2026 Northwest Self-Funded/Level Funded EPO Formulary - Covered Drugs

Sep 6, 2026

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2026 Northwest Self-Funded/Level Funded EPO Formulary provides a structured list of prescription drugs covered under a Kaiser Permanente Self-Funded plan. The document explains how formularies are developed by a Formulary and Therapeutics Committee to select safe, effective medications, and clarifies differences among generic and brand-name drugs. It also describes specialty-tier drugs and the chart layout, including drug naming conventions, tier categories, and common limits such as DS and PA.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages60

Reading Time2 h 31 min

AccessFree to download

What is the Kaiser Permanente Northwest Self-Funded/Level Funded EPO Formulary?

What is a generic drug?

What is a brand-name drug?

What are specialty-tier drugs?

How the formulary chart is organized

Drug naming and listings

Drug tier categories

Requirements and limits (DS, PA)

Drug list examples by category

2026 Northwest Self-Funded/Level Funded EPO Formulary (List of Covered Drugs) Please Read: This document contains information about the drugs we cover when you participate in a Kaiser Permanente Self-Funded plan. What is the Kaiser Permanente Northwest Self-Funded/Level Funded EPO Formulary? A formulary is a list of covered drugs chosen by a group of Kaiser Permanente physicians and pharmacists known as the Formulary and Therapeutics Committee. This committee meets regularly to evaluate and select the safest, most effective medications for our members. What is a generic drug? Our plan covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than brand-name drugs. What is a brand-name drug? Brand-name drugs are manufactured and sold by the pharmaceutical company that originally researched and developed the drug. When the patent on a brand-name drug expires, other pharmaceutical companies may manufacture and sell an FDA-approved generic version of the drug with the same active ingredient(s) at lower prices. What are specialty-tier drugs? Specialty-tier drugs are very high-cost drugs. Kaiser Permanente Formulary The formulary list that begins on page three provides coverage information about some of the drugs covered by our plan. The first column of the chart lists the drug name. A drug is listed alphabetically by its brand and generic names in the therapeutic category and class to which it belongs. The generic name of a brand-name drug is included after the brand name in parentheses and all bold and italicized lowercase letters. If a generic equivalent for a brand-name drug is available, and both the brand-name and generic equivalents are covered, the generic drug will be listed separately from the brand-name drug in all bold and italicized lowercase letters. If a generic drug is marketed under a proprietary, trademark protected brand name, the brand name is listed in all CAPITAL letters after the generic name in parentheses and regular typeface with the first letter of each word capitalized. | EXAMPLES | | | --- | --- | | Brand-name drug | CELONTIN CAPS 300 MG [methsuximide] | | Generic drug | allopurinol tabs 100 mg | | Generic drug marketed with a brand name | [Gentamicin Sulfate (ophth)] GENTAK OINT 0.3 % | The second column will indicate what tier the drug is in. Drugs on our formulary are categorized as Generic, Preferred Brand or Specialty. The third column of the chart will indicate any requirements or limits for that drug. DS = A drug that is limited to no more than a 30-day supply per dispense. PA = A drug that requires specific medical criteria be met and requires approval by the plan prior to being dispensed for benefit. Drug Name Tier Level Requirements/Limits |
ANALGESICS | | | | --- | --- | --- | | NO USP CLASS (COMBINATION PRODUCT) | | | | acetaminophen-codeine tabs 300-15 mg | Generic | | | acetaminophen-codeine tabs 300-30 mg | Generic | | | hydrocodone-acetaminophen soln 7.5-325 mg/15ml | Generic | DS | | hydrocodone-acetaminophen tabs 10-325 mg | Generic | DS | | hydrocodone-acetaminophen tabs 5-325 mg | Generic | DS | | oxycodone-acetaminophen tabs 5-325 mg | Generic | DS | | NONSTEROIDAL ANTI-INFLAMMATORY DRUGS | | | | celecoxib caps 100 mg | Generic | | | celecoxib caps 200 mg | Generic | | | celecoxib caps 400 mg | Generic | | | celecoxib caps 50 mg | Generic | | | etodolac caps 300 mg | Generic | | | etodolac tabs 400 mg | Generic | | | ibuprofen tabs 800 mg | Generic | | | indomethacin caps 25 mg | Generic | | | indomethacin caps 50 mg | Generic | | | indomethacin er cpcr 75 mg | Generic | | | ketorolac tromethamine soln 15 mg/ml | Generic | | | ketorolac tromethamine soln 30 mg/ml | Generic | | | ketorolac tromethamine soln 60 mg/2ml | Generic | | | meloxicam tabs 15 mg | Generic | | | meloxicam tabs 7.5 mg |

FAQs

Who determines which drugs are included in the formulary?

A Kaiser Permanente Formulary and Therapeutics Committee evaluates and selects medications. The committee meets regularly to choose the safest and most effective options for members.

How do generic drugs differ from brand-name drugs in this formulary?

Generic drugs have the same active ingredient(s) as the brand-name drug and are FDA-approved. The document notes that generics generally cost less.

What do DS and PA mean for drugs on the formulary?

DS indicates a drug is limited to no more than a 30-day supply per dispense. PA indicates the drug requires specific medical criteria and approval by the plan before dispensing for benefit.

Sep 6, 2026

Upload by Angel