2021 Formulary Kaiser Permanente a TRICARE® Prime Option
Total Page：16
File Type：pdf, Size：1020Kb
2021 Formulary Kaiser Permanente a TRICARE® Prime Option To search for a specific medication or condition: • Press “Ctrl” or “CMD” and “F” on your keyboard at the same time. • In the search window that pops up, enter the text that you wish to search for and press “Enter”. • Press enter again to move to the next result. • You can also find an alphabetic list of medication starting on page 89. For questions about specific drug costs, call us ta 1-877-904-0015. What is the Kaiser Permanente, a TRICARE® The drugs on this formulary are grouped into Prime Option Formulary? categories depending on the type of medical A formulary is a list of drugs determined to be condition that they are used to treat. For safe and effective for our members by our example, drugs used to treat a heart condition are Pharmacy and Therapeutics committee. Use of listed under the category, “Cardiovascular Drugs.” the formulary enables Kaiser Permanente to If you know what your drug is used for, simply provide optimal care to you and your family at look for the category name in the list. Then look reasonable costs. Kaiser Permanente continually under the category name for your drug. updates the formulary throughout the year based Alphabetical Listing on new medical evidence, considering the If you are not sure what category to look under, recommendations of appropriate physician you can look for the drug in the Index. The Index experts. Our physicians and pharmacists work provides an alphabetical list of all the drugs closely together to ensure that our formulary included in this document. Both brand-name meets your needs. drugs and generic drugs are listed in the Index. Does the formulary ever change? Look in the Index and find your drug. Next to the Yes, Kaiser Permanente periodically updates the drug, you will see the page number where you formulary based on new medical evidence, can find coverage information. Go to the page considering the recommendations of appropriate listed in the Index and find the name of your drug physician experts and notifies our doctors, on the list. pharmacists, and other clinicians about any What are generic drugs? changes. If a change in the formulary affects any Kaiser Permanente covers both brand-name drugs of your prescriptions, your doctor or pharmacist and generic drugs. will let you know. Generic drugs are produced and sold under their The enclosed formulary is effective as of chemical names after the patent of the brand September 9, 2021 and represents the most name drug expires. Although the price is lower, commonly prescribed medications. the quality and effectiveness of generic drugs is How do I use the Formulary? the same as brand name drugs. The Federal Food There is an easy way to find your drug within the and Drug Administration (FDA) requires that formulary: generic drugs contain the same active ingredients in the same amount as the brand name drug. To search for a specific medication or condition, Generic drugs are listed in lower-case italics (e.g., press the ‘CTRL’ key and the ‘F’ key on your amoxicillin) within the formulary. Brand-name keyboard at the same time. In the search window drugs are capitalized within the formulary (e.g., that pops up, enter the text you want to search FLOVENT). for and press ‘Enter.’ Press ‘Enter’ again to move to the next result. What are Formulary Brand name drugs? Medical Condition Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved. Kaiser Permanente, a TRICARE Prime Option Formulary 1 Formulary Brand name drugs are drugs that are those that are listed on the Kaiser Permanente, a produced and sold under the original TRICARE Prime Option drug formulary. Certain manufacturer’s name. diabetic supplies do not require a prescription but must still be listed in our formulary in order to be What are Non-Formulary Brand drugs? covered under the benefit. Non-Formulary Brand drugs are drugs that are Each prescription refill is provided on the same not included on the plan's list basis as the original prescription. Cost shares are of preferred prescription drugs. applied on a per prescription basis, for up to the Because all drug product strengths and package lesser of the dispensing amount listed in the sizes of a formulary drug will be included in your “Schedule of Benefits” or the standard plan’s benefits, just note the drug cost share prescription amount. coverage amount will be based on the specific The standard prescription amount for the tier of the formulary, check with your Kaiser following items is: Permanente pharmacist for clarification, if needed. • Migraine medications ― the smallest package How much will I pay for Covered Drugs? size commercially available • ― What you pay for covered drugs is determined by Ophthalmic and otic medications the the outpatient prescription drug benefit outlined smallest package size commercially available in your Evidence of Coverage. Kaiser Permanente, • Oral and nasal inhalers ― the smallest a TRICARE Prime Option plan has a three-tier standard package size open formulary benefit. Are there any other restrictions on coverage? Open formulary benefits have a generic cost Some covered drugs may have additional sharing requirement. This means that if you requirements or limits on coverage. These choose to fill a brand name drug when a generic is requirements and limits may include: available, then in addition to your standard cost share, you will also pay the difference in cost • Quantity Limits (QL): For certain drugs, Kaiser between the brand name and generic drug. Permanente limits the amount of the drug that will be covered. Generics drugs are those covered at the lowest cost share defined as Tier 1 coverage amount. • Age Restriction (Age): For certain drugs, Kaiser Formulary brand drugs are those brands which Permanente limits coverage based on a will be covered at your formulary brand cost designated age. share defined as Tier 2 coverage amount. Non- formulary brands drugs are covered at the non- • Prior Authorization (PA): For certain drugs, formulary cost share defined as Tier 3 coverage Kaiser Permanente requires review and amount. authorization prior to dispensing. Your Provider must obtain this review and Coverage for prescription drugs is limited to drugs authorization. The list of prescription drugs for which a prescription is required by law and Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved. Kaiser Permanente, a TRICARE Prime Option Formulary 2 requiring review and authorization is subject the formulary, check with your Kaiser Permanente to periodic review and modification by our pharmacist for clarification, if needed. Pharmacy and Therapeutics Committee. For more information • Step Therapy (ST): For certain drugs, Kaiser For more detailed information about your Kaiser Permanente requires the use of similar, Permanente, a TRICARE Prime Option prescription alternative medications prior to coverage. drug coverage, please review your Evidence of Coverage and other plan materials. You can find out if the drug has any additional requirements or limits by looking in the If you have questions about Kaiser Permanente, Restrictions Column on the formulary list. please call Member Services at 1-833-642-5973 or 770-291-4430, Monday through Friday 7:00 a.m. What if my drug is not on the Formulary? to 7 p.m. TTY/TDD users should call 1-800-255- Because all drug product strengths and package 0056. sizes of a formulary drug may not be included on Or visit kp.org/tricare. Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies. All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved. Kaiser Permanente, a TRICARE Prime Option Formulary 3 Kaiser Permanente, a TRICARE® Prime Option Formulary Restrictions Mailable Tier Generic Name Brand Name Coverage Status Antihistamine Drugs Antihistamine Drugs ST No 1 carbinoxamine maleate ARBINOXA Generic No 1 cyproheptadine PERIACTIN Generic chlorpheniramine, phenylephrine No 1 POLY HIST FORTE Generic & pyrilamine No 1 promethazine & phenylephrine PHENERGAN VC Generic QL No 1 promethazine PHENERGAN Generic Anti-infective Agents Anthelmintics No 2 albendazole ALBENZA Formulary Brand No 1 ivermectin STROMECTOL Generic PA, QL No 1 ivermectin (topical) SOOLANTRA Generic ST Yes 1 praziquantel BILTRICIDE Generic Anti-infectives, Miscellaneous bismuth subcitrate & Non-Formulary ST Yes 3 PYLERA metronidazole Brand metronidazole, tetracycline & Non-Formulary Yes 3 HELIDAC bismuth subsalicylate Brand Non-Formulary Yes 3 benznidazole benznidazole Brand Antibacterials Non-Formulary PA No 3 amikacin