The comprehensive formulary is a list of Part D drugs covered by our plan. The drugs are chosen by a team of Kaiser Permanente doctors and pharmacists. It also includes drugs required by Medicare.
Our plan usually covers all drugs listed in the formulary if:
- Your benefit plan includes Part D prescription drug coverage.
- The drug is medically necessary.
- Your prescription is written by a Kaiser Permanente or affiliated doctor.
- Your prescription is filled at a Kaiser Permanente or affiliated pharmacy.
- Other plan rules are followed.
We cover both brand-name drugs and generic drugs.
How do I download or print the formulary?
Click on the link below to see our formulary. You can save the document on your computer and print the pages you choose.
This formulary is effective as of 01/2020.
How do I find my drug in the formulary?
There are 2 ways to find your drug in the formulary:
- By category: Drugs are grouped by medical condition. For instance, drugs used to treat a heart condition are listed under the category “Cardiovascular drugs.”
- By alphabetical listing: Drugs are listed in alphabetical order in the “Index of drugs” section of the formulary.
What will I pay for prescriptions?
What you’ll pay for prescriptions depends on:
- Your coverage
- Whether you go to a Kaiser Permanente or affiliated pharmacy, or a non-affiliated pharmacy (out-of-network)
- Your drug’s cost-sharing tier on our formulary. (Note: This may not apply to all plans.)
Please refer to your Evidence of Coverage for details about your Medicare Part D coverage, including your cost-sharing amounts.
If you have an employer-sponsored group plan, your Part D benefits and coverage may be different. Check your group Evidence of Coverage or other plan materials for detail.
To find out how much you'll pay for your prescription drugs, you can use Kaiser Permanente's drug pricing tool. Sign on to your registered account on kp.org, select "Coverage & Costs" from the menu bar and select "Drug cost" to search for drug information, pharmacy pricing, and lower cost options. If you don't have an account yet, register for a secure account to use the service.
What if there are changes to the formulary?
While most changes in drug coverage happen at the beginning of the year, there are some changes that may happen during the year. For example, we may:
- Remove a drug from our formulary
- Replace a brand-name drug with a generic drug
- Add a requirement for prior authorization (PDF) (pre-approval by your doctor or our plan)
- Move a drug to a lower or higher cost-sharing tier (Note: This may not apply to all plans.)
Usually these types of changes won’t affect you until January 1 of the next year. But in some cases, you’ll be affected by a change before January 1. If that happens, we’ll either tell you 30 days before the change, or give you a 30-day supply when you ask for a refill at a Kaiser Permanente or affiliated pharmacy.
If the FDA decides a drug on our formulary isn’t safe, or if the drug’s manufacturer removes the drug from the market, we’ll immediately remove the drug from our formulary and notify members who take the drug.
For current information about drugs covered by Kaiser Permanente, call Member Services at 1-800-232-4404 (TTY 711), 8 a.m. to 8 p.m., 7 days a week.
The formularies on this page are updated regularly and will reflect any changes that happen during the year.
We’ll also let you know about these changes in your Explanation of Benefits.
What if the drug I want isn’t on the formulary or has restrictions?
If your drug isn’t on the formulary or there are restrictions, you can:
- Ask your Kaiser Permanente or affiliated doctor to prescribe a similar drug on our formulary
- Ask us to waive restrictions, such as prior authorization
- Ask us to make an exception and cover your drug
- Ask us to cover certain Part D formulary drugs at a lower cost-sharing level — as long as they aren’t in the specialty tier (Tier 5) (Note: This may not apply to all plans.)
In certain situations, you may be able to get a temporary supply of the drug. This will give you and your doctor time to change to another drug, or file for an exception. Please refer to your Evidence of Coverage for details.
How do I request an exception to the formulary?
If you or your doctor asks for an exception, you may give us a doctor’s statement supporting your request. Generally, we must make our decision within 72 hours of getting your request for a coverage decision if we have your doctor’s statement.
If waiting up to 72 hours could be harmful to your health, either you, your Kaiser Permanente doctor, or affiliated doctor can ask for an expedited (fast) exception. If the fast request is approved, we’ll make a decision within 24 hours of getting your doctor’s supporting statement.
If you can’t get a supporting statement from your doctor, you may ask for a coverage determination, which is a decision we make about whether we’ll cover a Medicare Part D drug and the amount you’ll need to pay.
Please keep in mind:
- Exceptions are only approved when alternative drugs on our formulary, lower-tiered drugs, or adding usage restrictions wouldn’t be effective or would be harmful.
- You can only request an exception for drugs considered to be Medicare Part D prescription drugs by the Centers for Medicare & Medicaid Services (CMS).
- You can’t get an exception for drugs that are excluded under Medicare Part D.
Please see your Evidence of Coverage for more information about exceptions or coverage determinations, including the appeals process. You can also go to our website’s FAQ section, which includes information on grievances, coverage determinations, and appeals.
What if I have a hospital stay or live in a long-term care or skilled nursing facility?
If you’re admitted to a hospital or a skilled nursing facility for a stay covered by our plan, we’ll generally cover the cost of your prescription drugs during your stay. Once you leave the hospital or skilled nursing facility, we’ll cover your drugs if they meet all our rules for coverage.
If you live in a long-term care facility, such as a nursing home, you may get your prescription drugs from the facility’s pharmacy if it’s an affiliated pharmacy.
To find out if a pharmacy is affiliated with Kaiser Permanente, check the pharmacy directory located under the Kaiser Permanente and affiliated pharmacies section. You can also call Member Services at 1-800-232-4404 (TTY 711), 8 a.m. to 8 p.m., 7 days a week.
Please see your Evidence of Coverage for details about your coverage, our transition policy (PDF), and drugs not covered by Medicare Part D.