Medications Serviced by Kaiser Permanente Washington Specialty Pharmacy

LISTING BY Tenofovir Alafenamide Tenofovir Alafenamide DISEASE STATE Crohn’s Disease (Vemlidy) (Symtuza) (Listing in alphabetical Adalimumab (Humira) Tenofovir Disoproxil Delavirdine (Rescriptor) order starts on page 3) Certolizumab (Cimzia) Fumarate (Viread)* Didanosine (Videx) Ustekinumab (Stelara) Dolutegravir (Tivicay) Acromegaly Hereditary Dolutegravir / Lanreotide (Somatuline) Cystic Fibrosis Angioedema Lamivudine (Dovato) Octreotide (Sandostatin, Dornase alfa Dolutegravir / Rilpivirine C1 esterase Inhibitor Bynfezia) (Pulmozyme) (Juluca) (Cinryze, Berinert, Pegvisomant (Somavert) Tobramycin (Tobi, Doravirine (Pifeltro) Haegarda, Ruconest) Kitabis, Bethkis) Doravirine / Lamivudine Icatibant (Firazyr) Amyloid / Tenofovir Disoproxil Lanadelumab-flyo cardiomyopathy Fumarate (Delstrigo) Gaucher’s Disease (Takhzyro) Efavirenz (Sustiva)* Tafamidis (Vyndamax) Eliglustat (Cerdelga) Tafamidis meglumine Efavirenz / Hormonal Emtricitabine / (Vyndaqel) Hematopoietics Therapies Tenofovir Disoproxil Filgrastim (Granix, Leuprolide (Eligard, Fumarate (Atripla) Ankylosing Neupogen, Zarxio) Lupron) Efavirenz / Lamivudine / Spondylitis Sargramostim (Leukine) Nafarelin (Synarel) Tenofovir Disoproxil Adalimumab (Humira) Somatropin Fumarate (Symfi, Symfi Certolizumab (Cimzia) Hepatitis (Genotropin, Lo) Etanercept (Enbrel) Adefovir (Hepsera) Humatrope, Elvitegravir / Cobicistat Golimumab (Simponi) Elbasvir / Grazoprevir Norditropin, Nutropin / Emtricitabine / Secukinumab (Cosentyx) (Zepatier) AQ Nuspin, Omnitrope, Tenofovir Disoproxil Emtricitabine/Tenofovir Saizen, Serostim, Fumarate (Stribild) Asthma Disoproxil Fumarate Zomacton, Zorbtive) Elvitegravir / Cobicistat Benralizumab (Truvada) / Emtricitabine / (Fasenra) Entecavir (Baraclude)* HIV Tenofovir Alafenamide Dupilumab (Dupixent) Glecaprevir/ Abacavir (Ziagen)* (Genvoya) Mepolizumab (Nucala) Pibrentasvir (Mavyret) Abacavir/Lamivudine Emtricitabine (Emtriva) Interferon alfa-2b (Epzicom)* Emtricitabine / (Intron A) Atopic Dermatitis Abacavir / Dolutegravir Rilpivirine / Tenofovir Lamivudine (Epivir Dupilumab (Dupixent) / Lamivudine (Triumeq) Disoproxil Fumarate HBV)* Abacavir / Lamivudine / (Complera) Ledipasvir / Sofosbuvir Zidovudine (Trizivir) Emtricitabine / Chelating Agent (Harvoni) Atazanavir (Reyataz)* Rilpivirine / Tenofovir Penicillamine Peginterferon alfa-2a Atazanavir / Cobicistat Alafenamide (Odefsey) (Cuprimine, Depen) (Pegasys) (Evotaz) Emtricitabine/Tenofovir Peginterferon alfa-2b Bictegravir / Alafenamide (Descovy) Chorea associated (PegIntron) Emtricitabine / Emtricitabine / with Huntington’s Ribavirin (Copegus, Tenofovir Alafenamide Tenofovir Disoproxil Moderiba, Rebetol, disease (Biktarvy) Fumarate (Truvada) Ribasphere, Ribapak) Deutetrabenazine Cobicistat (Tybost) Enfuvirtide (Fuzeon) Sofosbuvir (Sovaldi) (Austedo) Darunavir (Prezista) Etravirine (Intelence) Sofosbuvir / Velpatasvir Darunavir / Cobicistat Fosamprenavir (Lexiva) (Epclusa) (Prezcobix) Fostemsavir (Rukobia)

