Excluded Drug List

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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

Drugs to enhance athletic performance o Drugs to shorten the duration of the common cold o

o Drugs to treat infertility* o Drugs to treat sexual dysfunction* 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 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 o

*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 (1) INFERTILITY DRUGS (KIT) INHALER, SPACER/CHAMBER (DEVICE) LEUPROLIDE ACETATE (INJ)

(2) IN-OFFICE ADMINISTERED PRODUCTS * LEVITRA (ORAL)

INTRAROSA (VAG) LEVOCETIRIZINE DIHYDROCHLORIDE (ORAL)

INTRAROSA INST (VAG) LEVONORGESTREL (EMERGENCY OC) OTC (ORAL)

INTRA-UTERINE DEVICES (IUDS) LEVONORGESTREL IUD (DEVICE) LIDOCAINE-PENTAFLUOROPROP-TETRAFLUOROETH- INTRAVENOUS INJECTIONS * ULTRASOUND (KIT) INVEGA SUSTENNA SUSP (INJ) LIDOCAINE-PRILOCAINE (KIT)

INVEGA TRINZA SUSP (INJ) LIDOCAINE-PRILOCAINE-MENTHOL-METHYL SALICYLATE (KIT) ISOVACTIN AA PLUS BERRY (ORAL) LIDOCAINE-PRILOCAINE-SODIUM CHLORIDE (KIT)

IV CATHETER (SUPPLIES) LIDOCAINE-TRANSPARENT DRESSING (KIT)

IV SETS/TUBING (SUPPLIES) LIDOPAC (KIT)

KARAYA GUM (TOPICAL) LIMBREL (ORAL)

KETOCAL 3:1 POWDER (ORAL) LIPISTART (ORAL)

KETOCAL 4:1 LQ (ORAL) LIQUIGEN (ORAL)

KETOCAL 4:1 POWDER (ORAL) LIRAGLUTIDE (WEIGHT MANAGEMENT) (INJ)

KETOCONAZOLE & CLEANSER (KIT) LISTER-V (ORAL)

KETODAN (KIT) LORCASERIN HCL (ORAL)

KETOROCAINE-L (KIT) LORVATUS PHARMAPAK (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 5 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 LOXAPINE (INH) NAPROXEN SODIUM-MENTHOL (PACK)

LUKAID GLA (ORAL) NAPROXEN W/ LINIMENT (KIT)

LUNGLAID (ORAL) NAPROXEN-CAPSAICIN-MENTHOL (KIT)

MAKENA (INJ) NAPROXEN-ESOMEPRAZOLE MAGNESIUM (ORAL)

MARDEX-25 (KIT) NEOCATE JUNIOR (ORAL)

MCT OIL (ORAL) NEOCATE JUNIOR WITH PREBIOTICS (ORAL)

MECLIZINE HCL (ORAL) NEOCATE NUTRA (ORAL)

MEDROXYPROGESTERONE ACETATE SUSP (INJ) NEOCATE'S E028 SPLASH (ORAL)

MELOXICAM W/ LINIMENT (KIT) NEO-SYNALAR (KIT)Bottom of Form

MEMANTINE HCL-DONEPEZIL HCL (ORAL) NEUAC (KIT)

MENOTROPINS (INJ) (1) NEUREMEDY (ORAL)

MENTHOL (MOUTH-THROAT) (ORAL) NEXIUM (ORAL)

MIACALCIN (INJ) NEXPLANON CONTRACEPTIVE IMPLANT

MICONAZOLE NITRATE (VAG) NICAZELDOXY 30 (KIT)

MINOXIDIL (TOPICAL) NON-NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE COMBINATIONS (ORAL) MIRVASO GEL (TOPICAL) NON-NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE-ANALGESIC COMBINATIONS (ORAL) MISC NATURAL WEIGHTLOSS PRODUCTS (ORAL) NON-NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE-DECONGESTANT (ORAL) MONOBENZONE (TOPICAL) NON-NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE-DECONGESTANT-ANALGESIC MONOGEN (ORAL) COMBINATIONS (ORAL) MUGARD (ORAL) NON-NARCOTIC ANTITUSSIVE-1ST GENERATION- DECONGESTANT-SALICYLATE (ORAL) MULTIPLE VITAMINS W/ MINERALS & FOLIC ACID NON-NARCOTIC ANTITUSSIVE-ANALGESIC (ORAL) COMBINATIONS (ORAL) MUSE PELLETS (IMPLANT) (2) NON-NARCOTIC ANTITUSSIVE-DECONGESTANT COMBINATIONS (ORAL) NALTREXONE (INJ) NON-NARCOTIC ANTITUSSIVE-DECONGESTANT- ANALGESIC COMBINATIONS (ORAL) NALTREXONE HCL-BUPROPION HCL (ORAL) NON-NARCOTIC ANTITUSSIVE-DECONGESTANT- ANALGESIC-EXPECTORANT COMBINATIONS (ORAL) NAMZARIC CP24 (ORAL) NON-NARCOTIC ANTITUSSIVE-DECONGESTANT- NAPROPAK (PACK) EXPECTORANT 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 6 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 NON-NARCOTIC ANTITUSSIVE-EXPECTORANT PHENTERMINE HCL (ORAL) (3) COMBINATIONS (ORAL) (3) NORITATE (TOPICAL) PHENTERMINE HCL-TOPIRAMATE (ORAL)

