The following is a list of drugs and drug entities that are excluded from prescription benefit coverage. Prior authorization will not apply. Kasier Permanente reserves the right to exclude any drug at any time from the Kaiser Permanente Colorado Formulary for health and safety concerns or other reasons as determined by Kaiser Permanente at its discretion. If you have questions about the formulary status of a medication, or your prescription benefits, please call our Member Services Department at 1-888-681-7878 (toll free). For the hearing or speech impaired: 1-800- 521-4874 (toll free TTY). This list is subject to change at any time. EXCLUSION CRITERIA: o Drugs and supplies for cosmetic purposes o Drugs for the promotion, prevention, or other treatment of hair loss or growth o Drugs related to non-covered services o Drugs to enhance athletic performance o Drugs to shorten the duration of the common cold o Drugs to treat infertility* o Drugs to treat sexual dysfunction* o Drugs used in the treatment of weight management* o Medical supplies such as dressings and antiseptics o Nonprescription drugs, unless otherwise noted o Packaging of drugs other than the dispensing pharmacy’s standard packaging o Prescription drugs for which there is a nonprescription equivalent available, unless otherwise noted o Prescriptions filled at a non-plan pharmacy, except for emergencies as described in your EOC o Replacement of lost, stolen or damaged prescription drugs and/or devices o Vaccines (usually covered under medical) o Vitamins and nutritional supplements that can be purchased without a prescription o Medical service drugs o Any drug being used for a non-approved indication o Medical foods and medical devices *Drug Category is excluded unless your plan has a buy-up for that benefit Kaiser Permanente Commercial HMO Drug Exclusion List
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Excluded drug list - Kaiser Permanente · Kaiser Permanente Commercial HMO Drug Exclusion List Listed are items that are excluded from prescription benefit coverage. All of the excluded
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The following is a list of drugs and drug entities that are excluded from prescription benefit coverage. Prior authorization will not apply. Kasier Permanente reserves the right to exclude any drug at any time from the Kaiser Permanente Colorado Formulary for health and safety concerns or other reasons as determined by Kaiser Permanente at its discretion. If you have questions about the formulary status of a medication, or your prescription benefits, please call our Member Services Department at 1-888-681-7878 (toll free). For the hearing or speech impaired: 1-800-521-4874 (toll free TTY). This list is subject to change at any time.
EXCLUSION CRITERIA: o Drugs and supplies for cosmetic purposes o Drugs for the promotion, prevention, or other treatment of hair loss or growth o Drugs related to non-covered services o Drugs to enhance athletic performance o Drugs to shorten the duration of the common cold o Drugs to treat infertility* o Drugs to treat sexual dysfunction* o Drugs used in the treatment of weight management* o Medical supplies such as dressings and antiseptics o Nonprescription drugs, unless otherwise noted o Packaging of drugs other than the dispensing pharmacy’s standard packaging o Prescription drugs for which there is a nonprescription equivalent available, unless otherwise noted o Prescriptions filled at a non-plan pharmacy, except for emergencies as described in your EOC o Replacement of lost, stolen or damaged prescription drugs and/or devices o Vaccines (usually covered under medical) o Vitamins and nutritional supplements that can be purchased without a prescription o Medical service drugs o Any drug being used for a non-approved indication o Medical foods and medical devices
*Drug Category is excluded unless your plan has a buy-up for that benefit
Kaiser Permanente Commercial HMO Drug Exclusion List
Kaiser Permanente Commercial HMO Drug Exclusion List
Listed are items that are excluded from prescription benefit coverage. All of the excluded drug entities, strengths, formulations &/or package sizes may not be listed.
The list is not all inclusive and is subject to change. Office administered drugs and IV drugs are covered under the Medical benefit and excluded from being dispensed from retail pharmacy.
(1)(2)(3) Drug Category is excluded unless your plan has a buy-up for that benefit (1) Infertility Drug Category; (2) Sexual Dysfunction Drug Category; (3) Weight Loss Drug Category
KPCO Commercial HMO Drug Exclusion List Page 2 of 9 Revision date: April 2018
Kaiser Permanente Commercial HMO Drug Exclusion List
Listed are items that are excluded from prescription benefit coverage. All of the excluded drug entities, strengths, formulations &/or package sizes may not be listed.
The list is not all inclusive and is subject to change. Office administered drugs and IV drugs are covered under the Medical benefit and excluded from being dispensed from retail pharmacy.
(1)(2)(3) Drug Category is excluded unless your plan has a buy-up for that benefit (1) Infertility Drug Category; (2) Sexual Dysfunction Drug Category; (3) Weight Loss Drug Category
KPCO Commercial HMO Drug Exclusion List Page 3 of 9 Revision date: April 2018
Kaiser Permanente Commercial HMO Drug Exclusion List
Listed are items that are excluded from prescription benefit coverage. All of the excluded drug entities, strengths, formulations &/or package sizes may not be listed.