Sofosbuvir / Velpatasvir Darunavir / Cobicistat / Indinavir (Crixivan)

/ Voxilaprevir (Vosevi) Emtricitabine / Lamivudine (Epivir)*

¥Only service generic product °Service brand product only *Generic product available Inclusion on this list does NOT imply insurance coverage. Coverage will depend on a member’s prescription benefit plan and is subject to change. For information on coverage of these products, please contact Member Services at 1-888-901-4636. GP0002042-50-17 © 2018 Kaiser Foundation Health Plan of Washington page Updated Aug 2021 1 of 6

Lamivudine / Tenofovir Migraine Oncology Gilteritinib (Xospata) Disoproxil Fumarate Erenumab (Aimovig) Abemaciclib (Verzenio) Ibrutinib (Imbruvica) (Cimduo) Fremanezumab (Ajovy) Abiraterone (Zytiga)* Idelalisib (Zydelig) Lamivudine / Galcanezumab Acalabrutinib Imatinib (Gleevec)* Zidovudine (Combivir)* (Emgality) (Calquence) Infigratinib (Truseltiq) Lopinavir / Ritonavir Afatinib (Gilotrif) Interferon alfa-2b (Kaletra) Multiple Sclerosis Alectinib (Alecensa) (Intron A) Maraviroc (Selzentry) Ivosidenib (Tibsovo) Cladribine (Mavenclad) Alpelisib (Piqray) Nelfinavir (Viracept) Ixazomib (Ninlaro) Corticotropin (Acthar) Apalutamide (Erleada) Nevirapine (Viramune)* Lapatinib (Tykerb) Dalfampridine Avapritinib (Ayvakit) Raltegravir (Isentress) Larotrectinib (Vitrakvi) (Ampyra)*¥ Avatrombopag (Doptelet) Rilpivirine (Edurant) Lenalidomide (Revlimid) Dimethyl fumarate Axitinib (Inlyta) Ritonavir (Norvir)* Lenvatinib (Lenvima) (Tecfidera) Azacitidine (Onureg) Saquinavir Mesylate Leuprolide (Eligard, Diroximel fumarate Bexarotene (Invirase) Lupron) (Vumerity) (Targretin)*[tablet only] Stavudine (Zerit) Lomustine (Gleostine) Fingolimod (Gilenya) Binimetinib (Mektovi) Tenofovir Disoproxil Lorlatinib (Lorbrena) Glatiramer acetate Bosutinib (Bosulif) Fumarate (Viread)* Melphalan (Alkeran) (Copaxone, Glatopa)* Brigatinib (Alunbrig) Tipranavir (Aptivus) Mesna (Mesnex) Interferon beta-1a Busulfan (Myleran) Zidovudine (Retrovir)* Midostaurin (Rydapt) (Avonex) Cabozantinib