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Home , Deutetrabenazine, Ganirelix, Ivosidenib, Ombitasvir, Pirfenidone, Satralizumab

UPDATED September 2021

Drugs Limited To Specific Pharmacies

Some drugs are limited to either Kaiser Permanente Washington Specialty Pharmacy, BriovaRx Specialty Pharmacy or WA Institute for Coagulation Pharmacy. Limitations only apply to the pharmacy benefit, not the medical benefit. Limitations do not apply to Medicare. Members with an out-of-network benefit may use other pharmacies, but cost shares may be higher. Formulary status and limitations apply.

Medications Limited to Specific Pharmacies

CONTACT: You can reach Kaiser Permanente Washington Specialty Pharmacy at 1-800-483-3945 from 8 a.m.- 6 p.m. Monday - Friday. Please call 1-800-245-7979 for certain drugs* available at other Kaiser Permanente owned and operated pharmacies.

Visit the website for more information: kp.org/wa/specialtypharmacy DRUG LIST: Acromegaly Dornase alfa (Pulmozyme) (Olysio) Lanreotide (Somatuline) Tobramycin (Tobi, Kitabis, (Sovaldi) Octreotide (Sandostatin) Bethkis) Sofosbuvir / (Epclusa) Octreotide (Bynfezia) Sofosbuvir/ Velpatasvir / Pegvisomant (Somavert) Gaucher Disease (Vosevi) (Vemlidy) Eliglustat (Cerdelga)

Amyloid Cardiomyopathy Hematopoietics Hereditary Angioedema (Vyndaqel) Filgrastim (Neupogen, Zarxio, Granix) C1 esterase Inhibitor (Cinryze, Tafamidis (Vyndamax) Berinert, Ruconest, Haegarda) Filgrastim-aafi (Nivestym) Anemia Pegfilgrastim (Neulasta) Icatibant (Firazyr) -flyo (Takhzyro) Darbepoetin (Aranesp)* Oprelvekin (Neumega) Epoetin (Epogen, Procrit)* Sargramostim (Leukine) Hereditary -mediated Epoetin alfa-epbx (Retacrit)* Hepatitis Ankylosing Spondylitis (Tegsedi) (Hepsera) (Humira) (Daklinza) HIV (Cimzia) / (Zepatier) Abacavir (Ziagen) (Enbrel) (Baraclude) Abacavir / (Epzicom) (Simponi) / (Mavyret) Abacavir / Lamivudine / (Cosentyx) alfa-2b (Intron A) (Trizivir)

Ledipasvir / Sofosbuvir Abacavir / Dolutegravir / Lamivudine (Triumeq) Asthma (Harvoni) Atazanavir (Reyataz) auto-injector (Fasenra) Ombitasvir / / auto-injector (Nucala) Atazanavir / Cobicistat (Evotaz) (Technivie) Bictegravir / Emtricitabine / Tenofovir Ombitasvir / Paritaprevir / (Biktarvy) Chronic Immune Thrombocytopenia Ritonavir / (Viekira Avatrombopag (Doptelet) Cobicistat (Tybost) Pak) Fostamatinib (Tavalisse) Darunavir (Prezista) Peginterferon alfa-2a (Pegasys) Darunavir / Cobicistat / Emtricitabine / Crohn’s Disease Peginterferon alfa-2b Tenovovir (Symtuza) (PegIntron) Adalimumab (Humira) Darunavir / Cobicistat (Prezcobix) (Copegus, Moderiba, Certolizumab Pegol (Cimzia) Delavirdine (Rescriptor) Rebetol, Ribasphere, Didanosine (Videx) Cystic Virazole) Dolutegravir (Tivicay)

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*Available at other Kaiser Permanente owned and operated pharmacies page 1 of 4 Drugs Limited to Specific Pharmacies continued from page 1