(2) NUCALA INJ PHENTOLAMINE MESYLATE (INJ)

(2) NYSTATIN & EXFOLIATING AGENT (KIT) PHENTOLAMINE-ALPROSTADIL (INJ)

OMEGA-3/D-3 WELLNESS (KIT) PHENYLEPHRINE-ACETAMINOPHEN (ORAL) PHENYLEPHRINE-ACETAMINOPHEN-GUAIFENESIN OMEPRAZOLE-SODIUM BICARBONATE (ORAL) (ORAL) ONEXTON GEL (TOPICAL) PHENYLEPHRINE-DIPHENHYDRAMINE-GUAIFENESIN- ACETAMINOPHEN (ORAL) ORAL SYRINGES (SUPPLIES) PHENYLEPHRINE-GUAIFENESIN (ORAL)

ORAL WOUND CARE PRODUCTS (ORAL) PHENYLEPHRINE-IBUPROFEN (ORAL)

ORLISTAT (ORAL) PHENYLTOLOXAMINE-ACETAMINOPHEN (ORAL)

(2) OSPHENA (ORAL) PLAN B ONE-STEP (ORAL)

OTC PRODUCTS * PRASTERA (ORAL)

OZURDEX OPTHALMIC (IMPLANT) PREVACID (ORAL)

PAINGO KFT (KIT) PREVIDENT (DENTAL)

(2) PAPAVERINE (INJ) PROBARIMIN QT (ORAL)

(2) PAPAVERINE-ALPROSTADIL (INJ) PROBIOTIC PRODUCT (PACK)

(2) PAPAVERINE-PHENTOLAMINE (INJ) PROGESTERONE (INJ) (1)

(2) PAPAVERINE-PHENTOLAMINE-ALPROSTADIL (INJ) PROGESTERONE (VAG)

PARENTERAL ADMINISTRATION SETS (SUPPLIES) PROGESTERONE MICRONIZED (ORAL) (1)

PECTIN (MOUTH-THROAT) (ORAL) PROMETHAZINE W/ CODEINE (ORAL)

PEDIADERM AF (KIT) PROPECIA (ORAL)

PEDIADERM HC (KIT) PRO-STAT MAX (ORAL)

PERCURA (ORAL) PRO-STAT RENAL CARE (ORAL)

PHENAZOPYRIDINE HCL (ORAL) PRO-STAT SUGAR FREE (ORAL) PHENDIMETRAZINE TARTRATE (ORAL) (3) PRO-STAT SUGAR FREE AWC (ADVANCED WOUND CARE) (ORAL) PHENIRAMINE-PHENYLEPHRINE-ACETAMINOPHEN (ORAL) PRO-STAT SUGAR FREE AWC (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 7 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 PROSTIN VR (INJ) (2) STAXYN (ORAL) (2)

PROTEOLIN (ORAL) STENDRA (ORAL) (2)

PSEUDOEPHEDRINE-ACETAMINOPHEN (ORAL) SUBLOCADE SOSY INJ

PSEUDOEPHEDRINE-GUAIFENESIN (ORAL) SUMATRIPTAN-NAPROXEN SODIUM (ORAL)

PSEUDOEPHEDRINE-IBUPROFEN (ORAL) SUPER SOLUBLE DUOCAL (ORAL)

PSEUDOEPHEDRINE-NAPROXEN SODIUM (ORAL) SUPPRELIN LA/VANTAS (KIT)

RABIES IMMUNE GLOBULIN (HUMAN) (INJ) SYNAGIS (INJ)

RETISERT (IMPLANT) TAZAROTENE (FACIAL WRINKLES) (TOPICAL)

RHEUMATE (ORAL) TEARS AGAIN HYDRATE (ORAL)

RHO D IMMUNE GLOBULIN (HUMAN) (INJ) TERBINAFINE-HYDROXYPROPYL CHITOSAN (KIT)

RHOFADE CREAM (TOPICAL) TESTOSTERONE CYPIONATE (KIT)

RIDUZONE (ORAL) TESTOSTERONE PELLETS (IMPLANT)

ROSADAN KIT (TOPICAL) THERAMINE (ORAL)

SCULPTRA (INJ) THROAT LOZENGES (ORAL)

SENTRA AM (ORAL) THYROTROPIN ALFA (INJ)

SENTRA PM (ORAL) TICASPRAY (NASAL)

SEXUAL DYSFUNCTION DRUGS (ORAL/INJ) (2) TIZANIDINE & LINIMENT (PACK)

SIBUTRAMINE HCL MONOHYDRATE (ORAL) (3) TOCILIZUMAB (INJ)

SILAZONE THP (TOPICAL) TORADOL (INJ)

