What is the Kaiser Permanente, a TRICARE® ‘F’ key on your keyboard at the same Prime Option Formulary? time. In the search window that pops A formulary is a list of drugs determined up, enter the text you want to search to be safe and effective for our for and press Enter. Press Enter again to members by our Pharmacy and move to the next result. Therapeutics committee. Use of the Medical Condition formulary enables Kaiser Permanente The drugs on this formulary are to provide optimal care to you and grouped into categories depending on your family at reasonable costs. Kaiser the type of medical condition that they Permanente continually updates the are used to treat. For example, drugs formulary throughout the year based used to treat a heart condition are on new medical evidence, considering listed under the category, the recommendations of appropriate “Cardiovascular Drugs.” If you know physician experts. Our physicians and what your drug is used for, simply look pharmacists work closely together to for the category name in the list. Then ensure that our formulary meets your look under the category name for your needs. drug. Does the formulary ever change? Alphabetical Listing Yes, Kaiser Permanente periodically If you are not sure what category to updates the formulary based on new look under, you can look for the drug in medical evidence, considering the the Index. The Index provides an recommendations of appropriate alphabetical list of all the drugs physician experts and notifies our included in this document. Both brand- doctors, pharmacists, and other name drugs and generic drugs are clinicians about any changes. If a listed in the Index. Look in the Index change in the formulary affects any of and find your drug. Next to the drug, your prescriptions, your doctor or you will see the page number where pharmacist will let you know. you can find coverage information. The enclosed formulary is effective as Go to the page listed in the Index and of January 1, 2020 and represents the find the name of your drug on the list. most commonly prescribed What are generic drugs? medications. Kaiser Permanente covers both brand- How do I use the Formulary? name drugs and generic drugs. There is an easy way to find your drug Generic drugs are produced and sold within the formulary: under their chemical names after the To search for a specific medication or patent of the brand name drug condition, press the CTRL key and the expires. Although the price is lower, the *Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at KP Pharmacies and Network Pharmacies. **All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Xheck with your Kaiser Permanente pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved. Kaiser Permanente, a TRICARE Prime Option Formulary 1 quality and effectiveness of generic Open formulary benefits have a drugs is the same as brand name generic cost sharing requirement. This drugs. The Federal Food and Drug means that if you choose to fill a brand Administration (FDA) requires that name drug when a generic is generic drugs contain the same active available, then in addition to your ingredients in the same amount as the standard cost share, you will also pay brand name drug. Generic drugs are the difference in cost between the listed in lower-case italics (e.g., brand name and generic drug. amoxicillin) within the formulary. Brand- Generics drugs are those covered at name drugs are capitalized within the the lowest cost share defined as Tier 1 formulary (e.g., FLOVENT). coverage amount. Formulary brand What are Formulary Brand name drugs? drugs are those brands which will be Formulary Brand name drugs are drugs covered at your formulary brand cost that are produced and sold under the share defined as Tier 2 coverage original manufacturer’s name. amount. Non-formulary brands drugs are covered at the non-formulary cost What are Non-Formulary Brand drugs? share defined as Tier 3 coverage Non-Formulary Brand drugs are drugs amount. that are not included on the plan's list Coverage for prescription drugs is of preferred prescription drugs. limited to drugs for which a prescription Because all drug product strengths and is required by law and those that are package sizes of a formulary drug will listed on the Kaiser Permanente, a be included in your plan’s benefits, just TRICARE Prime Option drug formulary. note the drug cost share coverage Certain diabetic supplies do not amount will be based on the specific require a prescription but must still be tier of the formulary, check