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 1-888-681-7878 (tll free). Fr the hearing r speech impaired: 1-800- 521-4874 (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
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) BUTALBITAL-ACETAMINOPHEN CAPS 50-300 MG 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) (2)(3) 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: Octber 2018
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. CHLORHEXIDINE GLUCONATE-MUPIROCIN- DIMETHICONE-SILICONE (KIT) 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 CONTINUOUS BLOOD GLUCOSE SYSTEM/DEVICE 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 DEXILANT 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) (2)(3) 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: Octber 2018
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-CAPSAICIN (PACK) DICLOFENAC SODIUM-CAPSAICIN (TOPICAL) DICLOFENAC SODIUM-RANITIDINE HCL-CAPSAICIN (PACK) 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 DROXICIN LIQUID 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) (2)(3) 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: Octber 2018
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. GEL-ONE (INJ) GELSYN (INJ) GENVISC (INJ) GLIADEL WAFER (IMPLANT) GLUMETZA 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) ILUMYA (INJ) ILUVIEN IMPLANT 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) KELARX GEL 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 (2)(3) 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: Octber 2018
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. LEUPROLIDE ACETATE & NORETHINDRONE ACETATE (KIT) LEUPROLIDE ACETATE (INJ) LEVITRA (2) LEVOCETIRIZINE DIHYDROCHLORIDE LEVONORGESTREL (EMERGENCY OC) OTC LEVONORGESTREL IUD (DEVICE) LIDOCAINE-PENTAFLUOROPROP-TETRAFLUOROETH- ULTRASOUND (KIT) 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 LOPROX KIT LORCASERIN HCL LORVATUS PHARMAPAK (KIT) LOXAPINE (INH) LUKAID GLA LUNGLAID MACI SHEET 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) (2)(3) 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: Octber 2018
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. 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 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) NUDROXICIN (TOPICAL) NUDROXIPAK (KIT) 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) PENNSAID SOLN PERCURA PERSERIS (INJ) (2)(3) 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: Octber 2018
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. 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 PHENYLTOLOXAMINE-ACETAMINOPHEN PLAN B ONE-STEP PLIXDA PADS (EXTERNAL) 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) SIGNIFOR LAR (INJ) (2)(3) 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: Octber 2018
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. SILAZONE THP (TOPICAL) SILDENAFIL CITRATE (2) SILVER CARBOXYMETHYLCELLULOSE SOD/BANDAGES & RELATED PRODUCTS (SUPPLIES) SINUVA IMPLANT SMARTRX GABA THPK (PACK) SMARTRX GABA-V THPK (PACK) SODIUM FLUORIDE (DENTAL) SODIUM FLUORIDE-POTASSIUM NITRATE (DENTAL) SOLESTA GEL (IMPLANT) SPACER/AEROSOL HOLDING CHAMBERS (DEVICE) STAXYN (2) STENDRA (2) SUBLOCADE SOSY INJ SUMATRIPTAN-NAPROXEN SODIUM SUPER SOLUBLE DUOCAL SUPPRELIN LA/VANTAS (KIT) 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) TRIXYLITRAL PACK TRYPSIN, BALSAM PERU AND CASTOR OIL (TOPICAL) UREA (TOPICAL) UROFOLLITROPIN PURIFIED (INJ) UTI-STAT (2)(3) 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: Octber 2018
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. VACCINE/TOXOID COMBO (INJ) VACCINES (INJ) VANIQA (TOPICAL) VASCAZEN VASCULERA VASOLEX (TOPICAL) VAYACOG VAYARIN VAYAROL VENLAFAXINE HCL ER (TAB) VERAMYST SUSP (NASAL) VIAGRA (2) VIMOVO VP-GSTN VP-PRECIP VSL#3 WHYTEDERM (KIT) WOUND DRESSINGS (SUPPLIES) WPR PLUS WOUND HEALING SYSTEM XOLAIR (INJ) XRYLIX (TOPICAL) XYZAL YOSPRALA ZILRETTA (INJ) ZINC CITRATE-PHYTASE ZOLADEX (IMPLANT) VITRASERT (IMPLANT) (2)(3) 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: Octber 2018
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 1-800-632-9700 (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: 1-800-632-9700. 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 https://crprtal.hhs.gv/cr/prtal/lbby.jsf, 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, 1-800-368-1019, 1-800-537-7697 (TDD). Cmplaint frms are available at http://www.hhs.gv/cr/ffice/file/index.html. HELP IN YOUR LANGUAGE ATTENTION: If yu speak English, language assistance services, free f charge, are available t yu. Call 1-800-632-9700 (TTY: 711). አማርኛ (Amharic) ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ 1-800-632-9700 (TTY: 711). العربية (Arabic) ملحوظة: إذا كنت تتحدث العربية فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم 1-800-632-9700 :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 1-800-632-9700 (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 1-800-632-9700(TTY:711) 60577108_ACA_1557_MarCm_CO_2017_Taglines
فارسی (Farsi) توجه: اگر به زبان فارسی گفتگو می کنيد تسهيالت زبانی بصورت رايگان برای شما فراهم می باشد. با 1-800-632-9700 :TTY) 711) تماس بگيريد. Français (French) ATTENTION: Si vus parlez français, des services d'aide linguistique vus snt prpsés gratuitement. Appelez le 1-800-632-9700 (TTY: 711). Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kstenls sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-632-9700 (TTY: 711). Igb (Igb) NRỤBAMA: Ọ bụrụ na ị na asụ Igb, ọrụ enyemaka asụsụ, n efu, dịịrị gị. Kpọọ 1-800-632-9700 (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 1-800-632-9700(TTY: 711) まで お電話にてご連絡ください 한국어 (Krean) 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다. 1-800-632-9700 (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 1-800-632-9700 (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 1-800-632-9700 )TTY: 711( फ न गन ह स Afaan Orm (Orm) XIYYEEFFANNAA: Afaan dubbattu Ormiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-800-632-9700 (TTY: 711). Pусский (Russian) ВНИМАНИЕ: eсли вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-632-9700 (TTY: 711). Españl (Spanish) ATENCIÓN: si habla españl, tiene a su dispsición servicis gratuits de asistencia lingüística. Llame al 1-800-632-9700 (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 1-800-632-9700 (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 1-800-632-9700 (TTY: 711). Yrùbá (Yruba) AKIYESI: Ti ba ns ede Yruba fe ni iranlw lri ede wa fun yin. E pe er ibanisr yi 1-800-632-9700 (TTY: 711). 60577108_ACA_1557_MarCm_CO_2017_Taglines