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Kaiser Permanente Hawaii LIST

Four-tier drug benefit This formulary list provides coverage information about the drugs covered under our Four-Tier Pharmacy Plan. The list is organized in alphabetical order and each drug name includes a color box that shows which tier the drug falls within. If your prescription drug is not on this list, it is not covered under our four-tier benefit structure. TIER 1 TIER 2 TIER 3 TIER 4

Generic drugs Generic drugs Brand-name drugs Specialty drugs on the published list. not included in Tier 1. on the published list. on the published list.

Under the four-tier benefit structure, you pay a lower copayment for medically necessary generic and a higher copayment for specialty medications. Your copayments depend on your plan. For information about your prescription copayments, please review your Summary of Benefits.

If your physician has prescribed a medically necessary generic , but you prefer to have the brand-name drug, you will pay the full member rate for the brand-name medication. Certain drugs may deviate from the four-tier benefit structure. See the following definitions for abbreviations linked to certain drugs on this list: • ACA = Under the Affordable Care Act (ACA), certain over-the-counter and prescription drugs are covered at no charge when prescribed by a physician for preventative purposes. • HCR = Certain and Drug Administration-approved contraceptive drugs and devices are available at no charge under health care reform (HCR). • PAH = There are some drugs that are covered only for pulmonary arterial hypertension (PAH). • TC = There are no charges for approved tobacco cessation (TC) products.

This drug list is subject to change and drugs may be added or removed without notice. Some drugs fall in different tiers depending on strength and dosage form. For the most up-to-date listing of formulary drugs, including strengths and dosage forms available, visit kp.org/formulary and select “Covered drugs in your area”. You’ll find the Kaiser Permanente Hawaii Drug Formulary under the “Our formularies” section. Check back often for updates.

QUESTIONS? Please contact your employer or call Member Services at 1-800-966-5955, Monday through Friday, 8 a.m. to 5 p.m., and Saturday, 8 a.m. to noon. For the deaf, hard of hearing, or speech impaired, call TTY 711.

