No prior authorization
Does Kaiser Permanente require prior authorization for PEDIARIX?
Kaiser Permanente does not require prior authorization for PEDIARIX on the Medicare Part D plans that cover it.
No covering plan from this payer files a prior-authorization requirement for this drug.
By product strength
| RxNorm product | Plans covering | Require prior auth | Step therapy | Qty limit | Status |
|---|---|---|---|---|---|
| 0.5 ML acellular pertussis vaccine, inactivated 0.116 MG/ML / diphtheria toxoid vaccine, inactivated 50 UNT/ML / hepatitis B surface antigen vaccine 0.02 MG/ML / poliovirus vaccine inactivated, type 1 (Mahoney) 80 UNT/ML / poliovirus vaccine inactivated, type 2 (MEF-1) 16 UNT/ML / poliovirus vaccine inactivated, type 3 (Saukett) 64 UNT/ML / tetanus toxoid vaccine, inactivated 20 UNT/ML Prefilled Syringe [PEDIARIX]829989 | 115 / 115 | 0 | 0 | 0 | No prior authorization |
Product names come from RxNorm (U.S. National Library of Medicine).
Plan-by-plan detail — 0.5 ML acellular pertussis vaccine, inactivated 0.116 MG/ML / diphtheria toxoid vaccine, inactivated 50 UNT/ML / hepatitis B surface antigen vaccine 0.02 MG/ML / poliovirus vaccine inactivated, type 1 (Mahoney) 80 UNT/ML / poliovirus vaccine inactivated, type 2 (MEF-1) 16 UNT/ML / poliovirus vaccine inactivated, type 3 (Saukett) 64 UNT/ML / tetanus toxoid vaccine, inactivated 20 UNT/ML Prefilled Syringe [PEDIARIX]
| Plan | Contract | Tier | Prior auth | Step therapy | Qty limit |
|---|---|---|---|---|---|
| Kaiser Permanente Dual Complete (HMO D-SNP) | H0630-027 | 6 | No | No | No |
| Kaiser Permanente Dual Complete (HMO D-SNP) | H1170-015 | 6 | No | No | No |
| Kaiser Permanente Dual Complete Maui (HMO D-SNP) | H2704-016 | 6 | No | No | No |
| Kaiser Permanente Dual Complete North P16 (HMO D-SNP) | H8794-016 | 6 | No | No | No |
| Kaiser Permanente Dual Complete North P17 (HMO D-SNP) | H8794-017 | 6 | No | No | No |
| Kaiser Permanente Dual Complete North P18 (HMO D-SNP) | H8794-018 | 6 | No | No | No |
| Kaiser Permanente Dual Complete North P19 (HMO D-SNP) | H8794-019 | 6 | No | No | No |
| Kaiser Permanente Dual Complete North P2 (HMO D-SNP) | H8794-002 | 6 | No | No | No |
| Kaiser Permanente Dual Complete North P20 (HMO D-SNP) | H8794-020 | 6 | No | No | No |
| Kaiser Permanente Dual Complete North P21 (HMO D-SNP) | H8794-021 | 6 | No | No | No |
| Kaiser Permanente Dual Complete North P22 (HMO D-SNP) | H8794-022 | 6 | No | No | No |
| Kaiser Permanente Dual Complete North P23 (HMO D-SNP) | H8794-023 | 6 | No | No | No |
| Kaiser Permanente Dual Complete North P24 (HMO D-SNP) | H8794-024 | 6 | No | No | No |
| Kaiser Permanente Dual Complete North P25 (HMO D-SNP) | H8794-025 | 6 | No | No | No |
| Kaiser Permanente Dual Complete Oahu (HMO D-SNP) | H2704-015 | 6 | No | No | No |
| Kaiser Permanente Dual Complete Plan 1 MD (HMO D-SNP) | H2172-016 | 6 | No | No | No |
| Kaiser Permanente Dual Complete Plan 2 MD (HMO D-SNP) | H2172-017 | 6 | No | No | No |
| Kaiser Permanente Dual Complete Pueblo (HMO D-SNP) | H0630-024 | 6 | No | No | No |
| Kaiser Permanente Dual Complete South P1 (HMO D-SNP) | H8794-001 | 6 | No | No | No |
| Kaiser Permanente Dual Complete South P10 (HMO D-SNP) | H8794-010 | 6 | No | No | No |
| Kaiser Permanente Dual Complete South P11 (HMO D-SNP) | H8794-011 | 6 | No | No | No |
| Kaiser Permanente Dual Complete South P6 (HMO D-SNP) | H8794-006 | 6 | No | No | No |
| Kaiser Permanente Dual Complete South P7 (HMO D-SNP) | H8794-007 | 6 | No | No | No |
| Kaiser Permanente Dual Complete South P9 (HMO D-SNP) | H8794-009 | 6 | No | No | No |
| Kaiser Permanente Dual Essential (HMO D-SNP) | H0630-014 | 6 | No | No | No |
