycline Hyclate Tablet, Enteric-Coated (Doryx)
Doxycycline Monohydrate Capsule (Adoxa 150 mg)
Minocycline Hydrochloride (Solodyn)
Vibramycin Suspension
1.3 Cephalosporins
1.3.1 FIRST GENERATION CEPHALOSPORINS
TIER 1
Cefadroxil Hydrate (Duricef)
Cephalexin Monohydrate (Keflex)
Cephradine Capsule (Velosef)
TIER 2
Velosef 250 mg Suspension (Cephradine)
1.3.2 SECOND GENERATION CEPHALOSPORINS
TIER 1
Cefaclor (Ceclor, Ceclor CD)
Cefpodoxime Tablet (Vantin)
Cefprozil (Cefzil)
Cefuroxime Axetil Tablet (Ceftin)
TIER 3
CEFUROXIME SUSPENSION (Ceftin Suspension)
Cefaclor (Raniclor Tablet, Chewable)
1.3.3 THIRD GENERATION CEPHALOSPORINS
TIER 1
Cefditoren Pivoxil (Spectracef)
TIER 2
Cefdinir (Omnicef)
TIER 3
Ceftibuten (Cedax)
Cefixime (Suprax)
1. Anti-Infectives
1.4 Erythromycins & Other Macrolides
1.4.1 ERYTHROMYCINS & OTHER MACROLIDES
TIER 1
Azithromycin (Zithromax)
Clarithromycin Tablet (Biaxin)
Erythromycin Base Capsule, Delayed-Release (Eryc)
Erythromycin Base Tablet, Enteric-Coated 250, 333 mg
(E-Mycin, Ery-Tab)
Erythromycin Ethylsuccinate (E .E .S .)
Erythromycin Ethylsuccinate/Sulfisoxazole Acetyl (Pediazole)
TIER 2
Clarithromycin Suspension (Biaxin)
Clarithromycin Sustained-Release Tablet (Biaxin XL)
TIER 3
Erythromycin PCE (PCE)
Azithromycin (Zmax)
1.5 Quinolones
1.5.1 FLUOROQUINOLONES
TIER 1
Ciprofloxacin Tablet (Cipro)
Levofloxacin (Levaquin Tablet, Solution)
Ofloxacin (Floxin)
TIER 2
Cipro Suspension (Ciprofloxacin)
TIER 3
Moxifloxacin HCL (Avelox)
Ciprofloxacin Tablet, Sustained-Release 24 Hour (Cipro XR)
Gemifloxacin Mesylate (Factive)
Norfloxacin (Noroxin)
1.6 Sulfas & Related Agents
TIER 1
Erythromycin Ethylsuccinate/Sulfisoxazole Acetyl (Pediazole)
Sulfadiazine (Sulfadiazine)
Sulfamethoxazole/Trimethoprim
(Bactrim, Bactrim DS, Septra, Septra DS)
1.7 Urinary Tract Agents
TIER 1
Methenamine Mandelate (Methenamine Mandelate)
Nitrofurantoin Macrocrystal (Macrodantin 50, 100 mg)
Nitrofurantoin Suspension, Oral (Furadantin)
Nitrofurantoin/Nitrofurantoin Macrocrystal (Macrobid)
Trimethoprim (Proloprim)
TIER 2
Macrodantin 25 mg (Nitrofurantoin Macrocrystal)
TIER 3
Fosfomycin (Monurol)
Trimethoprim (Primsol)
1.4 Erythromycins & Other Macrolides
1.4.1 ERYTHROMYCINS & OTHER MACROLIDES
TIER 1
Azithromycin (Zithromax)
Clarithromycin Tablet (Biaxin)
Erythromycin Base Capsule, Delayed-Release (Eryc)
Erythromycin Base Tablet, Enteric-Coated 250, 333 mg
(E-Mycin, Ery-Tab)
Erythromycin Ethylsuccinate (E .E .S .)