7003MEM-17 | KAH2927 | September 2017 A ¢¢ Aminosalicylic ¢¢ Benazepril ¢¢ ¢¢ Abacavir ¢¢ ¢¢ Benzonatate ¢¢ Canakinumab ¢¢ Abacavir-Dolutegravir- ¢¢ ¢¢ Benzoyl peroxide- ¢¢ Candesartan Lamivudine ¢¢ Amlexanox ¢¢ Benztropine ¢¢ Capecitabine ¢¢ Abacavir-Lamivudine ¢¢ ¢¢ Benztropine 2mg ¢¢ Captopril ¢¢ Abacavir-Lamivudine-Zidovudine ¢¢ Amoxapine ¢¢ Benzyl ¢¢ 100mg ¢¢ Abatacept ¢¢ Amoxicillin-Clavulanate ¢¢ Bepotastine extended release tablet ¢¢ Abiraterone ¢¢ Amoxicillin ¢¢ Besifloxacin ¢¢ Carbamazepine ¢¢ Acamprosate ¢¢ Amphetamine- ¢¢ ¢¢ Carbidopa ¢¢ Dextroamphetamine ¢¢ Betaxolol ¢¢ Carbidopa-Levodopa ¢¢ Acebutolol ¢¢ Ampicillin ¢¢ ¢¢ Carbinoxamine ¢¢ Acetaminophen-Caffeine- ¢¢ Anagrelide ¢¢ Bexarotene capsule ¢¢ Carisoprodol ¢¢ Anakinra ¢¢ Bexarotene gel ¢¢ Carteolol ¢¢ Acetaminophen- ¢¢ Anastrozole ¢¢ ¢¢ Carvedilol tablet ¢¢ Acetazolamide ¢¢ Antipyrine- ¢¢ Bimatoprost ¢¢ Carvedilol suspension ¢¢ Acetic acid ¢¢ Apomorphine ACA Bisacodyl ¢¢ Cefaclor ¢¢ ¢¢ Apraclonidine ¢¢ Bisoprolol ¢¢ Cefadroxil ¢¢ Acetylcysteine ¢¢ Apremilast ¢¢ Bisoprolol-Hydrochlorothiazide ¢¢ Cefazolin ¢¢ Acitretin ¢¢ Aprepitant ¢¢ Boceprevir ¢¢ Cefdinir ¢¢ Acyclovir ¢¢ ¢¢ Bosentan ¢¢ Cefditoren ¢¢ Adalimumab ¢¢ Aripiprazole ¢¢ Bosutinib ¢¢ Cefixime ¢¢ Adapalene ¢¢ Armodafinil ¢¢ Brimonidine ophthalmic solution ¢¢ Cefpodoxime ¢¢ Adapalene-Benzoyl peroxide ¢¢ Artemether-Lumefantrine ¢¢ Brimonidine topical gel ¢¢ Cefprozil ¢¢ Adefovir ¢¢ Artificial tear ophthalmic ¢¢ Brimonidine-Timolol ¢¢ Ceftibuten ¢¢ Albendazole ¢¢ Asenapine ¢¢ Brinzolamide ¢¢ Cefuroxime ¢¢ Albuterol tablet ACA ¢¢ Bromfenac ¢¢ ¢¢ Albuterol 2mg/5ml syrup ¢¢ Aspirin-Extended release ¢¢ 0.8mg tablet ¢¢ Cephalexin ¢¢ Albuterol 0.083% dipyridamole ¢¢ Ceradroxil inhalation solution ¢¢ Bromocriptine 2.5mg tablet ¢¢ Atazanavir ¢¢ capsule ¢¢ Certolizumab ¢¢ Albuterol 0.5% ¢¢ Atenolol inhalation solution ¢¢ Budesonide inhalation ¢¢ Cevimeline ¢¢ Atenolol suspension ¢¢ Albuterol 1.25mg/3ml suspension ¢¢ Chlorambucil inhalation solution ¢¢ ¢¢ Budesonide 9mg tablet ¢¢ Chlordiazepoxide ¢¢ Albuterol 108mcg-actuation ¢¢ Atorvastatin ¢¢ ¢¢ Chlordiazepoxide-Clidinium inhaler ¢¢ ¢¢ patch ¢¢ ¢¢ Alcaftadine ¢¢ Atovaquone-Proguanil ¢¢ Buprenorphine sublingual tablet ¢¢ Chloroquine ¢¢ Alclometasone ¢¢ Atropine ¢¢ Buprenorphine- ¢¢ Chlorothiazide ¢¢ Alendronate ¢¢ Axitinib ¢¢ ¢¢ ¢¢ Alfuzosin ¢¢ Azathioprine TC Bupropion 150mg ¢¢ ¢¢ Aliskiren ¢¢ Azelaic sustained release tablet ¢¢ Chlorthalidone ¢¢ Alitretinoin ¢¢ Azelastine ¢¢ Buspirone ¢¢ ¢¢ Allopurinol ¢¢ Azelastine- ¢¢ Buspirone 5mg, 10mg tablet ACA Cholecalciferol ¢¢ Almotriptan ¢¢ Azilsartan ¢¢ Butalbital-Acetaminophen- ¢¢ Cholestyramine ¢¢ Alosetron ¢¢ Azithromycin Caffeine ¢¢ Choriogonadotropin alfa ¢¢ Alprazolam ¢¢ Azithromycin ophthalmic ¢¢ Butalbital-Aspirin-Caffeine ¢¢ ¢¢ Altretamine solution ¢¢ -- ¢¢ Benzocaine ¢¢ Aluminum acetate-Acetic acid ¢¢ Aztreonam ¢¢ Cilostazol ¢¢ Aluminum chloride B C ¢¢ Cimetidine ¢¢ Cabozantinib ¢¢ Alvimopan ¢¢ Bacitracin ¢¢ Cinacalcet ¢¢ Caffeine ¢¢ Amantadine ¢¢ Bacitracin-- ¢¢ Cincalcet 30 mg tablet Polymyxin B ¢¢ Calcipotriene ¢¢ Ambrisentan ¢¢ ¢¢ ¢¢ Calcipotriene-Betamethasone ¢¢ Amcinonide ¢¢ Ciprofloxacin- ¢¢ Balsalazide ¢¢ Calcitonin injection ¢¢ ¢¢ Ciprofloxacin-Hydrocortisone ¢¢ ¢¢ Calcitonin nasal spray ¢¢ Aminocaproic ¢¢ Citalopram ¢¢ Beclomethasone ¢¢ Calcitriol ¢¢ ¢¢ Belladonna-Opium ¢¢ Calcium acetate