Dolutegravir / Lamivudine (Dovato) Huntington’s chorea Dolutegravir / Rilpivirine (Juluca) (Austedo) Dalfampridine (Ampyra) - Generic only Doravirine (Pifeltro) (Tecfidera) Doravirine / Lamivudine / Tenofovir Hyperphenylalaninemia (Vumerity) (Delstrigo) Sapropterin (Kuvan)* (Gilenya) (Sustiva) (Copaxone) Efavirenz / Emtricitabine / Tenofovir Idiopathic Pulmonary Glatiramer acetate (Glatopa) (Atripla) Fibrosis Peg-interferon beta-1a Efavirenz / Lamivudine / Tenofovir (Symfi (Ofev) (Plegridy) Lo) Pirfenidone (Esbriet) (Ponvory) Elvitegravir / cobicistat / emtricitabine / Interferon beta-1a (Avonex) tenofovir (Genvoya) Immune Conditions Interferon beta-1a (Rebif) Elvitegravir / cobicistat / tenofovir Acitretin (Soriatane)* (Stribild) Interferon beta-1b (Extavia, Betaseron) Adalimumab (Humira) Emtricitabine (Emtriva) Monomethyl fumarate (Bafiertam) (Otezla) Emtricitabine / rilpivirine / tenofovir (Kesimpta) (Odefsey) Belumosudil (Rezurock) (Zeposia) Emtricitabine / rilpivirine / tenofovir (Siliq) Siponimod fumarate (Mayzent) (Complera) Certolizumab Pegol (Cimzia) (Aubagio)

Emtricitabine / tenofovir (Descovy) (Dupixent)

Emtricitabine / tenofovir (Truvada) Etanercept (Enbrel) Neurofibromatosis Type I Enfuvirtide (Fuzeon) Golimumab (Simponi) (Koselugo) Fosamprenavir (Lexiva) (Tremfya) (Taltz) Fostemsavir (Rokobia) Neurology (Other) Indinavir (Crixivan) -rzaa (Skyrizi) Corticotropin (Acthar) Lamivudine (Epivir) Secukinumab (Cosentyx) (Ingrezza) Lamivudine / Zidovudine (Combivir) (Stelara)

Lamivudine / Tenofovir (Cimduo) Neuromyelitis Optica Spectrum Immunodeficiency Lamivudine / Tenofovir (Temixys) Disorder Immune globulin (Hizentra) Lopinavir / Ritonavir (Kaletra) Satralizumab-mwge (Enspryng) Maraviroc (Selzentry) Infertility Nelfinavir (Viracept) Oncology Nevirapine (Viramune) (Cetrotide)* (Verzenio) Raltegravir (Isentress) Follitropin alfa (Gonal-F)* Abiraterone (Zytiga) Rilpivirine (Edurant) Follitropin beta (Follistim AQ)* (Calquence) Ritonavir (Norvir) Ganirelix (Ganirelix AC)* (Menopur)* (Gilotrif) Saquinavir (Invirase) (Alecensa) Stavudine (Zerit) Iron Overload Alpelisib (Piqray) Tenofovir (Viread) Deferasirox (Exjade, Jadenu) Altretamine (Hexalen) Tipranavir (Aptivus) Disorders Apalutamide (Erleada) Zidovudine (Retrovir) Alirocumab (Praluent) (Inlyta)

Evolocumab (Repatha) (Ayvakit) Hormonal Therapies Azacitidine (Onureg) Leuprolide (Eligard, Lupron) Long-chain fatty acid oxidation (Mektovi) (Synarel) disorders Bexarotene (Targretin) Somatropin (Humatrope, Triheptanoin (Dojolvi) (Bosulif) Genotropin, Norditropin, (Alunbrig) Norditropin AQ, Serostim, Migraine Busulfan (Myleran) Saizen, Omnitrope, Zorbtive, Erenumab-aooe (Aimovig) (Cabometyx, Cometriq) Tev-tropin) Fremanezumab-vfrm (Ajovy) Capecitabine (Xeloda) Galcanezumab-gnlm (Emgality) (Tabrecta)

