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glumet Kaiser Permanente Commercial HMO Drug Exclusion List The following is a list of drugs and drug entities that are excluded from prescription benefit coverage. Prior authorization will not apply. Kasier Permanente reserves the right to exclude any drug at any time from the Kaiser Permanente Colorado Formulary for health and safety concerns or other reasons as determined by Kaiser Permanente at its discretion. If you have questions about the formulary status of a medication, or your prescription benefits, please call our Member Services Department at 1-888-681-7878 (toll free). For the hearing or speech impaired: 1-800- 521-4874 (toll free TTY). This list is subject to change at any time. EXCLUSION CRITERIA: o Drugs and supplies for cosmetic purposes o Drugs for the promotion, prevention, or other treatment of hair loss or growth o Drugs related to non-covered services o Drugs to enhance athletic performance Drugs to shorten the duration of the common cold o Drugs to treat infertility* o Drugs to treat sexual dysfunction* o o Drugs used in the treatment of weight management* o Medical supplies such as dressings and antiseptics o Nonprescription drugs, unless otherwise noted o Packaging of drugs other than the dispensing pharmacy’s standard packaging o Prescription drugs for which there is a nonprescription equivalent available, unless otherwise noted o Prescriptions filled at a non-plan pharmacy, except for emergencies as described in your EOC o Replacement of lost, stolen or damaged prescription drugs and/or devices o Vaccines (usually covered under medical) o Vitamins and nutritional supplements that can be purchased without a prescription o Medical service drugs o Any drug being used for a non-approved indication o Medical foods and medical devices *Drug Category is excluded unless your plan has a buy-up for that benefit Kaiser Permanente Commercial HMO Drug Exclusion List Listed are items that are excluded from prescription benefit coverage. All of the excluded drug entities, strengths, formulations &/or package sizes may not be listed. The list is not all inclusive and is subject to change. Office administered drugs and IV drugs are covered under the Medical benefit and excluded from being dispensed from retail pharmacy. EXCLUDED DRUGS EXCLUDED DRUGS 1ST GENERATION ANTIHISTAMINE-DECONGESTANT- APPTRIM-D (ORAL) ANALGESIC COMBINATIONS (ORAL) 1ST GENERATION ANTIHISTAMINE-DECONGESTANT- ARIPIPRAZOLE LAUROXIL (INJ) ANALGESIC, SALICYLATE (ORAL) 1ST GENERATION ANTIHISTAMINE-DECONGESTANT- AVAILNEX (ORAL) ANALGESIC-EXPECTORANT COMBINATIONS (ORAL) 1ST GENERATION ANTIHISTAMINE-DECONGESTANT- AXONA (ORAL) EXPECTORANT COMBINATIONS (ORAL) BENZPHETAMINE HCL (ORAL) (3) 1ST GENERATION ANTIHISTAMINE-DECONGESTANT- NSAID, COX NONSPECIFIC (ORAL) BETAMETHASONE SOD PHOSPHATE & ACETATE (KIT) 2'-FUCOSYLLACTOSE, LACTO-N-NEOTETRAOSE (ORAL) BETAQUIK (ORAL) 2ND GENERATION ANTIHISTAMINE (ORAL) BIMATOPROST (TOPICAL) 2ND GENERATION ANTIHISTAMINE-DECONGESTANT (ORAL) BOTOX COSMETIC (INJ) ACANYA GEL (TOPICAL) BROMPHENIRAMINE-ACETAMINOPHEN (ORAL) ACETAMINOPHEN-GUAIFENESIN (ORAL) BULK PRODUCTS * ACETIC ACID (IRRIGATION) BUPRENORPHINE HCL (KIT) ACRIVASTINE & PSEUDOEPHEDRINE (ORAL) CAMPHOR (INH) ACTIVE-PAC/GABAPENTIN THPK (PACK) CAMPHOR-EUCALYPTUS-MENTHOL (INH) ACYCLOVIR-HYDROCORTISONE (TOPICAL) CAPXIB (KIT) ADASUVE (INH) CARDIOTEK RX (ORAL) ADDYI (ORAL) (2) CARISOPRODOL (ORAL) ALLEGRA (ORAL) CARISOPRODOL W/ ASPIRIN & CODEINE (ORAL) ALLEGRA-D (ORAL) CARISOPRODOL W/ ASPIRIN (ORAL) ALPROSTADIL (INJ) (2) CATHETERS (DEVICE) ANALGESIC, NON-SALICYLATE-1ST GENERATION ANTIHISTAMINE (ORAL) CAVERJECT (INJ) (2) ANALGESIC, NON-SALICYLATE-EXPECTORANT COMBINATIONS (ORAL) CELECOXIB-CAPSAICIN-MENTHOL (KIT) ANALGESICS, MIXED-1ST GENERATION CETIRIZINE HCL (ORAL) ANTIHISTAMINE (ORAL) ANTITUSSIVES, NON-NARCOTIC (ORAL) CETRORELIX ACETATE (KIT) (1) CHLORHEXIDINE GLUCONATE-MUPIROCIN- APPTRIM (ORAL) DIMETHICONE-SILICONE (KIT) (1)(2)(3) Drug Category is excluded unless your plan has a buy-up for that benefit (1) Infertility Drug Category; (2) Sexual Dysfunction Drug Category; (3) Weight Loss Drug Category KPCO Commercial HMO Drug Exclusion List Page 2 of 9 Revision date: April 2018 Kaiser Permanente Commercial HMO Drug Exclusion List Listed are items that are excluded from prescription benefit coverage. All of the excluded drug entities, strengths, formulations &/or package sizes may not be listed. The list is not all inclusive and is subject to change. Office administered drugs and IV drugs are covered under the Medical benefit and excluded from being dispensed from retail pharmacy. EXCLUDED DRUGS EXCLUDED DRUGS CHLORPHENIRAMINE-ACETAMINOPHEN (ORAL) DEPLIN (ORAL) CHLORPHENIRAMINE-PHENYLEPHRINE- DERMACINRX SILAPAK (KIT) ACETAMINOPHEN (ORAL) CHLORPHENIRAMINE-PHENYLEPHRINE-ASPIRIN DERMACINRX TICANASE (NASAL) (ORAL) CHLORPHENIRAMINE-PHENYLEPHRINE-IBUPROFEN DERMAPAK PAK PLUS (TOPICAL) (ORAL) CHLORPHENIRAMINE-PSEUDOEPHEDRINE-IBUPROFEN DERMASORB HC (KIT) (ORAL) DERMASORB TA (KIT) CHORIOGONADOTROPIN ALFA (INJ) (1) DESLORATADINE (ORAL) CHORIONIC GONADOTROPIN (INJ) (1) DESLORATADINE-PSEUDOEPHEDRINE (ORAL) CIALIS (ORAL) (2) DEXBROMPHENIRAMINE-ACETAMINOPHEN (ORAL) CICLOPIROX (KIT) DEXBROMPHENIRAMINE-PHENYLEPHRINE- CICLOPIROX-UREA (PACK) ACETAMINOPHEN (ORAL) DEXLIDO (KIT) CLIN SINGLE USE (KIT) CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE & DEXLIDO-M (KIT) MOISTURIZER (KIT) DEXTROMETHORPHAN (ORAL) CLINDAMYCIN PHOSPHATE-TRETINOIN (TOPICAL) DEXTROMETHORPHAN-BENZOCAINE (ORAL) CLINDAREACH (KIT) DEXTROMETHORPHAN-BENZOCAINE-MENTHOL (ORAL) CLODAN KIT (TOP) DEXTROMETHORPHAN-MENTHOL (ORAL) CLOMIPHENE CITRATE (ORAL) (1) DICLOFENAC SODIUM & ADHESIVE SHEETS (PACK) COSMETIC PRODUCTS * DICLOFENAC SODIUM & OCCLUSIVE DRESSING COUGH AND/OR COLD PREPARATIONS (ORAL) (TOPICAL) DICLOFENAC SODIUM & RANITIDINE HCL & CYANOCOBALAMIN (KIT) LIDOCAINE-PRILOCAINE (PACK) DICLOFENAC SODIUM (KIT) CYCLOBENZAPRINE HCL W/ LINIMENT (KIT) DICLOFENAC SODIUM-BENZALKONIUM CHLORIDE CYCLOBENZAPRINE-CAPSAICIN-MENTHOL (PACK) (PACK) DECONGESTANT-ANALGESIC, NON-SALICYLATE DICLOFENAC SODIUM-CAMPHOR-MENTHOL-METHYL COMBINATIONS (ORAL) SALICYLATE (KIT) DECONGESTANT-ANALGESIC-EXPECTORANT DICLOFENAC SODIUM-CAPSAICIN (PACK) COMBINATIONS (ORAL) DECONGESTANT-EXPECTORANT COMBINATIONS DICLOFENAC SODIUM-CAPSAICIN (TOPICAL) (ORAL) DICLOFENAC SODIUM-RANITIDINE HCL-CAPSAICIN DECONGESTANT-NSAID, COX NON-SPECIFIC (PACK) COMBINATIONS (ORAL) (1)(2)(3) Drug Category is excluded unless your plan has a buy-up for that benefit (1) Infertility Drug Category; (2) Sexual Dysfunction Drug Category; (3) Weight Loss Drug Category KPCO Commercial HMO Drug Exclusion List Page 3 of 9 Revision