Medicare Part D formulary 2024

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 one of the links below to see our formulary. You can save the document on your computer and print the pages you choose.

• Kaiser Permanente comprehensive formulary for HMO plans (updated 10/28/24) (PDF).
  
• Kaiser Permanente Senior Advantage Medicare Medicaid comprehensive formulary for HMO D-SNP Plans (updated 10/28/24).
  English (PDF) | 中文本 Chinese (PDF) | Iloko (Ilocano) (PDF)| 한국어 (Korean) (PDF) | Tiếng Việt (Vietnamese) (PDF) 

These formularies are effective as of 11/2024.

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 details.

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 “Benefits” from the menu bar, then under the "Plan for your care" 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 (updated 10/28/24) (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 may 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 1-800-805-2739 (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 or Provision of Notice (updated 09/18/24) (PDF).

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 receiving 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 1-800-805-2739 (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 (updated 10/01/23) (PDF), and drugs not covered by Medicare Part D.

The Medicare prescription payment plan is a new payment option to help you manage your out-of-pocket Part D drug costs, starting in 2025. This new payment option works with your current drug coverage, and it can help you manage your drug costs by spreading them across monthly payments that vary through the year (January – December). This payment option might help you manage your expenses, but doesn’t save you money or lower your drug costs.

“Extra Help” from Medicare and help from your SPAP and ADAP, for those who qualify, is more advantageous than participation in the Medicare Prescription Payment Plan. All members are eligible to voluntarily participate in this payment option, regardless of income level, and all Medicare drug plans and Medicare health plans with drug coverage must offer this payment option. There is no additional charge to participate.

To learn more about how this program works, whether it may benefit you, how monthly payments may be calculated, and other helpful resources, download the Medicare Prescription Payment Plan Fact Sheet (updated 10/01/24).
English (PDF) | Chinese (中文本) (PDF) | Korean (한국어) (PDF) | Vietnamese (Tiếng Việt) (PDF) | Ilocano (PDF)

To participate in the Medicare Prescription Payment Plan with an effective start date of January 1, 2025, you can choose one of the following options:

• Fill out the online Participation Request form
  
• Download the Participation Request form (updated 10/01/24)
  English (PDF) | Chinese (中文本) (PDF) | Korean (한국어) (PDF) | Vietnamese (Tiếng Việt) (PDF) | Ilocano (PDF)
• Mail to:

Kaiser Permanente – Medicare Unit
P.O. Box 232400
San Diego, CA 92193-2400

• Call Member Services at 1-800-805-2739, 7 days a week, 8 a.m. to 8 p.m.. TTY users can call 711.

For more information on this program, visit Medicare.gov/prescription-payment-plan, or call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users can call 1-877-486-2048.

In most cases, you must get your prescription filled at a Kaiser Permanente pharmacy or at one of the affiliated pharmacies we have a contract with to receive your prescription drug benefit.

How do I find a Kaiser Permanente or affiliated pharmacy near me?

You can find a Kaiser Permanente or affiliated pharmacy in these 3 ways:

• Download our provider and pharmacy directory for HMO Plans (updated 11/07/24) (PDF)
• Download our provider and pharmacy directory for Senior Advantage Medicare Medicaid Plan (HMO D-SNP) (updated 10/28/24)
  English (PDF) | 中文本 Chinese (PDF) | Iloko (Ilocano) (PDF) | 한국어 (Korean) (PDF) | Tiếng Việt (Vietnamese) (PDF)
• Call Member Services at 1-800-805-2739 (TTY 711), 8 a.m. to 8 p.m., 7 days a week, to request a printed version of our pharmacy directory.
• Search online for a pharmacy location.

How do I fill my prescription?

You must show your Kaiser Permanente Medicare Advantage (HMO or HMO-POS) ID card and photo ID at a Kaiser Permanente or affiliated pharmacy. You’ll need to pay your share of the cost when you pick up your prescription.

If you don’t have your ID card with you, or if you go to a non-affiliated pharmacy (out-of-network), you may have to pay full price for your medicines.

If this happens, ask us to pay you back for our share of the cost by submitting a claim form. Learn how to submit a claim in your Evidence of Coverage.

What if I use a pharmacy that isn’t a Kaiser Permanente or affiliated pharmacy?

This would be considered a non-affiliated or out-of-network pharmacy. Prescriptions filled at an out-of-network pharmacy will only be covered when a Kaiser Permanente or affiliated pharmacy isn’t available or certain situations.

Here are the situations when prescriptions at an out-of-network pharmacy would be covered:

• You need the drug right away and there’s no 24-hour Kaiser Permanente or affiliated pharmacy within a reasonable driving distance.
• You’re traveling within or outside the United States and need out-of-network emergency or urgent care.
• Your drug isn’t regularly stocked at an accessible Kaiser Permanente or affiliated pharmacy or isn’t available through our mail-order service.
• You can’t get drugs from a Kaiser Permanente or affiliated pharmacy during a disaster.