Neratinib (Nerlynx) Interferon beta-1a (Cabometyx) ° Nilotinib (Tasigna) Hyperkalemia (Rebif) Capecitabine (Xeloda)* Nilutamide (Nilandron) Patiromer (Veltassa) Interferon beta-1b Capmatinib (Tabtrecta) Niraparib (Zejula) Sodium Zirconium (Betaseron)* Ceritinib (Zykadia) Olaparib (Lynparza) Cyclosillicate (Lokelma) Interferon beta-1b Chlorambucil (Leukeran) Omacetaxine (Synribo) (Extavia)* Cobimetinib (Cotellic) Crizotinib (Xalkori) Osimertinib (Tagrisso) Idiopathic Monomethyl Fumarate Palbociclib (Ibrance) (Bafiertam) Cyclophosphamide Pulmonary Fibrosis Panobinostat (Farydak) Ofatumumab (Cytoxan)* Nintedanib (Ofev) Pazopanib (Votrient) (Kesimpta) Dabrafenib (Tafinlar) Pirfenidone (Esbriet) Peginterferon alfa-2b Ozanimod (Zeposia) Dacomitinib (Vizimpro) (PegIntron) Peg-interferon beta-1a Darolutamide (Nubeqa) Immune Deficiency Peginterferon alfa-2b (Plegridy) Dasatinib (Sprycel) (Sylatron) Immune Globulin Ponesimod (Ponvory) Decitabine/ (Hizentra) Pomalidomide Siponimod fumarate Cedazuridine (Inqovi) (Pomalyst) (Mayzent) Duvelisib (Copiktra) Ponatinib (Iclusig) Iron Overload Teriflunomide (Aubagio) Eltrombopag Deferasirox (Exjade, (Promacta) Pralsetinib (Gavreto) Jadenu) Enasidenib (Idhifa) Procarbazine Neurofibromatosis Encorafenib (Braftovi) (Matulane) Selumetinib (Kiselugo) Entrectinib (Rozlytrek) Regorafenib (Stivarga) Long-chain fatty Enzalutamide (Xtandi) Relugolix (Orgovyx) acid oxidation Neurogenic Erlotinib (Tarceva) Ribociclib (Kisqali) Disorders Orthostatic Estramustine (Emcyt) Ribociclib / Letrozole Triheptanoin (Dojolvi) (Kisqali Femara Co-Pack) Hypotension Etoposide (Toposar)¥ Ripretinib (Qinlock) Droxidopa (Northera) Everolimus (Afinitor) Rucaparib (Rubraca) Lipid Disorders Fedratinib (Inrebic) Ruxolitinib (Jakafi) Alirocumab (Praluent) Neuromyelitis Filgrastim (Granix, Selinexor (Xpovio) Evolocumab (Repatha) Satralizumab (Enspryng) Neupogen, Nivestym, Zarxio) Selpercatinib (Retevmo) Fostanatinib (Tavalisse) Sonidegib (Odomzo) Gefitinib (Iressa) Sorafenib (Nexavar)