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Ceritinib (Zykadia) (Pomalyst) Chlorambucil (Leukeran) (Inclusig) Pulmonary Arterial (Mavenclad) (Gavreto) (Cotellic) Procarbazine (Matulane) Sildenafil (Revatio) (Xalkori) (Stivarga) Tadalafil (Adcirca) Dabrafenib (Tafinlar) (Orgovyx) Ambrisentan (Letairis) - Generic only (Vizimpro) (Kisqali) Darolutamide (Nubeqa) (Qinlock) Rheumatoid Arthritis Rucaparib (Rubraca) (Sprycel) (Orencia) (Jakafi) Decitabine and Cedazuridine (Inqovi) Adalimumab (Humira) Selinexor (Xpovio) Duvelisib (Copiktra) (Kineret) (Retevmo) Eltrombopag (Promacta) (Olumiant) (Odomzo) (Xtandi) Certolizumab Pegol (Cimzia) (Nexavar) (Tarceva) Etanercept (Enbrel) (Lumakras) Enasidenib (Idhifa) Golimumab (Simponi) (Sutent) Encorafenib (Braftovi) (Kevzara) Talazoparib (Talzenna) (Rozlytrek) (Actemra) Estramustine (Emcyt) Tazemetostat (Tazverik) Tofacitinib (Xeljanz) Etoposide (Toposar) Temozolomide (Temodar) Upadacitinib (Rinvoq) (Tepmetko) (Afinitor) (Inrebic) (Thalomid) Systemic Lupus Erythematosus (Iressa) Thioguanine (Tabloid) (Benlysta) (Xospata) Topotecan (Hycamtin) (Imbruvica) Toremifine (Fareston) Ulcerative Colitis Idelalisib (Zydelig) Tretinoin (Vesanoid) Adalimumab (Humira) (Gleevec) (Mekinist) Golimumab (Simponi) (Truseltiq) Trifluridine / (Lonsurf) Wilson’s Disease Interferon alfa-2b (Intron A) (Tukysa) Penicillamine (Depen, Cupramine) Ivosidenib (Tibsovo) Umbralisib (Ukoniq) Trientine (Syprine) - Generic only Ixazomib (Ninlaro) Vemurafenib (Zelboraf)

Lapatinib (Tykerb) (Venclexta) (Vitrakvi) (Erivedge) (Revlimid) Vorinostat (Zolinza) (Lenvima) Voxelotor (Oxbryta) Leuprolide (Eligard, Lupron) (Brukinsa)

Lomustine (Gleostine) Osteoporosis (Lorbrena) Abaloparatide (Tymlos) Mesna (Mesnex) Teriparatide (Forteo) (Rydapt) Teriparatide (Brand Teriparatide) Mitotane (Lysodren) (Nerlynx) Orthostatic Hypotension (Tasigna) Droxidopa (Northera)

Nilutamide (Nilandron) Parkinson’s Disease Niraparib (Zejula) Olaparib (Lynparza) ER (Gocovri)* Levodopa inhalation powder (Inbrija)* Omacetaxine (Synribo) Tolcapone (Tasmar)* (Tagrisso)

Palbociclib (Ibrance) Pheochromocytoma Panobinostat (Farydak) Phenoxybenzamine (Dibenzyline)* (Votrient)

Peginterferon alfa-2b Primary Biliary Cholangitis (PegIntron) Obeticholic acid (Ocaliva) Peginterferon alfa-2b (Sylatron)

*Available at other Kaiser Permanente Owned and Operated Pharmacies page 3 of 4 Drugs Limited to BriovaRx Specialty Medication Pharmacy

CONTACT: You can reach BriovaRx Specialty Medication Pharmacy at 1-855-427-4682 from 5:30 a.m. - 7 p.m. Monday - Friday. Visit the website for more information: https://briovarx.com/patients.html DRUG LIST: Allergic Rhinitis Tezacaftor / Ivacaftor (Symdeko) Immunodeficiency Grass pollen (Oralair) Rho D immune globulin (Winrho SDF)

Ragweed pollen (Ragwitek) Hemostatic Timothy grass pollen (Grastek) Desmopressin acetate (Stimate) Multiple Sclerosis Dalfampridine (Ampyra) - Brand only Cystic Fibrosis Hyponatremia Elexacaftor / Tezacaftor / Ivacaftor Tolvaptan (Samsca, Jynarque) Wilson's Disease

(Trikafta) Gaucher disease Trientine (Cuprid, Spyrine) - Brand only Ivacaftor (Kalydeco) Eliglustat (Cerdelga) Ivacaftor / Lumacaftor (Orkambi)

Drugs Limited to WA Institute for Coagulation Pharmacy

CONTACT: You can reach WA Institute for Coagulation (WIC) at 1-206-614-1200 from 8 a.m. - 4:30 p.m. Monday - Friday. Visit the website for more information: https://wacbd.org/pharmacy/ DRUG LIST: Hemophilia Emicizumab-kxwh (Hemlibra)

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