Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015) - 1 - Kaiser Permanente Colorado PPO/POS Preferred Product List The following is a listing of the drugs on the Kaiser Permanente Southern Colorado PPO & Denver/Boulder PPO/POS preferred product listing. This product listing applies only to outpatient drugs provided to members for self-administration, and does not apply to medications used in inpatient settings or medications administered in a doctor’s off ice or infusion center. The listing does not provide information regarding the specific coverage, limitations or quotas an individual member may have. Many members have specific exclusions, copays, or coinsurances that are not reflected in the preferred product listing. Kaiser Permanente has many brand and generic medications on the preferred product listing. In most cases, a generic equivalent is used when available. Members will be notified when a generic equivalent is dispensed. If a member requests a brand name when a generic equivalent is routinely used, the member will pay the difference in price between the generic equivalent and the requested brand plus the appropriate copay. Kaiser Permanente may implement programs, such as a therapeutic interchange program, to promote safe and effective drug therapy. In these cases the prescribing provider and member are notified prior to a change occurring. How to use this Preferred Product List document Products available in a generic form are listed by their generic name in italics. With the exception of drugs where multiple branded products exist, medications only available as a brand name product are listed in all CAPITAL letters. Please remember that this list is subject to change and will be updated at least quarterly. Any product not found in this listing or in subsequent updates, will be considered a non-preferred drug. You can search the list by using the index, by using the “Find” function in Adobe Reader, or by therapeutic drug category. All dosage forms and strengths for a particular drug listed may not be formulary. Some drugs are available in more than one dosage form (example: tablet and injectable). Not all dosage forms of drugs are covered under the prescription drug benefit. Drugs that have at least one dosage form as an injectable on formulary are noted with an asterisk (*). Drugs that have certain strengths or forms (e.g., tablet, gel capsule, liquid) that are only available as brand drugs are subject to the brand cost share. Restrictions on medication coverage: Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Restricted to specialty: A drug that needs to be written by a physician specialized in the treatment of certain conditions for the drug to be covered under the patient’s pharmacy benefit. For example, Entocort EC ® , a drug used for colitis, is restricted to physicians specialized in Gastroenterology. Prior authorization: Some drugs require specific medical criteria be met prior to dispensing the drug for the patient’s pharmacy benefit.
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Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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Kaiser Permanente Colorado PPO/POS Preferred Product List
The following is a listing of the drugs on the Kaiser Permanente Southern Colorado PPO & Denver/Boulder PPO/POS preferred product listing. This product listing applies only to outpatient drugs provided to members for self-administration, and does not apply to medications used in inpatient settings or medications administered in a doctor’s office or infusion center. The listing does not provide information regarding the specific coverage, limitations or quotas an individual member may have. Many members have specific exclusions, copays, or coinsurances that are not reflected in the preferred product listing. Kaiser Permanente has many brand and generic medications on the preferred product listing. In most cases, a generic equivalent is used when available. Members will be notified when a generic equivalent is dispensed. If a member requests a brand name when a generic equivalent is routinely used, the member will pay the difference in price between the generic equivalent and the requested brand plus the appropriate copay. Kaiser Permanente may implement programs, such as a therapeutic interchange program, to promote safe and effective drug therapy. In these cases the prescribing provider and member are notified prior to a change occurring.
How to use this Preferred Product List document Products available in a generic form are listed by their generic name in italics. With the exception of drugs where multiple branded products exist, medications only available as a brand name product are listed in all CAPITAL letters. Please remember that this list is subject to change and will be updated at least quarterly. Any product not found in this listing or in subsequent updates, will be considered a non-preferred drug. You can search the list by using the index, by using the “Find” function in Adobe Reader, or by therapeutic drug category. All dosage forms and strengths for a particular drug listed may not be formulary. Some drugs are available in more than one dosage form (example: tablet and injectable). Not all dosage forms of drugs are covered under the prescription drug benefit. Drugs that have at least one dosage form as an injectable on formulary are noted with an asterisk (*). Drugs that have certain strengths or forms (e.g., tablet, gel capsule, liquid) that are only available as brand drugs are subject to the brand cost share.
Restrictions on medication coverage: Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
Restricted to specialty: A drug that needs to be written by a physician specialized in the treatment of certain conditions for the drug to be covered under the patient’s pharmacy benefit. For example, Entocort EC®, a drug used for colitis, is restricted to physicians specialized in Gastroenterology.
Prior authorization: Some drugs require specific medical criteria be met prior to dispensing the drug for the patient’s pharmacy benefit.
