Kaiser Permanente drug coverage
This formulary is a list of drugs selected by Kaiser Foundation Health Plan of Washington—and approved by the Centers for Medicare & Medicaid Services (CMS)—that are covered by Kaiser Permanente Medicare Advantage (HMO) health plans that include prescription drugs. Based on consultation with a team of health care providers, these prescription therapies are believed to be a necessary part of a quality treatment program.
Drugs are classified into 6 tiers. Learn more about Part D coverage.
2021 Kaiser Permanente Comprehensive Formulary (PDF)
(Go to the Formulary to download a PDF of our 2021 Medicare Advantage Part D comprehensive formulary. You can view it online or print a copy anytime. To request a printed formulary, contact Member Services at 1-888-901-4600 or TTY 711, 8 a.m. - 8 p.m., 7 days a week.)
Please note: Kaiser Permanente health plans require prior authorization for certain drugs. Here are the 2021 Prior Authorization Requirements (PDF).
In some cases, Kaiser Permanente requires you to first try certain drugs to treat your medical condition before covering another drug for that same condition. See 2021 Step Therapy Requirements. (PDF)
Changes to the formulary. Kaiser Permanente Medicare Advantage health plans may add or remove drugs from the formulary during the year.
Generally, if you are taking a drug that was covered at the beginning of the year, we will not discontinue coverage of the drug during the coverage year except when we receive information from the Food and Drug Administration (FDA) that a drug is no longer safe or effective. Complete information about these changes is included in the formulary documents above.
If your drug coverage is ever affected by a change to the formulary, we will either tell you 30 days before the change or give you a one-month supply when you ask for a refill.
Examples of changes that could affect you include:
- Removing a drug from our formulary
- Adding a requirement for prior authorization
- Moving a drug to a higher cost-sharing tier
Kaiser Permanente Medicare Advantage health plans cover selected brand name drugs and generic drugs. Generic drugs have the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the FDA to be as safe and effective as brand name drugs.
Kaiser Permanente will let you know about these changes through the Provision of Notice or Explanation of Benefits, which will also detail all your pharmacy transactions and annual accumulations.
If a drug isn't covered. If your doctor or pharmacist says that a certain prescription drug is not covered, call Member Services to ask why the drug was not covered. Here are other steps you can take:
- Talk to your doctor about alternative drugs that are on the Medicare Advantage Part D formulary.
- Ask your doctor to adhere to rules about quantity limits and prior authorization.
- Ask your pharmacist to recommend a prescription change to the doctor. Form: Request for Prescription Information or Change (PDF)
- If you would like to ask for a drug formulary exception from Kaiser Permanente, you can do so via phone, fax, mail, or online.
Also see: formulary exceptions information page
Medicare Star Quality Ratings
Our Medicare Advantage health plan was rated 4.5 out of 5 Stars in Washington for 2021. The Medicare Star Rating is based on quality, service, and member satisfaction. Our high rating means you can have peace of mind knowing that you're getting high-quality care and coverage — all in a single plan at a great value.1
NCQA Quality Rating
Kaiser Permanente Washington Medicare Advantage (HMO) plan was rated 4.5 out of 5 in the National Committee for Quality Assurance (NCQA) Medicare Health Insurance Plan Ratings 2019-2020.2