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Northwest Medical Benefit Formulary (List of Covered Drugs) Please Read

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Northwest Medical Benefit Formulary (List of Covered Drugs) Please Read Northwest Medical Benefit Formulary (List of Covered Drugs) Please Read: This document contains information about the drugs we cover when they are administered to you in a Participating Medical Office. What is the Kaiser Permanente Northwest Medical Benefit Formulary? A formulary is a list of covered drugs chosen by a group of Kaiser Permanente physicians and pharmacists known as the Formulary and Therapeutics Committee. This committee meets regularly to evaluate and select the safest, most effective medications for our members. Kaiser Permanente Formulary The formulary list that begins on the next page provides information about some of the drugs covered by our plan when they are administered to you in a Participating Medical Office. Depending on your medical benefits, you may pay a cost share for the drug itself. The first column of the chart lists the drug’s generic name. The second column lists the brand name. Most administered medications and vaccines are only available as brand name drugs. Contraceptive Drugs and Devices Your provider may prescribe as medically necessary any FDA-approved contraceptive drug or device, including those on this formulary, which you will receive at no cost share. Last Updated 09/01/2021 Generic Name Brand Name Clinic Administered Medications (ADMD) ABATACEPT ORENCIA ABOBOTULINUM TOXIN A DYSPORT ADALIMUMAB HUMIRA ADO-TRASTUZUMAB EMTANSINE KADCYLA AFAMELANOTIDE ACETATE SCENESSE AFLIBERCEPT EYLEA AGALSIDASE BETA FABRAZYME ALDESLEUKIN PROLEUKIN ALEMTUZUMAB LEMTRADA ALGLUCOSIDASE ALFA LUMIZYME ARALAST, GLASSIA, PROLASTIN-C, ALPHA-1 PROTEINASE INHIBITOR ZEMAIRA AMIFOSTINE AMIFOSTINE, ETHYOL AMINOLEVULINIC ACID HCL 20% LEVULAN KERASTICK 20% AMPHOTERICIN B LIPOSOME AMBISOME ANTIHEMOPHILIC FACTOR/VON WILLEBRAND ALPHANATE/VWF FACTOR COMPLEX (HUMAN) COMPLEX/HUMAN, WILATE ANTIINHIBITOR COAGULANT COMPLEX FEIBA ANTITHROMBIN III THROMBATE III ARIPIPRAZOLE EXTENDED RELEASE ABILIFY MAINTENA ARIPIPRAZOLE LAUROXIL ARISTADA/INITIO ASPARAGINASE ERWINIA CHRYSANTHEMI ERWINAZE ATEZOLIZUMAB TECENTRIQ AVELUMAB BAVENCIO AZACITIDINE AZACITIDINE, VIDAZA BELANTAMAB MAFODOTIN-BLMF BLENREP BELATACEPT NULOJIX BELIMUMAB BENLYSTA BENDAMUSTINE HCL BELRAPZO, BENDEKA, TREANDA BENRALIZUMAB FASENRA BLINATUMOMAB BLINCYTO BORTEZOMIB VELCADE BRENTUXIMAB VEDOTIN ADCETRIS BREXUCABTAGENE AUTOLEUCEL TECARTUS BROLUCIZUMAB-DBLL BEOVU BUPRENORPHINE EXTENDED RELEASE INJECTION SUBLOCADE BUROSUMAB-TWZA CRYSVITA C1 ESTERASE INHIBITOR (HUMAN) BERINERT, CINRYZE, HAEGARDA C1 ESTERASE INHIBITOR (RECOMBINANT) RUCONEST CABAZITAXEL JEVTANA CALCITONIN-SALMON MIACALCIN Last Updated 09/01/2021 CARFILZOMIB KYPROLIS CEFTAZIDIME-AVIBACTAM SODIUM AVYCAZ CEMIPLIMAB-RWLC LIBTAYO CERTOLIZUMAB PEGOL CIMZIA CETUXIMAB ERBITUX CIDOFOVIR