¥Only service generic product °Service brand product only *Generic product available Inclusion on this list does NOT imply insurance coverage. Coverage will depend on a member’s prescription benefit plan and is subject to change. For information on coverage of these products, please contact Member Services at 1-888-901-4636. GP0002042-50-17 © 2018 Kaiser Foundation Health Plan of Washington page Updated Aug 2021 2 of 6

Sotarasib (Lumkras) Primary Biliary Upadacitinib (Rinvoq) Adefovir (Hepsera) Sunitinib (Sutent) Cholangitis Afatinib (Gilotrif) Talazoparib (Talzenna) Obeticholic acid Sickle Cell Alectinib (Alecensa) Tazmetostat (Tazverik) (Ocaliva) Voxelotor (Oxbryta) Alirocumab (Praluent) Temozolomide Alpelisib (Piqray) (Temodar)* Ambrisentan Psoriatic Arthritis Systemic Lupus Tepotinib (Tepmetko) (Letairis)*¥ Adalimumab (Humira) Thalidomide (Thalomid) Erythematosus Anakinra (Kineret) Apremilast (Otezla) Thyrotropin alfa Belimumab (Benlysta) Apalutamide (Erleada) Certolizumab (Cimzia) (Thyrogen) Corticotropin (Acthar) Apremilast (Otezla) Corticotropin (Acthar) Thioguanine (Tabloid) Atazanavir (Reyataz)* Etanercept (Enbrel) Topotecan (Hycamtin) Tardive Dyskinesia Atazanavir / Cobicistat Golimumab (Simponi) Toremifene (Fareston)* Deutetrabenazine (Evotaz) Ixekizumab (Taltz) Trametinib (Mekinist) (Austedo) Avapritinib (Ayvakit) Secukinumab (Cosentyx) Tretinoin (Vesanoid)¥* Valbenazine (Ingrezza) Avatrombopag (Doptelet) Ustekinumab (Stelara) Trifluridine / Tipiracil Axitinib (Inlyta) (Lonsurf) Ulcerative Colitis Azacitidine (Onureg) Psoriasis Tucatinib (Tukysa) Adalimumab (Humira) Adalimumab (Humira) Umbralisib (Ukoniq) Golimumab (Simponi) B Apremilast (Otezla) Vemurafenib (Zelboraf) Baricitinib (Olumiant) Venetoclax (Venclexta) Brodalumab (Siliq) Wilson Disease Belimumab (Benlysta) Vismodegib (Erivedge) Etanercept (Enbrel) Trientine (Syprine) Benralizumab (Fasenra) Vorinostat (Zolinza) Guselkumab (Tremfya) Bexarotene Zanubrutinib (Brukinsa) Ixekizumab (Taltz) Infusion Medication (Targretin)*[tablet only] Methotrexate (Rasuvo) Bictegravir / Risankizumab (Skyrizi) Offered only in medical Osteoporosis facilities. Not serviced Emtricitabine / Abaloparatide (Tymlos) Secukinumab (Cosentyx) Tenofovir Alafenamide Ustekinumab (Stelara) through Specialty Teriparatide (Forteo) ° Pharmacy. Please contact (Biktarvy) member services at 1- Binimetinib (Mektovi) Pulmonary Arterial Phenylketonuria 888-901-4636. Bosentan (Tracleer)*¥ Sapropterin (Kuvan) Hypertension Bosutinib (Bosulif) Ambrisentan LISTING IN Brigatinib (Alunbrig) (Letairis)*¥ Brodalumab (Siliq) Polyneuropathy of ALPHABETICAL Bosentan (Tracleer)*¥ Busulfan (Myleran) ORDER Hereditary Sildenafil (Revatio)* Transthyretin Tadalafil (Adcirca)* C Mediated A C1 esterase Inhibitor Amyloidosis Rheumatoid Abacavir (Ziagen)* (Cinryze, Berinert, Abacavir / Dolutegravir Inotersen (Tegsedi) Arthritis Haegarda, Ruconest) / Lamivudine (Triumeq) Abatacept (Orencia) Cabozantinib Abacavir / Lamivudine Pre-exposure Adalimumab (Humira) (Cabometyx) ° (Epzicom)* Anakinra (Kineret) Capecitabine (Xeloda)* Prophylaxis (PrEP) Abacavir / Lamivudine / Baricitinib (Olumiant) Capmatinib (Tabrecta) Emtricitabine/Tenofovir Zidovudine (Trizivir) Certolizumab (Cimzia) Ceritinib (Zykadia) Disoproxil Fumarate Abaloparatide (Tymlos) Corticotropin (Acthar) Certolizumab (Cimzia) (Truvada) Abatacept (Orencia) Etanercept (Enbrel) Chlorambucil (Leukeran) Emtricitabine / Tenfovir Abemaciclib (Verzenio) Golimumab (Simponi) Cladribine (Mavenclad) Alafenamide (Descovy) Abiraterone (Zytiga)* Methotrexate (Rasuvo) Cobicistat (Tybost) Acalabrutinib Sarilumab (Kevzara) Cobimetinib (Cotellic) (Calquence) Tocilizumab (Actemra) Corticotropin (Acthar) Adalimumab (Humira) Tofacitinib (Xeljanz) Crizotinib (Xalkori)

¥Only service generic product °Service brand product only *Generic product available Inclusion on this list does NOT imply insurance coverage. Coverage will depend on a member’s prescription benefit plan and is subject to change. For information on coverage of these products, please contact Member Services at 1-888-901-4636. GP0002042-50-17 © 2018 Kaiser Foundation Health Plan of Washington page Updated Aug 2021 3 of 6