SILDENAFIL CITRATE (ORAL) (2) TOXICOLOGY SALIVA COLLECTION (KIT)

SILVER CARBOXYMETHYLCELLULOSE SOD/BANDAGES TOXOIDS (INJ) & RELATED PRODUCTS (SUPPLIES) SMARTRX GABA THPK (PACK) TOZAL (ORAL)

SMARTRX GABA-V THPK (PACK) TRELSTAR MIXJECT SUSR (INJ)

SODIUM FLUORIDE (DENTAL) TREPADONE (ORAL)

SODIUM FLUORIDE-POTASSIUM NITRATE (DENTAL) TRETINOIN (FACIAL WRINKLES) (TOPICAL)

SPACER/AEROSOL HOLDING CHAMBERS (DEVICE) TRETINOIN W/ CLEANSER & MOISTURIZER (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 8 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 TRETIN-X (KIT) VAYACOG (ORAL)

TREXIMET (ORAL) VAYARIN (ORAL)

TRIAMCINOLONE ACETONIDE (NASAL) VAYAROL (ORAL)

TRIAMCINOLONE ACETONIDE-DIMETHICONE-SILICONE VERAMYST SUSP (NASAL) (KIT) (2) TRIAMCINOLONE ACETONIDE-SILICONE (PACK) VIAGRA (ORAL)

TRI-LUMA (TOPICAL) VIMOVO (ORAL)

TRIPTODUR (INJ) VITRASERT (IMPLANT)

TRYPSIN, BALSAM PERU AND CASTOR OIL (TOPICAL) VP-GSTN (ORAL)

UREA (TOPICAL) VP-PRECIP (ORAL)

UROFOLLITROPIN PURIFIED (INJ) (1) VSL#3 (ORAL)

UTI-STAT (ORAL) WHYTEDERM (KIT)

VACCINE/TOXOID COMBO (INJ) WOUND DRESSINGS (SUPPLIES)

VACCINES (INJ) XOLAIR (INJ)

VANIQA (TOPICAL) XYZAL (ORAL)

VASCAZEN (ORAL) YOSPRALA (ORAL)

VASCULERA (ORAL) ZINC CITRATE-PHYTASE (ORAL)

VASOLEX (TOPICAL) ZOLADEX (IMPLANT)

(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 9 of 9 Revision date: April 2018 NONDISCRIMINATION NOTICE Kaiser Foundation Health Plan of Colorado (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 no cost 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

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If you need these services, call 1-800-632-9700 (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 at: Customer Experience Department, Attn: Kaiser Permanente Civil Rights Coordinator, 2500 South Havana, Aurora, CO 80014, or by phone at Member Services: 1-800-632-9700.

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 1-800-632-9700 (TTY: 711). አማርኛ (Amharic) ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-800-632-9700 (TTY: 711). العربية (Arabic) ملحوظة: إذا كنت تتحدث العربية، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم TTY( 1-800-632-9700: 711(. Ɓǎ sɔ́ ɔ̀ Wù ɖù (Bassa) Dè ɖɛ nìà kɛ dyéɖé gbo: Ɔ jǔ ké m̀ Ɓàsɔ́ ɔ̀ -wùɖù-po-nyɔ̀ jǔ ní, nìí, à wuɖu kà kò ɖò po-poɔ̀ ɓɛ́ìn m̀ gbo kpáa. Ɖá 1-800-632-9700 (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 1-800-632-9700（TTY：711）。

60577108_ACA_1557_MarCom_CO_2017_Taglines فارسی (Farsi) توجه: اگر به زبان فارسی گفتگو می کنيد، تسهيالت زبانی بصورت رايگان برای شما فراهم می باشد. با TTY) 1-800-632-9700: 711) تماس بگيريد. Français (French) ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-632-9700 (TTY: 711). Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-632-9700 (TTY: 711). Igbo (Igbo) NRỤBAMA: Ọ bụrụ na ị na asụ Igbo, ọrụ enyemaka asụsụ, n’efu, dịịrị gị. Kpọọ 1-800-632-9700 (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。1-800-632-9700（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. 1-800-632-9700 (TTY: 711) 번으로 전화해 주십시오. 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 1-800-632-9700 (TTY: 711).

नेपाली (Nepali) ध्यान दिनुहोस:् तपार्इंले नेपाली बो쥍नुहुन्छ भने तपार्इंको ननम्तत भाषा शु쥍क 셂पमा उपल녍ध छ । 1-800-632-9700 )TTY: 711( फोन गनुहु ोस ् ।ﴃसहायता सेवाह셂 नन Afaan Oromoo (Oromo) XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-800-632-9700 (TTY: 711). Pусский (Russian) ВНИМАНИЕ: eсли вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-632-9700 (TTY: 711). Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-632-9700 (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 1-800-632-9700 (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 1-800-632-9700 (TTY: 711). Yorùbá (Yoruba) AKIYESI: Ti o ba nso ede Yoruba ofe ni iranlowo lori ede wa fun yin o. E pe ero ibanisoro yi 1-800-632-9700 (TTY: 711).

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