¢ = Tier 1 ¢= Tier 2 ¢ = Tier 3 ¢ = Tier 4 ¢¢ Citalopram 20mg, 40mg tablet ¢¢ Denosumab 120 mg/1.7 ml ¢¢ suspension ¢¢ Estradiol Vaginal Ring ¢¢ Citric acid injection ¢¢ Dronabinol ¢¢ Estradiol Vaginal Tablet ¢¢ ¢¢ ¢¢ ¢¢ Estramustine ¢¢ Clemastine ¢¢ Desloratadine ¢¢ Duloxetine ¢¢ Estrogens conjugated ¢¢ Clindamycin ¢¢ Desmopressin ¢¢ Dutasteride ¢¢ Estropipate ¢¢ Clindamycin-Benzoyl peroxide ¢¢ Desonide ¢¢ Dyphylline ¢¢ Eszopiclone ¢¢ Desoximetasone ¢¢ Clindamycin-Tretinoin E ¢¢ Etanercept 25 mg injection ¢¢ Clobetasol ¢¢ Desvenlafaxine ¢¢ Echothiophate ¢¢ Etanercept 50 mg/ml injection ¢¢ Clocortolone ¢¢ Desvenlafaxine 100mg tablet ¢¢ ¢¢ Ethacrynic acid ¢¢ ¢¢ Dexamethasone ¢¢ Efavirenz ¢¢ Ethambutol ¢¢ Clonazepam ¢¢ Dexlansoprazole ¢¢ Efavirenz-Emtricitabine-Tenofovir HCR Ethinyl estradiol-Drospirenone ¢¢ Clonidine tablet ¢¢ Dexmethylphenidate ¢¢ Eletriptan HCR Ethinyl estradiol-Ethynodiol ¢¢ Clonidine suspension ¢¢ Dextroamphetamine ¢¢ Eltrombopag diacetate ¢¢ Clopidogrel ¢¢ - ¢¢ Elvitegravir-Cobicistat- ¢¢ Ethionamide ¢¢ Clorazepate HCR Diaphragm Emtricitabine-Tenofovir ¢¢ ¢¢ ¢¢ ¢¢ Emedastine ¢¢ ¢¢ Clotrimazole-Betamethasone ¢¢ ¢¢ ¢¢ Alcohol (Ethanol) 70% Lock ¢¢ ¢¢ ¢¢ Emtricitabine ¢¢ Etidronate ¢¢ Codeine ¢¢ Diclofenac gel ¢¢ Emtricitabine-Rilpivirine- ¢¢ ¢¢ Colchicine ¢¢ Dicloxacillin Tenofovir ¢¢ Etoposide ¢¢ Colchicine-Probenecid ¢¢ Dicyclomine ¢¢ Emtricitabine-Tenofovir ¢¢ Etravirine ¢¢ Colesevelam ¢¢ Didanosine ¢¢ Enalapril ¢¢ Everolimus ¢¢ Colestipol ¢¢ Diethylpropion ¢¢ Enalapril suspension ¢¢ Exemestane ¢¢ Collagenase ¢¢ Difenoxin-Atropine ¢¢ Enfuvirtide ¢¢ ACA Condoms: Female ¢¢ Diflorasone ¢¢ Enoxaparin ¢¢ Ezetimibe ACA Contraceptive sponge ¢¢ ¢¢ Entacapone ¢¢ Ezogabine ¢¢ Corticotropin ¢¢ Difluprednate ¢¢ Entecavir F ¢¢ Cortisone ¢¢ Digoxin ¢¢ Entecavir solution ¢¢ Famciclovir ¢¢ Crizotinib ¢¢ Digoxin solution ¢¢ ¢¢ Famotidine Suspension ¢¢ Cromolyn ¢¢ Dihydroergotamine ¢¢ Epinastine ¢¢ Febuxostat ¢¢ ¢¢ ¢¢ Epinephrine ¢¢ Felbamate ¢¢ Cyclobenzaprine ¢¢ Dimethyl fumarate ¢¢ Epinephrine injection ¢¢ ¢¢ Cyclophosphamide ¢¢ -- ¢¢ Eplerenone ¢¢ Fenofibrate ¢¢ Cycloserine Aluminum hydroxide- ¢¢ Epoetin ¢¢ Fenoprofen hydroxide- ¢¢ Eprosartan ¢¢ ¢¢ Cyclosporine ophthalmic and Simethicone solution ¢¢ Ergocalciferol ACA Ferrous sulfate ¢¢ Diphenoxylate-Atropine ¢¢ Cyclosporine capsule (by prescription/legend) ¢¢ ¢¢ Dipyridamole ¢¢ ACA Ergocalciferol (over the counter) ¢¢ Fidaxomicin ¢¢ ¢¢ Cysteamine ¢¢ ¢¢ Filgrastim injection ¢¢ Disopyramide controlled release ¢¢ Ergotamine ¢¢ Filgrastim Solution Prefilled D ¢¢ ¢¢ Dabigatran ¢¢ Ergotamine-Caffeine Syringe ¢¢ Divalproex ¢¢ Dalfampridine ¢¢ Erlotinib ¢¢ Finasteride ACA Docusate sodium ¢¢ Danazol ¢¢ Erythromycin tablet, ophthalmic ¢¢ Fingolimod ¢¢ ¢¢ Dantrolene ointment, topical solution ¢¢ ¢¢ Dolasetron ¢¢ ¢¢ Erythromycin suspension ¢¢ ¢¢ Dolutegravir ¢¢ ¢¢ Escitalopram ¢¢ ¢¢ Donepezil ¢¢ ¢¢ Esomeprazole ¢¢ ¢¢ Dornase ¢¢ Darunavir ¢¢ Esterified estrogens ¢¢ Fludrocortisone ¢¢ Dorzolamide ¢¢ Dasatinib ¢¢ Esterified estrogens- ¢¢ Fluocinolone ¢¢ Dorzolamide-Timolol Methyltestosterone ¢¢ Deferasirox ¢¢ Fluocinonide ¢¢ Doxazosin ¢¢ Esterified estrogens- ¢¢ Deferiprone ¢¢ Fluorometholone suspension ¢¢ Methyltestosterone ¢¢ Delavirdine ¢¢ Fluorouracil ¢¢ Doxepin 1.2mg-2.5mg tablet ¢¢ Demeclocycline ¢¢ Fluorouracil 1% cream ¢¢ Doxercalciferol ¢¢ Estradiol ¢¢ Denosumab 60 mg/ml injection ¢¢ Estradiol 0.5mg tablet ¢¢ Doxycycline (continues on next page)