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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Quantity Limits or Quotas: For certain drugs, Kaiser Permanente limits the amount of medication dispensed to a specific days supply or quantity per copay. For example, Tarceva® is limited to a 30-day supply. In addition, when there is a national shortage of a drug, we may limit the quantity of the drug dispensed per prescription per copayment.
Restricted to Benefit: Some drugs are not covered unless the individual prescription benefit specifically covers such medications. For example, Viagra® and other drugs for sexual dysfunction are not covered unless the prescription benefit specifically covers them.
Step therapy: Some medications require a similar therapy be attempted first. For example, before lansoprazole can be dispensed, a drug such as omeprazole must be tried first.
Restricted to a specific age: Some medications may be restricted to a certain age or age range.
Medication Exception Process: Upon request, Kaiser Permanente may make an exception to our coverage rules. The following are examples of exception requests:
o Request to cover a drug that is not on our preferred product list o Request to waive coverage restrictions or limitations
Generally Kaiser Permanente will only approve requests for an exception if the alternative drugs included on the plan’s preferred product list, or existing utilization restrictions, would not be as effective in treating a condition or would cause adverse medical effects.
Key: * (asterisk) = A drug where at least one of the dosage forms is an injectable. Some patients have a specific self-injectable coinsurance. (diamond) = A drug that is designated as a Specialty drug which may process at a Specialty tier of the individual prescription drug benefit, where applicable. † (dagger) = Certain strengths or forms of the drug (e.g., tablet, gel, liquid) are only available as brand drugs and are subject to the brand cost share. MD = A drug that is required to be written by a physician specialized in the treatment of certain conditions. PA = A drug that requires specific medical criteria be met prior to dispensing for prescription benefit. 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. ST = A drug that requires another class of medications be attempted prior to dispensing for prescription benefit. AG = A drug that is restricted to a specific age range. NC = A drug that is specifically excluded under certain benefit plans. This list of drugs should not be used to determine benefit issues such as prescription copay amounts. If you have questions about prescription benefits, please call Kaiser Permanente Member Services at 1-888-681-7878. The medications on this list are subject to change at any time throughout the year
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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Drug Name Drug Tier Requirements/Limits
ANTI-INFECTIVE AGENTS
ANTHELMINTICS
ALBENZA Brand
BILTRICIDE Brand
ivermectin Generic
MEBENDAZOLE Brand
ANTIBACTERIALS
amoxicillin Generic/Brand †
amoxicillin & pot clavulanate Generic/Brand †
ampicillin Generic/Brand †
azithromycin Generic/Brand †
CAYSTON Brand
cefaclor Generic/Brand †
cefadroxil Generic
cefdinir Generic
cefixime Generic
cefprozil Generic
cefuroxime axetil Generic/Brand †
cephalexin Generic
ciprofloxacin hcl Generic/Brand †
ciprofloxacin-ciprofloxacin hcl Generic
clarithromycin Generic
clindamycin hcl Generic
clindamycin palmitate hydrochloride Generic
dicloxacillin sodium Generic
doxycycline hyclate Generic
E.E.S. 400 Brand
ERYTHROCIN STEARATE Brand
erythromycin base Generic/Brand †
erythromycin-sulfisoxazole Generic
levofloxacin Generic
linezolid Generic/Brand * QL
minocycline hcl Generic
moxifloxacin hcl Generic
NEO-FRADIN Brand
NOROXIN Brand
PCE Brand
penicillin v potassium Generic
SPECTRACEF Brand
SULFADIAZINE Brand
sulfamethoxazole-trimethoprim Generic
sulfasalazine Generic
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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Drug Name Drug Tier Requirements/Limits
SUPRAX Brand
