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Drug Formulary This Drug Formulary Was Updated: July 1, 2021

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Drug Formulary This Drug Formulary Was Updated: July 1, 2021 Kaiser Permanente Insurance Company (KPIC) PPO and Out-of-Area Indemnity (OOA) Drug Formulary This Drug Formulary was updated: July 1, 2021 NOTE: This drug formulary is updated often and is subject to change. Upon revision, all previous versions of the drug formulary are no longer in effect. This document contains information regarding the drugs that are covered when you participate in the California Grandfathered PPO and Out-of- Area Indemnity (OOA) Health Insurance Plans for Large Groups offered by Kaiser Permanente Insurance Company(KPIC) and fill your prescription at a MedImpact network pharmacy. Please note that this Formulary does not have a specialty drug tier. If you are covered by a KPIC PPO plan with a specialty drug tier, please see the KPIC PPO and Out-of- Area Indemnity (OOA) Formulary with Specialty Drug Tier. Access to the most current version of the Formulary can be obtained by visiting: kp.org/kpic-ca-rx-ppo-gf. For help understanding your KPIC insurance plan benefits, including cost sharing for drugs under the prescription drug benefit and under the medical benefit, please call 1-800-788-0710 or 711 (TTY) Monday through Friday, 7 a.m. to 7 p.m. For help with this Formulary, including the processes for submitting an exception request and requesting prior authorization and step therapy exceptions, please call MedImpact 24 hours a day, 7 days a week, at 1-800- 788-2949 or 711 (TTY). For information about your cost share for the outpatient prescription drug benefits in your specific plan, please visit: kp.org/kpic-ca-rx-ppo-gf. For help in your preferred language, please see the “Kaiser Permanente Insurance Company Notice of Language Assistance” in this document. KPIC PPO GF Table of Contents Informational Section................................................................................................................................2 Alternative Therapy - Vitamins And Minerals........................................................................................... 9 Analgesic, Anti-Inflammatory Or Antipyretic - Drugs For Pain And Fever..............................................13 Anesthetics - Drugs For Pain And Fever................................................................................................42 Anorectal Preparations - Rectal Preparations........................................................................................ 43 Antidotes And Other Reversal Agents - Drugs For Overdose Or Poisoning.......................................... 45 Anti-Infective Agents - Drugs For Infections...........................................................................................47 Antineoplastics....................................................................................................................................... 73 Antineoplastics - Drugs For Cancer....................................................................................................... 73 Antiseptics And Disinfectants - Antiseptics And Disinfectants................................................................87 Biologicals - Biological Agents............................................................................................................... 88 Cardiovascular Therapy Agents - Drugs For The Heart.........................................................................97 Central Nervous System Agents - Drugs For The Nervous System.....................................................124 Chemical Dependency, Agents To Treat - Drugs For Addiction...........................................................179 Chemicals-Pharmaceutical Adjuvants..................................................................................................181 Cognitive Disorder Therapy - Drugs For The Nervous System............................................................184 Contraceptives - Drugs For Women.....................................................................................................185 Dermatological - Drugs For The Skin................................................................................................... 201 Diagnostic Agents................................................................................................................................ 271 Drugs To Treat Erectile Dysfunction - Drugs For The Urinary System.................................................272 Eating Disorder Therapy - Drugs For Eating Disorders........................................................................272 Electrolyte Balance-Nutritional Products - Drugs For Nutrition.............................................................272 Endocrine - Hormones......................................................................................................................... 310 Enzymes - Vitamins And Minerals........................................................................................................344 Fdb Class Obsolete-Not Used..............................................................................................................344 Gastrointestinal Therapy Agents - Drugs For The Stomach.................................................................345 Genitourinary Therapy - Drugs For The Urinary System......................................................................371 Gout And Hyperuricemia Therapy - Drugs For Pain And Fever...........................................................378 Hematological Agents.......................................................................................................................... 379 Hematological Agents - Drugs For The Blood......................................................................................379 Hepatobiliary System Treatment Agents - Drugs For The Liver...........................................................396 Immunosuppressive Agents - Drugs For Organ Transplants............................................................... 396 Locomotor System - Drugs For Muscles, Ligaments, Tendons, And Bones........................................398 Medical Supplies And Durable Medical Equipment (Dme) - Medical Supplies And Durable Medical Equipment............................................................................................................................................ 401 Medical Supply, Fdb Superset............................................................................................................. 508 Metabolic Disease Enzyme Replacement Agents - Drugs For Metabolic Disease.............................. 581 Metabolic Modifiers - Drugs That Alter Metabolism..............................................................................582 Mouth-Throat-Dental - Preparations - Drugs For The Mouth And Throat.............................................584 Multiple Sclerosis Agents - Drugs For The Nervous System................................................................589 Ophthalmic Agents - Drugs For The Eye............................................................................................. 592 Otic (Ear) - Drugs For The Ear............................................................................................................. 609 Respiratory Therapy Agents - Drugs For The Lungs............................................................................610 Vaginal Products - Drugs For Women..................................................................................................633 TOC-1 FORMULARY INFORMATION Notice: The Formulary is updated with changes on a monthly basis. Updates will be effective on the first day of the month. During the policy year, the following types of changes may be made: • Removal of a drug or dosage form of a drug from the Formulary; • A change in tier placement of a drug that results in an increase or decrease in cost sharing; and • Adding or changing utilization management procedures applicable to a drug. How to Use This Document This Formulary provides a list of the approved prescription medications covered under your KPIC Grandfathered PPO or OOA health insurance plan. This document applies only to prescribed outpatient prescription drugs obtained through a retail pharmacy within the MedImpact network. This document does not apply to medications administered in the doctor’s office or in the hospital which are covered under your medical benefit. For information on drugs covered under your medical benefit, please see the General Benefits section of your Certificate of Insurance. The Formulary may be accessed using either the categorical list of drugs or the alphabetical index. The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB), a widely-accepted independent drug 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 and 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 name drug 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
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