Kaiser Permanente  
             2022 Comprehensive 
             Formulary 
             (List of Covered Drugs) 
             PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE 
             COVER IN THIS PLAN 
              
             This formulary was updated on 12/01/22. For more recent information or other questions, 
             please contact the number for your Kaiser Permanente Region listed below, seven days a 
             week, 8 a.m. to 8 p.m., or visit kp.org/seniorrx.  
              
             Kaiser Permanente Regions 
                                                           
             CALIFORNIA REGIONS                           HAWAII REGION 
             Kaiser Permanente Senior Advantage (HMO)     Kaiser Permanente Senior Advantage (HMO) 
             Member Service Contact Center                Member Services 
             1-800-443-0815 TTY 711                       1-800-805-2739 TTY 711  
             COLORADO REGION                              MID-ATLANTIC STATES REGION 
             Kaiser Permanente Senior Advantage (HMO)     (District of Columbia, Maryland, 
                                                          and Virginia)  
             Member Services                              Kaiser Permanente Medicare Advantage (HMO)  
             1-800-476-2167 TTY 711                       Member Services 
             GEORGIA REGION                               1-888-777-5536 TTY 711  
             Kaiser Permanente Senior Advantage (HMO)     NORTHWEST REGION 
             and Senior Advantage Medicare Medicaid       Kaiser Permanente Senior Advantage (HMO)  
             Plan (HMO D-SNP)                             Member Services 
             Member Services                              1-877-221-8221 TTY 711
             1-800-232-4404 TTY 711     
                                                                        Y0043_N00031421_Final12_C 
                                       HPMS Approved Formulary File Submission 00022483, Version 19 
     Note to existing members: This formulary has changed since last year. Please review this 
     document to make sure that it still contains the drugs you take. 
      
     When this drug list (formulary) refers to “we,” “us,” or “our,” it means Kaiser Permanente. When it 
     refers to “plan” or “our plan,” it means Kaiser Permanente Senior Advantage or Kaiser Permanente 
     Medicare Advantage, depending upon the region in which you are enrolled. 
      
     This document includes a list of the drugs (formulary) for our plan which is current as of  
     December 1, 2022. For an updated formulary, please visit our website at kp.org/seniorrx or call 
     us. Contact information for your Kaiser Permanente Region, along with the date we last updated 
     the formulary, appears on the front and back cover pages. 
      
     You must generally use network pharmacies to use your prescription drug benefit. The formulary 
     and pharmacy network may change at any time. You will receive notice when necessary. 
      
      
      
            What is the Kaiser Permanente                          adding the new generic drug, we may decide 
            Formulary?                                             to keep the brand name drug on our Drug 
                                                                   List, but immediately move it to a different 
            A formulary is a list of covered drugs selected        cost-sharing tier or add new restrictions. If 
            by Kaiser Permanente in consultation with a            you are currently taking that brand name 
            team of health care providers, which                   drug, we may not tell you in advance before 
            represents the prescription therapies believed         we make that change, but we will later 
            to be a necessary part of a quality treatment          provide you with information about the 
            program. Our plan will generally cover the             specific change(s) we have made. 
            drugs listed in our formulary as long as the            
            drug is medically necessary, the prescription             •   If we make such a change, you or your 
            is filled at a Kaiser Permanente network                      prescriber can ask us to make an 
            pharmacy, and other plan rules are followed.                  exception and continue to cover the 
            For more information on how to fill your                      brand name drug for you. The notice 
            prescriptions, please review your Evidence                    we provide you will also include 
            of Coverage.                                                  information on how to request an 
                                                                          exception, and you can find 
            Contact information for your Kaiser                           information in the section below titled 
            Permanente Region, along with the date we                     “How do I request an exception to the 
            last updated the formulary, appears on the                    Kaiser Permanente Formulary?” 
            front and back cover pages.                                    
                                                                   Drugs removed from the market  
            Can the formulary (drug list)                          If the Food and Drug Administration (FDA) 
            change?                                                deems a drug on our formulary to be unsafe 
            Most changes in drug coverage happen on                or the drug’s manufacturer removes the drug 
            January 1, but Kaiser Permanente may add               from the market, we will immediately remove 
            or remove drugs on the Drug List during the            the drug from our formulary and provide 
            year, move them to different cost-sharing              notice to members who take the drug. 
            tiers, or add new restrictions. We must follow         Other changes 
            Medicare rules in making these changes.                 
                                                                   We may make other changes that affect 
            Changes that can affect you this year:                 members currently taking a drug. For 
                                                                   instance, we may add a generic drug that is 
            In the below cases, you will be affected by            not new to market to replace a brand name 
            coverage changes during the year:                      drug currently on the formulary or add new 
                                                                   restrictions to the brand name drug or move it 
            New generic drugs                                      to a different cost-sharing tier or both. Or we 
                                                                   may make changes based on new clinical 
            We may immediately remove a brand name                 guidelines. If we remove drugs from our 
            drug on our Drug List if we are replacing it           formulary, or add prior authorization, or move 
            with a new generic drug that will appear on            a drug to a higher cost-sharing tier, we must 
            the same or lower cost sharing tier and with           notify affected members of the change at 
            the same or fewer restrictions. Also, when             least 30 days before the change becomes 
                                                      Kaiser Permanente 2022 Comprehensive Formulary   •   1 
                                                                                                                   
