Denver/Boulder, Mountain & Northern Colorado Commercial HMO Drug
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Denver/Boulder, Mountain & Northern Colorado Commercial HMO Drug Formulary The following is a listing of the drugs on the Denver/Boulder, Mountain & Northern Colorado Commercial HMO drug Formulary. This formulary applies only to outpatient drugs provided to members for self- administration, and does not apply to medications used in inpatient settings or medications administered in a doctor’s office or infusion center. The listing does not provide information regarding the specific coverage, limitations or quotas an individual member may have. Many members have specific exclusions, copays, or coinsurances that are not reflected in the formulary. Kaiser Permanente has many brand and generic medications on the formulary. In most cases, a generic equivalent is used when available. Members will be notified when a generic equivalent is dispensed. If a member requests a brand name when a generic equivalent is routinely used, the member will pay the difference in price between the generic equivalent and the requested brand plus the appropriate copay. Kaiser Permanente may implement programs, such as a therapeutic interchange program, to promote safe and effective drug therapy. In these cases the prescribing provider and member are notified prior to a change occurring. How to use this Formulary document Products available in a generic form are listed by their generic name in italics. With the exception of drugs where multiple branded products exist, medications only available as a brand name product are listed in all CAPITAL letters. Please remember that this list is subject to change and will be updated at least quarterly. Any product not found in this listing or in subsequent updates, will be considered a non-preferred drug. You can search the list by using the index, by using the “Find” function in Adobe Reader, or by therapeutic drug category. All dosage forms and strengths for a particular drug listed may not be formulary. Some drugs are available in more than one dosage form (example: tablet and injectable). Not all dosage forms of drugs are covered under the prescription drug benefit. Drugs that have at least one dosage form as an injectable on formulary are noted with an asterisk (*). Drugs that have certain strengths or forms (e.g., tablet, gel capsule, liquid) that are only available as brand drugs are subject to the brand cost share. Restrictions on medication coverage: Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Restricted to specialty: A drug that needs to be written by a physician specialized in the treatment of certain conditions for the drug to be covered under the patient’s pharmacy benefit. Prior authorization: Some drugs require specific medical criteria be met prior to dispensing the drug for the patient’s pharmacy benefit. Quantity Limits or Quotas: For certain drugs, Kaiser Permanente limits the amount of medication dispensed to a specific days supply or quantity per copay. For example, Tarceva® is limited to a 30-day supply. In addition, when there is a national shortage of a drug, we may limit the quantity of the drug dispensed per prescription per copayment. Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 1 - Restricted to Benefit: Some drugs are not covered unless the individual prescription benefit specifically covers such medications. For example, Viagra® and other drugs for sexual dysfunction are not covered unless the prescription benefit specifically covers them. Step therapy: Some medications require a similar therapy be attempted first. For example, before lansoprazole can be dispensed, a drug such as omeprazole must be tried first. Restricted to a specific age: Some medications may be restricted to a certain age or age range. Medication Exception Process: Upon request, Kaiser Permanente may make an exception to our coverage rules. The following are examples of exception requests: o Request to cover a drug that is not on our preferred product list o Request to waive coverage restrictions or limitations Generally Kaiser Permanente will only approve requests for an exception if the alternative drugs included on the plan’s preferred product list, or existing utilization restrictions, would not be as effective in treating a condition or would cause adverse medical effects. Key: * (asterisk) = A drug where at least one of the dosage forms is an injectable. Some patients have a specific self-injectable coinsurance. (diamond) = A drug that is designated as a Specialty drug which may process at a Specialty tier of the individual prescription drug benefit, where applicable. † (dagger) = Certain strengths or forms of the drug (e.g., tablet, gel, liquid) are only available as brand drugs and are subject to the brand cost share. (triangle/delta) = This drug is only covered for benefit if your Evidence of Coverage states that contraceptives are covered at $0. Otherwise, this drug requires a medical necessity review to be covered for benefit. MD = A drug that is required to be written by a physician specialized in the treatment of certain conditions. PA = A drug that requires specific medical criteria be met prior to dispensing for prescription benefit. QL = A drug that has a quantity limit or is limited to a specific day supply. RB = A drug that is restricted to a certain benefit for coverage. ST = A drug that requires another class of medications be attempted prior to dispensing for prescription benefit. AG = A drug that is restricted to a specific age range. NC = A drug that is specifically excluded under certain benefit plans. This list of drugs should not be used to determine benefit issues such as prescription copay amounts. If you have questions about prescription benefits, please call Kaiser Permanente Member Services at 1-888-681-7878. The medications on this list are subject to change at any time throughout the year Drug Name Drug Tier Requirements/Limits ANTI-INFECTIVE AGENTS ANTHELMINTICS ALBENZA Brand BILTRICIDE Brand ANTI-INFECTIVE AGENTS ANTIBACTERIALS amoxicillin Generic/Brand † amoxicillin & potassium Generic/Brand † clavulanate Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 2 - Drug Name Drug Tier Requirements/Limits ampicillin Generic * AVELOX Brand * AZACTAM Brand * azithromycin Generic * bacitracin Generic bacitracin & polymyxin B Generic CAYSTON Brand * cefazolin sodium Generic * cefdinir Generic cefepime Generic * cefotaxime sodium Generic/Brand * † cefotetan Generic * ceftazidime Generic/Brand * † ceftriaxone sodium Generic * cefuroxime axetil Generic/Brand † cefuroxime sodium Generic * cephalexin Generic CIPRODEX Brand ciprofloxacin hcl Generic/Brand * † clarithromycin Generic clindamycin hcl Generic/Brand † clindamycin palmitate Generic hydrochloride clindamycin phosphate Generic/Brand * † dicloxacillin sodium Generic doxycycline hyclate Generic * doxycycline monohydrate Generic erythromycin base Generic/Brand † erythromycin ethylsuccinate Generic/Brand † erythromycin lactobionate Generic/Brand * † GANTRISIN Brand gentamicin sulfate Generic * INVANZ Brand * levofloxacin Generic* minocycline hcl Generic neomycin sulfate Generic penicillin g potassium Generic * penicillin g procaine Generic * penicillin g sodium Generic * penicillin v potassium Generic piperacillin-tazobactam Generic/Brand * † Kaiser Permanente Denver/Boulder, Mountain and Northern Colorado Commercial Formulary – June 2016 - 3 - Drug Name Drug Tier Requirements/Limits PRIMAXIN I.M.