Erythromycin Ethylsuccinate/Sulfisoxazole Acetyl (Pediazole)
TIER 2
Clarithromycin Suspension (Biaxin)
Clarithromycin Sustained-Release Tablet (Biaxin XL)
TIER 3
Erythromycin PCE (PCE)
Azithromycin (Zmax)
1.5 Quinolones
1.5.1 FLUOROQUINOLONES
TIER 1
Ciprofloxacin Tablet (Cipro)
Levofloxacin (Levaquin Tablet, Solution)
Ofloxacin (Floxin)
TIER 2
Cipro Suspension (Ciprofloxacin)
TIER 3
Moxifloxacin HCL (Avelox)
Ciprofloxacin Tablet, Sustained-Release 24 Hour (Cipro XR)
Gemifloxacin Mesylate (Factive)
Norfloxacin (Noroxin)
1.6 Sulfas & Related Agents
TIER 1
Erythromycin Ethylsuccinate/Sulfisoxazole Acetyl (Pediazole)
Sulfadiazine (Sulfadiazine)
Sulfamethoxazole/Trimethoprim
(Bactrim, Bactrim DS, Septra, Septra DS)
1.7 Urinary Tract Agents
TIER 1
Methenamine Mandelate (Methenamine Mandelate)
Nitrofurantoin Macrocrystal (Macrodantin 50, 100 mg)
Nitrofurantoin Suspension, Oral (Furadantin)
Nitrofurantoin/Nitrofurantoin Macrocrystal (Macrobid)
Trimethoprim (Proloprim)
TIER 2
Macrodantin 25 mg (Nitrofurantoin Macrocrystal)
TIER 3
Fosfomycin (Monurol)
Trimethoprim (Primsol)
KP Wellness
Jun 20, 2012 - Public1. Anti-Infectives
1.8 Antivirals
1.8.1 MISCELLANEOUS ANTIVIRALS
TIER 1
Acyclovir (Zovirax)
Amantadine HCl (Symmetrel)
Ganciclovir (Cytovene)
Ribavirin (Copegus)
Ribavirin (Rebetol Capsules)
Rimantadine HCl Tablet (Flumadine)
TIER 2
Baraclude (Entecavir)
Epivir HBV (Lamivudine)
Famciclovir (Famvir)
Hepsera (Adefovir Dipivoxil)
Rebetol Solution (Ribavirin)
Valacyclovir HCl (Valtrex)
Valcyte (Valganciclovir Hydrochloride)
TIER 3
Zanamivir (Relenza)
Oseltamivir Phosphate (Tamiflu)
Telbivudine (Tyzeka)
1.8.2 HIV/AIDS THERAPY
TIER 1
Didanosine Capsule, Enteric-Coated (Videx EC)
Stavudine (Zerit)
Zidovudine (Retrovir)
TIER 2
Aptivus (Tipranavir)
Atripla (Efavirenz/Emtricitabine/
Tenofovir)
Combivir (Zidovudine/Lamivudine)
Crixivan (Indinavir Sulfate)
Emtriva (Emtricitabine)
Epivir (Lamivudine)
Epzicom (Abacavir Sulfate/Lamivudine)
Fuzeon (Enfuvirtide)
Intelence (Etravirine)
Invirase (Saquinavir)
Isentress (Raltegravir Potassium)
Kaletra (Ritonavir/Lopinavir)
Lexiva (Fosamprenavir Calcium)
Norvir (Ritonavir)
Prezista (Darunavir Ethanolate)
Rescriptor (Delavirdine Mesylate)
Reyataz (Atazanavir Sulfate)
Selzentry (Maraviroc)
Reyataz (Atazanavir Sulfate)
Trizivir (Zidovudine/Lamivudine/ Abacavir)
Truvada (Emtricitabine/Tenofovir)
Viracept (Nelfinavir Mesylate)
Viramune (Nevirapine)
Viramune XR (Nevirapine Tablet, Extended-Release 24 Hour)
Viread (Tenofovir Disoproxil Fumarate)
Ziagen (Abacavir Sulfate)
1.8 Antivirals
1.8.1 MISCELLANEOUS ANTIVIRALS
TIER 1
Acyclovir (Zovirax)
Amantadine HCl (Symmetrel)
