2021 Five-Tier Formulary Benefit
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KAISER PERMANENTE OF GEORGIA 2021 FIVE-TIER FORMULARY BENEFIT This document includes Kaiser Permanente Georgia’s 5 Tier Plan Benefit Formulary as of September 9, 2021. For an updated formulary, please visit our website at members.kp.org or call 1-888-865-5813, Monday through Friday 7:00 a.m. to 7:00 p.m. TTY/TDD users should call 1-800-255-0056. What is the Kaiser Permanente Drug Brand-name drugs are capitalized in the Formulary? formulary (e.g., FLOVENT). A formulary is a list of drugs determined to There are two easy ways to find your drug be safe and effective for our members by within the formulary: our Pharmacy and Therapeutics Committee. Use of formulary drugs enables Kaiser Medical Condition Permanente to provide optimal care to you The drug list begins on page 4. The drugs and your family at reasonable costs. Kaiser on this formulary are grouped into Permanente continually updates the categories depending on the type of formulary throughout the year based on medical condition that they are used to new medical evidence, considering the treat. For example, drugs used to treat a recommendations of appropriate physician heart condition are listed under the experts. category, “Cardiovascular Drugs.” If you know what your drug is used for, simply Does the formulary ever change? look for the category name in the list that Yes, Kaiser Permanente continually updates begins on page 4. Then look under the the formulary based on new medical category name for your drug. evidence, considering the recommendations of appropriate physician Alphabetical Index experts and notifies our doctors, If you are not sure what category to look pharmacists, and other clinicians about any under, you can look for the drug in the changes. If a change in the formulary affects Index that begins on page 50. The Index any of your prescriptions, your doctor or provides an alphabetical list of all of the pharmacist will let you know. drugs included in this document. Both brand-name drugs and generic drugs are The enclosed formulary is current as of listed in the Index. Look in the Index and September 9, 2021. To get updated find your drug. Next to the drug, you will information about the drugs covered by see the page number where you can find Kaiser Permanente, please visit our Web coverage information. Turn to the page site at members.kp.org or call Member listed in the Index and find the name of Services at 1-888-865-5813, Monday your drug on the list. You may also use the through Friday 7:00 a.m. to 7:00 p.m. search function on your computer to search TTY/TDD users should call 1-800-255-0056. this document for the medication by name. How do I use the Formulary? What are generic drugs? Generic drugs are listed in lower-case italics Generic drugs are produced and sold under (e.g., amoxicillin) within the formulary. their chemical names after the patent of the Brand-name drug expires. Although the *Multiple tiers may be displayed for a medication where drug product strengths and different dosage forms may not be included on the same tier, check with your Kaiser Permanente pharmacist for clarification, if needed.* Tier 1=Preventative Generic, Tier 2=Preferred Generic, Tier 3=Preferred Brand, Tier 4=Non-preferred Drugs, Tier 5=Specialty Kaiser Permanente of Georgia 5 Tier Benefit Plan Formulary 1 price is lower, the quality and effectiveness covered at the specialty cost share defined of generic drugs is the same as Brand-name as Tier 5. Affordable Care Act (ACA) drugs. The Food and Drug Administration mandated preventive medications are (FDA) requires that generic drugs contain covered at a $0 cost share and labeled as the same active ingredients in the same ACA. Medical service drugs that are covered amount as the Brand-name drug. Kaiser under the medical benefit are label as Permanente pharmacies stock only generic Medical. drugs that have met the high standards of Coverage for prescription drugs is limited to both the FDA and the experts in our quality drugs for which a prescription is required by assurance program. law and those that are listed on the Kaiser Because all drug product strengths and Permanente drug formulary. Certain package sizes of a drug may not be included diabetic supplies do not require a on the formulary, check with your Kaiser prescription, but must still be listed in our Permanente pharmacist for clarification. formulary in order to be covered under the benefit. How much will I pay for Covered Drugs? What you pay for covered drugs is Each prescription refill is provided on the determined by the outpatient prescription same basis as the original prescription. drug benefit outlined in your Evidence of Copayments are applied on a per Coverage. Open formulary benefits have a