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) 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.
(Go to the Formulary to download a PDF of our 2020 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 WA Relay 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 2020 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 2020 Step Therapy Requirements. (PDF)
Kaiser Permanente Medicare Advantage 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 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 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 Food and Drug Administration (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 (PDF) (coming soon) 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 in Washington was rated 4.5 out of 5 Stars for 2019. Our 4.5 out of 5 Star rating is based on quality, service, and member satisfaction, so you get the peace of mind that comes with knowing you're getting high-quality care. 1