Kaiser Permanente Commercial HMO Drug Exclusion List

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glumet Kaiser Permanente Cmmercial HMO Drug Exclusin List The fllwing is a list f drugs and drug entities that are excluded frm prescriptin benefit cverage. Prir authrizatin will nt apply.

1 glumet Kaiser Permanente Cmmercial HMO Drug Exclusin List The fllwing is a list f drugs and drug entities that are excluded frm prescriptin benefit cverage. Prir authrizatin will nt apply. Kasier Permanente reserves the right t exclude any drug at any time frm the Kaiser Permanente Clrad Frmulary fr health and safety cncerns r ther reasns as determined by Kaiser Permanente at its discretin. If yu have questins abut the frmulary status f a medicatin, r yur prescriptin benefits, please call ur Member Services Department at (tll free). Fr the hearing r speech impaired: (tll free TTY). This list is subject t change at any time. EXCLUSION CRITERIA: Drugs and supplies fr csmetic purpses Drugs fr the prmtin, preventin, r ther treatment f hair lss r grwth Drugs related t nn-cvered services Drugs t enhance athletic perfrmance Drugs t shrten the duratin f the cmmn cld Drugs t treat infertility* Drugs t treat sexual dysfunctin* Drugs used in the treatment f weight management* Medical supplies such as dressings and antiseptics Nnprescriptin drugs, unless therwise nted Packaging f drugs ther than the dispensing pharmacy s standard packaging Prescriptin drugs fr which there is a nnprescriptin equivalent available, unless therwise nted Prescriptins filled at a nn-plan pharmacy, except fr emergencies as described in yur EOC Replacement f lst, stlen r damaged prescriptin drugs and/r devices Vaccines (usually cvered under medical) Vitamins and nutritinal supplements that can be purchased withut a prescriptin Medical service drugs Any drug being used fr a nn-apprved indicatin Medical fds and medical devices *Drug Categry is excluded unless yur plan has a buy-up fr that benefit

2 Kaiser Permanente Cmmercial HMO Drug Exclusin List Listed are items that are excluded frm prescriptin benefit cverage. All f the excluded drug entities, strengths, frmulatins &/r package sizes may nt be listed. The list is nt all inclusive and is subject t change. Office administered drugs and IV drugs are cvered under the Medical benefit and excluded frm being dispensed frm retail pharmacy. 1ST GENERATION ANTIHISTAMINE-DECONGESTANT- ANALGESIC COMBINATIONS 1ST GENERATION ANTIHISTAMINE-DECONGESTANT- ANALGESIC, SALICYLATE 1ST GENERATION ANTIHISTAMINE-DECONGESTANT- ANALGESIC-EXPECTORANT COMBINATIONS 1ST GENERATION ANTIHISTAMINE-DECONGESTANT- EXPECTORANT COMBINATIONS 1ST GENERATION ANTIHISTAMINE-DECONGESTANT- NSAID, COX NONSPECIFIC 2'-FUCOSYLLACTOSE, LACTO-N-NEOTETRAOSE 2ND GENERATION ANTIHISTAMINE 2ND GENERATION ANTIHISTAMINE-DECONGESTANT ACANYA GEL (TOPICAL) ACETAMINOPHEN-GUAIFENESIN ACETIC ACID (IRRIGATION) ACRIVASTINE & PSEUDOEPHEDRINE ACTIVE-PAC/GABAPENTIN THPK (PACK) ACYCLOVIR-HYDROCORTISONE (TOPICAL) ADASUVE (INH) ADDYI (2) ALLEGRA ALLEGRA-D ALPROSTADIL (INJ) (2) ANALGESIC, NON-SALICYLATE-1ST GENERATION ANTIHISTAMINE ANALGESIC, NON-SALICYLATE-EXPECTORANT COMBINATIONS ANALGESICS, MIXED-1ST GENERATION ANTIHISTAMINE ANTITUSSIVES, NON-NARCOTIC APPTRIM APPTRIM-D ARIPIPRAZOLE LAUROXIL (INJ) AVAILNEX AXONA BENZPHETAMINE HCL (3) BETAMETHASONE SOD PHOSPHATE & ACETATE (KIT) BETAQUIK BIMATOPROST (TOPICAL) BOTOX COSMETIC (INJ) BROMPHENIRAMINE-ACETAMINOPHEN BULK PRODUCTS * BUPRENORPHINE HCL (KIT) CAMPHOR (INH) CAMPHOR-EUCALYPTUS-MENTHOL (INH) CAPXIB (KIT) CARDIOTEK RX CARISOPRODOL CARISOPRODOL W/ ASPIRIN & CODEINE CARISOPRODOL W/ ASPIRIN CATHETERS (DEVICE) CAVERJECT (INJ) (2) CELECOXIB-CAPSAICIN-MENTHOL (KIT) CETIRIZINE HCL CETRORELIX ACETATE (KIT) CHLORHEXIDINE GLUCONATE-MUPIROCIN- DIMETHICONE-SILICONE (KIT) Drug Categry is excluded unless yur plan has a buy-up fr that benefit Infertility Drug Categry; (2) Sexual Dysfunctin Drug Categry; (3) Weight Lss Drug Categry KPCO Cmmercial HMO Drug Exclusin List Page 2 f 10 Revisin date: July 2018