prescription basis, for up to the lesser of the generic cost sharing requirement. This dispensing amount listed in the “Schedule means that if you fill a brand name drug of Benefits” or the standard prescription when a generic is available, that in addition amount, including maintenance drugs as to your standard copayment or determined by Health Plan. coinsurance, you will also pay the The standard prescription amount for the difference in cost between the brand name following items is: and generic drug. • Migraine medications ― the smallest Preventative generics are those covered at package size commercially available the lowest cost share amount defined as • Ophthalmic and otic medications ― the Tier 1. Preferred generics are those smallest package size commercially covered at the 2nd lowest cost share available amount defined as Tier 2. Preferred Brands • Oral and nasal inhalers ― the smallest are those Brands which will be covered at standard package unit your Preferred Brand cost share amount defined as Tier 3. Non-preferred drugs are Are there any other restrictions on those defined as Tier 4 and have a higher coverage? cost share. Specialty medications are *Multiple tiers may be displayed for a medication where drug product strengths and different dosage forms may not be included on the same tier, check with your Kaiser Permanente pharmacist for clarification, if needed.* Tier 1=Preventative Generic, Tier 2=Preferred Generic, Tier 3=Preferred Brand, Tier 4=Non-preferred Drugs, Tier 5=Specialty Kaiser Permanente of Georgia 5 Tier Benefit Plan Formulary 2 Some covered drugs may have additional * Only certain plans require step therapy requirements or limits on coverage. These restriction requirements and limits may include: You can find out if the drug has any • Quantity Limits (QL): For certain drugs, additional requirements or limits by looking Kaiser Permanente limits the amount of in the restriction’s column. the drug that will be covered. What if my drug is not on the • Age Restriction (AGE): For certain drugs, Formulary? Kaiser Permanente limits coverage You can contact Member Services at 1-888- based on a designated age. 865-5813, Monday through Friday 7:00 a.m. to 7:00 p.m. TTY/TDD users should call 1- • Prior Authorization Medication (PA): For 800-255-0056 and ask Member Services for certain drugs, Kaiser Permanente a list of similar drugs that are covered. requires review and authorization prior to dispensing. Your Provider must For more information obtain this review and authorization. For more detailed information about your The list of prescription drugs requiring Kaiser Permanente prescription drug review and authorization is subject to coverage, please review your Evidence of periodic review and modification by our Coverage and other plan materials. Pharmacy and Therapeutics Committee. If you have questions about Kaiser • Conditional PA: For certain drugs, Kaiser Permanente, please call Member Services Permanente requires review and at 1-888-865-5813, Monday through Friday authorization to determine if the 7:00 a.m. to 7:00 p.m. TTY/TDD users condition qualifies for coverage. should call 1-800-255-0056. • Step Therapy (ST)*: For certain drugs, Or visit members.kp.org. Kaiser Permanente requires the use of similar, alternative medications prior to coverage. *Multiple tiers may be displayed for a medication where drug product strengths and different dosage forms may not be included on the same tier, check with your Kaiser Permanente pharmacist for clarification, if needed.* Tier 1=Preventative Generic, Tier 2=Preferred Generic, Tier 3=Preferred Brand, Tier 4=Non-preferred Drugs, Tier 5=Specialty Kaiser Permanente of Georgia 5 Tier Benefit Plan Formulary 3 Category/Drug Name Tier Level Restrictions ALKYLATING AGENTS ANTIBACTERIALS, OTHER ACETIC ACID-ALUMINUM ACETATE 2 ANALGESICS NO USP CLASS (COMBINATION PRODUCT) acetaminophen w/ codeine 2 butalbital-acetaminophen-caffeine 2 butalbital-acetaminophen-caffeine w/ codeine 2 butalbital-aspirin-caffeine 2 butalbital-aspirin-caffeine w/cod 2 hydrocodone-acetaminophen 2 isometheptene-dichloralphenazone-acetaminophen 4 oxycodone w/ acetaminophen 2 oxycodone-aspirin 2 pramoxine-hc-chloroxylenol 2 pramoxine-hc-chloroxylenol aqueous 4 NONSTEROIDAL ANTI-INFLAMMATORY DRUGS diclofenac sodium 2 ibuprofen 2 indomethacin 2 meloxicam 2 nabumetone 2 naproxen 2 naproxen sodium 4 salsalate 2 sulindac 2 tolmetin sodium 2 OPIOID ANALGESICS, LONG-ACTING buprenorphine 4 QL, ST EXALGO 5 ST fentanyl 2, 4 QL methadone hcl 2 morphine sulfate 2 OXYCONTIN 5 QL, ST OXYMORPHONE HCL ER 5 ST OPIOID ANALGESICS, SHORT-ACTING BUTALBITAL-ACETAMINOPHEN 5 butorphanol tartrate 4 QL, ST hydromorphone hcl 2 meperidine hcl 4 ST morphine sulfate 2 oxycodone hcl 2 OXYCODONE-ACETAMINOPHEN 2 oxymorphone hcl 5 ST tramadol hcl 2 ANESTHETICS