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Drug Formulary Effective October 1, 2021

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Drug Formulary Effective October 1, 2021 Kaiser Permanente Hawaii QUEST Integration Drug Formulary Effective October 1, 2021 Kaiser Permanente Hawaii uses a drug formulary to ensure that the most appropriate and effective prescription drugs are available to you. The formulary is a list of drugs that have been approved by our Pharmacy and Therapeutics (P&T) Committee. Committee members include pharmacists, physicians, nurses, and other allied health care professionals. Our drug formulary allows us to select drugs that are safe, effective, and a good value for you. We review our formulary regularly so that we can add new drugs and remove drugs that can be replaced by newer, more effective drugs. The formulary also helps us restrict drugs that can be toxic or otherwise dangerous if. Our drug formulary is considered a closed formulary, which means that drugs on the list are usually covered under the prescription drug benefit, if you have one. However, drugs on our formulary may not be automatically covered under your prescription benefit because these benefits vary depending on your plan. Please check with your Kaiser Permanente pharmacist when you have questions about whether a drug is on our formulary or if there are any restrictions or limitations to obtaining a drug. NON-FORMULARY DRUGS Non-formulary drugs are those that are not included on our drug formulary. These include new drugs that haven’t been reviewed yet; drugs that our clinicians and pharmacists have decided to leave off the formulary, or a different strength or dosage of a formulary drug that we don’t stock in our Kaiser Permanente pharmacies. Even though non-formulary drugs are generally not covered under our prescription drug benefit options, your Kaiser Permanente doctor can request a non-formulary drug for you when formulary alternatives have failed and the non-formulary drug is medically necessary, provided the drug is not excluded under the prescription drug benefit. If the request is accepted, you may purchase your prescription at your usual supplemental charge. Non- formulary drugs are not usually stocked in our pharmacies, so it may take a little longer to have your prescription filled for one of these drugs. SHARE INFORMATION WITH YOUR DOCTOR If you’re taking multiple drugs–including prescription or over-the-counter drugs, herbs, natural supplements, and even nutraceuticals (foods or parts of a food that provide health benefits)–be sure to share this information with your physician or pharmacist. Because some drugs interact with others, we want to be sure that you get the maximum benefit and the least risk from everything you consume. Bring all your drugs to each physician appointment or call one of our pharmacies and make an appointment with a pharmacist to review everything you’re taking. Kaiser Permanente Hawaii Drug Formulary USING THE KAISER PERMANENTE HAWAII FORMULARY Prescription drugs are listed in alphabetical order for easy reference. Generic drugs are listed in lower case. BRAND names are CAPITALIZED. This list is subject to change and drugs may be added or removed without notice. Tier definitions: