Pharmacy

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.

Non-formulary exception process

The non-formulary exception process provides physicians and members with access to non-formulary drugs and facilitates prescription drug coverage of medically necessary, non-formulary drugs as determined by the prescribing practitioner.

Pharmacy policies

If you have questions about prescribing drugs to our members, please download a copy of our pharmacy policies. You will find information that includes:

prescription guidelines
the formulary system
guidelines for prescribing non-formulary drugs

Kaiser Permanente pharmacies

To find Kaiser Permanente pharmacies, please visit our searchable directory.* Now you can search for pharmacies, departments, facilities, and more, all in one place. Just select your area and choose the way you prefer to search. You can even narrow your results to find exactly what you need. Get phone numbers and addresses at a glance.

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