In these situations, you’ll have to pay the full cost when you fill the prescription. You’d then file a claim asking us to pay you back for our share.

To learn more about out-of-network pharmacy coverage and find out how to file a paper claim, see your Evidence of Coverage.

Save time by ordering your prescription refills through one of the following ways:

• Order online under the Pharmacy section at kp.org. You'll need to sign on to your registered account. If you don't have an account yet, register for a secure account to use the service.
• Order through the Kaiser Permanente mobile app. Download the app by searching for Kaiser Permanente on the Apple Store or the Google App Store.
• Call the phone number on the label of your medicine.
• Call our automated refill line at 808-643-7979 (TTY 711), 8:30 a.m. to 5 p.m., Monday through Friday.

When you order refills by mail, there’s no charge for shipping and your costs could be lower when you order a 3-month supply. Ask your Kaiser Permanente pharmacy, affiliated pharmacy, or our mail-order pharmacy if your prescription is available by mail.

Contact us at least 5 days before you run out of your medicines to make sure your next mail-order refill is shipped to you in time. Generally, you should receive them within 3-5 days.

If you can’t wait for your prescription to arrive from our mail-order pharmacy, you can get an urgent supply by calling your local Kaiser Permanente or affiliated pharmacy listed in your pharmacy directory located under the Kaiser Permanente and affiliated pharmacies section.

Find more information about our mail-order service* in your Evidence of Coverage.

*For certain drugs, you can get prescription refills mailed to you through our Kaiser Permanente mail-order pharmacy. Usually, you should receive them within 5 days. If not, please call 808-643-7979 (TTY 711).

Kaiser Permanente provides a Medication Therapy Management (MTM) program for eligible members who have several chronic medical conditions, take different prescription drugs at the same time, and have high drug costs.

The program connects you to specially trained pharmacists who make sure all the medicines you take are necessary, safe, and effective.

The MTM program isn’t a benefit. It’s a voluntary, extra service offered at no cost to members who qualify.

Am I eligible for the MTM Program?

To be eligible, you must be a current Kaiser Permanente member with a Medicare health plan that includes Medicare Part D coverage.

You must also be able to say yes to the following 3 factors.

1. You have 3 or more of these health conditions:

• High cholesterol
• High blood pressure
• Coronary artery disease
• Diabetes
• Stroke
• Rheumatoid arthritis
• Chronic obstructive pulmonary disease
• Osteoporosis
• Chronic non-cancer pain
• Asthma
• Gout
• Benign prostatic hyperplasia (BPH)
• Ulcer/reflux/acid

2. You take 5 or more of these prescription drugs:

• Drugs for high cholesterol
• Drugs for high blood pressure
• Drugs for diabetes
• Drugs for rheumatoid arthritis
• Drugs for gout
• Bronchodilators
• Inhaled corticosteroids
• Osteoporosis agents
• Urinary Incontinence Agents

3. You spend more than $5,330 each year on prescription drugs.

How do I enroll in the MTM program?

If you qualify, you’ll be automatically enrolled in the MTM program. A member of the MTM team will either call you or send you a letter asking you to set up an appointment for a comprehensive review of all your medicines.

To prepare for this review, please fill out this personal medication form (updated 10/01/23) (PDF) and include all the medicines you’re currently taking.

Most reviews are done by phone and take 15 to 20 minutes. In some cases, you may also need to do a targeted medication review that lasts 10 to 15 minutes.

We’ll talk about your prescription medicines and any over-the-counter, herbal, or dietary supplements you take. We’ll look for ways to reduce side effects, prevent harmful drug interactions, and lower drug costs.

You’ll receive a written summary of the review that includes an action plan based on your needs to help you get the most out of your medicines.

For more information, call Member Services at 1-800-805-2739 (TTY 711), 8 a.m. to 8 p.m., 7 days a week.

Kaiser Permanente has quality assurance measures that are meant to prevent medication errors, harmful drug interactions, and to improve medication use.

Our pharmacy policies and procedures meet state and federal laws and include:

• Drug utilization reviews that are performed before each new prescription is given to check for issues like interactions with other drugs or allergies
• Computerized systems that check records to spot drug therapy problems
• Systems to spot and reduce medication errors

If you have a complaint about your Kaiser Permanente care:

• You can file a grievance with Kaiser Permanente. For more information on how to file please see your Evidence of Coverage. Or call Member Services at 1-800-805-2739 (TTY 711), 8 a.m. to 8 p.m., 7 days a week.
• You can file a complaint with the Quality Improvement Organization (QIO). The QIO review of a quality-of-care issue is separate from Kaiser Permanente’s Medicare Part D grievance procedures, so you can file with both.

