ENHANCED FORMULARY for Medicare Plus Group Members

Transcription

1 ENHANCED FORMULARY for Medicare Plus Group Members H2150_EG_17_38 Kaiser Permanente 2018 Medicare Plus enhanced formulary for group members

2 DRUG NAME DRUG TIER REQUIRE MENTS/ LIMITS ANTICHOLINERGICS ANTIMUSCARINICS/ANTISPASMODICS hyoscyamine LIBRAX EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS MISCELLANEOUS phenylephrine (ophth) ELECTROLYTIC, CALORIC, AND WATER BALANCE ACIDIFYING AND ALKALINIZING AGENTS potassium citrate-citric acid HORMONE AND SYNTHETIC SUBSTITUTES ESTROGEN esterified estrogens & methlytestosterone GONADOTROPINS GANIRELIX ACETATE BRAVELLE clomiphene FOLLISTIM GONAL-F MENOPUR THYROID AGENTS NP thyroid RESPIRATORY TRACT AGENTS ANTITUSSIVES benzonatate DRUG NAME DRUG TIER REQUIRE MENTS/ LIMITS guaifenesin/codeine hydrocodone/ homatropine SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS (SKIN AND MUCOUS MEMBRANE) hydrocortisone/ iodoquinol urea lotion 40% VASODILATING AGENTS NITRATES nitroglycerin capsules PHOSPHODIESTERASE INHIBITORS CAVERJECT EDEX MUSE sildenafil for erectile dysfunction indication MISCELLANEOUS yohimbine VITAMINS iron polysaccharide complex-vit B-12-folic acid folic acid phytonadione (Vitamin K) potassium aminobenzoate vitamin B-12 injectable / Certain strengths or forms of the drug (e.g., tablet, gel capsule, liquid) are only available as brand drugs and are subject to the brand cost share. Drugs with this designation may be subject to a higher cost share. 1 Kaiser Permanente 2018 Medicare Plus enhanced formulary for group members

3 Notice of nondiscrimination Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Permanente 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: Qualified sign language interpreters. 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: Qualified interpreters. Information written in other languages. If you need these services, call Member Services at (TTY 711), 8 a.m. to 8 p.m., seven days a week. If you believe that Kaiser Permanente 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 our Civil Rights Coordinator by writing to 2101 East Jefferson Street, Rockville, MD or calling Member Services at the number listed above. You can file a grievance by mail or phone. If you need help filing a grievance, our 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 In Maryland and the District of Columbia, Kaiser Permanente is an HMO plan and a Cost plan with a Medicare contract. In Virginia, Kaiser Permanente is a Cost plan with a Medicare contract. Enrollment in Kaiser Permanente depends on contract renewal. H2150_H2172_17_05 accepted

4 Multi-language Interpreter Services English ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call (TTY: 711). Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). 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 (TTY:711) Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). Korean 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). 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 (TTY:711) まで お電話にてご連絡ください Thai เร ยน: ถ าค ณพ ดภาษาไทยค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร โทร (TTY: 711). Hindi ध य न द : य द आप ह द ब लत ह त आपक लए म फ त म भ ष सह यत स व ए उपलब ध ह (TTY: 711) पर क ल कर Amharic ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ (መስማት ለተሳናቸው: 711). H2150_H2172_17_06 accepted

5 Farsi توجھ: اگر بھ زبان فارسی گفتگو می کنید تسھیلات باشد. با( 711 (TTY: تماس بگیری زبانی بصورت رایگان برای شما می فراھم Arabic ملحوظة: إذا كنت ت حدثت اذكر اللغة ف خدماتا ن ھاتف الصم والبكم: المس عا دة اللغویة تتوافر لك بالمج ن.ا برقم ا صلت رقم( -711). German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). French ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : 711). Yoruba AKIYESI: Ti o ba nso ede Yoruba ofe ni iranlowo lori ede wa fun yin o. E pe ero ibanisoro yi (TTY: 711). Portuguese ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (TTY: 711) Italian ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 711). Bengali ল ক ন য দ আপ ন ব ল, কথ বল ত প রন, ত হ ল ন খরচ য় ভ ষ সহ য়ত প র ষব উপলৱ আ ছ ফ ন ক ন (TTY: 711) Urdu خبردار: اگر آپ اردو بولتے ہیں تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں کریں کال (TTY: 711). French Creole ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: 711). Gujarati ચન : જ તમ જર ત બ લત હ, ત ન: લ ક ભ ષ સહ ય સ વ ઓ તમ ર મ ટ ઉપલબ ધ છ. ફ ન કર (TTY: 711).

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7 kp.org/seniormedrx Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc East Jefferson Street Rockville, MD /1/17-12/31/18