TETRACYCLINE HCL Brand
TOBI Podhaler Brand QL
tobramycin neb Generic QL
vancomycin hcl Generic QL
ZYVOX Brand * QL
ANTIFUNGALS
fluconazole Generic
griseofulvin ultramicrosize Generic
itraconazole Generic/Brand †
ketoconazole Generic
nystatin Generic
nystatin (mouth-throat) Generic
terbinafine hcl Generic
voriconazole Generic
ANTIMYCOBACTERIALS
DAPSONE Brand
ethambutol hcl Generic
isoniazid Generic/Brand †
pyrazinamide Generic
rifabutin Generic
rifampin Generic
ANTIPROTOZOALS
atovaquone Generic
atovaquone-proguanil hcl Generic
chloroquine phosphate Generic
DARAPRIM Brand
hydroxychloroquine sulfate Generic
mefloquine hcl Generic
metronidazole Generic
NEBUPENT Brand
paromomycin sulfate Generic
PRIMAQUINE PHOSPHATE Brand
YODOXIN Brand
ANTIVIRALS
abacavir-lamivudine-zidovudine Generic
abacavir sulfate Generic/Brand †
acyclovir Generic
adefovir dipivoxil Generic QL
APTIVUS Brand
ATRIPLA Brand
BARACLUDE Brand
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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Drug Name Drug Tier Requirements/Limits
CRIXIVAN Brand
didanosine Generic/Brand †
EMTRIVA Brand
entecavir Generic †
EPIVIR HBV Brand
EPZICOM Brand
famciclovir Generic
GANCICLOVIR Brand QL
HARVONI Brand QL
INFERGEN Brand * QL
INTELENCE Brand
INVIRASE Brand
ISENTRESS Brand
KALETRA Brand
lamivudine Generic/Brand †
lamivudine-zidovudine Generic
LEXIVA Brand
nevirapine Generic
NORVIR Brand
PEG-INTRON Brand * QL
PEGASYS Brand * QL
PREZISTA Brand
RELENZA DISKHALER Brand QL
RESCRIPTOR Brand
REYATAZ Brand
ribavirin (hepatitis c) Generic QL
rimantadine hydrochloride Generic
SELZENTRY Brand
SOVALDI Brand QL
stavudine Generic
SUSTIVA Brand
TAMIFLU Brand QL
TRUVADA Brand
TYZEKA Brand QL
valacyclovir hcl Generic
valganciclovir Generic QL
VICTRELIS Brand QL
VIRACEPT Brand
VIRAZOLE Brand QL
VIREAD Brand
zidovudine Generic
URINARY ANTI-INFECTIVES
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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Drug Name Drug Tier Requirements/Limits
methenamine-hyosc-methylene blue-sod phos-phenyl sal Generic
nitrofurantoin Generic
nitrofurantoin macrocrystal Generic/Brand †
nitrofurantoin monohyd macro Generic
PRIMSOL Brand
trimethoprim Generic
ANTIHISTAMINE DRUGS
ANTIHISTAMINE DRUGS
cyproheptadine hcl Generic
promethazine hcl Generic/Brand *†
ANTINEOPLASTIC AGENTS
ANTINEOPLASTIC AGENTS
AFINITOR Brand QL
ALKERAN Brand
anastrozole Generic
bicalutamide Generic
capecitabine Generic
CEENU Brand
CYCLOPHOSPHAMIDE Brand
ELIGARD Brand *
EMCYT Brand QL
ETOPOSIDE Brand
exemestane Generic
flutamide Generic
GLEEVEC Brand QL
HEXALEN Brand
hydroxyurea Generic
IMBRUVICA Brand QL
INTRON-A Brand * QL
IRESSA Brand QL
letrozole Generic
LEUKERAN Brand
leuprolide acetate Generic/Brand * †
LUPRON DEPOT Brand *
LUPRON DEPOT-PED Brand *
LYSODREN Brand QL
MATULANE Brand QL
megestrol acetate Generic
melphalan hcl Generic *
mercaptopurine Generic
methotrexate sodium Generic/Brand †
MYLERAN Brand
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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Drug Name Drug Tier Requirements/Limits
NEXAVAR Brand QL
NILANDRON Brand
PURIXAN Brand
RHEUMATREX Brand
SPRYCEL Brand QL
SUTENT Brand QL
TABLOID Brand
tamoxifen citrate Generic
TARCEVA Brand QL
TARGRETIN Brand QL
temozolomide Generic QL
tretinoin (chemotherapy) Generic QL
TYKERB Brand QL
VOTRIENT Brand QL
XTANDI Brand QL
ZELBORAF Brand QL
ZOLINZA Brand QL
ZYDELIG Brand QL
ZYTIGA Brand QL
AUTONOMIC DRUGS
ANTICHOLINERGIC AGENTS
ATROVENT HFA Brand
clidinium & chlordiazepoxide Generic
dicyclomine hcl Generic/Brand †
DONNATAL Brand
glycopyrrolate Generic
hyoscyamine sulfate Generic
ipratropium bromide Generic
ipratropium bromide (nasal) Generic
SPIRIVA RESPIMAT Brand
AUTONOMIC DRUGS, MISCELLANEOUS
phenoxybenzamine hcl Generic
tamsulosin hcl Generic
PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS
bethanechol chloride Generic
cevimeline hcl Generic
donepezil hydrochloride Generic
galantamine hydrobromide Generic
PROSTIGMIN Brand
pyridostigmine bromide Generic/Brand †
SKELETAL MUSCLE RELAXANTS
baclofen Generic
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)