Kaiser Permanente Hmo Formulary

KAISER PERMANENTE HMO FOrMulary Prescription Drug List 2011 last updated: august 3, 2011 The following list contains the drugs covered on the Health Plan’s Commercial Drug Formulary. It is approved by the Kaiser Permanente Mid-Atlantic States Pharmacy and Therapeutics Committee.

This formulary applies only to outpatient drugs and self-administered drugs. It does not apply to medications used in inpatient settings or administered in one of the Kaiser Permanente medical centers.

Many members have specific exclusions, copays, or coinsurance amounts that are not reflected in the formulary. Please consult your Evidence of Coverage for additional information regarding your pharmacy benefits, including any specific limitations or exclusions.

Generic, brand name, and non-formulary medications Kaiser Permanente covers generic and brand name drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. In most cases, your doctor will prescribe a generic drug if one is available. Generic drugs generally cost less than brand name drugs.

Brand name drugs are manufactured and sold by the pharmaceutical company that originally researched and developed the drug. When the patent on a brand name drug expires, other pharmaceutical companies may then manufacture and sell the FDA-approved generic version of the drug at lower prices.

Generally, Kaiser Permanente will only approve your request for a non-formulary drug if your prescribing physician considers that drug to be medically necessary. If a non-formulary drug is not medically necessary but you decide nonetheless that you want the non- formulary drug, you will be responsible for paying the full cost share of that medication.

Using the Kaiser Permanente Commercial formulary When you look through the formulary listing, you will see that products available in a generic form are listed by their generic names. Medications that are only available as a brand name product are listed in bold ANd All CAPITAl letters, except where multiple branded products exist.

You can search the formulary by using the index, the “FIND” function in Adobe Reader, or by referencing the therapeutic drug category.

In some cases, a particular drug may be listed in the formulary, but only for certain strengths or in certain dosage forms. For example, some drugs are available in different milligram (mg) strengths (e.g., 5mg, 10mg), but only one strength may be on the formulary. For drugs that are available in more than one dosage form (e.g., tablet, injectable), only one may be on the formulary.

Please remember that this list is subject to change and will be updated from time to time during the year. Any product not found on this list will be considered a non-formulary drug.

2 Restrictions on medication coverage Some covered drugs may have additional requirements or limits on coverage, including but not limited to:

• Higher Copay: Some drugs may have a higher cost share. These drugs include, but are not limited to, infertility, growth hormone, and weight management medications.

• Limited Distribution: Some drugs may be subject to limited distribution or restricted access. A drug that is a limited distribution drug may only be available at one or a limited number of pharmacies.

• Oral Chemotherapy Drugs: Drugs that fall under the District of Columbia Oral Chemotherapy Parity Act. Cost shares for these drugs may be different for employer group plans not based in Washington, D.C.

• Quantity Limit: For certain drugs, Kaiser Permanente limits the amount of medication dispensed to a certain quantity per copay.

• Restricted to Benefit: Some drugs are not covered unless your benefits specifically cover such medications. For example, Viagra® and other drugs for sexual dysfunction are not covered unless specifically included under the member’s Evidence of Coverage.

Key: HC = A drug that may have a higher copay. ld = A drug that may be subject to limited distribution. oC = A drug included under the District of Columbia Oral Chemotherapy Parity Act. 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.

For more information about the Kaiser Permanente Commercial Drug Formulary, you may contact Member Services at 301-468-6000 or 1-800-777-7902 (TTY 301-879-6380). Representatives are available Monday through Friday, 7:30 a.m. until 5:30 p.m.

11345_RxFormularyIntro_A_pdf 8/10/11–8/10/13

3 November 2011

REQUIREMENTS REQUIREMENTS DRUG NAME DRUG NAME AND LIMITS AND LIMITS ANTIHISTAMINE DRUGS Penicillin V Potassium Cyproheptadine HCl Sulfadiazine Promethazine HCL Sulfasalazine Sulfamethoxazole- ANTI-INFECTIVE AGENTS Trimethoprim Anthelmintics SUPRAX Mebendazole Tetracycline HCL YODOXIN TOBI NEB Antibacterials VANOCIN XIFAXAN Amoxicillin ZYVOX Amoxicillin & Pot Clavulanate Ampicillin Antifungals AVELOX Fluconazole Azithromycin Griseofulvin Microsize Cefaclor Griseofulvin Ultramicrosize Cefdinir Itraconazole Cefuroxime Axetil Ketoconazole Cephalexin Nystatin Ciprofloxacin Terbinafine Clarithromycin Voriconazole Clindamycin Antimycobacterials Clindamycin Palmitate HCL DAPSONE Dicloxacillin Sodium Ethambutol HCL Doxycycline Hyclate Isoniazid Doxycycline Monohydrate MYCOBUTIN ERYPED SUSP Pyrazinamide Erythromycin Base Rifabutin Erythromycin Ethylsuccinate Rifampin Erythromycin-Sulfisoxazole TRECATOR Levofloxacin Antiprotozoals Minocycline HCL COARTEM Neomycin Sulfate Chloroquine Phosphate

LEGEND • Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD dispensed as the formulary agent • Quantity Limits—QL • Higher Copay—HC • Oral Chemo Drugs—OC 44 November 2011

REQUIREMENTS REQUIREMENTS DRUG NAME DRUG NAME AND LIMITS AND LIMITS DARAPRIM REYATAZ Hydroxychloroquine Sulfate Ribavirin Mefloquine HCL Rimantadine HCL MEPRON SELZENTRY Metronidazole SUSTIVA NEBUPENT INH TAMIFLU QL Primaquine Phosphate TRIZIVIR Antivirals TRUVADA Amantadine HCL VALCYTE APTIVUS VIRACEPT ATRIPLA VIRAMUNE BARACLUDE VIRAMUNE XR COMBIVIR VIREAD CRIXIVAN ZIAGEN Didanosine Zidovudine EDURANT Urinary Anti-Infectives EMTRIVA Methenamine Hippurate EPIVIR Nitrofurantoin EPZICOM Nitrofurantoin Monohyd FUZEON Macro Ganciclovir Nitrofurantoin Macrocrystals HEPSERA Trimethoprim INTELENCE ANTINEOPLASTIC AGENTS INVIRASE Antineoplastic Agents ISENTRESS AFINITOR OC KALETRA ALKERAN OC LEXIVA Anastrozole OC NORVIR AROMASIN OC PEGASYS QL Bicalutamide OC PEG-INTRON QL CEENU OC PREZISTA Cyclophosphamide OC RESCRIPTOR