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Medi-Cal Formulary

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Medi-Cal Formulary 2021年加州Medi-Cal管理式護 理承付藥物手冊 （承保藥物清單） 請閱讀：本文件包含當您參與由KAISER PERMANENTE所提供的MEDI-CAL管理式保健計劃 時，屬於計劃承保範圍的藥物相關資訊。 本承付處方藥物手冊是於 09/01/2021 更新且自 September 7, 2021, 起生效。本承付藥物 手冊文件可能會有變更且內容可能會隨您的保健計劃而異。如需最新資訊或對哪份承付藥 物手冊適用於您的計劃有疑問，請瀏覽kp.org/formulary（英文）或致電會員服務聯絡中心 ，服務時間為每週七天，每天24小時（假日休息）。英文1-800-464-4000（並提供超過 150種語言的服務）、西班牙文1-800-788-0616、華語方言1-800-757-7585以及供失聰或 聽障人士使用的聽障及語障電話專線711。 什麼是Kaiser Permanente《加州Medi-Cal管理式護理承付藥物手冊》？ 《加州Medi-Cal管理式護理承付藥物手冊》(California Medi-Cal Managed Care Formulary) 是一份承保藥物清單，這些藥物是由Kaiser Permanente醫生和藥劑師所組成的藥事委員會 所挑選。藥事委員會將會定期舉行會議，以替會員評估和選擇安全有效的藥物。本承付藥物 手冊符合州法律的規定、條例以及Medi-Cal管理式保健計劃的準則。 哪些藥物屬於承保範圍？ Kaiser Permanente承保列於《加州Medi-Cal管理式護理承付藥物手冊》的品牌藥、非品牌藥及 專科藥物， 但條件是該藥物是醫療上必要的藥物、處方是在Kaiser Permanente或附屬藥房配領且有遵守其 他保險規定。 如果醫生開立《加州Medi-Cal管理式護理承付藥物手冊》中的藥物給您，該藥物將會根據 您的藥物理賠條款獲得承保。 獲得承付藥物手冊例外處理 未列於承付藥物手冊中的藥物稱為非承付藥物手冊藥物。當Kaiser Permanente醫生認定非承付 藥物手冊藥物是醫療上適當且必要的藥物，該藥物將會根據您的理賠條款獲得承保（如果您享 有處方藥理賠）。如果您未享有特定類型的處方藥（如性功能障礙及不孕）保險，您將需為該 藥物支付零售價的全額。 您可向醫生洽詢是否需要進行承付藥物手冊例外處理。您和醫生最能確定您的藥物需求。 Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 1 of 144 您也可與會員服務部聯絡，服務時間為每週7天，每天24小時。 如果您想使用醫生認定為非醫療上必 要的非承付藥物手冊藥物，您可能必須向會員服務部提出抱怨。 承付藥物手冊中的承保藥物有任何限制嗎？ 有些承保藥物可能有其他承保範圍規定或限制，如藥量限制。Kaiser Permanente可能會將特 定藥物的發配藥量限制在一定天數的藥量。此外，當某項藥物在全國發生短缺時，我們也可能 會限制該藥物的發配藥量。 什麼是品牌藥？ 品牌藥通常是由最初研發藥物的製藥公司所製造和販售。當品牌藥的專利到期之後，其他製藥 公司便可使用相同的活性成分並以較低的價格製造和販售經由食品及藥物管理署 (Food and Drug Administration, FDA) 核准的非品牌藥版本。 什麼是非品牌藥？ 非品牌藥是經由FDA核准且與品牌藥具備相同活性成分的藥物。非品牌藥的費用通常低於品 牌藥。 什麼是專科藥物？ 專科藥物是非常高價位、經由FDA核准且列於承付藥物手冊中，用於治療如風濕性關節炎、 多發性硬化症或癌症等複雜慢性病的藥物。 哪些藥物有資格透過郵購藥房郵寄？ 大多數藥物皆可透過郵購藥房郵寄。某些藥物（如非常高價位或需要特殊處理的藥物）可能 不符合郵寄資格。藥物無法郵寄至美國以外的地區。 您可透過郵購服務在kp.org/refill（英文）網站訂購續配藥物，或者透過電話或行動裝置應用 程式訂購。郵購無需額外收費。適當的成本分擔（依據您的處方藥理賠）將適用。 請參閱《承保範圍說明書》(Evidence of Coverage) 以瞭解處方藥理賠的完整詳細資訊。 Kaiser Permanente《加州Medi-Cal管理式護理承付藥物手冊》 Kaiser Permanente可能會在一年當中新增或移除《加州Medi-Cal管理式護理承付藥物手冊》 中的藥物。我們會依據可用的新資訊或新藥物修改承付藥物手冊。 如何使用承付藥物手冊？ 您可以透過以下兩種方法在承付藥物手冊中尋找您的藥物： 病症 承付藥物手冊正文從第 4 頁開始。本承付藥物手冊中的藥物是根據其用於治療的病症類型加 以分類。例如，用於治療心臟病症的藥物列於「Cardiovascular Drugs」（心血管藥物）類 別。如果您知道您所使用的藥物適用的病症，請在從第 4 頁開始的清單中查找該類別名稱， 然後在該類別名稱下查找您的藥物。 Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 2 of 144 按字母順序排列 如果您不確定應該查找哪個類別，您應在從第 95頁開始的索引中查找您的藥物。索引按字 母順序列出本文件所包含的所有藥物。請在索引中查找您的藥物。您將會在您的藥物旁看到 提供保險資訊的頁碼。翻到索引所列的頁面並在清單的第一欄中查找您的藥物名稱。 表格第一欄所列的是藥物名稱。品牌藥使用英文大寫字母標示（如ALBENZA），非品 牌藥使用斜體英文小寫字母標示（如amoxicillin）。 