Cyclophosphamide Efavirenz / Lamivudine / Fingolimod (Gilenya) Lanadelumab-flyo (Cytoxan)* Tenofovir Disoproxil Fosamprenavir (Lexiva) (Takhzyro) Fumarate (Symfi, Symfi Fostamatinib (Tavalisse) Lanreotide (Somatuline) D Lo) Fostemsavir (Rukobia) Lapatinib (Tykerb) Dabrafenib (Tafinlar) Elbasvir / Grazoprevir Fremanezumab (Ajovy) Larotrectinib (Vitrakvi) Dacomitinib (Vizimpro) (Zepatier) Ledipasvir / Sofosbuvir Dalfampridine (Ampyra) Eliglustat (Cerdelga) G (Harvoni) *¥ Eltrombopag Galcanezumab Lenalidomide (Revlimid) Darolutamide (Nubeqa) (Promacta) (Emgality) Lenvatinib (Lenvima) Darunavir (Prezista) Emtricitabine (Emtriva) Gefitinib (Iressa) Leuprolide (Eligard, Darunavir / Cobicistat Emtricitabine / Gilteritinib (Xospata) Lupron) (Prezcobix) Rilpivirine / Tenofovir Glatiramer acetate Lomustine (Gleostine) Darunavir / Cobicistat / Disoproxil Fumarate (Copaxone, Glatopa)* Lopinavir / Ritonavir Emtricitabine / (Complera) Glecaprevir / (Kaletra) Tenofovir Alafenamide Emtricitabine / Pibrentasvir (Mavyret) Lorlatinib (Lorbrena) (Symtuza) Rilpivirine / Tenofovir Golimumab (Simponi) Dasatinib (Sprycel) Alafenamide (Odefsey) Guselkumab (Tremfya) M Decitabine/ Emtricitabine / Maraviroc (Selzentry) Cobicistat / Elvitegravir Cedazuridine (Inqovi) I Melphalan (Alkeran) / Tenofovir Disoproxil Deferasirox (Exjade, Ibrutinib (Imbruvica) Mepolizumab (Nucala) Fumarate (Stribild) Jadenu) Icatibant (Firazyr) Mesna (Mesnex) Emtricitabine / Delavirdine (Rescriptor) Idelalisib (Zydelig) Methotrexate (Rasuvo) Cobicistat / Elvitegravir Deutetrabenazine Imatinib (Gleevec)* Midostaurin (Rydapt) / Tenofovir Alafenamide (Austedo) Immune Globulin Monomethyl Fumarate (Genvoya) Didanosine (Videx) (Hizentra) (Bafiertam) Emtricitabine / Dimethyl fumarate Indinavir (Crixivan) Tenofovir Alafenamide (Tecfidera) Infigratinib (Truseltiq) N (Descovy) Diroximel fumarate Inotersen (Tegsedi) Nafarelin (Synarel) Emtricitabine / (Vumerity) Interferon alfa-2b Nelfinavir (Viracept) Dolutegravir (Tivicay) Tenofovir Disoproxil Fumarate (Truvada) (Intron A) Neratinib (Nerlynx) Dolutegravir / Interferon beta-1a Nevirapine (Viramune)* Enasidenib (Idhifa) Lamivudine (Dovato) (Avonex) Nilotinib (Tasigna) Encorafenib (Braftovi) Dolutegravir / Rilpivirine Interferon beta-1a Nilutamide (Nilandron) Enfuvirtide (Fuzeon) (Juluca) (Rebif) Nintedanib (Ofev) Entecavir (Baraclude) Doravirine (Pifeltro) Interferon beta-1b Niraparib (Zejula) Entrectinib (Rozlytrek) Doravirine / Lamivudine (Betaseron) / Tenofovir Disoproxil Enzalutamide (Xtandi) Interferon beta-1b O Fumarate (Delstrigo) Erenumab (Aimovig) (Extavia) Obeticholic acid Dornase alfa Erlotinib (Tarceva) Ivosidenib (Tibsovo) (Ocaliva) (Pulmozyme) Estramustine (Emcyt) Ixazomib (Ninlaro) Octreotide (Sandostatin, Droxidopa (Northera) Etanercept (Enbrel) Ixekizumab (Taltz) Bynfezia) Dupilumab (Dupixent) Etoposide (Toposar)¥ Ofatumumab Duvelisib (Copiktra) Etravirine (Intelence) Everolimus (Afinitor) L (Kesimpta) Evolocumab (Repatha) Lamivudine (Epivir / Olaparib (Lynparza) E Epivir HBV)* Omacetaxine (Synribo) Efavirenz (Sustiva)* F Lamivudine / Tenofovir Osimertinib (Tagrisso) Efavirenz / Disoproxil Fumarate Ozanimod (Zeposia) Fedratinib (Inrebic) Emtricitabine / (Cimduo) Filgrastim (Granix, Tenofovir Disoproxil Lamivudine / Neupogen, Nivestym, P Fumarate/ (Atripla) Zidovudine (Combivir)* Zarxio) Palbociclib (Ibrance)