Ganciclovir (Cytovene)
Ribavirin (Copegus)
Ribavirin (Rebetol Capsules)
Rimantadine HCl Tablet (Flumadine)
TIER 2
Baraclude (Entecavir)
Epivir HBV (Lamivudine)
Famciclovir (Famvir)
Hepsera (Adefovir Dipivoxil)
Rebetol Solution (Ribavirin)
Valacyclovir HCl (Valtrex)
Valcyte (Valganciclovir Hydrochloride)
TIER 3
Zanamivir (Relenza)
Oseltamivir Phosphate (Tamiflu)
Telbivudine (Tyzeka)
1.8.2 HIV/AIDS THERAPY
TIER 1
Didanosine Capsule, Enteric-Coated (Videx EC)
Stavudine (Zerit)
Zidovudine (Retrovir)
TIER 2
Aptivus (Tipranavir)
Atripla (Efavirenz/Emtricitabine/
Tenofovir)
Combivir (Zidovudine/Lamivudine)
Crixivan (Indinavir Sulfate)
Emtriva (Emtricitabine)
Epivir (Lamivudine)
Epzicom (Abacavir Sulfate/Lamivudine)
Fuzeon (Enfuvirtide)
Intelence (Etravirine)
Invirase (Saquinavir)
Isentress (Raltegravir Potassium)
Kaletra (Ritonavir/Lopinavir)
Lexiva (Fosamprenavir Calcium)
Norvir (Ritonavir)
Prezista (Darunavir Ethanolate)
Rescriptor (Delavirdine Mesylate)
Reyataz (Atazanavir Sulfate)
Selzentry (Maraviroc)
Reyataz (Atazanavir Sulfate)
Trizivir (Zidovudine/Lamivudine/ Abacavir)
Truvada (Emtricitabine/Tenofovir)
Viracept (Nelfinavir Mesylate)
Viramune (Nevirapine)
Viramune XR (Nevirapine Tablet, Extended-Release 24 Hour)
Viread (Tenofovir Disoproxil Fumarate)
Ziagen (Abacavir Sulfate)
KP Wellnes
Jun 20, 2012 - Public1. Anti-Infectives
1.9 Antifungal Agents
TIER 1
Clotrimazole Troche (Mycelex)
Fluconazole (Diflucan)
Griseofulvin Microsize Suspension (Grifulvin V)
Griseofulvin Ultramicrosize (Gris-Peg 250 mg)
Itraconazole Capsule (Sporanox Capsule)
Ketoconazole (Nizoral)
Nystatin (Mycostatin)
Terbinafine HCl Tablet (Lamisil)
Voriconazole (Vfend)
TIER 2
Mycostatin (Nystatin Lozenge)
Noxafil (Posaconazole Suspension, Oral)
Sporanox Solution, Oral (Itraconazole Solution, Oral)
TIER 3
Flucytosine (Ancobon)
Lamisil Granules
1.10 Vancomycin
TIER 2
Vancocin HCl (Vancomycin HCl)
1.11 Miscellaneous Anti-infectives
1.11.1 MISCELLANEOUS ANTI-INFECTIVES
TIER 1
Clindamycin HCl (Cleocin HCl 150, 300 mg)
Dimethyl Sulfoxide Solution, Non-Oral (Rimso-50)
Neomycin Sulfate (Neomycin Sulfate)
TIER 2
Cayston (Aztreonam Lysine Vial, Nebulizer)
Cleocin HCl 75 mg (Clindamycin HCl)
Clindamycin Palmitate HCl (Cleocin Palmitate)
Dapsone (Dapsone)
Tobi (Tobramycin Ampul for Nebulization)
Zyvox (Linezolid)
TIER 3
Telithromycin (Ketek)
Rifaximin (Xifaxan)
1.9 Antifungal Agents
TIER 1
Clotrimazole Troche (Mycelex)
Fluconazole (Diflucan)
Griseofulvin Microsize Suspension (Grifulvin V)
Griseofulvin Ultramicrosize (Gris-Peg 250 mg)
Itraconazole Capsule (Sporanox Capsule)
Ketoconazole (Nizoral)
Nystatin (Mycostatin)
Terbinafine HCl Tablet (Lamisil)
