Drugs and supplies included on the drug formulary are covered under a member's drug benefit. To be covered under the drug benefit, prescriptions must be dispensed from one of the following:

A Kaiser Permanente Medical Center pharmacy
A Kaiser Permanente mail-order pharmacy
An affiliated network community pharmacy designated by the health plan

Please direct patients with questions to Kaiser Permanente customer service at 1-888-865-5813 (toll-free).

Unless otherwise specified by the physician, generic drugs may be used. Unless otherwise noted, the Kaiser Permanente drug benefit allows a member to pay one copayment for up to the lesser of a 30-day supply or the standard prescription amount, including maintenance drugs as determined by the health plan. The standard prescription amount for the following items is:

Migraine medications (smallest package size commercially available)
Ophthalmic and optic medications (smallest package size commercially available)
Oral and nasal inhalers (smallest standard package size commercially available)

For additional information, see:

HMO Drug Formulary Information

Qualified Health Plan Drug Formulary Information

Pharmacy listings and contact information

Formulary Update Newsletter

2024

2023

2022

Drug formulary for practitioners

2024 Federal Employee Health Benefit Formulary
2024 Five Tier Benefit Formulary
2024 Four Tier Benefit Formulary
2024 HMO Formulary
2024 Medicare Part D Formulary
2024 State Employee Health Benefit Formulary
2024 Dual Choice PPO Formulary

Formulary conversions

A list of non-formulary drugs and their approved alternatives may be downloaded from Kaiser Permanente HealthConnect™ Online-Affiliate.* Listed alternatives also apply to step therapy medications. For more information on the non-formulary and step therapy process click here.

Criteria Restricted Medications (Prior Authorization)

The criteria restricted medications identify drugs that the Pharmacy and Therapeutics Committee has placed under specific designations. Criteria restricted medications on the Targeted Review List require review and approval before the prescription can be dispensed as a covered benefit. To access the criteria restricted medication (QRM) list and coverage criteria, you must log on to Clinical Library to review the Criteria Restricted Medications document. If you need assistance with logging on to Clinical Library, please call Provider Relations at 877-465-0029 (toll-free) or 404-364-4934. To request review of a criteria restricted medication, the provider should call Kaiser Permanente Quality Resource Management (QRM) at 404-364-7320 and select option 3 or fax 866-452-4585. The list of prescription drugs requiring review and authorization is subject to periodic review and modification by our Pharmacy and Therapeutics Committee.

Adding new drugs to the formulary

The Pharmacy and Therapeutics Committee regularly reviews requests for additions or deletions of drugs from the formulary. The committee may elect to withhold review of newly marketed drugs for six months pending availability of post-marketing safety data. Medical literature references that demonstrate advantages of the proposed drug must be submitted with the application. Application forms submitted without supportive scientific data (for example, clinical studies, case reports, consensus statements, etc.) will not be reviewed by the committee until such data is presented by the requestor.

Fill out the application form and disclosure form to request that a new drug be added to the formulary. The application form must be legibly completed and mailed to:

Kaiser Permanente
Pharmacy Administration
4000 Dekalb Technology Pkwy
Suite 320
Atlanta, Georgia 30340

Formulary Conversions

Please note for criteria restricted medications (Prior Authorization) on the Targeted Review List, the provider must call Quality Resource Management at 404-364-7320 (Option 3) or fax 866-452-4585. For more information click here.

Non-formulary or step therapy prescription process

When a patient is allergic to, intolerant of, or has failed a therapeutic trial of formulary medication(s), non-formulary or step therapy drugs may be prescribed using the non-formulary exception process to request benefit coverage for the patient. To request review of a non-formulary or step therapy drug, please complete the Kaiser Permanente

Non-Formulary or Restricted Drug Prescription Form and fax to the Pharmacy Consult Service at 404-467-2731. Completing this form with appropriate documentation will reduce pharmacy phone calls to your office. Most importantly, it will help improve service to our patients. To request a blank form or discuss a request, call the Pharmacy Consult Service at (404) 365-4159.

Practitioners who are not part of the Southeast Permanente Medical Group or affiliated network practitioner group are not eligible to access the non-formulary exception process and cannot obtain benefit coverage of non-formulary drugs for Kaiser Permanente members.

When non-formulary or step therapy medications are prescribed but are not medically necessary, patients should be informed that they will pay retail price for the medication instead of their usual copayment. Benefit coverage is not available for medications excluded from the Kaiser Permanente drug benefit (weight-loss, sexual dysfunction, infertility, cosmetic, or smoking-cessation medications), unless the member's group has purchased a rider allowing coverage of these medications.

Instructions for filling out the non-formulary drug prescription

Pharmacy policies

Pharmacy and Therapeutics committee

The Pharmacy and Therapeutics (P&T) committee—with expert guidance from various specialists who serve as ad hoc members—evaluates, appraises, and selects from available drugs those considered to be the most appropriate for patient care and general use within the Georgia region.

Participation

Members of the Pharmacy and Therapeutics committee include:

Actively practicing physicians in Internal Medicine, Pediatrics, Behavioral Health, and Obstetrics/Gynecology from The Southeast Permanente Medical Group
A nursing representative from Kaiser Foundation Health Plan
Three pharmacy representatives from Kaiser Foundation Health Plan
A pharmacy and physician representative who are experts in care of the elderly and disabled ad hoc specialists as needed who are not actual voting members of the committee; however, these practitioners make recommendations to the committee

Affiliated pharmacies

In addition to Kaiser Permanente pharmacies, our members can go to participating Rite Aid or Walgreens, Kaiser Permanente's authorized network pharmacies, in the Atlanta metro area. (Some plans cover prescriptions and refills only when filled at Kaiser Permanente pharmacies or other specified pharmacies.)

Non-formulary process: Our Pharmacy Benefit Manager (PBM), MedImpact is handling non-formulary requests presented at network pharmacies for our PPO and POS members, including our Dual Choice benefit. MedImpact can be contacted at 1-800-788-2949.

If the patient presents a non-formulary form, or states that they cannot tolerate the formulary alternative, then the network pharmacy will contact MedImpact and provide reasons why the patient cannot use formulary alternatives.

If the patient meets our criteria, the non-formulary medication will be approved and MedImpact will enter a Prior Authorization number. If the patient does not meet our criteria, MedImpact will send a Medication Request Form (MRF) to the prescriber or pharmacy.

Once the MRF form is completed by either the pharmacy or prescriber, the form is faxed back to MedImpact. If the patient has the completed form, it must accompany the MRF form. Once MedImpact receives the MRF form from the prescriber or pharmacy,MedImpact will determine whether or not a Prior Authorization will be granted. The pharmacy will be notified of the decision. MedImpact will administer therapeutic guidelines and enter Prior Authorization for non-formulary medications. If there are no guidelines available, then the pharmacy staff will be instructed by MedImpact to contact the Kaiser Permanente Call Center at 404-365-4159.