| Kaiser Permanente Dual Essential Plan 1 (HMO D-SNP) | H1170-008 | 6 | No | No | No |
| Kaiser Permanente Dual Essential Plan 1 MD (HMO D-SNP) | H2172-018 | 6 | No | No | No |
| Kaiser Permanente Dual Essential Plan 2 (HMO D-SNP) | H1170-011 | 6 | No | No | No |
| Kaiser Permanente Dual Essential Plan 2 MD (HMO D-SNP) | H2172-019 | 6 | No | No | No |
| Kaiser Permanente Medicare Advantage Anchor (HMO) | H5050-023 | 6 | No | No | No |
| Kaiser Permanente Medicare Advantage Care Plus MD (HMO-POS) | H2172-014 | 6 | No | No | No |
| Kaiser Permanente Medicare Advantage Care Plus VA (HMO-POS) | H2172-013 | 6 | No | No | No |
| Kaiser Permanente Medicare Advantage Centennial (HMO) | H5050-021 | 6 | No | No | No |
| Kaiser Permanente Medicare Advantage Columbia (HMO) | H5050-019 | 6 | No | No | No |
| Kaiser Permanente Medicare Advantage Essential (HMO) | H5050-009 | 6 | No | No | No |
| Kaiser Permanente Medicare Advantage Essential Kng (HMO) | H5050-024 | 6 | No | No | No |
| Kaiser Permanente Medicare Advantage Essential Pce (HMO) | H5050-025 | 6 | No | No | No |
| Kaiser Permanente Medicare Advantage Essential Sno (HMO) | H5050-026 | 6 | No | No | No |
| Kaiser Permanente Medicare Advantage Essential Thu (HMO) | H5050-027 | 6 | No | No | No |
| Kaiser Permanente Medicare Advantage Harbor (HMO) | H5050-017 | 6 | No | No | No |
| Kaiser Permanente Medicare Advantage High DC (HMO-POS) | H2172-001 | 6 | No | No | No |
| Kaiser Permanente Medicare Advantage High MD (HMO-POS) | H2172-002 | 6 | No | No | No |
| Kaiser Permanente Medicare Advantage High VA (HMO-POS) | H2172-008 | 6 | No | No | No |
| Kaiser Permanente Medicare Advantage Key (HMO) | H5050-022 | 6 | No | No | No |
| Kaiser Permanente Medicare Advantage Key King (HMO) | H5050-028 | 6 | No | No | No |
| Kaiser Permanente Medicare Advantage Key Pierce (HMO) | H5050-029 | 6 | No | No | No |
| Kaiser Permanente Medicare Advantage Key Snohomish (HMO) | H5050-030 | 6 | No | No | No |
| Kaiser Permanente Medicare Advantage Key Thurston (HMO) | H5050-031 | 6 | No | No | No |
| Kaiser Permanente Medicare Advantage Optimal (HMO) | H5050-004 | 6 | No | No | No |
| Kaiser Permanente Medicare Advantage Standard 1 MD (HMO-POS) | H2172-021 | 6 | No | No | No |
| Kaiser Permanente Medicare Advantage Standard 1 VA (HMO-POS) | H2172-009 | 6 | No | No | No |
| Kaiser Permanente Medicare Advantage Standard 2 MD (HMO-POS) | H2172-022 | 6 | No | No | No |
| Kaiser Permanente Medicare Advantage Standard 2 VA (HMO-POS) | H2172-023 | 6 | No | No | No |
| Kaiser Permanente Medicare Advantage Standard DC (HMO-POS) | H2172-020 | 6 | No | No | No |
| Kaiser Permanente Medicare Advantage Value 1 MD (HMO) | H2172-025 | 6 | No | No | No |
| Kaiser Permanente Medicare Advantage Value 1 VA (HMO-POS) | H2172-010 | 6 | No | No | No |
| Kaiser Permanente Medicare Advantage Value 2 MD (HMO) | H2172-026 | 6 | No | No | No |
| Kaiser Permanente Medicare Advantage Value 2 VA (HMO-POS) | H2172-024 | 6 | No | No | No |
| Kaiser Permanente Medicare Advantage Value DC (HMO-POS) | H2172-027 | 6 | No | No | No |
| Kaiser Permanente Medicare Advantage Vital Sound (HMO) | H5050-032 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Alam., SF, Napa (HMO) | H0524-032 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Basic (HMO) | H1230-003 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Basic 1 (HMO) | H1170-009 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Basic 2 (HMO) | H1170-012 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Basic Alameda (HMO) | H0524-059 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Basic Fresno (HMO) | H0524-046 