ACA = Affordable Care Act drugs HCR = Health Care Reform drugs PAH = Only for Pulmonary Arterial Hypertension TC = Tobacco Cessation (continued) H ¢¢ Ipratropium-Albuterol ¢¢ Lidocaine- ¢¢ Fluorouracil/Diclofenac Sodium ¢¢ Halcinonide ¢¢ Irbesartan ¢¢ Lidocaine-Tetracaine 5%/1% Topical Cream ¢¢ Halobetasol ¢¢ ¢¢ Linaclotide ¢¢ ¢¢ ¢¢ Isocarboxazid ¢¢ ¢¢ Fluoxymesterone ¢¢ Heparin ¢¢ Isoniazid ¢¢ Lindane ¢¢ Fluphenazine ¢¢ Hexachlorophene ¢¢ Isoniazid-Rifampin ¢¢ Linezolid ¢¢ Flurandrenolide ¢¢ Hydralazine ¢¢ Isosorbide dinitrate ¢¢ Liothyronine ¢¢ ¢¢ Hydralazine 10mg, 25mg tablet ¢¢ Isosorbide Mononitrate 30mg, ¢¢ Liotrix ¢¢ ¢¢ Hydrochlorothiazide 25mg tablet 60mg extended release tablet ¢¢ ¢¢ Fluticasone ¢¢ Hydrochlorothiazide ¢¢ Isosorbide Mononitrate ¢¢ Lisdexamfetamine ¢¢ Fluticasone- ¢¢ -Acetaminophen ¢¢ Isotretinoin ¢¢ Lisinopril ¢¢ Fluticasone- ¢¢ Hydrocodone-Chlorpheniramine ¢¢ ¢¢ Lisinopril suspension, 30mg ¢¢ Fluvastatin ¢¢ Hydrocodone-Homatropine ¢¢ tablet ¢¢ Fluvoxamine ¢¢ Hydrocortisone ¢¢ Itraconazole solution ¢¢ Lisinopril-Hydrochlorothiazide tablet ¢¢ Folic acid solution ¢¢ Hydrocortisone-Acetic acid- ¢¢ ¢¢ Lithium carbonate ACA Folic acid 400mcg, 800mcg Propylene glycol ¢¢ tablet ¢¢ ¢¢ Ixazomib citrate ¢¢ Lithium citrate ¢¢ Hydroxychloroquine ¢¢ ¢¢ K ¢¢ Fosamprenavir ¢¢ Hydroxyurea ¢¢ ¢¢ Lomitapide ¢¢ Fosfomycin ¢¢ Hydroxyzine ¢¢ ¢¢ Lomustine ¢¢ Fosinopril I ¢¢ ¢¢ Lopinavir-Ritonavir ¢¢ Frovatriptan ¢¢ Ibandronate ¢¢ L ¢¢ Losartan ¢¢ ¢¢ ¢¢ Labetalol ¢¢ Losartan-Hydrochlorothiazide ¢¢ Furosemide solution ¢¢ Icatibant ¢¢ ¢¢ Loteprednol G ¢¢ Icosapent ¢ ¢ Lactic acid-Ammonium ¢ ¢¢ ¢¢ Idelalisib hydroxide ¢ Lovastatin ¢ ¢¢ ¢¢ Iloperidone ¢¢ Lactulose ¢ Loxapine ¢ ¢¢ Galantamine ¢¢ Iloprost ¢¢ Lamivudine ¢ Lubiprostone ¢ ¢¢ Ganciclovir ophthalmic ¢¢ Imatinib ¢¢ Lamivudine-Zidovudine ¢ Lurasidone ¢¢ Gatifloxacin ¢¢ ¢¢ M ¢¢ Gefitinib ¢¢ Imiquimod ¢¢ Lansoprazole ¢¢ Mafenide ¢¢ Gemfibrozil ¢¢ ¢¢ ACA Magnesium citrate ¢¢ Gemifloxacin ¢¢ Indapamide ¢¢ Lapatinib ¢¢ ¢¢ Gentamicin ¢¢ Indinavir ¢¢ Latanoprost ¢¢ Maprotiline ¢¢ Gentamicin-Prednisolone ¢¢ Indomethacin ¢¢ Ledipasvir-Sofosbuvir ¢¢ Maraviroc ¢¢ Glatiramer ¢¢ Ingenol ¢¢ Leflunomide ¢¢ Mecasermin ¢¢ ¢¢ aspart ¢¢ Lenalidomide ¢¢ Meclofenamate ¢¢ ¢¢ ¢¢ Letrozole ¢¢ Medroxyprogesterone ¢¢ Glipizide extended release tablet ¢¢ ¢¢ Leucovorin ¢¢ ¢¢ Glipizide- ¢¢ ¢¢ Levalbuterol ¢¢ ¢¢ Glucagon ¢¢ Insulin isophane ¢¢ ¢¢ Megestrol ¢¢ Glyburide ¢¢ Insulin isophane-Insulin regular ¢¢ Levobunolol ¢¢ Meloxicam ¢¢ Glyburide-Metformin 70/30 ¢¢ Levocarnitine ¢¢ Melphalan ¢¢ Glycerol phenylbutyrate ¢¢ ¢¢ Levocetirizine ¢¢ Memantine ¢¢ Glycopyrrolate ¢¢ Insulin regular ¢¢ ¢¢ Mepenzolate ¢¢ Golimumab ¢¢ Insulin regular 500u/ml HCR Levonorgestrel ¢¢ ¢¢ Granisetron ¢¢ Interferon alfa-2b HCR Levonorgestrel-Ethinyl ¢¢ Mercaptopurine ¢¢ ¢¢ Interferon beta-1a estradiol ¢¢ Mesalamine enema ¢¢ Guaifenesin-Codeine ¢¢ Interferon beta-1b ¢¢ ¢¢ Mesalamine tablet ¢¢ Guanfacine 1 mg tablet ¢¢ Interferon gamma-1b ¢¢ Levothyroxine ¢¢ Metaproterenol ¢¢ Guanfacine 2 mg tablet ¢¢ Iodoquinol-Hydrocortisone ¢¢ Lidocaine ¢¢ Metaxalone ¢¢ Guanfacine ¢¢ Ipratropium nasal solution ¢¢ Lidocaine-Aluminum hydroxide- ¢¢ Metformin sustained release tablet ¢¢ Ipratropium inhalation solution - ¢¢ Metformin 750 mg sustained ¢¢ Guanidine ¢¢ Ipratropium inhaler Simethicone release tablet