¥Only service generic product °Service brand product only *Generic product available Inclusion on this list does NOT imply insurance coverage. Coverage will depend on a member’s prescription benefit plan and is subject to change. For information on coverage of these products, please contact Member Services at 1-888-901-4636. GP0002042-50-17 © 2018 Kaiser Foundation Health Plan of Washington page Updated Aug 2021 4 of 6

Panobinostat (Farydak) Rilpivirine (Edurant) AQ Nuspin, Omnitrope, Tocilizumab (Actemra) Patiromer (Veltassa) Ripretinib (Qinlock) Saizen, Serostim, Tofacitinib (Xeljanz) Pazopanib (Votrient) Risankizumab (Skyrizi) Zomacton, Zorbtive) Topotecan (Hycamtin) Peginterferon alfa-2a Ritonavir (Norvir)* Sonidegib (Odomzo) Toremifene (Fareston)* (Pegasys) Rucaparib (Rubraca) Sorafenib (Nexavar) Trametinib (Mekinist) Peginterferon alfa-2b Ruxolitinib (Jakafi) Sotarasib (Lumkras) Tretinoin (Vesanoid) ¥* (PegIntron) Stavudine (Zerit) Trientine (Syprine)* Peginterferon alfa-2b S Sunitinib (Sutent) Trifluridine / Tipiracil (Sylatron) Sapropterin (Kuvan) (Lonsurf) Peg-interferon beta-1a Saquinavir Mesylate T Triheptanoin (Dojolvi) (Plegridy) (Invirase) Tadalafil (Adcirca)* Tucatinib (Tukysa) Pegvisomant (Somavert) Sarilumab (Kevzara) Tafamidis (Vyndamax) Penicillamine Satralizumab (Enspryng) Tafamidis meglumine U (Cuprimine, Depen) Sargromostim (Leukine) (Vyndaqel) Umbralisib (Ukoniq) Pirfenidone (Esbriet) Secukinumab (Cosentyx) Talazoparib (Talzenna) Upadacitinib (Rinvoq) Pomalidomide Selinexor (Xpovio) Tazmetostat (Tazverik) Ustekinumab (Stelara) (Pomalyst) Selpercatinib (Retevmo) Temozolomide Ponatinib (Iclusig) Selumetinib (Koselugo) (Temodar)* V Ponesimod (Ponvory) Sildenafil (Revatio)* Tenofovir Alafenamide Pralsetinib (Gavreto) Valbenazine (Ingrezza) Siponimod fumarate (Vemlidy) Vemurafenib (Zelboraf) Procarbazine (Mayzent) Tenofovir Disoproxil (Matulane) Venetoclax (Venclexta) Sodium Zirconium Fumarate (Viread)* Vismodegib (Erivedge) Cyclosillicate (Lokelma) Tepotinib (Tepmetko) Vorinostat (Zolinza) R Sofosbuvir (Sovaldi) Teriflunomide (Aubagio) Voxelotor (Oxbryta) Raltegravir (Isentress) Sofosbuvir / Velpatasvir Teriparatide(Forteo)° Regorafenib (Stivarga) (Epclusa) Thalidomide (Thalomid) Z Relugolix (Orgovyx) Sofosbuvir / Velpatasvir Thioguanine (Tabloid) Zidovudine (Retrovir)* Ribavirin (Copegus, / Voxilaprevir (Vosevi) Thyrotropin alfa Zanubrutinib (Brukinsa) Moderiba, Rebetol, Somatropin (Thyrogen)

Ribasphere, Ribapak) (Genotropin, Tipranavir (Aptivus) Ribociclib (Kisqali) Humatrope, Tobramycin (Tobi, Ribociclib / Letrozole Norditropin, Nutropin Kitabis, Bethkis) (Kisqali Femara Co-Pack)

