Formulary (covered drugs)

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Oregon and Washingon

Medicare Part D formulary

Learn more about our drug formulary for Senior Advantage members:

Medicare Part D formulary

Federal Employees Health Benefit formulary

Learn more about our drug formulary when you participate in a Federal Employees Health Benefit (FEHB) plan offered by Kaiser Permanente.

2019 FEHB formulary (PDF)

FEHB Prescription Drug Lookup

Specialty drug list

Learn more about drugs Kaiser Permanente considers specialty. For further information about whether this list applies to your benefit, please see your Evidence of Coverage.

Specialty drug list (PDF)

30-day supply limit drug list

Certain drugs are limited to a maximum 30–day supply per dispense.

30–day drug list (PDF)

Quantity limit drug list

Certain drugs are limited to a maximum quantity within a certain period of days.

Quantity limit drug list (PDF)

Contraceptive benefits

Learn more about contraceptive methods covered under the Affordable Care Act (ACA).

Contraceptive Benefits Flyer (PDF)

Changes to the formulary

Our regional Formulary and Therapeutics Committee meets monthly to update our formulary.

Getting an exception to the formulary

FOR PRESCRIBERS ONLY: Please prescribe formulary medication(s) for your patients with Kaiser Permanente benefits. If a formulary medication is not appropriate, complete the Drug Coverage Request Form (PDF) and fax to 1-866-618-6569.

Drugs not listed on the formulary are called non-formulary drugs. When a Kaiser Permanente physician determines that a non-formulary drug is medically appropriate and necessary, that drug will be covered under the terms of your benefits (if you have a prescription drug benefit). If you do not have a prescription drug benefit, you will be charged the retail price for the drug.

The most effective way to get an exception to the formulary is to send a secure email to your doctor. You and your doctor are best able to determine your medication needs.

You may also contact Member Services by submitting an online form. Or call Member Services, Monday through Friday, 8 a.m. to 6 p.m. at:

  • Portland area: 503-813-2000
  • All other areas: 1-800-813-2000 (toll free)
  • TTY (for the hearing/speech impaired): 1-800-735-2900 (toll free)
  • Language interpretation services: 1-800-324-8010 (toll free)

If you want to request a non-formulary drug that our physician does not determine to be medically necessary, you may initiate an exception review or grievance (or for Senior Advantage and Medicare Cost members, file a coverage determination). To start the process, contact Membership Services (see below).

Prior authorization

Certain drugs may be subject to prior authorization. For a list of restricted drugs and the criteria used, see below. For further information on their restrictions, please see your Evidence of Coverage.