           effective, or at the time the member requests         How do I use the formulary?  
           a refill of the drug, at which time the member 
           will receive a 30-day supply of the drug.             There are two ways to find your drug within 
                                                                 the formulary: 
               •  If we make other changes, you or your           
                  prescriber can ask us to make an               Medical condition 
                  exception and continue to cover the             
                  brand name drug for you. The notice            The formulary begins on page 6. The drugs in 
                  we provide you will include information        this formulary are grouped into categories 
                  on how to request an exception. You            depending on the type of medical conditions 
                  can find information in the section            that they are used to treat. For example, 
                  below entitled “How do I request an            drugs used to treat a heart condition are listed 
                  exception to the Kaiser Permanente             under the category, “Cardiovascular Drugs”.  
                  Formulary?”                                    If you know what your drug is used for, look 
                                                                 for the category name in the list that begins 
           Changes that will not affect you if you are           on page 8. Then look under the category 
           currently taking the drug.  
                                                                 name for your drug.  
           Generally, if you are taking a drug on our             
           2022 formulary that was covered at the                Alphabetical listing 
           beginning of the year, we will not discontinue 
           or reduce coverage of the drug during the             If you are not sure what category to look 
           2022 coverage year except as described                under, you should look for your drug in the 
           above.  This means these drugs will remain            index that begins on page 70.  The index 
           available at the same cost-sharing and with           provides an alphabetical list of all the drugs 
           no new restrictions for those members taking          included in this document. Preferred generic 
           them for the remainder of the coverage year.          and generic drugs, preferred brand-name and 
           You will not get direct notice this year about        nonpreferred brand-name drugs, specialty-tier 
           changes that do not affect you. However, on           drugs, and injectable vaccines are listed in 
           January 1 of the next year, such changes 
           would affect you, and it is important to check        the index. Look in the index and find your 
           the Drug List for the new benefit year for any        drug. Next to your drug, you will see the page 
           changes to drugs.                                     number where you can find coverage 
                                                                 information. Turn to the page listed in the 
            The enclosed formulary is current as of              index and find the name of your drug in the 
           December 1, 2022. To get updated                      first column of the list. 
           information about the drugs covered by our             
           plan, please call us. Contact information for         What are generic drugs? 
           your Kaiser Permanente Region appears on 
           the front and back cover pages.                       Our plan covers both brand-name drugs and 
           In the event of a midyear                             generic drugs. A generic drug is approved by 
           non-maintenance formulary change,                     the FDA as having the same active ingredient 
           we will provide details in the Medicare               as the brand-name drug. Generally, generic 
           Part D Explanation of Benefits that                   drugs cost less than brand-name drugs. Cost 
           we send you or Provision of Notice                    sharing for preferred generic drugs may be 
           posted at kp.org/seniorrx.                            different than for generic drugs. Please see 
           2  •   Kaiser Permanente 2022 Comprehensive Formulary