¥Only service generic product °Service brand product only *Generic product available Inclusion on this list does NOT imply insurance coverage. Coverage will depend on a member’s prescription benefit plan and is subject to change. For information on coverage of these products, please contact Member Services at 1-888-901-4636. GP0002042-50-17 © 2018 Kaiser Foundation Health Plan of Washington page Updated Aug 2021 5 of 6

Medications Serviced by Kaiser Permanente Washington Pharmacies Please direct prescriptions and prescription-related questions for the medications listed below to the Kaiser Permanente Washington Pharmacy Call Center at 1-800-245-7979. Amantadine ER (Gocovri) Ganirelix AC (Ganirelix) Cetrorelix (Cetrotide) Levodopa (Inbrija) Darbopoetin (Aranesp) Menotropins (Menopur) Epoetin Alfa (Epogen, Procrit, Retacrit) Phenoxybenzamine (Dibenzyline) Follitropin alpha (Gonal-F) Soriatane (Acitretin) Follitropin beta (Follistim AQ) Tolcapone (Tasmar)

Medications Serviced Outside of Kaiser Permanente Washington Pharmacies At this time, the Kaiser Permanente Washington owned and operated pharmacies are not able to service the medications listed below. Please call the Kaiser Permanente Washington Specialty Pharmacy at 1-800-483-3945 to be directed to the appropriate pharmacy. Abiraterone (Yonsa) Mifepristone (Korlym) Ambrisentan (Letaris – brand only) Migalastat (Galafold) Amifampridine (Firdapse) Mitotane (Lysodren) Amifampridine (Ruzurgi) Octreotide (Mycapssa) Asfotase Alfa (Strensiq) Odevicibat (Bylvay) Aztreonam (Cayston) Parathyroid Hormone (Natpara) Berotralstat (Orladeyo) Pegvaliase-pqpz (Palynziq) Bosentan (Tracleer – brand only) Pemagitinib (Pemazyre) Cabozantinib (Cometriq) Pexidartinib (Turalio) Cannabidiol (Epidiolex) Pitolisant (Wakix) Dalfampridine (Ampyra - brand only) Ragweed Pollen (Ragwitek) Deflazacort (Emflaza) Rho D Immune Globulin (Winrho SDF) Desmopressin acetate (Stimate) Riociguat (Adempas) Dichlorphenamide (Keveyis) Risdiplam (Evrysdi) Elexacaftor/Ivacaftor/Tezacaftor (Trikafta) Selexipag (Uptravi) Erdafitinib (Balversa) Stiripentol (Diacomit) Glasdegib (Daurismo) Tasimelteon (Hetlioz) Glutamine (Endari) Tesamorelin (Egrifta) Grass Pollen (Oralair) Timothy Grass Pollen (Grastek) Hydroxyurea (Siklos) Tivozanib (Fotivda) Immune Globulin (Cutaquiq) Tolvaptan (Jynarque) Immune Globulin (Xembify) Tolvaptan (Samsca) Ivacaftor (Kalydeco) Treprostinil inhalation (Tyvaso) Ivacaftor / Lumacaftor (Orkambi) Treprostinil injectable (Remodulin) Ivacaftor / Tezacaftor (Symdeko) Treprostinil oral (Orenitram) Istradefylline (Nourianz) Vandetanib (Caprelsa) Lonafarnib (Zokinvy) Vigabatrin (Sabril) Macitentan (Opsumit) Voclosporin (Lupkynis) Mannitol (Bronchitol)

Kaiser Permanente Washington

SPECIALTY PHARMACY Phone: 1-800 -483-3945 Fax: 1-800- 340-4230 www.kp.org/wa/sp ¥Only service generic product °Service brand product only *Generic product available Inclusion on this list does NOT imply insurance coverage. Coverage will depend on a member’s prescription benefit plan and is subject to change. For information on coverage of these products, please contact Member Services at 1-888-901-4636. GP0002042-50-17 © 2018 Kaiser Foundation Health Plan of Washington page Updated Aug 2021 6 of 6