3 Kaiser Permanente Cmmercial HMO Drug Exclusin List Listed are items that are excluded frm prescriptin benefit cverage. All f the excluded drug entities, strengths, frmulatins &/r package sizes may nt be listed. The list is nt all inclusive and is subject t change. Office administered drugs and IV drugs are cvered under the Medical benefit and excluded frm being dispensed frm retail pharmacy. CHLORPHENIRAMINE-ACETAMINOPHEN CHLORPHENIRAMINE-PHENYLEPHRINE- ACETAMINOPHEN CHLORPHENIRAMINE-PHENYLEPHRINE-ASPIRIN CHLORPHENIRAMINE-PHENYLEPHRINE-IBUPROFEN CHLORPHENIRAMINE-PSEUDOEPHEDRINE-IBUPROFEN CHORIOGONADOTROPIN ALFA (INJ) CHORIONIC GONADOTROPIN (INJ) CIALIS (2) CICLOPIROX (KIT) CICLOPIROX-UREA (PACK) CLIN SINGLE USE (KIT) CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE & MOISTURIZER (KIT) CLINDAMYCIN PHOSPHATE-TRETINOIN (TOPICAL) CLINDAREACH (KIT) CLODAN KIT (TOP) CLOMIPHENE CITRATE COSMETIC PRODUCTS * COUGH AND/OR COLD PREPARATIONS CYANOCOBALAMIN (KIT) CYCLOBENZAPRINE HCL W/ LINIMENT (KIT) CYCLOBENZAPRINE-CAPSAICIN-MENTHOL (PACK) DECONGESTANT-ANALGESIC, NON-SALICYLATE COMBINATIONS DECONGESTANT-ANALGESIC-EXPECTORANT COMBINATIONS DECONGESTANT-EXPECTORANT COMBINATIONS DECONGESTANT-NSAID, COX NON-SPECIFIC COMBINATIONS DEPLIN DERMACINRX SILAPAK (KIT) DERMACINRX TICANASE (NASAL) DERMAPAK PAK PLUS (TOPICAL) DERMASORB HC (KIT) DERMASORB TA (KIT) DESLORATADINE DESLORATADINE-PSEUDOEPHEDRINE DEXBROMPHENIRAMINE-ACETAMINOPHEN DEXBROMPHENIRAMINE-PHENYLEPHRINE- ACETAMINOPHEN DEXLIDO (KIT) DEXLIDO-M (KIT) DEXTROMETHORPHAN DEXTROMETHORPHAN-BENZOCAINE DEXTROMETHORPHAN-BENZOCAINE-MENTHOL DEXTROMETHORPHAN-MENTHOL DICLOFENAC SODIUM & ADHESIVE SHEETS (PACK) DICLOFENAC SODIUM & OCCLUSIVE DRESSING (TOPICAL) DICLOFENAC SODIUM & RANITIDINE HCL & LIDOCAINE-PRILOCAINE (PACK) DICLOFENAC SODIUM (KIT) DICLOFENAC SODIUM-BENZALKONIUM CHLORIDE (PACK) DICLOFENAC SODIUM-CAMPHOR-MENTHOL-METHYL SALICYLATE (KIT) DICLOFENAC SODIUM-CAPSAICIN (PACK) DICLOFENAC SODIUM-CAPSAICIN (TOPICAL) DICLOFENAC SODIUM-RANITIDINE HCL-CAPSAICIN (PACK) Drug Categry is excluded unless yur plan has a buy-up fr that benefit Infertility Drug Categry; (2) Sexual Dysfunctin Drug Categry; (3) Weight Lss Drug Categry KPCO Cmmercial HMO Drug Exclusin List Page 3 f 10 Revisin date: July 2018

