Drug formulary (covered drugs)


Use this formulary if you have a Kaiser Permanente Medicare health plan.

Medicare Part D formulary

Use this formulary if you have an FEHB plan offered by Kaiser Permanente.

2019 FEHB formulary (PDF)

FEHB Prescription Drug Cost Lookup

Learn more about what Kaiser Permanente considers specialty drugs. For more information about whether this list applies to your plan, please refer to your Evidence of Coverage.

Specialty drug list (PDF)

See a list of drugs that are limited to a 30-day supply each time a prescription is filled.

30-day drug list (PDF)

See a list of drugs that are limited to a maximum amount within a certain period of days.

Quantity-limit drug list (PDF)

Learn more about contraceptive, or birth control, methods covered under the Affordable Care Act.

Women’s contraceptive benefits flyer (PDF)

The Pharmacy and Therapeutics Committee, a group of Kaiser Permanente doctors and pharmacists, chooses which drugs to include in our formulary. To make sure you always have the most effective, safe, and affordable drug options, the committee regularly reviews information about new and existing drugs. The formulary is updated monthly based on new information or when new drugs become available.

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, known as nonformulary drugs, aren’t covered by your plan. If your doctor decides that a nonformulary drug is medically necessary, your doctor can request an exception. With an exception, the drug will be covered by your prescription drug benefit — if your plan has one. Without an exception, you’ll be charged the full 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 can also contact Membership Services by submitting an online form. Or you can call us, Monday through Friday, 8 a.m. to 6 p.m. at:

Portland area: 503-813-2000

All other areas: 1-800-813-2000

TTY Oregon : 1-800-735-2900

TTY Washington: 711

Language interpretation services: 1-800-324-8010

If you want a nonformulary drug that your doctor doesn’t believe to be medically necessary, you can file a grievance (Senior Advantage and Medicare Cost members can file a coverage determination). To start the process, call Membership Services at the numbers above.

Certain drugs may need prior authorization before they can be prescribed. For a list of these drugs and the criteria used to prescribe them, see below. For more information, please see your Evidence of Coverage.

Drugs requiring preauthorization:

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)
Androderm – Criteria (PDF)
Androgel 1% – Criteria (PDF)
Androgel 1.62% – Criteria (PDF)
Anoro Ellipta – 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)
Avonex – Criteria (PDF)
Axert – Criteria (PDF)
Axiron – Criteria (PDF)
Azor – Criteria (PDF)
Bevespi Aerosphere – Criteria (PDF)
Brand Product with Generic Equivalent Available – Criteria (PDF)
Belsomra – Criteria (PDF)
Benlysta – Criteria (PDF)
Breo Ellipta – Criteria (PDF)
Brintellix – Criteria (PDF)
Briviact – Criteria (PDF)
Butrans – Criteria (PDF)
Bydureon_Bydureon_BCise – Criteria (PDF)
Byetta – 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)
dalfampridine – Criteria (PDF)
Daytrana – Criteria (PDF)
Depo-Testosterone – Criteria (PDF)
Desoxyn – Criteria (PDF)
Desvenlafaxine Base by Ranbaxy – Criteria (PDF)
Dexilant – Criteria (PDF)
dexmethylphenidate ER – Criteria (PDF)
Duaklir Pressair – Criteria (PDF)
Dulera – Criteria (PDF)
Dupixent – Criteria (PDF)
Dyanavel XR® – Criteria (PDF)
Edarbi – Criteria (PDF)
Edarbyclor – Criteria (PDF)
Effexor XR – Criteria (PDF)
Eliquis – Criteria (PDF)
Emflaza® – Criteria (PDF)
Emgality – Criteria (PDF)
Entresto® – Criteria (PDF)
Epidiolex – Criteria (PDF)
EpiPen – Criteria (PDF)
Erivedge – Criteria (PDF)
Esbriet® – Criteria (PDF)
Eucrisa – Criteria (PDF)
Evekeo – Criteria(PDF)
Evzio – Criteria (PDF)
Exalgo ER – Criteria (PDF)
Fanapt – Criteria (PDF)
Farxiga – Criteria (PDF)
Fasenra – Criteria (PDF)
Fentora – Criteria (PDF)
Fetzima – 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)
frovatriptan – 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)
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)
Humulin R U-500/KWIKPen – Criteria (PDF)
Ingrezza – 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)
Jornay PM – Criteria (PDF)
Kalydeco® – Criteria (PDF)
Kazano – Criteria (PDF)
Kevzara – Criteria (PDF)
Khedezla – Criteria (PDF)
Kombiglyze_XR – Criteria (PDF)
Korlym – 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)
Lucemyra – Criteria (PDF)
Lyrica_CR – Criteria (PDF)
Marinol – Criteria (PDF)
methylphenidate ER – 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)
Nucala – Criteria (PDF)
Nuplazid – Criteria (PDF)
Odomzo – Criteria (PDF)
Ofev® – Criteria (PDF)
Olumiant – 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)
Praluent – Criteria (PDF)
Precision Xtra meter – Criteria (PDF)
Precision Xtra test strips – Criteria (PDF)
Prevacid – Criteria (PDF)
Prevacid Oral Suspension– 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)
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® – Criteria (PDF)
Simponi Aria – 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)
Takhzyro – 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 (PDF)
Tresiba – Criteria (PDF)
Treximet – Criteria (PDF)
Trintellix – Criteria (PDF)
Trulance – Criteria (PDF)
Trulicity – Criteria (PDF)
Tymlos – Criteria (PDF)
Uloric – Criteria (PDF)
Utibron Neohaler – Criteria (PDF)
Viberzi – Criteria (PDF)
Victoza – Criteria (PDF)
vigabatrin – Criteria (PDF)
Viibryd – Criteria (PDF)
Vogelxo – Criteria (PDF)
Vraylar – Criteria (PDF)
Vyndamax/Vyndaqel  – 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
Zovirax – Criteria (PDF)
Zyflo – Criteria (PDF)
Zyflo CR – Criteria (PDF)

Not sure if you have a prescription drug benefit? Need more information? Please let us know how we can help. You can reach Membership Services, Monday through Friday, 8 a.m. to 6 p.m., at:

Portland area: 503-813-2000

All other areas: 1-800-813-2000

TTY Oregon: 1-800-735-2900

TTY Washington: 711

Language interpretation services: 1-800-324-8010

Medicare/Senior Advantage members can call Membership Services at 1-877-221-8221 (TTY 711), 7 days a week, 8 a.m. to 8 p.m. You can also send us a secure message.

 

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