¢ = Tier 1 ¢= Tier 2 ¢ = Tier 3 ¢ = Tier 4 ¢¢ ¢¢ Mupirocin topical ointment HCR Norethindrone 0.35mg tablet ACA Polyethylene glycol-Sodium ¢¢ Methamphetamine ¢¢ Mycophenolate ¢¢ Norethindrone bicarbonate- ¢¢ Methazolamide N HCR Norethindrone-Estradiol- ACA Polyethylene glycol-Potassium ¢¢ Methenamine hippurate ¢¢ Nabilone Ferrous Fumarate chloride-Sodium bicarbonate- Sodium chloride-Sodium sulfate ¢¢ Methimazole ¢¢ Nabumetone HCR Norethindrone-Ethinyl ¢¢ Pegfilgrastim ¢¢ Methocarbamol ¢¢ Nadolol Estradiol ¢¢ Peginterferon alfa-2a ¢¢ Methotrexate ¢¢ Nafarelin ¢¢ Norfloxacin ¢¢ Peginterferon alfa-2b ¢¢ Methscopolamine ¢¢ HCR Norgestimate-Ethinyl estradiol ¢¢ ¢¢ Peginterferon alfa-2b 296 mcg, ¢¢ Methsuximide ¢¢ Naloxone 444 mcg, 888 mcg kit ¢¢ Methyclothiazide ¢¢ ¢¢ Nortriptyline 10mg, 25mg capsule ¢¢ Pegvisomant ¢¢ Methyldopa ¢¢ Naphazoline ¢¢ ¢¢ Penbutolol ¢¢ Methyldopa 500mg tablet ¢¢ ¢¢ Nystatin- ¢¢ Penciclovir ¢¢ Methylergonovine ¢¢ Naratriptan ¢¢ Penicillamine ¢¢ Methylnaltrexone ¢¢ O ¢¢ Octreotide ¢¢ ¢¢ Methylphenidate ¢¢ ¢¢ ¢¢ Pentafluoropropane- ¢¢ Methylprednisolone ¢¢ Nebivolol ¢¢ Olanzapine Tetrafluoroethane ¢¢ Methyltestosterone ¢¢ ¢¢ Olmesartan ¢¢ ¢¢ Metipranolol ¢¢ Nefazodone ¢¢ inhalation solution ¢¢ Pentosan ¢¢ Metoclopramide ¢¢ Nelfinavir ¢¢ Olopatadine nasal ¢¢ Pentoxifylline ¢¢ Metolazone ¢¢ Neomycin ¢¢ Olopatadine ophthalmic ¢¢ Perindopril ¢¢ Metoprolol succinate ¢¢ Neomycin-Bacitracin- ¢¢ Olsalazine ¢¢ ¢¢ Metoprolol tartrate Polymyxin B ¢¢ Omacetaxine ¢¢ Perphenazine ¢¢ Metoprolol tartrate suspension ¢¢ Neomycin-Colistin- ¢¢ Omega-3-Acid ¢¢ ¢¢ Hydrocortisone-Thonzonium ¢¢ Omeprazole ¢¢ Phenelzine ¢¢ ¢¢ Neomycin-Fluocinolone ¢¢ Omeprazole-Sodium bicarbonate ¢¢ ¢¢ Midazolam ¢¢ Neomycin-Polymyxin B- Dexamethasone ¢¢ Ondansetron ¢¢ Phenoxybenzamine ¢¢ Midodrine ¢¢ Neomycin-Polymyxin B- ¢¢ Oprelvekin ¢¢ Phentermine ¢¢ Mifepristone Gramicidin ¢¢ ¢¢ Phenylephrine ¢¢ ¢¢ Neomycin-Polymyxin B- ¢¢ Oseltamivir capsule ¢¢ Phenylepherine-- ¢¢ Miglustat Codeine Hydrocortisone otic suspension ¢¢ Oseltamivir suspension ¢¢ Milnacipran ¢¢ Phenazoptridine ¢¢ Neomycin-Polymyxin B- ¢¢ Oxandrolone ¢¢ Hydrocortisone topical cream ¢¢ ¢¢ Oxaprozin ¢¢ ¢¢ Nepafenac ¢¢ Phytonadione ¢¢ Oxazepam ¢¢ Mipomersen ¢¢ Nevirapine ¢¢ Pilocarpine ¢¢ ¢¢ ¢¢ ¢¢ Pimecrolimus ¢¢ ¢¢ Mirtazapine TC Nicotine ¢¢ ¢¢ ¢¢ Misoprostol ¢¢ Nicotine inhaler ¢¢ Pindolol ¢¢ ¢¢ Mitotane ¢¢ ¢¢ ¢¢ Oxycodone ¢¢ Modafinil ¢¢ Nilotinib controlled release tablet ¢¢ Piroxicam ¢¢ Moexipril ¢¢ ¢¢ Oxycodone-Acetaminophen ¢¢ Pitavastatin ¢¢ inhaler ¢¢ solution ¢¢ Oxycodone-Aspirin ¢¢ Podofilox ¢¢ Mometasone topical ¢¢ Nimodipine ¢¢ Oxycodone-Ibuprofen ¢¢ Polyethylene glycol-electrolyte solution 100gm ¢¢ Mometasone-Formoterol ¢¢ ¢¢ Oxymetholone ¢¢ ¢¢ Nitazoxanide ¢¢ Polyethylene glycol-electrolyte ¢¢ solution 240gm ¢¢ extended release ¢¢ Nitisinone tablet, solution P ¢¢ Polymyxin B-Trimethoprim ¢¢ Nitrofurantoin ¢¢ Palbociclib ¢¢ Morphine tablet, suppository ¢¢ Pomalidomide ¢¢ Nitrofurantoin 25mg capsule ¢¢ Pancrelipase ¢¢ Morphine-Naltrexone ¢¢ ¢¢ Nitroglycerin 0.3mg/hr patch ¢¢ Pancrelipase 5000unit capsule ¢¢ Moxifloxacin ¢¢ Potassium aminobenzoate ¢¢ Nitroglycerin ¢¢ Pantoprazole ¢¢ Moxifloxacin ophthalmic capsule, ointment, patch ¢¢ Potassium bicarbonate ¢¢ Paricalcitol solution ¢¢ Nitroglycerin rectal ointment ¢¢ Potassium chloride ¢¢ Paroxetine ¢¢ Multivitamin-Fluoride ¢¢ Nitroglycerin sublingual tablet ¢¢ Potassium citrate ¢¢ Paroxetine 10mg, 20mg tablet ¢¢ Multivitamin-Iron-Fluoride ¢¢ Nizatidine ¢¢ Potassium citrate-Citric acid ¢¢ Pasireotide ¢¢ Mupirocin nasal ointment ACA Nonoxynol-9 ¢¢ ¢¢ Pazopanib (continues on next page)