Tier 1 covers Generic drugs on the published list Tier 2 covers Brand name drugs on the published list Your Cost 2-Tier Plan $0 Tier 1 and 2 Please refer to your QUEST Integration Member Handbook for additional information. To find out the cost of your drugs, you may contact our QUEST Integration Call Center at 1-800-651-2237. There is no charge for covered drugs. If you choose to get drugs that are not covered, or if you get drugs from a pharmacy not owned or contracted by Kaiser Permanente, you will have to pay for them and Kaiser Permanente QUEST Integration might not cover those drugs. For a complete list of Kaiser Permanente and affiliate pharmacies, visit kp.org/locations. Abbreviations/Definitions used in list: Abbreviation Definition PAH Pulmonary Arterial Hypertension OVER THE COUNTER (OTC) DRUGS OTC drugs must be prescribed by your Kaiser Permanente doctor in order to be covered by QUEST Integration. Additional OTC drugs not published in this list may be covered, if deemed medically necessary by your Kaiser Permanente doctor. Please refer to your QUEST Integration Member Handbook for additional information. 2 Kaiser Permanente Hawaii Drug Formulary 2-Tier Plan GENERIC COMMONBRAND Tier Your Cost Abacavir 300mg Tablet ZIAGEN 1 $0 Abacavir/Dolutegravir/Lamivudine 600mg/50mg/300mg Tablet TRIUMEQ 2 $0 Abacavir/Lamivudine 600mg/300mg Tablet EPZICOM 1 $0 Abacavir/Lamivudine/Zidovudine 300mg/150mg/300mg Tablet TRIZIVIR 1 $0 Abatacept 125mg/ml Subcutaneous Solution ORENCIA 2 $0 Abiraterone Acetate 250mg Tablet ZYTIGA 1 $0 Abiraterone Acetate 500mg Tablet ZYTIGA 1 $0 Acalabrutinib 100mg Capsule CALQUENCE 2 $0 Acamprosate 333mg Delayed Release Enteric Coated Tablet CAMPRAL 1 $0 Acarbose 100mg Tablet PRECOSE 1 $0 Acarbose 25mg Tablet PRECOSE 1 $0 Acarbose 50mg Tablet PRECOSE 1 $0 Acebutolol 200mg Capsule SECTRAL 1 $0 Acetaminophen 100mg/ml Solution -- 1 $0 Acetaminophen 120mg Rectal Suppository -- 1 $0 Acetaminophen 160mg/5ml Suspension -- 1 $0 Acetaminophen 325mg Tablet -- 1 $0 Acetaminophen/Caffeine/Dihydrocodeine 320.5mg/30mg/16mg Capsule -- 1 $0 Acetaminophen/Codeine 120mg-12mg/5ml Solution TYLENOL WITH CODEINE 1 $0 Acetaminophen/Codeine 300mg/30mg Tablet TYLENOL WITH CODEINE NO. 3 1 $0 Acetaminophen/Codeine 300mg/60mg Tablet TYLENOL WITH CODEINE NO. 4 1 $0 Acetazolamide 125mg Tablet DIAMOX 1 $0 Acetazolamide 25mg/ml Suspension DIAMOX 1 $0 Acetazolamide 500mg Extended Release Capsule DIAMOX 1 $0 Acetic Acid 0.25% Irrigation Solution -- 1 $0 Acetic Acid 2% Otic Solution VOSOL 1 $0 Acetohydroxamic Acid 250mg Tablet LITHOSTAT 2 $0 Acetone Urine Test Strip KETOSTIX 2 $0 Acetylcysteine 20% Inhalation/Oral Solution MUCOMYST 1 $0 Acitretin 10mg Capsule SORIATANE 1 $0 Acitretin 17.5mg Capsule SORIATANE 1 $0 Acitretin 25mg Capsule SORIATANE 1 $0 Acyclovir 200mg Capsule ZOVIRAX 1 $0 Acyclovir 200mg/5ml Suspension ZOVIRAX 1 $0 Acyclovir 400mg Tablet ZOVIRAX 1 $0 Acyclovir 5% Topical Ointment ZOVIRAX 1 $0 Acyclovir 800mg Tablet ZOVIRAX 1 $0 3 Kaiser Permanente Hawaii Drug Formulary 2-Tier Plan GENERIC COMMONBRAND Tier Your Cost Adalimumab 20mg/0.4ml Subcutaneous Injection Kit HUMIRA 2 $0 Adalimumab 40mg/0.8ml Subcutaneous Injection Kit HUMIRA 2 $0 Adalimumab Citrate-Free 10mg/0.1ml Subcutaneous Injection HUMIRA 2 $0 Adalimumab