You can file a complaint with the local QIO by writing to:

Livanta
BFCC – QIO Program
10820 Guilford Road, Suite 202
Annapolis Junction, MD 20701-1105

Or call the QIO at 1-877-588-1123 (TTY 711).

Drug utilization management

Kaiser Permanente has requirements, restrictions, or limits on some covered prescription drugs. These are established by a team of doctors and pharmacists to prevent waste, manage member costs, ensure safe and effective drug use, and to comply with FDA and Medicare guidelines. For example, there are limits on opioid prescriptions, such as lower doses and shorter courses, to ensure your prescribed drug is safe, appropriate, and medically necessary.

You may need to get preapproval (prior authorization) from us before you fill certain prescriptions. If you don’t get preapproval, we may not cover the drug.

Drugs needing our approval (updated 08/28/24) (PDF) could be covered under Medicare Part B or Part D, depending on your medical diagnosis. More details from your prescriber might be required to make that decision.

You may need to get an approval for certain Part D drugs if you’re admitted to hospice. Hospice providers can complete this form (updated 10/01/23) (PDF) if necessary.

For more information, please see the Kaiser Permanente comprehensive formulary.

Let us know right away if you have questions, concerns, or problems related to your covered services or care by calling Member Services at 1-800-805-2739  (TTY 711), 8 a.m. to 8 p.m., 7 days a week.

A representative will help determine whether your concern should be handled as a grievance, coverage determination, or an appeal. Here’s the difference:

• A grievance is a type of complaint you make about us, including a complaint about the quality of your care. It doesn’t involve coverage or payment disagreements.
• A coverage determination is a decision about whether a drug prescribed for you will be covered by us and the amount you’ll need to pay for it, or reimbursement if you feel you’ve paid too much.
• An appeal can be made if you disagree with our decision to deny a request about your Part D drugs.

A Member Services representative can help you file a grievance, coverage determination, and/or appeal. You can also refer to your Evidence of Coverage for more information about the process.

How do I ask for a coverage determination?

You, your appointed representative, your Kaiser Permanente or affiliated doctor, or another prescriber can request a coverage determination.

The CMS coverage determination form (updated 10/01/23) (PDF) makes it easy to provide evidence supporting your request. You don’t have to use the form, but your request must include all the information from the form.

If you appoint a representative to act on your behalf, you both must sign and date a Disclosure Authorization form along with your Medicare Authorized Representative statement, which gives that person legal permission to act as your appointed representative (updated 10/01/23) (PDF). 

You can ask for a coverage determination in the following ways:

• Call OptumRx Member Services Prior Authorization Dept. at 1-888-277-3917 or (TTY 711), 8 a.m. to 8 p.m., 7 days a week.
• Fax the completed form or information to OptumRx Member Services Prior Authorization Dept. at 1-844-403-1028.
• Mail the completed form or information to: 
  • OptumRx
    Prior Authorization Department
    P.O. Box 2975
    Mission, KS 66201

How do I appoint a representative?

You can appoint a representative to help you. Your representative can be a family member, friend, advocate, attorney, doctor, or someone else who will act on your behalf. Fill out an Appointment of Representative form (updated 10/01/23) (PDF) and send it in with your appeal.

How long will it take for a decision?

A standard decision will be made within 72 hours. For exception requests, the time frame begins when your doctor or other prescriber provides a supporting statement.

An expedited (fast) decision will be made within 24 hours. For exception requests, the time frame begins when your doctor or other prescriber provides a supporting statement.

What if my request for an expedited decision isn’t approved?

An expedited decision will only be allowed if your doctor confirms that waiting 72 hours could seriously harm your health.

If your request for an expedited decision isn’t approved, we’ll make our decision in the standard 72-hour time frame.

If we deny your expedited review by phone and you disagree with our decision, you can ask for a 24-hour expedited grievance at that time. Otherwise, we’ll send a letter within 3 calendar days explaining how to file the expedited grievance. It’ll also explain that we’ll automatically give you an expedited decision if you get the prescribing Kaiser Permanente or affiliated doctor’s support for an expedited review.

If you believe you were incorrectly charged through our coverage determination process, you may submit a reimbursement request. Once we receive it, we’ll respond within 14 calendar days. If approved, payment will be made within 14 calendar days.

To ask questions or to check on the status of a request, call Member Services at 1-800-805-2739 (TTY 711), 8 a.m. to 8 p.m., 7 days a week.

How do I file an appeal to a coverage determination?

If you disagree with our coverage determination, you have the right to file an appeal called a plan redetermination. You must ask for it within 60 days from the date of our denial notice, unless you can show good cause for the delay.

You can file your request for a plan redetermination in writing by mailing it to the address on your denial notice. An expedited request may also be filed in writing, or by contacting us by telephone or fax at the numbers provided in your coverage determination denial letter.