4 Kaiser Permanente Cmmercial HMO Drug Exclusin List Listed are items that are excluded frm prescriptin benefit cverage. All f the excluded drug entities, strengths, frmulatins &/r package sizes may nt be listed. The list is nt all inclusive and is subject t change. Office administered drugs and IV drugs are cvered under the Medical benefit and excluded frm being dispensed frm retail pharmacy. DICLOFENAC SODIUM-RANITIDINE HCL-LIDOCAINE (PACK) DIETARY MANAGEMENT PRODUCTS * DIETHYLPROPION HCL DIHYDROXYACETONE (TOPICAL) DIPHENHYDRAMINE-ACETAMINOPHEN DIPHENHYDRAMINE-PHENYLEPHRINE- ACETAMINOPHEN DITHOL THPK (PACK) DMT SUIK (KIT) DNA COLLECTION PRODUCT (KIT) DOLOTRANZ (KIT) DOUBLEDEX (KIT) DOXYCYCLINE HYCLATE W/ CLEANSER (KIT) DOXYLAMINE-PHENYLEPHRINE-ACETAMINOPHEN DUROLANE (INJ) DUEXIS DYMISTA SUSP (NASAL SPRAY) EDEX (INJ) (2) ELFOLATE ELIGEN B12 EMOLLIENT-SKIN MOISTURIZERS (TOPICAL) ENLYTE ENTERAGAM ENTERAL NUTRITION (SUPPLIES) EPHEDRINE-GUAIFENESIN EPICERAM EMUL (TOP) ESKATA SOLN (TOPICAL) ESOMEPRAZOLE MAGNESIUM EUFLEXXA (INJ) EXPECTORANTS EXPECTORANTS, COMBINATIONS FASENRA (INJ) FEEDING TUBES/SETS (DEVICE) FERREX 150 FORTE PLUS FEXOFENADINE HCL FEXOFENADINE-PSEUDOEPHEDRINE FIBER-STAT FINASTERIDE (ALOPECIA) FOLBIC FOLIC ACID-CYANOCOBALMIN-PYRIDOXINE FOLLITROPIN ALFA (INJ) FOLLITROPIN BETA (INJ) FORTAMET FOSTEUM FOSTEUM PLUS FOVEX GABADONE GANIRELIX ACETATE (INJ) GEL-ONE (INJ) GELSYN (INJ) GENVISC (INJ) GLUMETZA Drug Categry is excluded unless yur plan has a buy-up fr that benefit Infertility Drug Categry; (2) Sexual Dysfunctin Drug Categry; (3) Weight Lss Drug Categry KPCO Cmmercial HMO Drug Exclusin List Page 4 f 10 Revisin date: July 2018

