KAISER PERMANENTE PREVENTIVE DRUG LIST

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1 KAISER PERMANENTE PREVENTIVE DRUG LIST

2 Kaiser Permanente offers preventive drugs at a lower cost share than other drugs covered under the outpatient prescription drug rider. Please consult your Evidence of Coverage to determine if you have outpatient prescription drug coverage and are eligible for a lower cost share on preventive drugs. Medications that are only available as a brand name product are listed in ALL CAPITAL letters. The list is subject to change and updated periodically. For a current copy, please call Member Services at or (TTY 711). Representatives are available Monday through Friday, 7:30 a.m. until 5:30 p.m. Preventive Drugs ACE INHIBITORS (for High Blood Pressure and Diabetes) Captopril Enalapril Lisinopril Lisinopril & Hydrochlorothiazide ALPHA-AGONISTS Clonidine Guanfacine HCL ALPHA-2 BLOCKERS Phenoxybenzamine HCL Terazosin HCL ALPHA-BETA BLOCKERS Carvedilol Labetalol HCL ANGIOTENSIN II Losartan Potassium Losartan Potassium & Hydrochlorothiazide ANTI-ASTHMA STEROID INHALER (for Asthma) ADVAIR DISKUS 100/50 ASMANEX Budesonide (inhalation) Preventive Drugs COMBIVENT RESPIMAT DULERA FLOVENT HFA 44 mcg QVAR ANTIDIABETIC DRUGS (for Diabetes) Acarbose Pioglitazone Glipizide HUMULIN 70/30 VIAL HUMULIN N VIAL HUMULIN R VIAL HUMALOG VIAL LANTUS VIAL Metformin Metformin ER ANTIHYPERLIPIDEMICS (for High Cholesterol) Atorvastatin Calcium Cholestyramine Cholestyramine Light Colestipol Fenofibrate Gemfibrozil Lovastatin Niacin Pravastatin Simvastatin 2

3 Preventive Drugs ASTHMA SUPPLIES (for Asthma) Spacer/aerosol-holding chambers Peak Flow Meter BETA BLOCKERS Atenolol Atenolol & Chlorthalidone Bisoprolol & Hydrochlorothiazide Bisoprolol Fumarate Metoprolol Succinate Metoprolol Tartrate Propranolol HCL Sotalol HCL BLOODTHINNING AGENTS (for Stroke Prevention) Aspirin/Dipyridamole Cilostazol Clopidogrel Dipyridamole EFFIENT Enoxaparin Fondaparinux Heparin Sodium Warfarin Sodium CALCIUM CHANNEL BLOCKER (for High Blood Pressure and Heart Disease) Amlodipine Besylate Diltiazem HCL Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc East Jefferson Street, Rockville, MD _PrevDrugList_M_pdf 11/01/16 11//31/17 Preventive Drugs Diltiazem HCL Coated Beads Nifedipine Verapamil HCL DIURETICS Amiloride HCL Amiloride & Hydrochlorothiazide Bumetanide Chlorothiazide Chlorthalidone Furosemide Hydrochlorothiazide Indapamide Metolazone Reserpine Spironolactone Spironolactone & Hydrochlorothiazide Triamterene & Hydrochlorothiazide DIRECT VASODILATORS Hydralazine HCL Minoxidil OSTEOPOROSIS (for Bone Health) Alendronate Sodium Calcitonin Etidronate Disodium Raloxifene SMOKING CESSATION (for Tobacco Cessation) NICOTINE INHALER SYMPATHOLYTIC Methyldopa 3

4 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (Kaiser Health Plan) complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We also: Provide no cost aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats, such as large print, audio, and accessible electronic formats Provide no cost language services to people whose primary language is not English, such as: o o Qualified interpreters Information written in other languages If you need these services, call the number provided below. District of Columbia Maryland Virginia TTY 711 If you believe that Kaiser Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with the Kaiser Civil Rights Coordinator, 2101 East Jefferson Street, Rockville, MD 20852, telephone number: You can file a grievance by mail or phone. If you need help filing a grievance, the Kaiser Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, , (TDD). Complaint forms are available at ACA 1557 MAS portrait EN 2016 v1

5 LEGEND Brand-name drugs are in bold type and all capital letters For drugs not indicated in bold, generic drugs will be dispensed as the formulary agent Limited Distribution-LD Quantity Limits-QL Oral Chemo Drugs-OC 18

6 LEGEND Brand-name drugs are in bold type and all capital letters For drugs not indicated in bold, generic drugs will be dispensed as the formulary agent Limited Distribution-LD Quantity Limits-QL Oral Chemo Drugs-OC 19

7 LEGEND Brand-name drugs are in bold type and all capital letters For drugs not indicated in bold, generic drugs will be dispensed as the formulary agent Limited Distribution-LD Quantity Limits-QL Oral Chemo Drugs-OC 20

8 LEGEND Brand-name drugs are in bold type and all capital letters For drugs not indicated in bold, generic drugs will be dispensed as the formulary agent Limited Distribution-LD Quantity Limits-QL Oral Chemo Drugs-OC 21

The 365-day period begins with the first dispensing transaction for each Ontario Drug Benefit (ODB) recipient on or after October 1, 2015.

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