Kaiser Permanente Point-of-Service Drug Formulary

1 Kaiser Permanente Point-of-Service drug Formulary For California Point-of-Service (POS) Plans*. Effective January 1, 2016. PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION REGARDING THE DRUGS. THAT ARE COVERED WHEN YOU PARTICIPATE IN OUR POS HEALTH INSURANCE. PLAN(S) AND USE A MEDIMPACT PHARMACY. IF YOU BELONG TO OUR POS PLAN. AND YOU INTEND TO FILL YOUR PRESCRIPTIONS AT A Kaiser Permanente . PHARMACY, PLEASE VISIT FOR DETAILS ON THE DRUGS. COVERED THROUGH YOUR TIER 1 BENEFIT. This Formulary was updated on December 22, 2015, and is effective on January 1, 2016. For more recent information or other questions, please call MedImpact 24 hours a day, 7 days a week (closed holidays), at 1-800-788-2949.

2 You can also view the Kaiser Permanente Point-of- Service (POS) Formulary on our website at What is the Kaiser Permanente Point-of-Service (POS) Formulary ? The Kaiser Permanente POS Formulary is an open Formulary of unrestricted drugs that are covered under your POS health insurance plan's Tier 2 benefit. The Formulary consists of generic and brand drugs that are covered when you use a MedImpact pharmacy. Unless specifically excluded under your plan, all FDA-approved drugs are part of your plan's open Formulary . What drugs are covered? Kaiser Permanente will generally cover prescribed generic and brand-name drugs listed on the Kaiser Permanente POS Formulary as long as the drug is medically necessary, the prescription is filled at a MedImpact pharmacy, and other coverage rules are followed.

3 All FDA-approved contraceptive drugs and devices for women are covered, including over-the- counter contraceptives when prescribed by a licensed health care professional authorized to prescribe drugs and obtained at a MedImpact pharmacy. POS Standard Formulary Last revised 12/22/2015, 1 Additionally, if your plan covers preventive drugs at no cost share (because your group elected to include preventive-care benefits required under the Affordable Care Act in their grandfathered plan), then contraceptives for women, tobacco-cessation drugs, and certain over-the-counter drugs (such as aspirin, iron supplements, folic acid supplements, vitamin D, and oral fluoride supplements) are covered at no cost share regardless of the drug tier indicated on the Kaiser Permanente POS Formulary .

4 For more information about coverage of preventive drugs, please refer to the Preventive Care under the General Benefits section of your Certificate of Insurance. What drugs are not covered? Drugs not listed on the Kaiser Permanente POS Formulary are not covered. Are there any restrictions on the drugs covered on the Kaiser Permanente POS. Formulary ? There are no step therapy or prior authorization requirements for any drugs covered under your plan. However, for certain drugs, Kaiser Permanente may limit the amount of the drug dispensed to a certain days' supply. Generic and brand drugs are limited to 100 days of supply. What is a generic drug ? A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug .

5 Generally, generic drugs cost less than brand-name drugs. Under your POS Plan, you will pay different amounts for preferred generic drugs and non-preferred generic drugs. Preferred drugs cost you less than non-preferred drugs. What is a brand-name drug ? Brand-name drugs are usually manufactured and sold by the drug company that originally researched and developed the drug . When the patent on a brand-name drug expires, other drug companies may manufacture and sell an FDA-approved generic version of the drug with the same active ingredient(s) at lower prices. Under your POS Plan, you will pay different amounts for preferred brand drugs and non- preferred brand drugs.

6 Preferred drugs cost you less than non-preferred drugs. If you request a brand-name drug when a generic drug is prescribed, you may be responsible for paying the brand-name copay plus the difference in cost between the generic drug and the brand-name drug . Please see your Certificate of Insurance for details. POS Standard Formulary Last revised 12/22/2015, 2 What drugs are eligible to be mailed from the mail-order pharmacy? This drug Formulary only applies to drugs obtained at a MedImpact retail pharmacy. There is no mail-order pharmacy coverage available through MedImpact pharmacies. Mail-order pharmacy coverage is provided under the HMO portion of the POS Plan through Kaiser Permanente 's mail-order pharmacy.

