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Kaiser Permanente Bernard J. Tyson School of Medicine, Inc. Exclusive Provider Organization (EPO) Student Blanket Health Plan Drug Formulary

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Kaiser Permanente Bernard J. Tyson School of Medicine, Inc. Exclusive Provider Organization (EPO) Student Blanket Health Plan Drug Formulary Kaiser Permanente Bernard J. Tyson School of Medicine, Inc. Exclusive Provider Organization (EPO) Student Blanket Health Plan Drug Formulary Effective September 1, 2021 Health Plan Products: Kaiser Permanente Bernard J. Tyson School of Medicine, EPO Student Blanket Health Plan offered by Kaiser Permanente Insurance Company For the most current list of covered medications or for help understanding your KPIC insurance plan benefits, including cost sharing for drugs under the prescription drug benefit and under the medical benefit: Call 1-800-533-1833, TTY 711, Monday through Friday, 7 a.m. to 9 p.m. ET Visit kaiserpermanente.org to: • Find a participating retail pharmacy by ZIP code. • Look up possible lower-cost medication alternatives. • Compare medication pricing and options. • Find an electronic copy of the formulary here. • Get plan coverage information. For cost sharing information for the outpatient prescription drug benefits in your specific plan, please visit kp.org/kpic-websiteTBD The formulary is subject to change and all previous versions of the formulary are no longer in effect. Kaiser Permanente Last updated: September 1, 2021 Table of Contents Informational Section...........................................................................................................................................3 ANTIHISTAMINE DRUGS - Drugs for Allergy.....................................................................................................9 ANTI-INFECTIVE AGENTS - Drugs for Infections............................................................................................ 11 ANTINEOPLASTIC AGENTS - Drugs for Cancer............................................................................................. 30 ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINES - DRUGS FOR THE IMMUNE SYSTEM..................... 45 AUTONOMIC DRUGS - Drugs for the Nervous System................................................................................... 52 BLOOD FORMATION, COAGULATION, THROMBOSIS - Drugs for the Blood...............................................65 CARDIOVASCULAR DRUGS - Drugs for the Heart......................................................................................... 78 CELLULAR AND GENE THERAPY - Drugs for Cancer................................................................................. 117 CENTRAL NERVOUS SYSTEM AGENTS - Drugs for the Nervous System..................................................117 DEVICES - Medical Supplies and Durable Medical Equipment...................................................................... 160 DIAGNOSTIC AGENTS.................................................................................................................................. 167 DISINFECTANTS (FOR NON-DERMATOLOGIC USE) - Disinfectants......................................................... 173 ELECTROLYTIC, CALORIC, AND WATER BALANCE..................................................................................173 ENZYMES....................................................................................................................................................... 183 EYE, EAR, NOSE AND THROAT (EENT) PREPS......................................................................................... 184 GASTROINTESTINAL DRUGS...................................................................................................................... 197 GASTROINTESTINAL DRUGS - Drugs for the Stomach............................................................................... 197 GOLD COMPOUNDS..................................................................................................................................... 206 HEAVY METAL ANTAGONISTS - Drugs to Reduce Iron............................................................................... 206 HORMONES AND SYNTHETIC SUBSTITUTES - Hormones........................................................................207 LOCAL ANESTHETICS (PARENTERAL) - Drugs for Numbing......................................................................247 MISCELLANEOUS THERAPEUTIC AGENTS................................................................................................248 NONHORMONAL CONTRACEPTIVES - Drugs for Women.......................................................................... 273 OXYTOCICS - Drugs for Women....................................................................................................................274 PHARMACEUTICAL AIDS..............................................................................................................................274 RADIOACTIVE AGENTS................................................................................................................................ 275 RESPIRATORY TRACT AGENTS - Drugs for the Lungs............................................................................... 275 SKIN AND MUCOUS MEMBRANE AGENTS - Drugs for the Skin.................................................................288 SMOOTH MUSCLE RELAXANTS - Drugs to Relax Muscles......................................................................... 327 VITAMINS....................................................................................................................................................... 328 TOC-2 Understanding your formulary What is a formulary? This formulary provides a list of the approved prescription About this formulary medications covered under your Health Insurance Plan including Where differences between both generic and brand-name drugs. This list applies only to this formulary and your benefit prescribed outpatient prescription drugs obtained through a plan exist, the benefit plan Kaiser Permanente pharmacy or a retail pharmacy within the documents rule. This may OptumRx network. not be a complete list of This list does not apply to medications administered in the medications that are covered doctor’s office or in the hospital which are covered under your by your plan, and it doesn’t medical benefit. For information on drugs covered under your mean that you are guaranteed medical benefit, please see the General Benefits section of your to receive a medication on this Certificate of Insurance. list. Please review your benefit plan for full details. Review the formulary using either the categorical list of drugs or the alphabetical index. The categorical list of drugs groups medications into drug categories and classes that are organized by the American Hospital Formulary Service (AHFS) Pharmacologic-Therapeutic Classification system. A prescription drug may be located by looking up the therapeutic category and class to which the drug belongs or the brand or generic name of the drug in the alphabetical index. A drug is listed alphabetically by the brand and generic name in the therapeutic category and class to which it belongs. The generic name for a brand-name drug is included after the brand-name in parentheses in all lowercase italicized letters. If a generic equivalent for a brand-name drug is both available and covered, the generic drug will be listed separately from the brand medication in all lowercase italicized letters. If a generic drug is marketed under a proprietary, trademark protected brand name, the brand name will be listed after the generic name in parentheses and regular typeface with the first letter of each word capitalized. If a generic equivalent for a brand-name drug is not available on the market or is not covered, the drug will not be separately listed by its generic name. How do I use my formulary? You and your doctor can use the formulary to help you choose the most cost-effective prescription medications. This guide tells you if a medication is generic or brand, and if special rules apply. Bring this list with you when you see your doctor. A non-formulary drug must be covered when your doctor says it is medically necessary. If your medication is not listed here, please visit your plan’s member website or call the number on your member ID card to submit a non-formulary exception request. Some medications on your formulary have extra requirements before they can be covered. A few of the most common coverage programs are prior authorization (PA), step therapy (ST), Non-formulary (NF), quantity limits (QL) or max day supply limit per prescription (DSL). Please note, this formulary is not subject to PA or ST programs. 3 Understanding your formulary You may request exception to certain non-formulary programs when your doctor feels it is necessary. If OptumRx doesn’t respond to your non-urgent NF exception request within 72 hours or your urgent NF exception request within 24 hours, then your request will be automatically granted. You may appeal the denial of an exception request. Please review your coverage documents for more information on appeal rights and procedures. We use programs like these to help make sure the medication you take is safe and effective. When you request coverage of a non-formulary drug, we will notify you or your designee and your provider of the coverage determination within these time frames. If the decision is to provide coverage for a non-urgent request, coverage will be for the duration of the prescription, including refills. If the coverage decision is based on exigent circumstances, coverage will be for the duration of the exigency. Check your plan documents for more information. Some Affordable Care Act (ACA) or Health Care Reform (HCR) preventive medications may have coverage restrictions. What are tiers? Tiers
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