with your listed in our formulary in order to be Kaiser Permanente pharmacist for covered under the benefit. clarification, if needed. Each prescription refill is provided on How much will I pay for Covered Drugs? the same basis as the original What you pay for covered drugs is prescription. Cost shares are applied determined by the outpatient on a per prescription basis, for up to prescription drug benefit outlined in the lesser of the dispensing amount your Evidence of Coverage. Kaiser listed in the “Schedule of Benefits” or Permanente, a TRICARE Prime Option the standard prescription amount. plan has a three-tier open formulary The standard prescription amount for benefit. the following items is: *Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at KP Pharmacies and Network Pharmacies. **All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Xheck with your Kaiser Permanente pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved. Kaiser Permanente, a TRICARE Prime Option Formulary 2 • Migraine medications ― the • Step Therapy (ST): For certain drugs, smallest package size commercially Kaiser Permanente requires the use available of similar, alternative medications • Ophthalmic and otic medications ― prior to coverage. the smallest package size commercially available You can find out if the drug has any • Oral and nasal inhalers ― the additional requirements or limits by smallest standard package size looking in the Restrictions Column on the formulary list. Are there any other restrictions on What if my drug is not on the Formulary? coverage? Because all drug product strengths and Some covered drugs may have package sizes of a formulary drug may additional requirements or limits on not be included on the formulary, coverage. These requirements and check with your Kaiser Permanente limits may include: pharmacist for clarification, if needed. • Quantity Limits (QL): For certain drugs, For more information Kaiser Permanente limits the amount For more detailed information about of the drug that will be covered. your Kaiser Permanente, a TRICARE Prime Option prescription drug • Age Restriction (Age): For certain drugs, coverage, please review your Kaiser Permanente limits coverage Evidence of Coverage and other plan based on a designated age. materials. • Prior Authorization (PA): For certain If you have questions about Kaiser drugs, Kaiser Permanente requires Permanente, please call Member review and authorization prior to Services at 1-833-642-5973 or 770-291- dispensing. Your Provider must 4430, Monday through Friday 7:00 a.m. obtain this review and authorization. to 7 p.m. TTY/TDD users should call 1- The list of prescription drugs 800-255-0056. requiring review and authorization is subject to periodic review and Or visit kp.org/tricare. modification by our Pharmacy and Therapeutics Committee. *Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at KP Pharmacies and Network Pharmacies. **All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Xheck with your Kaiser Permanente pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved. Kaiser Permanente, a TRICARE Prime Option Formulary 3 Kaiser Permanente, a TRICARE Prime Option Formulary ST = Step Therapy, PA = Prior Authorization, QL = Quantity Limit, Age = Age Restriction Coverage Restrictions Tier Generic Name Brand Name Status Antihistamine Drugs Antihistamine Drugs ST 1 carbinoxamine maleate ARBINOXA Generic 1 cyproheptadine PERIACTIN Generic chlorpheniramine, phenylephrine 1 POLY HIST FORTE Generic & pyrilamine 1 promethazine & phenylephrine PHENERGAN VC Generic QL 1 promethazine PHENERGAN Generic Anti-infective Agents Anthelmintics Preferred 2 albendazole ALBENZA Brand 1 ivermectin STROMECTOL Generic PA 3 ivermectin SOOLANTRA Non-Preferred ST 1 praziquantel BILTRICIDE Generic Anti-infectives, Miscellaneous ST 3 bismuth subcitrate & metronidazole PYLERA Non-Preferred metronidazole, tetracycline & 3 HELIDAC Non-Preferred bismuth subsalicylate 3 benznidazole benznidazole Non-Preferred Antibacterials ST 3 amikacin liposomal Inhalation ARIKAYCE Non-Preferred 1 amoxicillin AMOXIL Generic amoxicillin & clavulanate 1 AUGMENTIN Generic potassium amoxicillin & clavulanate 1 AUGMENTIN XR Generic potassium extended-release 1 ampicillin sodium AMPICILLIN Generic 1 azithromycin ZITHROMAX Generic 1 cefaclor CECLOR Generic 1 cefadroxil DURICEF Generic 1 cefdinir OMNICEF Generic ST 1 cefditoren SPECTRACEF Generic 3 cefixime SUPRAX Non-Preferred 1 cefixime solution SUPRAX Generic 1 cefpodoxime VANTIN Generic 1 cefprozil CEFZIL