CIDOFOVIR, VISTIDE CLOFARABINE CLOLAR COAGULATION FACTOR IX (RECOMBINANT) IXINITY COAGULATION FACTOR IX (RECOMBINANT) REBINYN GLYCOPEGYLATED COLLAGENASE CLOSTRIDIUM HISTOLYTICUM XIAFLEX CORTICORELIN OVINE TRIFLUTATE ACTHREL CORTICOTROPIN ACTHAR HP CRIZANLIZUMAB-TMCA ADAKVEO CYCLOPHOSPHAMIDE CYCLOPHOSPHAMIDE, CYTOXAN CYTOMEGALOVIRUS IMMUNE GLOBULIN CYTOGAM DACTINOMYCIN COSMEGEN DALBAVANCIN DALVANCE DARATUMUMAB DARZALEX DAUNORUBICIN-CYTARABINE LIPOSOME VYXEOS DENILEUKIN DIFTITOX ONTAK DENOSUMAB PROLIA, XGEVA DEXAMETHASONE INTRAVITREAL IMPLANT OZURDEX DEXRAZOXANE, TOTECT, DEXRAZOXANE ZINECARD DIMETHYL SULFOXIDE RIMSO-50 DOXIL, DOXORUBICIN HCL DOXORUBICIN HCL LIPOSOMAL LIPOSOMAL, LIPODOX DURVALUMAB IMFINZI ECULIZUMAB SOLIRIS EDARAVONE RADICAVA ELOSULFASE ALFA VIMIZIM ELOTUZUMAB EMPLICITI EMICIZUMAB-KXWH HEMLIBRA EPTINEZUMAB-JJMR VYEPTI ERIBULIN MESYLATE HALAVEN ETANERCEPT ENBREL ETHANOLAMINE OLEATE ETHAMOLIN ETONOGESTREL CONTRACEPTIVE IMPLANT NEXPLANON FACTOR IX COMPLEX BEBULIN, PROFILNINE FACTOR VIII (ANTIHEMOPHILIC FACTOR, KOVALTRY, RECOMBINATE RECOMBINANT) FAM-TRASTUZUMAB DERUXTECAN-NXKI ENHERTU FERUMOXYTOL FERAHEME Last Updated 09/01/2021 FILGRASTIM NEUPOGEN FLUOCINOLONE ACETONIDE INTRAVITREAL ILUVIEN, RETISERT, YUTIQ IMPLANT FOSAPREPITANT DIMEGLUMINE EMEND FOSCARNET SODIUM FOSCAVIR FULVESTRANT FASLODEX GALSULFASE NAGLAZYME GIVOSIRAN SODIUM GIVLAARI GOLIMUMAB SIMPONI GOSERELIN ACETATE IMPLANT ZOLADEX GUSELKUMAB TREMFYA HEMIN PANHEMATIN HEPAGAM B, HYPERHEP B, NABI- HEPATITIS B IMMUNE GLOBULIN HB HISTRELIN IMPLANT SUPPRELIN LA, VANTAS HYDROXYPROGESTERONE HYDROXYPROGESTERONE CAPROATE CAPROATE, MAKENA ICATIBANT FIRAZYR IDURSULFASE ELAPRASE ASCENIV, BIVIGAM, CARIMUNE, CUTAQUIG, CUVITRU, FLEBOGAMMA, GAMASTAN S/D, GAMMAGARD, GAMMAKED, GAMMAPLEX, GAMMAR-P, IMMUNE GLOBULIN GAMUNEX, HIZENTRA, HYQVIA, OCTAGAM, PANGLOBULIN, PANZYGA, POLYGAM S/D, PRIVIGEN, VENOGLOBULIN, VIVAGLOBIN, XEMBIFY INCOBOTULINUM TOXIN A XEOMIN INFLIXIMAB REMICADE INFLIXIMAB BIOSIMILAR INFLECTRA, RENFLEXIS INOTUZUMAB OZOGAMICIN BESPONSA INTERFERON ALFA-2B RECOMBINANT INTRON A INTERFERON BETA-1A AVONEX, REBIF INTRAUTERINE COPPER CONTRACEPTIVE PARAGARD IPILIMUMAB YERVOY IRINOTECAN LIPOSOME ONIVYDE ISATUXIMAB-IRFC SARCLISA IXABEPILONE IXEMPRA LANREOTIDE SOMATULINE DEPOT LEUPROLIDE ACETATE ELIGARD, LUPRON DEPOT LEVONORGESTREL-RLS INTRAUTERINE MIRENA CONTRACEPTIVE LURBINECTEDIN ZEPZELCA Last Updated 09/01/2021 LUSPATERCEPT-AAMT REBLOZYL MARGETUXIMAB-CMKB MARGENZA MEPOLIZUMAB NUCALA MITOMYCIN FOR PYELOCALYCEAL INSTILLATION JELMYTO MOMETASONE FUROATE SINUS IMPLANT SINUVA MOXETUMOMAB PASUDOTOX-TDFK LUMOXITI NALTREXONE DEPOT VIVITROL NATALIZUMAB TYSABRI NELARABINE ARRANON NIVOLUMAB OPDIVO NUSINERSEN SPINRAZA OBINUTUZUMAB GAZYVA OCRELIZUMAB OCREVUS OCRIPLASMIN JETREA OCRIPLASMIN FOR INTRAOCULAR INJECTION JETREA OCTREOTIDE DEPOT SANDOSTATIN LAR DEPOT OFATUMUMAB ARZERRA OLARATUMAB LARTRUVO OMALIZUMAB XOLAIR ONABOTULINUM TOXIN A BOTOX PACLITAXEL PROTEINBOUND PARTICLES ABRAXANE PALIPERIDONE PALMITATE EXTENDED