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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
Prior Authorization
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

Prior Authorization Criteria

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization Criteria.* (PDF)

Prior Authorization Forms

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Acthar Gel (Repository Corticotropin Injection).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Anti-epileptic agents.* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for CGRP Inhibitors-Injectable Emgality, Aimovig, Ajovy.* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Dalfampridine (Ampyra).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Emflaza (deflazacort).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Epidiolex (cannabidiol).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Firdapse (amifampridine).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Multiple Sclerosis Highly effective DMTs.* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Multiple Sclerosis Modestly Effective DMTs.* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Ruzurgi (amifampridine).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Tegsedi (inotersen).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Ubrelvy (urbrogepant).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Amitiza (lubiprostone).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Hepatitis C Antivirals.* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Linzess (linaclotide).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Motegrity (prucalopride).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Movantik (naloxegol).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Ocaliva (obeticholic acid).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Relistor (methylnaltrexone).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Symproic (naldemedine).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Trulance (plecanatide).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Viberzi (eluxadoline).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Tremfya, Skyrizi, Taltz, Siliq , Ilumya.* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Actemra (tocilizumab).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Anakinra (Kineret).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for certolizumab (Cimzia).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Cosentyx (secukinumab).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Dupixent (dupilumab).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Enbrel (etanercept).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for golimumab (Simponi).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Ilaris (canakinumab).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Kevzara (sarilumab).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Methotrexate (Rasuvo, Otrexup).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Orencia (abatacept).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Otezla (apremilast).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Rinvoq, Olumiant.* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Stelara (ustekinumab).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Xeljanz (tofacitinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form Humira (adalimubab).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Aranesp (darbepoetin alfa).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Jynarque (tolvaptan).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Retacrit (epoetin alfa-epbx).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Mircera.* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Cayston (aztreonam lysine).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Esbriet (pirfenidone).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Fasenra (benralizumab).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Nucala (mepolizumab).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Ofev (nintedanib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Xolair (omalizumab).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Xyrem (sodium oxybate).* (PDF)

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

Download the HMO/Flexible choice/District of Columbia/Maryland and Virginia (exchange) Prior Authorization (PA) Form for Epinephrine Anaphylaxis Auvi-Q.* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Abiraterone.* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Alecensa (alectinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Ibrance (palbociclib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Imbruvica (ibrutinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Nexavar (sorafenib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Ninlaro (ixazomib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Pomalyst (pomalidomide).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Revlimid (lenalidomide).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Sprycel (dasatinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Tagrisso (osimertinib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Votrient (pazopanib).* (PDF)

Download the HMO, District of Columbia, Maryland and Virginia (exchange) Prior Authorization (PA) Form for Xtandi (enzalutamide).* (PDF)

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Commonwealth of Virginia Medicaid and FAMIS Preferred Drug List

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

Prior Authorization Criteria

Download the Virginia Medicaid-FAMIS Prior Authorization and Step Therapy Criteria.* (PDF)

Prior Authorization Forms

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Abiraterone.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Alecensa (alectinib).* (PDF)

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

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

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Anticonvulsant.* (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 (PA) Form for Ibrance (palbociclib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Imbruvica (ibrutinib).* (PDF)

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

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Nexavar (sorafenib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Ninlaro (ixazomib).* (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 (PA) Form for Pomalyst (pomalidomide).* (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 (PA) Form for Revlimid (lenalidomide).* (PDF)

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

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Sprycel (dasatinib).* (PDF)

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

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Tagrisso (osimertinib).* (PDF)

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

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Votrient (pazopanib).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Xtandi (enzalutamide).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) for AntiMigraine Calcitonin Gene Related Peptide Antagonist.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) for extended release buprenorphine (Sublocade).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Interleukin Inhibitors (Dupixent).* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Multiple Sclerosis (Gilenya) ST.* (PDF)

Download the Virginia Medicaid-FAMIS Prior Authorization (PA) Form for Epinephrine Anaphylaxis Auvi-Q.* (PDF)

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Maryland Health Choice Preferred Drug List

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

Prior Authorization Criteria

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

Prior Authorization Forms

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

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

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

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

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

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

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

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

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

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

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

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

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)

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)

Download the Maryland Health Choice Prior Authorization (PA) Form for Epinephrine Anaphylaxis Auvi-Q.* (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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