Drugs requiring prior authorization

Abstral – Criteria (PDF)
AcipHex Sprinkle – Criteria (PDF)
Actiq – Criteria (PDF)
Actonel – Criteria (PDF)
Adempas® – Criteria (PDF)
Adlyxin – Criteria (PDF)
Advair HFA – Criteria (PDF)
Aimovig – Criteria (PDF)
Ajovy – Criteria (PDF)
Amitiza – Criteria (PDF)
Ampyra® – Criteria (PDF)
Androderm – Criteria (PDF)
Androgel 1% Packet – Criteria (PDF)
Androgel 1.62% – Criteria (PDF)
Androgel 1% Pump – Criteria (PDF)
Aptensio XR – Criteria (PDF)
Astagraf XL – Criteria (PDF)
Atacand – Criteria (PDF)
Atacand HCT – Criteria
Aubagio® – Criteria (PDF)
Austedo® – Criteria (PDF)
Auvi-Q – Criteria (PDF)
Avandamet – Criteria (PDF)
Avandaryl – Criteria (PDF)
Avandia – Criteria (PDF)
Aveed – Criteria (PDF)
Axert – Criteria (PDF)
Axiron – Criteria (PDF)
Azor – Criteria (PDF)
Brand Product with Generic Equivalent Available – Criteria (PDF)
Belsomra – Criteria (PDF)
Benlysta – Criteria (PDF)
Breo Ellipta – Criteria (PDF)
Brilinta – Criteria (PDF)
Brintellix – Criteria (PDF)
Briviact – Criteria (PDF)
Butrans – Criteria (PDF)
Bydureon/BCise – Criteria (PDF)
Byetta – Criteria (PDF)
Cambia – Criteria  (PDF)
Cequa – Criteria  (PDF)
Cerdelga – Criteria (PDF)
Chantix – Criteria (PDF)
Cimzia® – Criteria (PDF)
Cometriq – Criteria (PDF)
Complera - Criteria (PDF)
Concerta – Criteria (PDF)
Condylox Gel – Criteria
Corlanor® – Criteria (PDF)
Cotempla XR-ODT® – Criteria (PDF)
Daliresp – Criteria (PDF)
Daytrana – Criteria (PDF)
Denavir – Criteria (PDF)
Depo-Testosterone – Criteria (PDF)
Desoxyn – Criteria (PDF)
Desvenlafaxine Base by Ranbaxy – Criteria (PDF)
Dexilant – Criteria (PDF)
Dulera – Criteria (PDF)
Dupixent – Criteria (PDF)
Dyanavel XR® – Criteria (PDF)
Edarbi – Criteria (PDF)
Edarbyclor – Criteria (PDF)
Edecrin – Criteria (PDF)
Effexor XR – Criteria (PDF)
Eliquis – Criteria (PDF)
Emflaza® – Criteria (PDF)
Emgality – Criteria (PDF)
Emverm - Criteria (PDF)
Entresto® – Criteria (PDF)
Epidiolex – Criteria (PDF)
EpiPen – Criteria (PDF)
Esbriet® – Criteria (PDF)
Eucrisa – Criteria (PDF)
Evekeo – Criteria (PDF)
Evzio – Criteria (PDF)
Exalgo ER – Criteria (PDF)
Fanapt – Criteria (PDF)
Farxiga – Criteria (PDF)
Fentora – Criteria (PDF)
Fetzima – Criteria (PDF)
Fiasp – Criteria (PDF)
Fiasp FlexTouch – Criteria (PDF)
Flector Patch – Criteria (PDF)
fluvastatin – Criteria (PDF)
Focalin XR – Criteria (PDF)
Forfivo XL – Criteria (PDF)
Fortamet – Criteria (PDF)
Forteo – Criteria (PDF)
Fortesta – Criteria (PDF)
Freestyle Libre – Criteria  (PDF)
Frova – Criteria (PDF)
Fycompa – Criteria (PDF)
Gattex® – Criteria (PDF)
Gilenya – Criteria (PDF)
Glumetza – Criteria (PDF)
Glyxambi – Criteria (PDF)
Gocovri –Criteria (PDF)
Gralise – Criteria (PDF)
Hetlioz® – Criteria (PDF)
Horizant – Criteria (PDF)
HP Acthar – Criteria (PDF)
Humalog 75-25 KWIKPen – Criteria (PDF)
Humalog Cartridges – Criteria (PDF)
Humalog Junior KWIKPen® – Criteria (PDF)
Humalog KWIKPen – Criteria (PDF)
Humalog Vial – Criteria (PDF)
Humira – Criteria (PDF)
Humulin 70-30 Pen – Criteria (PDF)
Humulin N Pen – Criteria (PDF)
Ingrezza – Criteria (PDF)
Intermezzo – Criteria (PDF)
Intrarosa – Criteria (PDF)
Invokamet – Criteria (PDF)
InvokametXR – Criteria (PDF)
Invokana – Criteria (PDF)
Janumet – Criteria (PDF)
JanumetXR – Criteria (PDF)
Januvia – Criteria (PDF)
Jardiance® – Criteria (PDF)
Jentadueto – Criteria (PDF)
JentaduetoXR – Criteria (PDF)
Jynarque – Criteria (PDF)
Kalydeco® – Criteria (PDF)
Kazano – Criteria (PDF)
Keveyis – Criteria (PDF)
Kevzara – Criteria (PDF)
Khedezla – Criteria (PDF)
Kombiglyze_XR – Criteria (PDF)
Korlym – Criteria (PDF)
lansoprazole oral disintegrating tablet - Criteria (PDF)
Lantus – Criteria
Lantus Solostar – Criteria (PDF)
Latuda – Criteria (PDF)
Lazanda – Criteria (PDF)
Lenvima – Criteria (PDF)
Lescol XL – Criteria (PDF)
Letairis® – Criteria (PDF)
LevemirFlexPen – Criteria (PDF)
Levemir – Criteria (PDF)
Levitra – Criteria (PDF)
Levo-Dromoran® – Criteria (PDF)
Lidoderm – Criteria (PDF)
Linzess – Criteria (PDF)
Livalo – Criteria (PDF)
Lonhala Magnair – Criteria  (PDF)
Lorbrena - Criteria (PDF)
Lucemyra – Criteria (PDF)
Lyrica_CR – Criteria (PDF)
Marinol – Criteria (PDF)
Micardis HCT – Criteria (PDF)
Movantik® – Criteria (PDF)
Mydayis – Criteria (PDF)
Myrbetriq® – Criteria (PDF)
Natesto – Criteria (PDF)
Nesina – Criteria (PDF)
Novolin 70-30 – Criteria (PDF)
