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Formulary

Covered drugs
Medicare Part D drug formulary
District of Columbia, Maryland, and Virginia (exchange) preferred drug list
Commonwealth of Virginia Medicaid and FAMIS Preferred Drug List
HMO formulary
Flexible Choice formulary
Maryland Health Choice Preferred Drug List
Request to review medications for addition/deletion to the formulary

Covered drugs

The Kaiser Permanente Mid-Atlantic States Region Drug Formulary (Preferred Drug) List includes those drugs that are preferred for use over other agents and comprise the Health Plan’s drug formulary.  This list is approved by the Kaiser Permanente Mid-Atlantic States Pharmacy and Therapeutics Committee.  This committee is composed of Plan physicians, pharmacists and nurses.  The committee thoroughly reviews the medical literature and selects drugs for the formulary based on a number of factors including safety and effectives.  Plan providers (including contracted providers) should use the list to guide their decisions when they prescribe drugs.

Selection of generic medications is based on clinical effectiveness, safety, and therapeutic equivalence to a branded drug in accordance with all applicable federal, state and/or local statutes. If an FDA AB-rated approved therapeutically equivalent generic medication becomes available, the generic medication is added to formulary without Pharmacy and Therapeutic Committee review if the brand name medication is already on the formulary and has been reviewed in the past. Selected generic drugs such as hormonal therapy, narrow therapeutic index drugs, or non-formulary drugs may require a formal review by the Pharmacy and Therapeutic Committee before they are added to the drug formulary. The corresponding brand name drug is deleted from the drug formulary after review and approval by the Pharmacy and Therapeutic Committee.

Periodically a list of target drugs with potential for significant member and organizational cost savings if targeted for therapeutic conversion. The Clinical Pharmacy in collaboration with the MAPMG Physician Director of Pharmacy and Therapeutics Drug Utilization Management develops a standard process for therapeutic conversion for these agents. This process assures proper communication, implementation, and education of practitioners, pharmacists and KPMAS members about each drug conversion.

Upon evaluation, if a member qualifies for therapeutic conversion, an order is placed to the pharmacy. The member is informed of the therapeutic conversion and to call the pharmacy to have the prescription filled when they are ready to receive their medication. If the patient had an allergy or adverse reaction to the preferred drug, the preferred product is ineffective or patient refuses, this is documented in patient’s EMR and patient receives the preferred product.

Mandatory counseling by the dispensing pharmacist is in place to ensure patient education of the therapeutic conversion occurs at the time of dispensing.

Medications included on the Plan’s formulary are covered under the Member’s prescription drug benefit unless otherwise excluded by the Member’s specific group plan.  For additional information regarding a Member’s pharmacy benefits, please call Member Services at 1-800-777-7902.  Coverage for products not included on this list is granted when considered medically necessary by the member’s prescribing provider.

The cost of prescriptions may vary depending upon the type of drug and the member's particular pharmacy benefit. If members have questions about their pharmacy benefits, please refer them to the Evidence of Coverage document that they received at the beginning of this renewal year.

Copay information related to prescriptions drugs may be found on the following link: https://businessnet.kp.org/health/plans/mid/assistemployees/supportmaterials

To get updated information about the drugs included in the formulary, review the comprehensive listing of formulary drugs or contact Member Services.

Formulary for HMO members*(PDF)
Formulary for Flexible Choice members* (PDF)

Search our online drug formulary* (courtesy of Lexi-Comp) for HMO and Flexible Choice formulary.

Please note the following:

  • Drugs can be searched by brand or generic names.
  • Drugs that are not on the commercial formulary are not listed.
  • The Medicare Part D formulary may be found by clicking the Medicare Part D formulary below.

To request a paper copy of our formularies, please contact our Provider Relations department at 1-877-806-7470.

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Medicare Part D drug formulary

Our Kaiser Permanente’s Medicare Part D drug formulary is a list of the prescription drugs that are approved for coverage.

     Medicare Part D comprehensive formulary*

To request a paper copy of our formularies, please contact our Provider Relations department at 1-877-806-7470.

 

District of Columbia, Maryland, and Virginia (exchange) preferred drug list

Download our District of Columbia, Maryland, and Virginia (exchange) preferred drug list.* (PDF)

HMO formulary

Download our HMO formulary.* (PDF)

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Flexible Choice formulary

Download our Flexible Choice formulary.* (PDF)

Prior Authorization

Download the HMO/Flexible choice/District of Columbia/Maryland and Virginia (exchange) Prior Authorization for PCSK9 inhibitor drugs.* (PDF)

Commonwealth of Virginia Medicaid and FAMIS Preferred Drug List

Download our Preferred Drug List for Virginia Medicaid and FAMIS members.* (PDF)

Prior Authorization

Download the Virginia Medicaid-FAMIS Prior Authorization for Androgenic Agent (Topical Testosterone).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Angiotensin Receptor Blockers (Entresto).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Antibiotics, Inhaled (Tobi Podhaler) ST.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Antiemetic Agents (Cannabinoid Derivatives).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Antiobesity Agents.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Antipsychotic Agents.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Beta Adrenergics & Combinations.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Dipeptidyl Peptidase IV (DPP-IV) Inhibitors.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Gastrointestinal (GI) Motility Agents.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Growth Hormones.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Hepatitis C Agents.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Hereditary Angioedema (HAE) Agents.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Immunomodulators (Atopic Dermatitis).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Neuropathic Pain Agents (Lyrica) ST.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Opioid Agents.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Opioid-Benzodiazepine Concurrent Use.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Opioid Dependency Agents.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Pancreatic Enzymes.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Proprotein Convertase Subtilisin Kexin Type-9 (PCSK-9) Inhibitors.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Pulmonary Arterial Hypertension (PAH) Agents.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Sodium Glucose Cotransporter-2 (SGLT-2) Inhibitors.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Stimulants/Kapvay SR (ADHD).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization for Topical Retinoids.* (PDF)

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Maryland Health Choice Preferred Drug List

Download our Maryland Health Choice Preferred Drug List.* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Forms for Glucagon-like peptide-1 (GLP1) Agonists.* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Forms for Dipeptidyl peptidase-4 (DPP4) Inhibitors.* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Growth Hormones.* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Hepatitis C Therapy.* (PDF)

Prior Authorization

Download the Prior Authorization (PA) Form for SGLT-2 Inhibitors.* (PDF)

Download the Maryland Health Choice Prior Authorization for PCSK9 inhibitor drugs.* (PDF)

Download the Maryland Health Choice Prior Authorization (PA) Form for Opioids.* (PDF)

Request to review medications for addition/deletion to the formulary

The Kaiser Permanente Mid-Atlantic State Pharmacy and Therapeutics Committee will consider requests from Kaiser Permanente members, physicians, or pharmacists as well as network-affiliated providers to review medications for addition to, or deletion from, the Health Plan’s drug formulary. You can download a form to submit this request.* (PDF)

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