ACA = Affordable Care Act drugs HCR = Health Care Reform drugs PAH = Only for Pulmonary Arterial Hypertension TC = Tobacco Cessation (continued) ¢¢ Rifabutin ¢¢ ¢¢ Temazepam ¢¢ Povidone-Iodine ¢¢ Rifampin ¢¢ Sodium phenylbutyrate ¢¢ Temozolomide ¢¢ ¢¢ Rifapentine ¢¢ Sodium phenylbutyrate tablet ¢¢ Tenofovir ¢¢ ¢¢ Rifaximin ¢¢ Sodium phosphate ¢¢ Terazosin ¢¢ Pramoxine-Hydrocortisone ¢¢ Rilonacept ACA Sodium phosphate solution ¢¢ ¢¢ Prasugrel ¢¢ Rilpivirine ¢¢ Sodium picosulfate-Magnesium ¢¢ ¢¢ Pravastatin ¢¢ ¢¢ Sodium polystyrene ¢¢ ¢¢ Praziquantel ¢¢ Rimantadine ¢¢ Sofosbuvir ¢¢ Teriflunomide ¢¢ Prazosin ¢¢ Rimexolone ¢¢ Sofosbuvir-Velpatasvir ¢¢ Teriparatide ¢¢ Prednicarbate ¢¢ Risedronate 5 mg tablet ¢¢ ¢¢ Tesamorelin 1 ¢¢ Prednisolone ¢¢ Risedronate 35 mg tablet ¢¢ Somatropin ¢¢ Testosterone 1 ¢¢ Prednisolone 0.12% ophthalmic ¢¢ Risperidone ¢¢ Somatropin ¢¢ Tetrabenazine 1 ¢¢ Prednisolone 1% ophthalmic ¢¢ Ritonavir ¢¢ Somatropin ¢¢ ¢¢ Prednisone ¢¢ Rivaroxaban ¢¢ Sorafenib ¢¢ Thalidomide ¢¢ ¢¢ Rivastigmine ¢¢ ¢¢ ¢¢ Primaquine ¢¢ Rizatriptan ¢¢ Sotalol 80 mg tablet ¢¢ Thioguanine ¢¢ ¢¢ ¢¢ ¢¢ ¢¢ Probenecid ¢¢ Ropinirole ¢¢ Spironolactone ¢¢ Thiothixene ¢¢ Procarbazine ¢¢ ¢¢ Spironolactone 25mg tablet ¢¢ Thyroid ¢¢ Prochlorperazine ¢¢ Rosuvastatin ¢¢ Spironolactone- ¢¢ Tiagabine Hydrochlorothiazide ¢¢ Progesterone ¢¢ ¢¢ Ticagrelor ¢¢ Stavudine ¢¢ Promethazine ¢¢ Ruxolitinib ¢¢ Ticlopidine ¢¢ Sterile water for irrigation ¢¢ Promethazine-Codeine S ¢¢ Timolol ¢¢ Sacubitril/Valsartan solution ¢¢ Tinidazole ¢¢ Promethazine-Phenylephrine ¢¢ Succimer ¢¢ ¢¢ Salsalate ¢¢ Tiotropium ¢¢ Saquinavir ¢¢ Sucralfate tablet ¢¢ Tipranavir ¢¢ ¢¢ Sucralfate suspension ¢¢ Propylthiouracil ¢¢ ¢¢ Tizanidine ¢¢ Scopolamine ¢¢ ¢¢ Tobramycin ¢¢ Protriptyline ¢¢ Sulfacetamide ¢¢ Pyrazinamide ¢¢ Secukinumab ¢¢ Tobramycin ophthalmic ¢¢ Sulfacetamide-Prednisolone ointment ¢¢ Pyridostigmine ¢¢ Selegiline ¢¢ Sulfadiazine ¢¢ Tobramycin-dexamethasone ¢¢ Pyrimethamine ¢¢ Selegiline patch ¢¢ Selenium ¢¢ Sulfamethoxazole- ¢¢ Tofacitinib Trimethoprim Q ¢¢ ¢¢ ¢¢ Sulfasalazine ¢¢ Quetiapine ¢¢ Sertraline ¢¢ ¢¢ Sulindac ¢¢ Quetiapine ¢¢ Sevelamer ¢¢ Tolcapone extended release tablet ¢¢ Sumatriptan ¢¢ PAH Sildenafil ¢¢ Tolmetin ¢ ¢¢ Sunitinib ¢ Quinapril ¢¢ Silodosin ¢¢ ¢ ¢ Quinidine ¢¢ Silver sulfadiazine T ¢¢ Tolvaptan ¢ ¢¢ Tacrolimus ¢ Quinine ¢¢ Silver nitrate-Potassium ¢¢ ¢¢ Tafluprost R ¢¢ Simvastatin ¢¢ Toremifene ¢¢ Rabeprazole ¢¢ ACA Tamoxifen 10 mg tablet ¢¢ Sinecatechins ¢¢ Torsemide ¢¢ ACA Raloxifene ACA Tamoxifen ¢¢ Sirolimus ¢¢ ¢¢ Raltegravir ¢¢ Tamsulosin ¢¢ ¢¢ Trandolapril ¢¢ Ramelteon ¢¢ ¢¢ Sodium chloride ¢¢ Tranylcypromine ¢¢ Ramipril ¢¢ Tazarotene ¢¢ Sodium citrate-Citric acid ¢¢ Travoprost ¢¢ Ranitidine ¢¢ Tazarotene 0.1% cream ¢ ¢¢ Trazodone ¢ ¢ ACA 0.25mg, ¢ 0.5mg, 1mg chewable tablet ¢¢ Tedizolid ¢¢ Tretinoin ¢¢ Rasagiline ¢¢ ACA Sodium fluoride ¢¢ Teduglutide ¢¢ Triamcinolone ¢¢ Regorafenib 0.25mg/drop solution ¢¢ Telaprevir ¢¢ Triamcinolone-LCD ¢¢ ¢¢ ACA Sodium fluoride ¢¢ Telithromycin ¢¢ ¢¢ Ribavirin 0.55mg/drop, ¢¢ Telmisartan 1.1mg/ml solution 1 Some drugs fall in different tiers depending on the strength and dosage form. Check the online formulary at kp.org/formulary for the most up-to-date information.