5 Kaiser Permanente Cmmercial HMO Drug Exclusin List Listed are items that are excluded frm prescriptin benefit cverage. All f the excluded drug entities, strengths, frmulatins &/r package sizes may nt be listed. The list is nt all inclusive and is subject t change. Office administered drugs and IV drugs are cvered under the Medical benefit and excluded frm being dispensed frm retail pharmacy. GOSERELIN ACETATE (IMPLANT) GUAIFENESIN HALAC (KIT) HALONATE (KIT) HALOPERIDOL DECANOATE (INJ) HEPATITIS B IMMUNE GLOBULIN (HUMAN) (INJ) HYALGAN (INJ) HYDROQUINONE (TOPICAL) HYDROQUINONE MICROSPHERES (TOPICAL) HYDROQUINONE W/ SUNSCREENS (TOPICAL) HYDROXYPROGESTERONE CAPROATE (ANTINEOPLASTIC) (INJ) HYMOVIS (INJ) HYPERTENSA IBUPROFEN (OTC EQUIV) IBUPROFEN W/ LINIMENT (KIT) IMMUNE GLOBULIN (HUMAN) (INJ) INCONTINENCE SUPPLIES/WOUND CARE DRAINAGE (SUPPLIES) INFERTILITY DRUGS INHALER, SPACER/CHAMBER (DEVICE) IN-OFFICE ADMINISTERED PRODUCTS * INTRAROSA (VAG) INTRAROSA INST (VAG) INTRA-UTERINE DEVICES (IUDS) INTRAVENOUS INJECTIONS * INVEGA SUSTENNA SUSP (INJ) INVEGA TRINZA SUSP (INJ) ISOVACTIN AA PLUS BERRY IV CATHETER (SUPPLIES) IV SETS/TUBING (SUPPLIES) KARAYA GUM (TOPICAL) KETOCAL 3:1 POWDER KETOCAL 4:1 LQ KETOCAL 4:1 POWDER KETOCONAZOLE & CLEANSER (KIT) KETODAN (KIT) KETOROCAINE-L (KIT) KETOROCAINE-LM (KIT) KETOROLAC TROMETHAMINE (INJ) KETOTIFEN FUMARATE (OPHTH) KETOVIE 4:1 KETOVIE PEPTIDE LANSOPRAZOLE (OTC EQUIV) LETROZOLE LEUPROLIDE ACETATE & NORETHINDRONE ACETATE (KIT) LEUPROLIDE ACETATE (INJ) LEVITRA (2) LEVOCETIRIZINE DIHYDROCHLORIDE LEVONORGESTREL (EMERGENCY OC) OTC LEVONORGESTREL IUD (DEVICE) LIDOCAINE-PENTAFLUOROPROP-TETRAFLUOROETH- ULTRASOUND (KIT) Drug Categry is excluded unless yur plan has a buy-up fr that benefit Infertility Drug Categry; (2) Sexual Dysfunctin Drug Categry; (3) Weight Lss Drug Categry KPCO Cmmercial HMO Drug Exclusin List Page 5 f 10 Revisin date: July 2018