承付藥物手冊可能並未列出特定藥物的所有劑型和劑量。某些藥物有多種劑型。在此類情況下 ，某些劑型可能有列於承付藥物手冊中，有些劑型則沒有。 注意：這些藥物當中的某些藥物可能僅可在診所使用。 第二欄的「藥物等級」將會列出藥物所屬的等級號碼。《加州Medi-Cal管理式護理承付 藥物手冊》中的藥物均歸屬於等級1。 表格的第三欄將會列出適用於該藥物的所有規定或限制： QL = 藥量限制 (Quantity Limits) -針對特定藥物，我們可能會限制您可領取的藥量。此 外，當某項藥物在全國發生短缺時，我們也可能會限制該藥物的發配藥量。 LD = 發配受限的藥物只能透過特定專科藥房配取。如欲尋找專科藥房，請參閱 kp.org/eguidebook（英文）（位於設施名錄之下）的電子版會員健康服務指南或與會 員服務部聯絡。 OTC = Over-the-Counter 請參閱kp.org/eguidebook的電子版會員健康服務指南，以查看您可使用的網絡藥房完 整清單或與會員服務部聯絡。 Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 3 of 144 藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 INTELENCE TABS 25 MG ANTI-INFECTIVE AGENTS 1 ANTHELMINTICS [etravirine] ALBENZA TABS 200 MG INVIRASE TABS 500 MG 1 1 [albendazole] [saquinavir mesylate] BILTRICIDE TABS 600 ISENTRESS CHEW 100 1 MG [praziquantel] MG [raltegravir 1 ivermectin tabs 3 mg 1 potassium] ISENTRESS CHEW 25 ANTI-HIV AGENTS MG [raltegravir 1 abacavir sulfate tabs 300 1 potassium] mg ISENTRESS HD TABS abacavir sulfate- 600 MG [raltegravir 1 1 lamivudine tabs 600-300 potassium] mg ISENTRESS TABS 400 abacavir-lamivudine- MG [raltegravir 1 1 zidovudine tabs 300-150- potassium] 300 mg KALETRA SOLN 400-100 APTIVUS CAPS 250 MG 1 MG/5ML [lopinavir- 1 [tipranavir] ritonavir] BIKTARVY TABS 50-200- KALETRA TABS 100-25 25 MG [bictegravir- 1 1 MG [lopinavir-ritonavir] emtricitabine-tenofovir KALETRA TABS 200-50 alafenamide fumarate] 1 MG [lopinavir-ritonavir] CIMDUO TABS 300-300 lamivudine soln 10 MG [lamivudine- 1 1 mg/ml tenofovir disoproxil lamivudine tabs 150 mg 1 fumarate] COMPLERA TABS 200- lamivudine tabs 300 mg 1 lamivudine-zidovudine 25-300 MG 1 [emtricitabine-rilpivirine- 1 tabs 150-300 mg LEXIVA TABS 700 MG tenofovir disoproxil 1 fumarate] [fosamprenavir calcium] CRIXIVAN CAPS 200 MG nevirapine er tb24 400 1 1 [indinavir sulfate] mg CRIXIVAN CAPS 400 MG nevirapine susp 50 1 1 [indinavir sulfate] mg/5ml didanosine cap 125mg 1 nevirapine tabs 200 mg 1 NORVIR SOLN 80 MG/ML DOVATO TABS 50-300 1 MG [dolutegravir 1 [ritonavir] PREZISTA TABS 150 MG sodium-lamivudine] 1 EDURANT TABS 25 MG [darunavir ethanolate] 1 PREZISTA TABS 600 MG [rilpivirine hcl] 1 EMTRIVA SOLN 10 [darunavir ethanolate] 1 PREZISTA TABS 75 MG MG/ML [emtricitabine] 1 FUZEON SOLR 90 MG [darunavir ethanolate] 1 QL - 30 day(s) PREZISTA TABS 800 MG [enfuvirtide] 1 INTELENCE TABS 100 [darunavir ethanolate] 1 MG [etravirine] RESCRIPTOR TABS 100 INTELENCE TABS 200 MG [delavirdine 1 1 MG [etravirine] mesylate] Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 