Diagnostics & Miscellaneous

KP Wellness

11:32 AM  -  Public

16. Diagnostics & Miscellaneous Agents

16.1  Miscellaneous Agents
TIER 1
Alendronate Sodium (Fosamax 40 mg)
Anagrelide HCl (Agrylin)
Disulfiram (Antabuse)
Etidronate Disodium (Didronel)
Levocarnitine (Carnitor)
Midodrine HCl (ProAmatine)
Pilocarpine HCl (Salagen)
Sodium Polystyrene Sulfonate (Kayexalate)
TIER 2
Actonel 30 mg (Risedronate Sodium)
Carbaglu (Carglumic Acid)
Chemet (Succimer)
Exjade (Deferasirox Tablet, Dispersible)
Fosrenol (Lanthanum Carbonate)
Increlex (Mecasermin)
Renagel (Sevelamer HCl)
Renvela (Sevelamer Carbonate)
Rilutek (Riluzole)
TIER 3
Acamprosate Calcium (Campral)
Nitisinone (Orfadin)

16.2  Smoking Deterrents
TIER 1
Bupropion HCl Tablet, Sustained-Action (Zyban)
Nicotine Patch, Transdermal 24 Hour (Habitrol)
TIER 2
Chantix1 (Varenicline Tartrate)
TIER 3
Nicotine Nasal Spray (Nicotrol NS)

16.3 Anorexiants
Appetite Suppressants (e .g . Ionamin, Meridia, Xenical, etc .,
and amphetamines when used as appetite suppressants) are
Tier 3 . Coverage is determined by the consumer’s prescription
drug benefit plan .