Citrate-Free 20mg/0.2ml Subcutaneous Injection HUMIRA 2 $0 Adalimumab Citrate-Free 40mg/0.4ml Subcutaneous Injection HUMIRA 2 $0 Adalimumab Citrate-Free 40mg/0.4ml Subcutaneous Pen Injector HUMIRA 2 $0 Adapalene 0.1% Topical Cream DIFFERIN 1 $0 Adapalene 0.1% Topical Gel DIFFERIN 1 $0 Adapalene 0.3% Topical Gel DIFFERIN 1 $0 Adapalene/Benzoyl Peroxide 0.1%/2.5% Topical Gel EPIDUO 1 $0 Adefovir 10mg Tablet HEPSERA 1 $0 Albendazole 200mg Tablet ALBENZA 1 $0 Albuterol 0.083% Inhalation Solution ACCUNEB 1 $0 Albuterol 0.5% Inhalation Solution ACCUNEB 1 $0 Albuterol 1.25mg/3ml Inhalation Solution ACCUNEB 1 $0 Albuterol 108mcg/Actuation Inhaler PROVENTIL 1 $0 Albuterol 108mcg/Actuation Inhaler VENTOLIN 1 $0 Albuterol 2mg Tablet -- 1 $0 Albuterol 2mg/5ml Syrup -- 1 $0 Albuterol 4mg Tablet -- 1 $0 Alcaftadine 0.25% Ophthalmic Solution LASTACAFT 2 $0 Alclometasone Dipropionate 0.05% Topical Ointment ACLOVATE 1 $0 Alcohol (Ethanol) 70% Lock -- 2 $0 Alendronate 10mg Tablet FOSAMAX 1 $0 Alendronate 40mg Tablet FOSAMAX 1 $0 Alendronate 70mg Tablet FOSAMAX 1 $0 Alfuzosin 10mg Extended Release Tablet UROXATRAL 1 $0 Alirocumab 150mg/ml Subcutaneous Solution PRALUENT 2 $0 Alirocumab 75mg/ml Subcutaneous Solution PRALUENT 2 $0 Aliskiren Fumarate 150mg Tablet TEKTURNA 1 $0 Alitretinoin 0.1% Topical Gel PANRETIN 2 $0 Allopurinol 100mg Tablet ZYLOPRIM 1 $0 Allopurinol 20mg/ml Suspension ZYLOPRIM 1 $0 Almotriptan 6.25mg Tablet AXERT 1 $0 Alosetron 0.5mg Tablet LOTRONEX 1 $0 Alprazolam 0.25mg Tablet XANAX 1 $0 Alprazolam 0.5mg Tablet XANAX 1 $0 4 Kaiser Permanente Hawaii Drug Formulary 2-Tier Plan GENERIC COMMONBRAND Tier Your Cost Altretamine 50mg Capsule HEXALEN 2 $0 Aluminum Acetate/Acetic acid 10%/2% Otic Solution DOMEBORO 1 $0 Aluminum Chloride Hexahydrate 20% Topical Solution DRYSOL 1 $0 Aluminum Hydroxide/Magnesium Carbonate 95mg- 358mg/15ml Suspension GAVISCON 1 $0 Alvimopan 12mg Capsule ENTEREG 2 $0 Amantadine 100mg Capsule SYMMETREL 1 $0 Amantadine 50mg/5ml Syrup SYMMETREL 1 $0 Ambrisentan 10mg Tablet LETAIRIS 1 $0 Ambrisentan 5mg Tablet LETAIRIS 1 $0 Amcinonide 0.1% Topical Cream -- 1 $0 Amcinonide 0.1% Topical Ointment -- 1 $0 Amiloride 5mg Tablet -- 1 $0 Aminocaproic Acid 500mg Tablet AMICAR 1 $0 Aminophylline 100mg Tablet -- 1 $0 Aminosalicylic Acid 4gm Granule PASER 1 $0 Amiodarone 200mg Tablet CORDARONE 1 $0 Amitriptyline 10mg Tablet ELAVIL 1 $0 Amitriptyline 25mg Tablet ELAVIL 1 $0 Amitriptyline 50mg Tablet ELAVIL 1 $0 Amitriptyline 75mg Tablet ELAVIL 1 $0 Amitriptyline Bulk Powder -- 2 $0 Amlexanox 5% Oral Paste APHTHASOL 2 $0 Amlodipine 10mg Tablet NORVASC 1 $0 Amlodipine 2.5mg Tablet NORVASC 1 $0 Amlodipine 5mg Tablet NORVASC 1 $0 Amlodipine Besylate/Benazepril 10mg/20mg Capsule LOTREL 1 $0 Amlodipine Besylate/Benazepril 10mg/40mg Capsule LOTREL 1 $0 Amlodipine Besylate/Benazepril 2.5mg/10mg Capsule LOTREL 1 $0 Amlodipine Besylate/Benazepril 5mg/10mg Capsule LOTREL 1 $0 Amlodipine Besylate/Benazepril 5mg/20mg Capsule LOTREL 1 $0 Amlodipine Besylate/Benazepril 5mg/40mg Capsule LOTREL 1 $0 Amoxapine 100mg Tablet -- 1 $0 Amoxicillin 125mg Chewable Tablet -- 1 $0 Amoxicillin 250mg Capsule -- 1 $0 Amoxicillin 250mg Chewable Tablet -- 1 $0 Amoxicillin 400mg/5ml Suspension -- 1
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