date: April 2018 Kaiser Permanente Commercial HMO Drug Exclusion List Listed are items that are excluded from prescription benefit coverage. All of the excluded drug entities, strengths, formulations &/or package sizes may not be listed. The list is not all inclusive and is subject to change. Office administered drugs and IV drugs are covered under the Medical benefit and excluded from being dispensed from retail pharmacy. EXCLUDED DRUGS EXCLUDED DRUGS DICLOFENAC SODIUM-RANITIDINE HCL-LIDOCAINE FASENRA (INJ) (PACK) DIETARY MANAGEMENT PRODUCTS * FEEDING TUBES/SETS (DEVICE) DIETHYLPROPION HCL (ORAL) FERREX 150 FORTE PLUS (ORAL) DIHYDROXYACETONE (TOPICAL) FEXOFENADINE HCL (ORAL) DIPHENHYDRAMINE-ACETAMINOPHEN (ORAL) FEXOFENADINE-PSEUDOEPHEDRINE (ORAL) DIPHENHYDRAMINE-PHENYLEPHRINE- FIBER-STAT (ORAL) ACETAMINOPHEN (ORAL) FINASTERIDE (ALOPECIA) (ORAL) DMT SUIK (KIT) FOLBIC (ORAL) DNA COLLECTION PRODUCT (KIT) FOLIC ACID-CYANOCOBALMIN-PYRIDOXINE (ORAL) DOLOTRANZ (KIT) FOLLITROPIN ALFA (INJ) (1) DOUBLEDEX (KIT) FOLLITROPIN BETA (INJ) (1) DOXYCYCLINE HYCLATE W/ CLEANSER (KIT) DOXYLAMINE-PHENYLEPHRINE-ACETAMINOPHEN FORTAMET (ORAL) (ORAL) FOSTEUM (ORAL) DUEXIS (ORAL) FOSTEUM PLUS (ORAL) DYMISTA SUSP (NASAL SPRAY) FOVEX (ORAL) EDEX (INJ) (2) GABADONE (ORAL) ELFOLATE (ORAL) GANIRELIX ACETATE (INJ) (1) ELIGEN B12 (ORAL) GLUMETZA (ORAL) EMOLLIENT-SKIN MOISTURIZERS (TOPICAL) GOSERELIN ACETATE (IMPLANT) ENLYTE (ORAL) GUAIFENESIN (ORAL) ENTERAGAM (ORAL) HALAC (KIT) ENTERAL NUTRITION (SUPPLIES) HALONATE (KIT) EPHEDRINE-GUAIFENESIN (ORAL) HALOPERIDOL DECANOATE (INJ) EPICERAM EMUL (TOP) HEPATITIS B IMMUNE GLOBULIN (HUMAN) (INJ) ESOMEPRAZOLE MAGNESIUM (ORAL) HYDROQUINONE (TOPICAL) EXPECTORANTS (ORAL) HYDROQUINONE MICROSPHERES (TOPICAL) EXPECTORANTS, COMBINATIONS (ORAL) (1)(2)(3) Drug Category is excluded unless your plan has a buy-up for that benefit (1) Infertility Drug Category; (2) Sexual Dysfunction Drug Category; (3) Weight Loss Drug Category KPCO Commercial HMO Drug Exclusion List Page 4 of 9 Revision date: April 2018 Kaiser Permanente Commercial HMO Drug Exclusion List Listed are items that are excluded from prescription benefit coverage. All of the excluded drug entities, strengths, formulations &/or package sizes may not be listed. The list is not all inclusive and is subject to change. Office administered drugs and IV drugs are covered under the Medical benefit and excluded from being dispensed from retail pharmacy. EXCLUDED DRUGS EXCLUDED DRUGS HYDROQUINONE W/ SUNSCREENS (TOPICAL) KETOROCAINE-LM (KIT) HYDROXYPROGESTERONE CAPROATE KETOROLAC TROMETHAMINE (INJ) (ANTINEOPLASTIC) (INJ) HYPERTENSA (ORAL) KETOTIFEN FUMARATE (OPHTH) IBUPROFEN (OTC EQUIV) (ORAL) KETOVIE 4:1 (ORAL) IBUPROFEN W/ LINIMENT (KIT) KETOVIE PEPTIDE (ORAL) IMMUNE GLOBULIN (HUMAN) (INJ) LANSOPRAZOLE (OTC EQUIV) (ORAL) INCONTINENCE SUPPLIES/WOUND CARE DRAINAGE LETROZOLE (ORAL) (1) (SUPPLIES) LEUPROLIDE ACETATE & NORETHINDRONE ACETATE
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  • Vitiligo AHM

