Our Regional Formulary and Therapeutics Committee is made up of Participating Physicians, other Participating Providers, pharmacists, and administrative staff. The committee chooses drugs for the Formulary based on several factors, including safety and effectiveness as determined from a review of the scientific literature. They may not approve a drug if there is not enough scientific evidence that it is clinically effective. They may also exclude a drug if it does not have a clinical or cost advantage over comparable Formulary drugs. The Regional Formulary and Therapeutics Committee meets to review new drugs and reconsider drugs currently on the market. After this review, they may add drugs to the Formulary or remove drugs from it. If a drug is removed from the Formulary, you will need to switch to another comparable drug that is on the drug Formulary, unless your old drug meets exception criteria. Refer to the “Drug Formulary exception process.” When a drug is removed from the Formulary, we will notify Members who filled a prescription for the drug at a Participating Pharmacy within the prior three months. If a Formulary change affects a prescription drug you are taking, we encourage you to discuss any questions or concerns with your Participating Provider or another member of your health care team. Drugs on our Formulary may move to a different drug tier during the Year. For example, a drug could move from the Non-Preferred Brand-Name Drug list to the Preferred Brand-Name Drug list. If we move a drug you are taking to a different drug tier, this could change the Cost Share amount you pay for that drug. To see if a drug or supply is on our drug Formulary, or to find out what drug tier the drug is in, go online to kp.org/formulary. You may also call our Formulary Application Services Team (FAST) at 503-261-7900 or toll free at 1-888-572-7231. If you would like a copy of our drug Formulary or additional information about the Formulary process, please call Member Services. The presence of a drug on our drug Formulary does not necessarily mean that your Participating Provider will prescribe it for a particular medical condition. Prior Authorization and Step Therapy Prescribing Criteria Prior authorization is required when you are prescribed certain drugs or supplies before they can be covered. A Participating Provider may request prior authorization if they determine that the drug or supply is Medically Necessary. Prescribing Participating Providers must supply to Kaiser the medical information necessary for Kaiser to make the prior authorization determination. Coverage for a prescribed drug or supply that is approved for prior authorization begins on the date Kaiser approves the request. A list of those drugs and supplies that require prior authorization and the Utilization Review criteria we use are available online at kp.org/formulary or you may contact Member Services. We apply step therapy prescribing criteria, developed by Medical Group and approved by Kaiser, to certain drugs and supplies. The step therapy prescribing criteria require that you try a therapeutically similar drug (step 1) for a specified length of time before we will cover another drug (step 2) prescribed for the same condition. A list of drugs and supplies subject to step therapy prescribing criteria, and the requirements for moving to the next step drug, is available online at kp.org/formulary or you may contact Member Services. Prior Authorization Exception Process We have a process for you or your prescribing Participating Provider to request a review of a prior authorization determination that a drug or supply is not covered. This exception process is not available for drugs and supplies that the law does not require to bear the legend “Rx only.” Your prescribing Participating Provider may request an exception if they determine that the drug or supply is Medically Necessary. Prescribing Participating Providers must supply to the Participating Pharmacy the medical information necessary to review the request for exception. A coverage determination will be made within 72 hours of receipt for standard requests and within 24 hours of receipt for expedited requests. A request may be expedited if you are experiencing a health condition that may seriously jeopardize your life, EWCLGDED1983ACT0124 60 WAPEBB-CL-ACT