RELEASE INVEGA PANITUMUMAB VECTIBIX PATISIRAN ONPATTRO PEGAPTANIB MACUGEN PEGASPARGASE ONCASPAR PEGFILGRASTIM NEULASTA PEGFILGRASTIM BIOSIMILAR FULPHILA PEGLOTICASE KRYSTEXXA PEMBROLIZUMAB KEYTRUDA PEMETREXED ALIMTA PENTOSTATIN NIPENT, PENTOSTATIN PERTUZUMAB PERJETA PHENTOLAMINE MESYLATE PHENTOLAMINE MESYLATE POLATUZUMAB VEDOTIN-PIIQ POLIVY PRALATREXATE FOLOTYN RAMUCIRUMAB CYRAMZA RANIBIZUMAB LUCENTIS RASBURICASE ELITEK RAVULIZUMAB-CWVZ ULTOMIRIS RIBOFLAVIN 5’-PHOSPHATE OPHTHALMIC SOLN PHOTREXA RISPERIDONE LONG ACTING RISPERDAL CONSTA RITUXIMAB RITUXAN Last Updated 09/01/2021 RITUXIMAB-ABBS BIOSIMILAR TRUXIMA RITUXIMAB-HYALURONIDASE RITUXAN HYCELA ROMIDEPSIN ISTODAX ROMIPLOSTIM NPLATE ROMOSOZUMAB-AQQG EVENITY SACITUZUMAB GOVITECAN-HZIY TRODELVY SECRETIN ACETATE (HUMAN) CHIRHOSTIM SILTUXIMAB SYLVANT SIPULEUCEL-T PROVENGE STREPTOZOCIN ZANOSAR TALIMOGENE LAHERPAREPVEC IMLYGIC TEMSIROLIMUS TORISEL TETANUS IMMUNE GLOBULIN HYPERTET THIOTEPA TEPADINA, THIOTEPA THYROTROPIN ALPHA THYROGEN TILDRAKIZUMAB-ASMN ILUMYA TOCILIZUMAB ACTEMRA TRABECTEDIN YONDELIS TRASTUZUMAB HERCEPTIN TRASTUZUMAB-ANNS BIOSIMILAR KANJINTI TRIAMCINOLONE ACETONIDE ZILRETTA TRIAMCINOLONE HEXACETONIDE ARISTOSPAN USTEKINUMAB STELARA VEDOLIZUMAB ENTYVIO VINCRISTINE SULFATE LIPOSOME MARQIBO VON WILLEBRAND FACTOR COMPLEX HUMAN HUMATE-P RISTOCETIN ZIV-AFLIBERCEPT ZALTRAP ZOLEDRONIC ACID RECLAST, ZOMETA Vaccines DIPHTHERIA TETANUS ACELLULAR PERTUSSIS KINRIX AND POLIO VACCINE DIPHTHERIA-TETANUS TOXOIDS VACCINE DT DIPHTHERIA-TETANUS-ACELLULAR PERTUSS, PENTACEL POLIO-HAEMOPHILUS B VACCINE DIPHTHERIA-TETANUS-ACELLULAR PERTUSSIS INFANRIX VACCINE HAEMOPHILUS INFLUENZAE B VACCINE ACTHiB HAEMOPHILUS INFLUENZAE B VACCINE HIBERIX HEPATITIS A VACCINE HAVRIX HEPATITIS A VACCINE VAQTA HEPATITIS B IMMUNE GLOBULIN NABI-HB HEPATITIS B VACCINE ENGERIX-B HEPATITIS B VACCINE RECOMBIVAX Last Updated 09/01/2021 HUMAN PAPILLOMAVIRUS VACCINE GARDASIL 9 JAPANESE ENCEPHALITIS VACCINE IXIARO MEASLES-MUMPS-RUBELLA VACCINE M-M-R II MEASLES-MUMPS-RUBELLA-VARICELLA VACCINE PROQUAD MENINGOCOCCAL B VACCINE TRUMENBA MENINGOCOCCAL B VACCINE BEXSERO MENINGOCOCCAL CONJUGATE VACCINE MENVEO MENINGOCOCCAL CONJUGATE VACCINE MENACTRA PNEUMOCOCCAL 13 VALENT CONJUGATE PREVNAR 13 VACCINE PNEUMOCOCCAL POLYSACCHARIDE VACCINE PNEUMOVAX 23 POLIO VACCINE INACTIVATED IPOL RABIES IMMUNE GLOBULIN IMOGAM RABIES VACCINE RABAVERT RABIES VACCINE IMOVAX ROTAVIRUS VACCINE ROTARIX ROTAVIRUS VACCINE ROTATEQ TETANUS (HUMAN) IMMUNE GLOBULIN HYPERTET S/D TETANUS DIPHTHERIA ACELLULAR PERTUSSIS ADACEL VACCINE TETANUS DIPHTHERIA ACELLULAR PERTUSSIS BOOSTRIX VACCINE TETANUS DIPHTHERIA TOXOID VACCINE TENIVAC TETANUS DIPHTHERIA TOXOID VACCINE Td (generic) TUBERCULIN TEST APLISOL TUBERCULIN TEST TUBERSOL TYPHOID VACCINE TYPHIM VI VARICELLA VACCINE VARIVAX VARICELLA ZOSTER IMMUNE GLOBULIN (HUMAN) VARIZIG YELLOW FEVER VACCINE YF-VAX YELLOW FEVER VACCINE STAMARIL ZOSTER VACCINE ZOSTAVAX Last Updated 09/01/2021 .
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