6 Kaiser Permanente Cmmercial HMO Drug Exclusin List Listed are items that are excluded frm prescriptin benefit cverage. All f the excluded drug entities, strengths, frmulatins &/r package sizes may nt be listed. The list is nt all inclusive and is subject t change. Office administered drugs and IV drugs are cvered under the Medical benefit and excluded frm being dispensed frm retail pharmacy. LIDOCAINE-PRILOCAINE (KIT) LIDOCAINE-PRILOCAINE-MENTHOL-METHYL SALICYLATE (KIT) LIDOCAINE-PRILOCAINE-SODIUM CHLORIDE (KIT) LIDOCAINE-TRANSPARENT DRESSING (KIT) LIDOPAC (KIT) LIMBREL LIPISTART LIQUIGEN LIRAGLUTIDE (WEIGHT MANAGEMENT) (INJ) LISTER-V LORCASERIN HCL LORVATUS PHARMAPAK (KIT) LOXAPINE (INH) LUKAID GLA LUNGLAID MAKENA (INJ) MARDEX-25 (KIT) MCT OIL MECLIZINE HCL MEDROXYPROGESTERONE ACETATE SUSP (INJ) MELOXICAM W/ LINIMENT (KIT) MEMANTINE HCL-DONEPEZIL HCL MENOTROPINS (INJ) MENTHOL (MOUTH-THROAT) MIACALCIN (INJ) MICONAZOLE NITRATE (VAG) MINOXIDIL (TOPICAL) MIRVASO GEL (TOPICAL) MISC NATURAL WEIGHTLOSS PRODUCTS MONOBENZONE (TOPICAL) MONOGEN MONOVISC (INJ) MUGARD MULTIPLE VITAMINS W/ MINERALS & FOLIC ACID MUSE PELLETS (IMPLANT) (2) NALTREXONE (INJ) NALTREXONE HCL-BUPROPION HCL NAMZARIC CP24 NAPROPAK (PACK) NAPROXEN SODIUM-MENTHOL (PACK) NAPROXEN W/ LINIMENT (KIT) NAPROXEN-CAPSAICIN-MENTHOL (KIT) NAPROXEN-ESOMEPRAZOLE MAGNESIUM NEOCATE JUNIOR NEOCATE JUNIOR WITH PREBIOTICS NEOCATE NUTRA NEOCATE'S E028 SPLASH NEO-SYNALAR (KIT)Bttm f Frm NEUAC (KIT) NEUREMEDY Drug Categry is excluded unless yur plan has a buy-up fr that benefit Infertility Drug Categry; (2) Sexual Dysfunctin Drug Categry; (3) Weight Lss Drug Categry KPCO Cmmercial HMO Drug Exclusin List Page 6 f 10 Revisin date: July 2018

7 Kaiser Permanente Cmmercial HMO Drug Exclusin List Listed are items that are excluded frm prescriptin benefit cverage. All f the excluded drug entities, strengths, frmulatins &/r package sizes may nt be listed. The list is nt all inclusive and is subject t change. Office administered drugs and IV drugs are cvered under the Medical benefit and excluded frm being dispensed frm retail pharmacy. NEXIUM NEXPLANON CONTRACEPTIVE IMPLANT NICAZELDOXY 30 (KIT) NON-NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE COMBINATIONS NON-NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE-ANALGESIC COMBINATIONS NON-NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE-DECONGESTANT NON-NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE-DECONGESTANT-ANALGESIC COMBINATIONS NON-NARCOTIC ANTITUSSIVE-1ST GENERATION- DECONGESTANT-SALICYLATE NON-NARCOTIC ANTITUSSIVE-ANALGESIC COMBINATIONS NON-NARCOTIC ANTITUSSIVE-DECONGESTANT COMBINATIONS NON-NARCOTIC ANTITUSSIVE-DECONGESTANT- ANALGESIC COMBINATIONS NON-NARCOTIC ANTITUSSIVE-DECONGESTANT- ANALGESIC-EXPECTORANT COMBINATIONS NON-NARCOTIC ANTITUSSIVE-DECONGESTANT- EXPECTORANT COMBINATIONS NON-NARCOTIC ANTITUSSIVE-EXPECTORANT COMBINATIONS NORITATE (TOPICAL) NUCALA INJ NYSTATIN & EXFOLIATING AGENT (KIT) OMEGA-3/D-3 WELLNESS (KIT) OMEPRAZOLE-SODIUM BICARBONATE ONEXTON GEL (TOPICAL) ORAL SYRINGES (SUPPLIES) ORAL WOUND CARE PRODUCTS ORLISTAT ORTHOVISC (INJ) OSPHENA (2) OTC PRODUCTS * OZURDEX OPTHALMIC (IMPLANT) PAINGO KFT (KIT) PAPAVERINE (INJ) (2) PAPAVERINE-ALPROSTADIL (INJ) (2) PAPAVERINE-PHENTOLAMINE (INJ) (2) PAPAVERINE-PHENTOLAMINE-ALPROSTADIL (INJ) (2) PARENTERAL ADMINISTRATION SETS (SUPPLIES) PECTIN (MOUTH-THROAT) PEDIADERM AF (KIT) PEDIADERM HC (KIT) PERCURA PHENAZOPYRIDINE HCL PHENDIMETRAZINE TARTRATE (3) PHENIRAMINE-PHENYLEPHRINE-ACETAMINOPHEN PHENTERMINE HCL (3) PHENTERMINE HCL-TOPIRAMATE (3) PHENTOLAMINE MESYLATE (INJ) (2) PHENTOLAMINE-ALPROSTADIL (INJ) (2) PHENYLEPHRINE-ACETAMINOPHEN PHENYLEPHRINE-ACETAMINOPHEN-GUAIFENESIN PHENYLEPHRINE-DIPHENHYDRAMINE-GUAIFENESIN- ACETAMINOPHEN PHENYLEPHRINE-GUAIFENESIN PHENYLEPHRINE-IBUPROFEN Drug Categry is excluded unless yur plan has a buy-up fr that benefit Infertility Drug Categry; (2) Sexual Dysfunctin Drug Categry; (3) Weight Lss Drug Categry KPCO Cmmercial HMO Drug Exclusin List Page 7 f 10 Revisin date: July 2018