Voriconazole (Vfend)
TIER 2
Mycostatin (Nystatin Lozenge)
Noxafil (Posaconazole Suspension, Oral)
Sporanox Solution, Oral (Itraconazole Solution, Oral)
TIER 3
Flucytosine (Ancobon)
Lamisil Granules
1.10 Vancomycin
TIER 2
Vancocin HCl (Vancomycin HCl)
1.11 Miscellaneous Anti-infectives
1.11.1 MISCELLANEOUS ANTI-INFECTIVES
TIER 1
Clindamycin HCl (Cleocin HCl 150, 300 mg)
Dimethyl Sulfoxide Solution, Non-Oral (Rimso-50)
Neomycin Sulfate (Neomycin Sulfate)
TIER 2
Cayston (Aztreonam Lysine Vial, Nebulizer)
Cleocin HCl 75 mg (Clindamycin HCl)
Clindamycin Palmitate HCl (Cleocin Palmitate)
Dapsone (Dapsone)
Tobi (Tobramycin Ampul for Nebulization)
Zyvox (Linezolid)
TIER 3
Telithromycin (Ketek)
Rifaximin (Xifaxan)
KP Wellness
Jul 4, 2012 (edited) - Public1. Anti-Infectives
1.11.2 ANTIPARASITICS
TIER 1
Mebendazole (Vermox)
Metronidazole (Flagyl)
Paromomycin Sulfate (Humatin)
TIER 2
Albenza (Albendazole)
Alinia (Nitazoxanide)
Biltricide (Praziquantel)
Mepron (Atovaquone)
NebuPent (Pentamidine Isethionate)
Stromectol (Ivermectin)
TIER 3
Flagyl ER Tablet
Tinidazole (Tindamax)
1.11.3 ANTIMALARIALS
TIER 1
Chloroquine Phosphate (Aralen Phosphate)
Hydroxychloroquine Sulfate (Plaquenil)
Mefloquine HCl (Lariam)
TIER 2
Atovaquone/Proguanil HCl (Malarone)**
Coartem (Artemether/Lumefantrine)
Daraprim (Pyrimethamine)
Primaquine (Primaquine Phosphate)
TIER 3
Quinine Sulfate Capsules (Qualaquin)
1.11.4 ANTIMYCOBACTERIALS
TIER 1
Ethambutol HCl (Myambutol)
Isoniazid (Isoniazid)
Pyrazinamide (Pyrazinamide)
Rifampin (Rifadin)
Rifampin/Isoniazid (Rifamate)
TIER 2
Lamprene (Clofazimine)
Priftin (Rifapentine)
Rifater (Rifampin/Isoniazid/Pyrazinamide)
Trecator-Sc (Ethionamide)
1.11.2 ANTIPARASITICS
TIER 1
Mebendazole (Vermox)
Metronidazole (Flagyl)
Paromomycin Sulfate (Humatin)
TIER 2
Albenza (Albendazole)
Alinia (Nitazoxanide)
Biltricide (Praziquantel)
Mepron (Atovaquone)
NebuPent (Pentamidine Isethionate)
Stromectol (Ivermectin)
TIER 3
Flagyl ER Tablet
Tinidazole (Tindamax)
1.11.3 ANTIMALARIALS
TIER 1
Chloroquine Phosphate (Aralen Phosphate)
Hydroxychloroquine Sulfate (Plaquenil)
Mefloquine HCl (Lariam)
TIER 2
Atovaquone/Proguanil HCl (Malarone)**
Coartem (Artemether/Lumefantrine)
Daraprim (Pyrimethamine)
Primaquine (Primaquine Phosphate)
TIER 3
Quinine Sulfate Capsules (Qualaquin)
1.11.4 ANTIMYCOBACTERIALS
TIER 1
Ethambutol HCl (Myambutol)
Isoniazid (Isoniazid)
Pyrazinamide (Pyrazinamide)
Rifampin (Rifadin)
Rifampin/Isoniazid (Rifamate)
TIER 2
Lamprene (Clofazimine)
Priftin (Rifapentine)
Rifater (Rifampin/Isoniazid/Pyrazinamide)
Trecator-Sc (Ethionamide)
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