¢ = Tier 1 ¢= Tier 2 ¢ = Tier 3 ¢ = Tier 4 (continued) ¢¢ Triamterene- Hydrochlorothiazide ¢¢ Triazolam ¢¢ Trientine ¢¢ ¢¢ Trifluridine ¢¢ Trihexyphenidyl ¢¢ Trimethobenzamide ¢¢ Trimethoprim ¢¢ Trimipramine ¢¢ Trivitamin-Fluoride ¢¢ Trospium U ¢¢ Ulipristal ¢¢ ¢¢ Ursodiol ¢¢ Ustekinumab V ¢¢ Valacylovir ¢¢ Valganciclovir solution ¢¢ Valganciclovir tablet ¢¢ ¢¢ Valproic acid ¢¢ Valsartan ¢¢ Vancomycin TC Varenicline ¢¢ Vemurafenib ¢¢ Venlafaxine ¢¢ ¢¢ Verapamil sustained release tablet, suspension ¢¢ Vigabatrin ¢¢ Vilazodone ¢¢ Vismodegib ¢¢ ¢¢ Vorinostat W ¢¢ Warfarin

Z ¢¢ ¢¢ ¢¢ Zanamivir ¢¢ Zidovudine ¢¢ ¢¢ Ziprasidone ¢¢ Zolmitriptan ¢¢ ¢¢ NONDISCRIMINATION NOTICE Kaiser Foundation Health Plan, Inc. (Kaiser Health Plan) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We also:

• Provide free aids and services to people with disabilities to communicate effectively with us, such as: • Qualified sign language interpreters • Written information in other formats, such as large print, audio, and accessible electronic formats

• Provide free language services to people whose primary language is not English, such as: • Qualified interpreters • Information written in other languages

If you need these services, call 1-800-966-5955 (TTY: 711)

If you believe that Kaiser Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by mail or phone at:

Membership Services Attn: Kaiser Civil Rights Coordinator 711 Kapiolani Blvd Honolulu, HI 96813 1-800-966-5955

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 1-800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. ______HELP IN YOUR LANGUAGE ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800-966-5955 (TTY: 711). Cebuano (Bisaya) ATENSYON: Kung nagsulti ka og Cebuano, aduna kay magamit nga mga serbisyo sa tabang sa lengguwahe, nga walay bayad. Tawag sa 1-800-966-5955 (TTY: 711). 中文 (Chinese) 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-966-5955（TTY：711）。

60577110_ACA_1557_MarCom_HI_2017_Taglines NONDISCRIMINATION NOTICE Kaiser Foundation Health Plan, Inc. (Kaiser Health Plan) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We also:

• Provide free aids and services to people with disabilities to communicate effectively with us, such as: • Qualified sign language interpreters • Written information in other formats, such as large print, audio, and accessible electronic formats

• Provide free language services to people whose primary language is not English, such as: • Qualified interpreters • Information written in other languages

If you need these services, call 1-800-966-5955 (TTY: 711)

If you believe that Kaiser Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by mail or phone at:

Membership Services Attn: Kaiser Civil Rights Coordinator 711 Kapiolani Blvd Honolulu, HI 96813 1-800-966-5955

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 1-800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. ______HELP IN YOUR LANGUAGE ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800-966-5955 (TTY: 711). Cebuano (Bisaya) ATENSYON: Kung nagsulti ka og Cebuano, aduna kay magamit nga mga serbisyo sa tabang sa lengguwahe, nga walay bayad. Tawag sa 1-800-966-5955 (TTY: 711). 中文 (Chinese) 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-966-5955（TTY：711）。 Chuuk (Chukese) MEI AUCHEA: Ika iei foosun fonuomw: Foosun Chuuk, iwe en mei tongeni omw kopwe angei aninisin chiakku, ese kamo. Kori 1-800-966-5955 (TTY: 711). 60577110_ACA_1557_MarCom_HI_2017_Taglines ʻŌlelo Hawaiʻi (Hawaiian) E NĀNĀ MAI: Inā hoʻopuka ʻoe i ka ʻōlelo Hawaiʻi, hiki iā ʻoe ke loaʻa i ke kōkua manuahi. E kelepona i ka helu 1-800-966-5955 (TTY: 711). Iloko (Ilocano) PAKDAAR: No agsasaoka iti Ilokano, dagiti awan bayadna a serbisio a para iti beddeng ti lengguahe ket sidadaan para kenka. Awagan ti 1-800-966-5955 (TTY: 711) 日本語 (Japanese) 注意事項：日本語を話される場合、無料の言語支援をご利用い ただけます。1-800-966-5955（TTY: 711）まで、お電話にてご連絡ください。 한국어 (Korean) 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-966-5955 (TTY: 711) 번으로 전화해 주십시오. ລາວ (Laotian) ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ ້ າພາສາ ລາວ, ການບໍລິການຊ່ວຍເຫ ອດ້ານພາສາ, ໂດຍບໍ່ ເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ 1-800-966-5955 (TTY: 711). Kajin Majōḷ (Marshallese) LALE: Ñe kwōj kōnono Kajin Ṃajōḷ, kwomaroñ bōk jerbal in jipañ ilo kajin ṇe aṃ ejjeḷọk wōṇāān. Kaalọk 1-800-966-5955 (TTY: 711). Naabeehó (Navajo) Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bee áká’ánída’áwo’dé̖ é̖ ’, t’áá jiik’eh, éí ná hóló̖ , koji̖ ’ hódíílnih 1-800-966-5955 (TTY: 711). Lokaiahn Pohnpei (Pohnpeian) MEHN KAIR: Ma komw kin lokiaiahn Pohnpei, wasahn sawas en palien lokaia kak sawas ni sohte isais. Koahl nempe 1-800-966-5955 (TTY: 711). Faa-Samoa (Samoan) MO LOU SILAFIA: Afai e te tautala Gagana fa'a Sāmoa, o loo iai auaunaga fesoasoani, e fai fua e leai se totogi, mo oe, Telefoni mai: 1-800-966-5955 (TTY: 711). Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-966-5955 (TTY: 711). Tagalog (Tagalog) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-966-5955 (TTY: 711). Lea Faka-Tonga (Tongan) FAKATOKANGA’I: Kapau ‘oku ke Lea Faka-Tonga, ko e kau tokoni fakatonu lea ‘oku nau fai atu ha tokoni ta’etotongi, pea teke lava ‘o ma’u ia. Telefoni mai 1-800-966-5955 (TTY: 711). Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-966-5955 (TTY: 711).

60577110_ACA_1557_MarCom_HI_2017_Taglines