8 Kaiser Permanente Cmmercial HMO Drug Exclusin List Listed are items that are excluded frm prescriptin benefit cverage. All f the excluded drug entities, strengths, frmulatins &/r package sizes may nt be listed. The list is nt all inclusive and is subject t change. Office administered drugs and IV drugs are cvered under the Medical benefit and excluded frm being dispensed frm retail pharmacy. PHENYLTOLOXAMINE-ACETAMINOPHEN PLAN B ONE-STEP PRASTERA PREVACID PREVIDENT (DENTAL) PROBARIMIN QT PROBIOTIC PRODUCT (PACK) PROGESTERONE (INJ) PROGESTERONE (VAG) PROGESTERONE MICRONIZED PROMETHAZINE W/ CODEINE PROPECIA PRO-STAT MAX PRO-STAT RENAL CARE PRO-STAT SUGAR FREE PRO-STAT SUGAR FREE AWC (ADVANCED WOUND CARE) PRO-STAT SUGAR FREE AWC PROSTIN VR (INJ) (2) PROTEOLIN PSEUDOEPHEDRINE-ACETAMINOPHEN PSEUDOEPHEDRINE-GUAIFENESIN PSEUDOEPHEDRINE-IBUPROFEN PSEUDOEPHEDRINE-NAPROXEN SODIUM RABIES IMMUNE GLOBULIN (HUMAN) (INJ) RETISERT (IMPLANT) RHEUMATE RHO D IMMUNE GLOBULIN (HUMAN) (INJ) RHOFADE CREAM (TOPICAL) RIDUZONE RITUXAN HYCELA SOLN (INJ) ROSADAN KIT (TOPICAL) SCULPTRA (INJ) SENTRA AM SENTRA PM SEXUAL DYSFUNCTION DRUGS (ORAL/INJ) (2) SIBUTRAMINE HCL MONOHYDRATE (3) SILAZONE THP (TOPICAL) SILDENAFIL CITRATE (2) SILVER CARBOXYMETHYLCELLULOSE SOD/BANDAGES & RELATED PRODUCTS (SUPPLIES) SMARTRX GABA THPK (PACK) SMARTRX GABA-V THPK (PACK) SODIUM FLUORIDE (DENTAL) SODIUM FLUORIDE-POTASSIUM NITRATE (DENTAL) SPACER/AEROSOL HOLDING CHAMBERS (DEVICE) STAXYN (2) STENDRA (2) SUBLOCADE SOSY INJ SUMATRIPTAN-NAPROXEN SODIUM SUPER SOLUBLE DUOCAL SUPPRELIN LA/VANTAS (KIT) Drug Categry is excluded unless yur plan has a buy-up fr that benefit Infertility Drug Categry; (2) Sexual Dysfunctin Drug Categry; (3) Weight Lss Drug Categry KPCO Cmmercial HMO Drug Exclusin List Page 8 f 10 Revisin date: July 2018

