Colorado HMO Specialty Pharmacy Information Sheet & Drug Listing

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Colorado HMO Specialty Pharmacy Information Sheet & Drug Listing Kaiser Permanente s Colorado HMO plan members in need of specific Specialty medications should receive them from the designated

1 Colorado HMO Specialty Pharmacy Information Sheet & Drug Listing Kaiser Permanente s Colorado HMO plan members in need of specific Specialty medications should receive them from the designated pharmacies indicated below. On August 1, 2017, this applies to all Colorado service areas. In an effort to provide appropriate quality and care to our Colorado members receiving Specialty medications the following pharmacies have been designated as the preferred pharmacies to dispense select Specialty medications. The designated pharmacies have been selected due to their expertise and knowledge in managing these medications. For example, Kaiser Permanente Specialty Pharmacy (KSP) in Daly City, CA has years of experience in managing high risk medications. Those designated as KP can be dispensed at all Kaiser Permanente Colorado pharmacies. The medications listed can only be dispensed as indicated by the pharmacies listed below. Please note this listing is subject to change at any time. Kaiser Permanente Specialty Pharmacy - KSP Locations: Kaiser National Specialty Pharmacy - San Francisco, California Hours: Monday Friday, 9:00am - 6:00pm MST Phone: (650) Kaiser Daly City Specialty Pharmacy Daly City, California Hours: Monday Friday, 9:30am - 6:00pm MST Phone: (877) ( KPSP) Fax: (650) Note: Cut off hours for same day shipments 1:00pm MST Kaiser Permanente Mail Order Pharmacy KP Kaiser Permanente Colorado Outpatient Pharmacy KP Locations: Kaiser Permanente Mail Order Pharmacy Aurora, CO & all Kaiser Permanente Pharmacies located in Colorado Mail Order Hours: Monday Friday, 8:00am 6:00pm MST Mail Order Phone: (866) Mail Order Fax: (866) The following list of drugs must be filled as indicated by one of the designated pharmacies listed above:

2 Drug SPECIALTY PHARMACY Drug SPECIALTY PHARMACY Actemra - KP Acthar H.P. - KSP Adcirca - KSP Adempas - KSP Alunbrig - KP Ampyra - KP Aubagio - KSP Austedo - KP Avandamet - KP Avandaryl - KP Avandia - KP Avonex - KP Betaseron - KP Bosulif - KP Braftovi - KP Calquence - KP Cerdelga - KSP Cholbam - KP Cimzia - KP Cometriq Kit - KSP Copaxone - KP Copiktra - KP Cosentyx - KP Daklinza - KP Dupixent - KP Egrifta - KSP Emflaza - KSP Enbrel - KP Epclusa - KP Erivedge - KP Esbriet - KSP Extavia - KP Gattex - KSP Gilotrif - KP Gleevec - KP Glatopa - KP Gocovri - KSP Growth Hormones - KP Harvoni - KP Hetlioz - KSP Hemlibra - KP Humira - KP Ibrance - KP Ilaris - KP Imbruvica - KP Intron-A - KP Kisqali - KP Korlym - KSP Lenvima - KSP Letairis - KSP Lynparza - KP Matulane - KP Mavyret - KP Mektovi - KP Moderiba - KP Ocaliva - KSP Ofev - KSP Olysio - KP Onfi - KP Opsumit - KSP Orencia - KP Orfadin - KSP Orilissa - KP Otezla - KP Pegasys - KP PegIntron - KP Plegridy - KP Pomalyst - KSP Praluent - KP Promacta - KSP Qsymia - KSP Ravicti - KSP Rebetol Soln - KP Rebif - KP Repatha - KP Revlimid - KSP Ribasphere - KP Ribavirin - KP Ridaura - KSP Rydapt - KP Signifor - KSP Siliq - KSP Simponi - KP Somavert - KSP Sovaldi - KP Sprycel - KP Stelara - KP Strensiq - KSP Taltz - KP Tasigna - KP Tecfidera - KSP Technivie - KP Thalomid - KSP Tibsovo - KP Tracleer - KSP Tremfya - KP Valchlor - KSP Verzenio - KP Victrelis - KP

3 Drug SPECIALTY PHARMACY Viekira - KP Virazole - KP Vosevi - KP Xeljanz - KP Zavesca - KP Zepatier - KP

4 NONDISCRIMINATION NOTICE Kaiser Foundation Health Plan of Colorado (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: 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 (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 by mail at: Customer Experience Department, Attn: Kaiser Permanente Civil Rights Coordinator, 2500 South Havana, Aurora, CO 80014, or by phone at Member Services: 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 HELP IN YOUR LANGUAGE ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY: 711). አማርኛ (Amharic) ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ (TTY: 711). العربية (Arabic) ملحوظة: إذا كنت تتحدث العربية فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم :TTY(.)711 Ɓa sɔ ɔ Wu ɖu (Bassa) Dè ɖɛ nìà kɛ dyéɖé gbo: Ɔ jǔ ké m Ɓàsɔ ɔ -wùɖù-po-nyɔ jǔ ní, nìí, à wuɖu kà kò ɖò po-poɔ ɓɛ ìn m gbo kpáa. Ɖá (TTY: 711) 中文 (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) _ACA_1557_MarCom_CO_2017_Taglines

5 فارسی (Farsi) توجه: اگر به زبان فارسی گفتگو می کنيد تسهيالت زبانی بصورت رايگان برای شما فراهم می باشد. با :TTY) 711) تماس بگيريد. Français (French) ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (TTY: 711). Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). Igbo (Igbo) NRỤBAMA: Ọ bụrụ na ị na asụ Igbo, ọrụ enyemaka asụsụ, n efu, dịịrị gị. Kpọọ (TTY: 711). 日本語 (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 한국어 (Korean) 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. Naabeehó (Navajo) Díí baa akó nínízin: Díí saad bee yáníłti go Diné Bizaad, saad bee áká ánída áwo dé é, t áá jiik eh, éí ná hóló, koji hódíílnih (TTY: 711). न प ल (Nepali) ध य न द न ह स : तप र इ ल न प ल ब ल न ह न छ भन तप र इ क ननम तत भ ष सह यत स व हर नन श ल क र पम उपलब ध छ )TTY: 711( फ न गन ह स Afaan Oromoo (Oromo) XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa (TTY: 711). Pусский (Russian) ВНИМАНИЕ: eсли вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (TTY: 711). Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). Tagalog (Tagalog) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). Tiếng Việt (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). Yorùbá (Yoruba) AKIYESI: Ti o ba nso ede Yoruba ofe ni iranlowo lori ede wa fun yin o. E pe ero ibanisoro yi (TTY: 711) _ACA_1557_MarCom_CO_2017_Taglines

Notice of Privacy Practices

Notice of Privacy Practices Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-406- 657-4760 (TTY: 1-406-657-4760) German: ACHTUNG: Wenn