4 of 144 藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 RESCRIPTOR TABS 200 zidovudine syrp 50 1 MG [delavirdine 1 mg/5ml mesylate] zidovudine tabs 300 mg 1 SELZENTRY TABS 150 1 ANTIBACTERIALS MG [maraviroc] amikacin sulfate soln SELZENTRY TABS 25 1 1 500 mg/2ml MG [maraviroc] amoxicillin caps 250 mg 1 SELZENTRY TABS 300 1 amoxicillin caps 500 mg 1 MG [maraviroc] amoxicillin chew 125 mg 1 SELZENTRY TABS 75 1 1 MG [maraviroc] amoxicillin chew 250 mg amoxicillin susr 125 stavudine caps 15 mg 1 1 mg/5ml stavudine caps 20 mg 1 amoxicillin susr 200 1 1 stavudine caps 30 mg mg/5ml stavudine caps 40 mg 1 amoxicillin susr 250 1 STRIBILD TABS 150-150- mg/5ml 200-300 MG [elvitegravir- amoxicillin susr 400 1 1 cobicistat-emtricitabine- mg/5ml tenofovir df] amoxicillin-pot SYMFI LO TABS 400-300- clavulanate chew 200- 1 300 MG [efavirenz- 1 28.5 mg lamivudine-tenofovir amoxicillin-pot disoproxil fumarate] clavulanate chew 400-57 1 SYMFI TABS 600-300-300 mg MG [efavirenz- 1 amoxicillin-pot lamivudine-tenofovir clavulanate susr 200- 1 disoproxil fumarate] 28.5 mg/5ml SYMTUZA TABS 800-150- amoxicillin-pot 200-10 MG [darunavir- 1 clavulanate susr 250- 1 cobicistat-emtricitabine- 62.5 mg/5ml tenofovir alafenamide] amoxicillin-pot TIVICAY TABS 50 MG 1 clavulanate susr 400-57 1 [dolutegravir sodium] mg/5ml TRIUMEQ TABS 600-50- amoxicillin-pot 300 MG [abacavir- 1 clavulanate susr 600- 1 dolutegravir-lamivudine] 42.9 mg/5ml VIDEX SOLR 2 GM 1 amoxicillin-pot [didanosine] clavulanate tabs 250-125 1 VIDEX SOLR 4 GM 1 mg [didanosine] amoxicillin-pot VIRACEPT TABS 250 MG 1 clavulanate tabs 500-125 1 [nelfinavir mesylate] mg VIRACEPT TABS 625 MG 1 amoxicillin-pot [nelfinavir mesylate] clavulanate tabs 875-125 1 VIRAMUNE SUSP 50 1 mg MG/5ML [nevirapine] amp-sulbacta inj 1.5gm 1 ZIAGEN SOLN 20 MG/ML 1 ampicillin cap 250mg 1 [abacavir sulfate] ampicillin caps 500 mg 1 zidovudine caps 100 mg 1 Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 5 of 144 藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 ampicillin sodium solr 1 bacitracin solr 50000 1 1 gm unit ampicillin sodium solr 10 BICILLIN L-A SUSP 1 gm 1200000 UNIT/2ML 1 ampicillin sodium solr [penicillin g benzathine] 1 125 mg BICILLIN L-A SUSP ampicillin sodium solr 2 2400000 UNIT/4ML 1 1 gm [penicillin g benzathine] ampicillin sodium solr BICILLIN L-A SUSP 1 250 mg 600000 UNIT/ML 1 ampicillin sodium solr [penicillin g benzathine] 1 CAYSTON SOLR 75 MG QL - 30 500 