Novolin N – Criteria (PDF)
Novolin R – Criteria (PDF)
Novolog 70-30 FlexPen – Criteria (PDF)
Novolog 70-30 – Criteria (PDF)
NovologFlexpen – Criteria (PDF)
NovologPenfill – Criteria (PDF)
Novolog – Criteria (PDF)
Nuplazid – Criteria (PDF)
Ofev® – Criteria (PDF)
Olumiant – Criteria (PDF)
Omnipod – Criteria (PDF)
Onglyza – Criteria (PDF)
Onsolis – Criteria (PDF)
Opana – Criteria (PDF)
Opana ER® – Criteria (PDF)
Opium Tincture – Criteria (PDF)
Opsumit® – Criteria (PDF)
Oracea – Criteria (PDF)
Orfadin – Criteria (PDF)
Orkambi® – Criteria (PDF)
Oseni – Criteria (PDF)
Otezla – Criteria (PDF)
OxyContin – Criteria (PDF)
Ozempic – Criteria (PDF)
Plegridy® – Criteria (PDF)
Pomalyst® – Criteria (PDF)
potassium chloride liquid – Criteria (PDF)
potassium chloride packet – Criteria (PDF)
Praluent – Criteria (PDF)
Precision Xtra meter – Criteria (PDF)
Precision Xtra test strips – Criteria (PDF)
Prevacid – Criteria (PDF)
Prevacid Oral Suspension– Criteria
Prevymis – Criteria
ProAir HFA – Criteria (PDF)
Promacta® – Criteria (PDF)
Protonix – Criteria
Proventil HFA – Criteria (PDF)
Qtern – Criteria (PDF)
Qualaquin – Criteria (PDF)
QuilliChew ER – Criteria (PDF)
Quillivant XR – Criteria (PDF)
QVAR RediHaler – Criteria (PDF)
Ranbaxy (manufacturer) – Criteria (PDF)
Ranexa – Criteria (PDF)
Ravicti® – Criteria (PDF)
Rebif – Criteria (PDF)
Relistor_injection – Criteria (PDF)
Relistor_tablet – Criteria (PDF)
Repatha – Criteria (PDF)
Restasis – Criteria (PDF)
Revlimid® – Criteria (PDF)
Rexulti – Criteria (PDF)
Ritalin LA – Criteria (PDF)
Saphris – Criteria (PDF)
Savaysa – Criteria (PDF)
Savella – Criteria (PDF)
Segluromet – Criteria (PDF)
Siliq – Criteria (PDF)
Simponi 50mg – Criteria (PDF)
Simponi 100mg – Criteria  (PDF)
Solaraze – Criteria (PDF)
Soliqua – Criteria
Somavert – Criteria
Soolantra® – Criteria (PDF)
Steglatro – Criteria (PDF)
Steglujan – Criteria (PDF)
Stelara – Criteria (PDF)
Stendra – Criteria (PDF)
Striant – Criteria (PDF)
Stribild - Criteria (PDF)
Subsys – Criteria (PDF)
Symbicort – Criteria (PDF)
Symdeko – Criteria
Symproic – Criteria (PDF)
Synjardy – Criteria (PDF)
Synjardy_XR – Criteria (PDF)
Taltz – Criteria (PDF)
Tanzeum – Criteria (PDF)
Tecfidera® – Criteria (PDF)
Testim – Criteria (PDF)
Testopel – Criteria (PDF)
Testosterone Enanthate – Criteria
Testosterone 1% Gel – Criteria
Teveten – Criteria (PDF)
Teveten HCT – Criteria (PDF)
Thalomid – Criteria (PDF)
Tirosint® – Criteria (PDF)
Toujeo – Criteria (PDF)
Tracleer® – Criteria (PDF)
Tradjenta – Criteria (PDF)
Tremfya – Criteria
Tresiba – Criteria (PDF)
Treximet – Criteria (PDF)
Trintellix – Criteria (PDF)
Trulance – Criteria (PDF)
Trulicity – Criteria (PDF)
Tymlos – Criteria (PDF)
Uloric – Criteria (PDF)
Viberzi – Criteria (PDF)
Victoza – Criteria (PDF)
Viibryd – Criteria (PDF)
Vogelxo – Criteria (PDF)
Vraylar – Criteria (PDF)
Vytorin – Criteria (PDF)
Vyvanse – Criteria (PDF)
Xarelto – Criteria (PDF)
Xermelo – Criteria (PDF)
Xeljanz – Criteria (PDF)
Xeljanz XR – Criteria (PDF)
Xhance – Criteria (PDF)
Xifaxan® – Criteria (PDF)
Xigduo_XR – Criteria (PDF)
Xiidra – Criteria (PDF)
Xultophy – Criteria
Xyrem – Criteria  (PDF)
Yupelri – Criteria  (PDF)
Zipsor – Criteria  (PDF)
Zorvolex – Criteria (PDF)
Zovirax – Criteria (PDF)
Zyflo – Criteria (PDF)
Zyflo CR – Criteria (PDF)

CMSSD-4075

Have questions?

Not sure if you have a prescription drug benefit? Need more information? Please let us know how we can help. Our pharmacy staff and Membership Services are happy to answer your questions. You can reach our Membership Services department from 8 a.m. to 6 p.m. Monday through Friday by calling:

  • Portland area: 503-813-2000
  • All other areas: 1-800-813-2000 (toll free)
  • TTY (for the hearing/speech impaired): 1-800-735-2900 (toll free)
  • Language interpretation services: 1-800-324-8010 (toll free)

Medicare/Senior Advantage members can call Membership Services from 8 a.m. to 8 p.m. seven days a week at:

  • 1-877-221-8221 (toll free)
  • TTY (for the hearing/speech impaired): 1-800-735-2900 (toll free)

You can also send a secure message to Membership Services.

Reviewed by: Emily Thomas, PharmD, May 2014

NCQA content reviewed by: Tiffany Dorsey, NCQA lead, February 2014

This page was last updated: October 8, 2018, at 12 a.m. PT

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