You can also complete the coverage redetermination form (updated 10/01/23) (PDF) and fax it to the Part D Unit at 1-808-432-5260. Or mail it to the following address:

Kaiser Foundation Health Plan, Inc
Attention: Regional Appeals Office
711 Kapiolani Blvd.
Honolulu, HI 96813

You also have the right to give us new information supporting your appeal in writing, by telephone, by fax, or by hand-delivering it to your local Member Services department.

How long does a decision on an appeal take?

A standard appeal decision will be made within 7 calendar days. For pre-service exception requests, the timeframe begins when your doctor or other prescriber provides a supporting statement, if not provided during the initial review. If our decision is fully in your favor, we must authorize the service within 7 days and/or make the payment within 14 calendar days.

If waiting for a standard decision could seriously harm your health or compromise your ability to regain maximum function, you or your prescribing Kaiser Permanente or affiliated doctor may request an expedited appeal for a decision within 72 hours. For exception requests, the timeframe begins when your doctor or other prescriber provides a supporting statement, if not provided during the initial review. This process doesn’t apply to denied claims for payment.

Who do I contact if I have questions?

If you have questions or concerns about services or your care, problems with a particular Medicare Part D drug, or need help getting a representative to handle your coverage determination or appeal, you may submit a complaint online or call Member Services at 1-800-805-2739 or (TTY 711), 8 a.m. to 8 p.m., 7 days a week.

For additional assistance, you can also visit the Member Services department at your local Kaiser Permanente facility.

To send a complaint directly to Medicare, you may use the online Medicare Complaint Form.

How do I find out about grievances, appeals, and exceptions filed by other plan members?

You can get a summary of the appeals and grievances other plan members have filed with Kaiser Permanente by calling Member Services.

How do I report suspected fraud or other unlawful acts?

We encourage anyone to let us know if anything happens at Kaiser Permanente that could be unlawful. If we know about it, we can take action.

If you believe you’ve experienced fraud, or you become aware of fraud, waste, or abuse involving Kaiser Permanente members or resources, please contact Member Services at 1-800-805-2739 (TTY 711), 8 a.m. to 8 p.m., 7 days a week.

You can also contact Medicare for fraud-related questions and concerns at:

1-800-HHS-TIPS (1-800-447-8477)
TTY: 1-800-377-4950
Fax: 1-800-223-8164

Mail
U.S. Department of Health and Human Services Office of Inspector General
Attn: OIG HOTLINE OPERATIONS
P.O. Box 23489
Washington, DC 20026

If you leave Kaiser Permanente Senior Advantage (HMO), you have other prescription drug coverage options:

• Medicare Prescription Drug Plan (PDP) This plan adds prescription drug benefits to your Original Medicare coverage. To enroll, you must be entitled to Medicare benefits under Part A and/or currently enrolled in Part B and live in the plan’s service area.
• Medicare Advantage Prescription Drug Plan (MA-PD) You can join another Medicare Advantage Plan if it’s available in your area, is accepting new members, and you meet the plan’s eligibility requirements.
  

If you choose to join another Medicare Advantage plan that offers prescription drug coverage, then you must get your Medicare prescription drug coverage through that Medicare Advantage plan.

For more information about disenrolling from our plan, please review chapter 10 in your Evidence of Coverage.

Click on one of the links below to see your Evidence of Coverage, which you can then save to your computer.

Kaiser Permanente Senior Advantage (HMO) and Senior Advantage Medicare Medicaid (HMO D-SNP)

2024 EOC for Senior Advantage Basic (HMO) and Enhanced (HMO) Plans (updated 10/01/23) (PDF)

2024 EOC for Senior Advantage Hawaii Island Plan (updated 10/01/23) (PDF)

2024 EOC for Senior Advantage Maui Plan (updated 10/01/23) (PDF)

2024 EOC for Kaiser Permanente Senior Advantage Medicare Medicaid Plan (HMO D-SNP) (updated 10/01/23) (PDF)

Interpreter services

We have interpreters for more than a dozen languages, available at no cost. Learn more about our multi-language interpreter services that are just a toll-free phone call away.

For general information about Kaiser Permanente: Please call Member Services at 1-800-805-2739 or (TTY 711), 8 a.m. to 8 p.m., 7 days a week.

Or you can mail a letter to:

Kaiser Foundation Health Plan, Inc.
Member Services
711 Kapiolani Blvd.
Honolulu, HI 96813

If you have questions about your medicines: Please talk to your Kaiser Permanente or affiliated doctor, or to someone in your Kaiser Permanente or affiliated pharmacy.

For more information about Medicare prescription drug coverage: Call 1-800-MEDICARE (1-800-633-4227) or (TTY 1-877-486-2048), 24 hours a day, 7 days a week. Or visit the Medicare website.