9 Kaiser Permanente Cmmercial HMO Drug Exclusin List Listed are items that are excluded frm prescriptin benefit cverage. All f the excluded drug entities, strengths, frmulatins &/r package sizes may nt be listed. The list is nt all inclusive and is subject t change. Office administered drugs and IV drugs are cvered under the Medical benefit and excluded frm being dispensed frm retail pharmacy. SYNAGIS (INJ) SYNVISC (INJ) TAZAROTENE (FACIAL WRINKLES) (TOPICAL) TEARS AGAIN HYDRATE TERBINAFINE-HYDROXYPROPYL CHITOSAN (KIT) TESTOSTERONE CYPIONATE (KIT) TESTOSTERONE PELLETS (IMPLANT) THERAMINE THROAT LOZENGES THYROTROPIN ALFA (INJ) TICASPRAY (NASAL) TIZANIDINE & LINIMENT (PACK) TOCILIZUMAB (INJ) TORADOL (INJ) TOUJEO MAX SOLOSTAR (INJ) TOXICOLOGY SALIVA COLLECTION (KIT) TOXOIDS (INJ) TOZAL TRELSTAR MIXJECT SUSR (INJ) TREPADONE TRETINOIN (FACIAL WRINKLES) (TOPICAL) TRETINOIN W/ CLEANSER & MOISTURIZER (KIT) TRETIN-X (KIT) TREXIMET TRIAMCINOLONE ACETONIDE (NASAL) TRIAMCINOLONE ACETONIDE-DIMETHICONE-SILICONE (KIT) TRIAMCINOLONE ACETONIDE-SILICONE (PACK) TRI-LUMA (TOPICAL) TRIPTODUR (INJ) TRYPSIN, BALSAM PERU AND CASTOR OIL (TOPICAL) UREA (TOPICAL) UROFOLLITROPIN PURIFIED (INJ) UTI-STAT VACCINE/TOXOID COMBO (INJ) VACCINES (INJ) VANIQA (TOPICAL) VASCAZEN VASCULERA VASOLEX (TOPICAL) VAYACOG VAYARIN VAYAROL VERAMYST SUSP (NASAL) VIAGRA (2) VIMOVO VITRASERT (IMPLANT) VP-GSTN VP-PRECIP VSL#3 WHYTEDERM (KIT) Drug Categry is excluded unless yur plan has a buy-up fr that benefit Infertility Drug Categry; (2) Sexual Dysfunctin Drug Categry; (3) Weight Lss Drug Categry KPCO Cmmercial HMO Drug Exclusin List Page 9 f 10 Revisin date: July 2018

10 Kaiser Permanente Cmmercial HMO Drug Exclusin List Listed are items that are excluded frm prescriptin benefit cverage. All f the excluded drug entities, strengths, frmulatins &/r package sizes may nt be listed. The list is nt all inclusive and is subject t change. Office administered drugs and IV drugs are cvered under the Medical benefit and excluded frm being dispensed frm retail pharmacy. WOUND DRESSINGS (SUPPLIES) XOLAIR (INJ) XYZAL ZILRETTA (INJ) ZINC CITRATE-PHYTASE ZOLADEX (IMPLANT) YOSPRALA Drug Categry is excluded unless yur plan has a buy-up fr that benefit Infertility Drug Categry; (2) Sexual Dysfunctin Drug Categry; (3) Weight Lss Drug Categry KPCO Cmmercial HMO Drug Exclusin List Page 10 f 10 Revisin date: July 2018

