Injectable drugs requiring prior authorization

Kaiser Permanente requires prior authorization of certain injectable medications administered in the office or home infusion setting. These reviews ensure that benefits are adjudicated and that use is in line with Pharmacy & Therapeutics Committee criteria.

Pre-service Medicare routine reviews are processed within 72 hours. You may request an expedited review by clearly stating your request on your fax cover sheet and calling Review Services. Expedited requests are processed within 24 hours.

Non-Medicare reviews are processed within 5 calendar days. If Kaiser Permanente contacts the provider for additional information, please respond within 5 calendar days. If the supporting statement is sufficient, we will render our decision and provide notification within 4 calendar days of receipt of your statement. Expedited requests will be processed within 2 calendar days. If Kaiser Permanente contacts the provider for additional information for an expedited request, please respond within 2 calendar days.

Non-Medicare Electronic Prior Authorization (EPA) reviews are processed within 3 calendar days. If Kaiser Permanente contacts the provider for additional information, please respond within 5 calendar days. If the supporting statement is sufficient, we will render our decision and provide notification within 4 calendar days of receipt of your statement. Expedited requests will be processed within 1 calendar days. If Kaiser Permanente contacts the provider for additional information for an expedited request, please respond within 2 calendar days.

Review current lists of injectable drugs requiring prior authorization:

• Non-Medicare drug list (PDF)
• Medicare Advantage drug list (PDF)
• Medicare Part B step therapy (PDF)

Kaiser Permanente requires site of care prior authorization for select injectable drugs that are given under the medical benefit. All new requests for the select specialty medicines require a medical necessity and a Site of Care review. Site of care restriction does NOT apply to Medicare or patients under 13 years old.

• Infusion Site of Care Policy (PDF)

Kaiser Foundation Health Plan of Washington (Kaiser Permanente) requires Site of Service prior authorization for HMO coverage of select injectable drugs that are given under the medical benefit. The drugs included in this policy are mostly high cost and/or complex specialty medicines.

• Infusion Site of Service Policy (PDF)