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    Vitiligo AHM Clinical indication Any one of the following established methods for the treatment of Vitiligo is considered medically necessary : o Excimer laser (e.g., XTRAC, PhotoMedex, Radnor, PA; EX-308, Ra Medical Systems, Inc., Carlsbad, CA) o Narrow-band ultraviolet B (UVB) o Topical and oral psoralen photochemotherapy (PUVA) Note: Continued PUVA or narrow-band UVB therapy is not medically necessary unless there is significant follicular pigmentation after 6 months of therapy (8 to 10 treatments per month) o Topical and systemic corticosteroids Indications considered Not Medically Necessary Treatments for vitiligo are considered cosmetic if they do not affect the underlying condition and do not result in improved protection against skin cancer; specifically micropigmentation (tattooing) and depigmentation (with monobenzylether of hydroquinone/monobenzone) are considered cosmetic. The following treatments for the condition vitiligo are considered not medically necessary as there is a lack of evidence regarding the safety and effectiveness have not been established o Home phototherapy o Melanocyte transplantation/cultured and non-cultured cellular melanocyte keratinocyte transfer for the treatment of vitiligo o Vitamin D analogs (e.g., calcitriol and paricalcitol) o Tumor necrosis factor-alpha agents (e.g., adalimumab, etanercept, and infliximab) o Alpha-melanocyte stimulating hormone (e.g., afamelanotide) o Chimeric monoclonal antibody to CD20 (e.g., rituximab) o Autologous mini-punching grafting, blister roof grafting (suction epidermal blister grafting) and split thickness skin grafting AC-AEVITI082014 Page 1 of 5 Copyright 2016 No part of this document may be reproduced without permission ActiveHealth Management Medical Management Guidelines References: 1. Grimes PE. Diseases of hypopigmentation. In: Principles and Practice of Dermatology.
  • PRICE LIST – 2017 Cosmetic / Dermatology Products

    PRICE LIST – 2017 Cosmetic / Dermatology Products

    PRICE LIST – 2017 Cosmetic / Dermatology Products Updated: January 2017 P: 1300 731 755 F: (07) 5530 6677 1 | P a g e Index: (A-Z) Non-PBS / Private Compounded Items ALA (Aminolevulinic Acid) Page 3 Acne Treatments Page 4 Anesthetic Products Page 5 Depigmenting Products Page 6 Hydroquinone Cream Page 6 Peel Products Page 7 Tretinoin Page 10 Jessner Peels Page 7 Peptides (Topical) Page 8 & 9 Topical Anaesthetics Page 5 Tretinoin Page 10 2 | P a g e ALA – Amino Levuleniuc Acid ** The following items require a Doctor prescription ** These are the most commonly used strengths and quantities, if it is not on the list please call us for a quote. Note: Upon arrival at your clinic please store Aminolevulinic Acid in the freezer. Instructions for use: 1. Remove Aminolevulinic Acid Hydrochloride from freezer 2. Add the Aminolevulinic Acid (5) HCI Solvent Mixture to the glass vial containing Aminolevulinic Acid Hydrochloride 3. Screw on the black phenolic cap securely and mix for one (1) – two (2) minutes with gentle shaking and swirling motion until the solid is completely dissolved. 4. Let the bottle stand for a minute or so to allow the solution to go down to the bottom of the bottle. 5. Replace the black phenolic cap with the droptainer cap and apply. Note: Use within two (2) hours of mixing and discard excess/unused solution ALA: (Strength) Quantity: Price: 1 unit $35.00 20% 2 units $49.00 3 or more units $90.00 1 unit $35.00 25% 2 units $49.00 3 or more units $90.00 3 | P a g e Acne Treatments ** The following items require a Doctor prescription ** These are the most commonly used strengths and quantities, if it is not on the list please call us for a quote.