11 NONDISCRIMINATION NOTICE Kaiser Fundatin Health Plan f Clrad (Kaiser Health Plan) cmplies with applicable Federal civil rights laws and des nt discriminate n the basis f race, clr, natinal rigin, age, disability, r sex. Kaiser Health Plan des nt exclude peple r treat them differently because f race, clr, natinal rigin, age, disability, r sex. We als: Prvide n cst aids and services t peple with disabilities t cmmunicate effectively with us, such as: Qualified sign language interpreters Written infrmatin in ther frmats, such as large print, audi, and accessible electrnic frmats Prvide n cst language services t peple whse primary language is nt English, such as: Qualified interpreters Infrmatin written in ther languages If yu need these services, call (TTY: 711) If yu believe that Kaiser Health Plan has failed t prvide these services r discriminated in anther way n the basis f race, clr, natinal rigin, age, disability, r sex, yu can file a grievance by mail at: Custmer Experience Department, Attn: Kaiser Permanente Civil Rights Crdinatr, 2500 Suth Havana, Aurra, CO 80014, r by phne at Member Services: Yu can als file a civil rights cmplaint with the U.S. Department f Health and Human Services, Office fr Civil Rights electrnically thrugh the Office fr Civil Rights Cmplaint Prtal, available at r by mail r phne at: U.S. Department f Health and Human Services, 200 Independence Avenue SW., Rm 509F, HHH Building, Washingtn, DC 20201, , (TDD). Cmplaint frms are available at HELP IN YOUR LANGUAGE ATTENTION: If yu speak English, language assistance services, free f charge, are available t yu. Call (TTY: 711). አማርኛ (Amharic) ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ (TTY: 711). العربية (Arabic) ملحوظة: إذا كنت تتحدث العربية فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم :TTY(.)711 Ɓa sɔ ɔ Wu ɖu (Bassa) Dè ɖɛ nìà kɛ dyéɖé gb: Ɔ jǔ ké m Ɓàsɔ ɔ -wùɖù-p-nyɔ jǔ ní, nìí, à wuɖu kà kò ɖò p-pɔ ɓɛ ìn m gb kpáa. Ɖá (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 (TTY:711) _ACA_1557_MarCm_CO_2017_Taglines

12 فارسی (Farsi) توجه: اگر به زبان فارسی گفتگو می کنيد تسهيالت زبانی بصورت رايگان برای شما فراهم می باشد. با :TTY) 711) تماس بگيريد. Français (French) ATTENTION: Si vus parlez français, des services d'aide linguistique vus snt prpsés gratuitement. Appelez le (TTY: 711). Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kstenls sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). Igb (Igb) NRỤBAMA: Ọ bụrụ na ị na asụ Igb, ọrụ enyemaka asụsụ, n efu, dịịrị gị. Kpọọ (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 (TTY: 711) までお電話にてご連絡ください 한국어 (Krean) 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. Naabeehó (Navaj) Díí baa akó nínízin: Díí saad bee yáníłti g Diné Bizaad, saad bee áká ánída áw dé é, t áá jiik eh, éí ná hóló, kji hódíílnih (TTY: 711). न प ल (Nepali) ध य न द न ह स : तप र इ ल न प ल ब ल न ह न छ भन तप र इ क ननम तत भ ष सह यत स व हर नन श ल क र पम उपलब ध छ )TTY: 711( फ न गन ह स Afaan Orm (Orm) XIYYEEFFANNAA: Afaan dubbattu Ormiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa (TTY: 711). Pусский (Russian) ВНИМАНИЕ: eсли вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (TTY: 711). Españl (Spanish) ATENCIÓN: si habla españl, tiene a su dispsición servicis gratuits de asistencia lingüística. Llame al (TTY: 711). Tagalg (Tagalg) PAUNAWA: Kung nagsasalita ka ng Tagalg, maaari kang gumamit ng mga serbisy ng tulng sa wika nang walang bayad. Tumawag sa (TTY: 711). Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành ch bạn. Gọi số (TTY: 711). Yrùbá (Yruba) AKIYESI: Ti ba ns ede Yruba fe ni iranlw lri ede wa fun yin. E pe er ibanisr yi (TTY: 711) _ACA_1557_MarCm_CO_2017_Taglines

Kaiser Permanente Commercial HMO Drug Exclusion List

glumet 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.