7 Please see your Evidence of Coverage or visit for details of this benefit. Kaiser Permanente POS Formulary The most current Kaiser Permanente POS Formulary list begins on page 4. It provides information about the drugs covered by Kaiser Permanente . All dosage forms and strengths for a particular drug may not appear on the Formulary . Some drugs have multiple dosage forms. In such cases, some dosages may be listed on the Formulary and others may not. In cases where a particular drug has multiple dosage forms and/or strengths, the drug may be associated with multiple drug tiers. You can call MedImpact at 1-800-788-2949 to confirm which cost-sharing tier applies for the specific dosage form and strength you want.

8 Kaiser Permanente may add or remove drugs from the Formulary during the year. These changes to the Formulary are based on new information or new drugs that become available. Tier designations The table below identifies drugs based on their drug category preferred generic (Tier 1), preferred brand (Tier 2), or non-preferred generic or brand (Tier 3). Typically, you will pay a copay for prescriptions filled at a MedImpact pharmacy as shown in your Schedule of Coverage. * Kaiser Foundation Health Plan, Inc. (KFHP), underwrites the HMO portion of the Kaiser Permanente POS Plan and Kaiser Permanente Insurance Company (KPIC), a subsidiary of KFHP, underwrites the PPO and Out-of-Network portions of the Kaiser Permanente POS Plan.

9 POS Standard Formulary Last revised 12/22/2015, 3 drug CATEGORY & NAME drug TIER ALLERGY 2ND GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONS CLARINEX D 12 HOUR 2 SEMPREX D 2 ALLERGENIC EXTRACTS, THERAPEUTICS ASPERGILLUS FUMIGATUS 2 GRASTEK 2 ORALAIR 2 RAGWITEK 2 ANTIHISTAMINES 1ST GENERATION CARBINOXAMINE MALEATE 1 CLEMASTINE FUMARATE 1, 2 CYPROHEPTADINE HCL 1 DIPHENHYDRAMINE HCL 1 HYDROXYZINE HCL 1 HYDROXYZINE PAMOATE 1, 2 KARBINAL ER 2 PROMETHAZINE HCL 1, 2 VISTARIL 2 ANTIHISTAMINES 2ND GENERATION CETIRIZINE HCL 1 CLARINEX 2 DESLORATADINE 1 FEXOFENADINE HCL 1 LEVOCETIRIZINE DIHYDROCHLORIDE 1 XYZAL 2 ZYRTEC 2 NASAL ANTIHISTAMINE ASTEPRO 2 AZELASTINE HCL 1 OLOPATADINE HCL 1 PATANASE 2 NASAL ANTIHISTAMINE & ANTI INFLAM.

10 STEROID COMB. DYMISTA 2 NASAL ANTI INFLAMMATORY STEROIDS BECONASE AQ 2 BUDESONIDE 1 FLUNISOLIDE 1 FLUTICASONE PROPIONATE 1 NASONEX 2 POS Standard Formulary Last revised 12/22/2015, 4 drug CATEGORY & NAME drug TIER OMNARIS 2 QNASL 2 QNASL CHILDREN 2 RHINOCORT AQUA 2 TRIAMCINOLONE ACETONIDE 1 VERAMYST 2 ZETONNA 2 ANTIEMESIS/ANTIVERTIGO ANTIEMETIC/ANTIVERTIGO AGENTS AKYNZEO 2 ANTIVERT 2 ANZEMET 2 CESAMET 2 COMPAZINE 2 DEXTROSE/FRUCTOSE/SODIUM CIT 1 DICLEGIS 2 DRONABINOL 1 EMEND 2 GRANISETRON HCL 1 MARINOL 2 MECLIZINE HCL 1 ONDANSETRON 1 ONDANSETRON HCL 1 PROCHLORPERAZINE 1 PROCHLORPERAZINE MALEATE 1 PROMETHAZINE HCL 1 SANCUSO 2 TIGAN 2 TRANSDERM SCOP 2 TRIMETHOBENZAMIDE HCL 1 ZOFRAN 2 ZOFRAN ODT 2 ZUPLENZ 2 ASTHMA AND COPD 5 LIPOXYGENASE INHIBITORS ZYFLO 2 ZYFLO CR 2 BETA ADRENERGIC AGENTS ALBUTEROL SULFATE 1 ARCAPTA NEOHALER 2 POS