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Basic Kern (HMO) | H0524-036 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Basic Marin (HMO) | H0524-064 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Basic San Mateo (HMO) | H0524-065 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Basic SF (HMO) | H0524-060 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Basic SnJoaq (HMO) | H0524-043 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Basic Solano (HMO) | H0524-063 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Basic Stanis (HMO) | H0524-041 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Bronze DM (HMO-POS) | H0630-025 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Care Plus (HMO-POS) | H1170-013 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Choice DM (PPO) | H3138-001 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Choice North (PPO) | H3138-003 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Choice South (PPO) | H3138-002 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Core DM (HMO) | H0630-013 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Core North (HMO) | H0630-020 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Core South (HMO) | H0630-017 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Enhanced (HMO-POS) | H0630-023 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Enhanced (HMO-POS) | H9003-001 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Enhanced (HMO) | H1230-001 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Enhanced 1 (HMO) | H1170-002 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Enhanced Fresno (HMO) | H0524-038 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Enhanced Kern (HMO) | H0524-035 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Enhanced SnJoaq (HMO) | H0524-042 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Enhanced Solano (HMO) | H0524-008 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Enhanced Stanis (HMO) | H0524-040 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Gold (HMO-POS) | H0630-016 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Hawaii Island (HMO) | H1230-014 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Inland Empire (HMO) | H0524-015 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage LA, Orange Co. (HMO) | H0524-003 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Maui (HMO) | H1230-013 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage San Diego (HMO) | H0524-037 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage San Diego Value (HMO) | H0524-082 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Santa Cruz (HMO) | H0524-054 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Silver DM (HMO-POS) | H0630-015 | 6 | No | No | No |
| Kaiser Permanente Senior Advantage Silver North (HMO-POS) | H0630-021 | 6 | No | No | No |
Showing 100 of 115 covering plans.
Source
Monthly Prescription Drug Plan Formulary and Pharmacy Network Information — Basic Drugs Formulary File- Effective
- 2026-06-30
- Retrieved
- 2026-07-19
- SHA-256
- e626e6bcda1aa6a0071e6f0df6bafe686ae41842cdf0a9feffdc649b6d3ff3ae
We publish the hash of the exact file we ingested so any answer can be audited against the bytes CMS served that day.
PEDIARIX at other payers
Administrative information only. Benefily reports what a payer has published in its own prior-authorization policy as of the effective date shown. It is not medical advice, not a coverage or payment guarantee, and not an authorization. Requirements vary by plan, place of service and member benefits — always verify with the payer before rendering service.