How our formulary works

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Medications listed in the formulary are chosen by a group of Kaiser Permanente physicians and pharmacists known as the Pharmacy and Therapeutics Committee. This committee meets regularly to evaluate and select the safest, most effective medications for our members.

What drugs are covered?

Drugs listed on the formulary are covered by your prescription benefit (if your plan has this benefit). Coverage can vary from plan to plan, and not all Kaiser Permanente health plans include prescription drug coverage. If your plan doesn’t include a prescription benefit, you can still use a Kaiser Permanente pharmacy but you will need to pay the full retail price for your prescriptions. Please refer to your Evidence of Coverage or Certificate of Insurance for more information. Some plans may exclude certain drugs, cover generic drugs only, or limit the amount of the drug you can get with a prescription or copayment.

The day supply of your medication may be reduced at the outpatient pharmacy to a limited day supply in any 30-day period if it’s determined that the item is in limited supply in the market or for specific drugs (your Plan Pharmacy can tell you if a drug you take is one of these drugs).

What drugs are not covered?

Other drugs not listed on the formulary (i.e., nonformulary) are not covered unless a Kaiser Permanente physician determines that they are medically necessary. Prescriptions for non-formulary medications may be filled at Kaiser Permanente pharmacies. However, you should expect to pay the full retail cost unless your doctor has obtained an exception.

Drugs not normally covered by your Kaiser Permanente prescription drug benefit include:

  • drugs prescribed for cosmetic purposes
  • drugs related to an excluded service
  • drugs used to lose weight
  • investigational or experimental drugs
  • drugs used to enhance athletic performance
  • vitamins and nutritional supplements
  • drugs used to treat symptoms of the common cold

Please refer to your Evidence of Coverage for complete details of your prescription drug benefit.

Reviewed by: Mark Groshek, MD, and David McWaters, PharmD, JD, May 2014
© 2014 Kaiser Permanente

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