mg 1 ampicillin sus 125/5ml 1 [aztreonam lysine] day(s),LD ampicillin sus 250/5ml 1 cefaclor caps 250 mg 1 ampicillin-sulbactam cefaclor caps 500 mg 1 sodium solr 1.5 (1-0.5) 1 cefadroxil caps 500 mg 1 gm cefazolin sodium solr 1 1 ampicillin-sulbactam 1 gm sodium solr 15 (10-5) gm cefazolin sodium solr 10 1 ampicillin-sulbactam 1 gm sodium solr 3 (2-1) gm cefazolin sodium solr 20 1 AUGMENTIN SUSR 125- gm 31.25 MG/5ML cefazolin sodium solr 1 1 [amoxicillin & pot 500 mg clavulanate] CEFAZOLIN SODIUM- AVELOX SOLN 400 DEXTROSE SOLN 1-4 1 MG/250ML [moxifloxacin 1 GM/50ML-% [cefazolin hcl in sodium chloride] sodium-dextrose] AZACTAM IN DEXTROSE CEFAZOLIN SODIUM- SOLN 1 GM/50ML 1 DEXTROSE SOLR 1-4 1 [aztreonam-dextrose] GM-%(50ML) [cefazolin AZACTAM IN DEXTROSE sodium-dextrose] SOLN 2 GM/50ML 1 cefdinir susr 125 mg/5ml 1 [aztreonam-dextrose] cefdinir susr 250 mg/5ml 1 azithromycin solr 500 1 cefepime hcl solr 1 gm 1 mg cefepime hcl solr 2 gm 1 azithromycin susr 100 1 CEFEPIME-DEXTROSE mg/5ml SOLR 1-5 GM-%(50ML) 1 azithromycin susr 200 1 [cefepime hcl-dextrose] mg/5ml CEFEPIME-DEXTROSE azithromycin tabs 250 1 SOLR 2-5 GM-%(50ML) 1 mg [cefepime hcl-dextrose] azithromycin tabs 500 1 cefixime caps 400 mg 1 mg cefotaxime sodium inj azithromycin tabs 600 1 1 10gm mg cefotaxime sodium solr aztreonam solr 1 gm 1 1 1 gm aztreonam solr 2 gm 1 Kaiser Permanente 2021 年《加州Medi-Cal管理式護理承付藥物手冊》 • 第 6 of 144 藥物等 藥物等 藥物名稱 規定／限制 藥物名稱 規定／限制 級 級 cefotaxime sodium solr ceftriaxone sodium solr 1 1 2 gm 10 gm cefotaxime sodium solr ceftriaxone sodium solr 1 1 500 mg 2 gm cefotetan disodium solr ceftriaxone sodium solr 1 1 1 gm 250 mg cefotetan disodium solr ceftriaxone sodium solr 1 1 2 gm 500 mg CEFOTETAN DISODIUM- CEFTRIAXONE SODIUM- DEXTROSE SOLR 1-3.58 DEXTROSE SOLR 1-3.74 1 1 GM-%(50ML) [cefotetan GM-%(50ML) [ceftriaxone disodium and dextrose] sodium and dextrose] CEFOTETAN DISODIUM- CEFTRIAXONE SODIUM- DEXTROSE SOLR 2-2.08 DEXTROSE SOLR 2-2.22 1 1 GM-%(50ML) [cefotetan GM-%(50ML) [ceftriaxone disodium and dextrose] sodium and dextrose] cefoxitin sodium solr 1 cefuroxime axetil tabs 1 1 gm 250 mg cefoxitin sodium solr 10 cefuroxime axetil tabs 1 1 gm 500 mg cefoxitin sodium solr 2 cefuroxime sodium solr 1 1 gm 1.5 gm CEFOXITIN SODIUM- cefuroxime sodium solr 1 DEXTROSE SOLR 1-4 7.5 gm 1 GM-%(50ML) [cefoxitin cefuroxime sodium solr 1 sodium and dextrose] 750 mg CEFOXITIN SODIUM- cephalexin caps 250
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