The list is not all inclusive and is subject to change. Office administered drugs and IV drugs are covered under the Medical benefit and excluded from being dispensed from retail pharmacy.
(1)(2)(3) Drug Category is excluded unless your plan has a buy-up for that benefit (1) Infertility Drug Category; (2) Sexual Dysfunction Drug Category; (3) Weight Loss Drug Category
KPCO Commercial HMO Drug Exclusion List Page 4 of 9 Revision date: April 2018
Kaiser Permanente Commercial HMO Drug Exclusion List
Listed are items that are excluded from prescription benefit coverage. All of the excluded drug entities, strengths, formulations &/or package sizes may not be listed.
The list is not all inclusive and is subject to change. Office administered drugs and IV drugs are covered under the Medical benefit and excluded from being dispensed from retail pharmacy.
(1)(2)(3) Drug Category is excluded unless your plan has a buy-up for that benefit (1) Infertility Drug Category; (2) Sexual Dysfunction Drug Category; (3) Weight Loss Drug Category
KPCO Commercial HMO Drug Exclusion List Page 5 of 9 Revision date: April 2018
Kaiser Permanente Commercial HMO Drug Exclusion List
Listed are items that are excluded from prescription benefit coverage. All of the excluded drug entities, strengths, formulations &/or package sizes may not be listed.
The list is not all inclusive and is subject to change. Office administered drugs and IV drugs are covered under the Medical benefit and excluded from being dispensed from retail pharmacy.
(1)(2)(3) Drug Category is excluded unless your plan has a buy-up for that benefit (1) Infertility Drug Category; (2) Sexual Dysfunction Drug Category; (3) Weight Loss Drug Category
KPCO Commercial HMO Drug Exclusion List Page 6 of 9 Revision date: April 2018
Kaiser Permanente Commercial HMO Drug Exclusion List
Listed are items that are excluded from prescription benefit coverage. All of the excluded drug entities, strengths, formulations &/or package sizes may not be listed.
The list is not all inclusive and is subject to change. Office administered drugs and IV drugs are covered under the Medical benefit and excluded from being dispensed from retail pharmacy.
(1)(2)(3) Drug Category is excluded unless your plan has a buy-up for that benefit (1) Infertility Drug Category; (2) Sexual Dysfunction Drug Category; (3) Weight Loss Drug Category
KPCO Commercial HMO Drug Exclusion List Page 7 of 9 Revision date: April 2018
Kaiser Permanente Commercial HMO Drug Exclusion List
Listed are items that are excluded from prescription benefit coverage. All of the excluded drug entities, strengths, formulations &/or package sizes may not be listed.
The list is not all inclusive and is subject to change. Office administered drugs and IV drugs are covered under the Medical benefit and excluded from being dispensed from retail pharmacy.
(1)(2)(3) Drug Category is excluded unless your plan has a buy-up for that benefit (1) Infertility Drug Category; (2) Sexual Dysfunction Drug Category; (3) Weight Loss Drug Category
KPCO Commercial HMO Drug Exclusion List Page 8 of 9 Revision date: April 2018
Kaiser Permanente Commercial HMO Drug Exclusion List
Listed are items that are excluded from prescription benefit coverage. All of the excluded drug entities, strengths, formulations &/or package sizes may not be listed.
The list is not all inclusive and is subject to change. Office administered drugs and IV drugs are covered under the Medical benefit and excluded from being dispensed from retail pharmacy.
(1)(2)(3) Drug Category is excluded unless your plan has a buy-up for that benefit (1) Infertility Drug Category; (2) Sexual Dysfunction Drug Category; (3) Weight Loss Drug Category
KPCO Commercial HMO Drug Exclusion List Page 9 of 9 Revision date: April 2018
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اگر به زبان فارسی گفتگو می کنيد، تسهيالت زبانی بصورت رايگان برای توجه: (Farsi) فارسی تماس بگيريد.1-800-632-9700 (TTY: 711) شما فراهم می باشد. با
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नपाली (Nepali) धयान दिनहोस: तपारइल नपाली बोलनहनछ भन तपारइको ननमतत भाषा सहायता सवाहर ननिःशलक रपमा उपलबध छ । 1-800-632-9700 )TTY: 711( फोन गनहोस । Afaan Oromoo (Oromo) XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-800-632-9700 (TTY: 711).
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Yorùbá (Yoruba) AKIYESI: Ti o ba nso ede Yoruba ofe ni iranlowo lori ede wa fun yin o. E pe ero ibanisoro yi 1-800-632-9700 (TTY: 711).