Our plan usually covers all drugs listed in the formulary if:
We cover both brand-name drugs and generic drugs.
There are 2 ways to find your drug in the formulary:
What you’ll pay for prescriptions depends on:
Please refer to your Evidence of Coverage for details about your Medicare Part D coverage, including your cost-sharing amounts.
If you have an employer-sponsored group plan, your Part D benefits and coverage may be different. Check your group Evidence of Coverage or other plan materials for details. To find out how much you’ll pay for your prescription drugs, you can use Kaiser Permanente’s drug pricing tool. Sign on to your registered account on kp.org, select Coverage & Costs from the menu bar, then select Drug cost to search for drug information, pharmacy pricing, and lower cost options. If you don’t have an account yet, register for a secure account to use the service.
If your drug isn’t on the formulary or there are restrictions, you can:
In certain situations, you may be able to get a temporary supply of the drug. This will give you and your doctor time to change to another drug, or file for an exception. Please refer to your Evidence of Coverage for details.
If you or your doctor asks for an exception, you may give us a doctor’s statement supporting your request. Generally, we must make our decision within 72 hours of getting your request for a coverage decision if we have your doctor’s statement.
If waiting up to 72 hours could be harmful to your health, either you, your Kaiser Permanente doctor, or affiliated doctor can ask for an expedited (fast) exception. If the fast request is approved, we’ll make a decision within 24 hours of receiving your doctor’s supporting statement.
If you can’t get a supporting statement from your doctor, you may ask for a coverage determination, which is a decision we make about whether we’ll cover a Medicare Part D drug and the amount you’ll need to pay.
Please keep in mind:
Please see your Evidence of Coverage for more information about exceptions or coverage determinations, including the appeals process. You can also go to the Grievances, coverage determinations, and appeals section, which includes information on grievances, coverage determinations, and appeals.
In most cases, you must get your prescriptions filled at a Kaiser Permanente preferred cost-sharing pharmacy or through our mail-order pharmacy, which offers lower pricing than a standard cost-sharing pharmacy.
You can find a Kaiser Permanente or affiliated pharmacy in these 3 ways:
You must show your Kaiser Permanente Medicare Advantage (HMO and HMO-POS) ID card and photo ID at a Kaiser Permanente or affiliated pharmacy. You’ll need to pay your share of the cost when you pick up your prescription.
If you don’t have your ID card with you, or if you go to a non-affiliated pharmacy (out-of-network), you may have to pay full price for your medicines.
If this happens, ask us to pay you back for our share of the cost by submitting a claim form. Learn how to submit a claim in your Evidence of Coverage.
This would be considered a non-affiliated or out-of-network pharmacy. Prescriptions filled at an out-of-network pharmacy will only be covered when a Kaiser Permanente or affiliated pharmacy isn’t available in certain situations.
Here are the situations when prescriptions at an out-of-network pharmacy would be covered:
In these situations, you’ll have to pay the full cost when you fill the prescription. You’d then file a claim asking us to pay you back for our share. To learn more about out-of-network pharmacy coverage and find out how to file a paper claim, see your Evidence of Coverage.
Save time by ordering your prescription refills through one of the following ways:
When you order refills by mail, there’s no charge for shipping and your costs could be lower when you order a 3-month supply. Ask your Kaiser Permanente pharmacy, affiliated pharmacy, or our mail-order pharmacy if your prescription is available by mail.
Contact us at least 5 days before you run out of your medicines to make sure your next mail order refill is shipped to you in time. Generally, you should receive them within 3-5 days.
If you can’t wait for your prescription to arrive from our mail order pharmacy, you can get an urgent supply by calling your local Kaiser Permanente or affiliated pharmacy listed in your pharmacy directory located under the Kaiser Permanente and affiliated pharmacies section.
Find more information about our mail order pharmacy* in your Evidence of Coverage.
*Some medications are not eligible for Mail Order Pharmacy. Mail Order Pharmacy can deliver to addresses in MD, VA, DC, and certain locations outside the service area.
Kaiser Permanente provides a Medication Therapy Management (MTM) program for eligible members who have several chronic medical conditions, take different prescription drugs at the same time, and have high drug costs.
The program connects you to specially trained pharmacists who make sure all the medicines you take are necessary, safe, and effective.
The MTM program isn’t a benefit. It’s a voluntary, extra service offered at no cost to members who qualify.
To be eligible, you must be a current Kaiser Permanente member with a Medicare health plan that includes Medicare Part D coverage. You must also be able to say yes to the following three factors.
You have three or more of these health conditions:
If you’re a Kaiser Permanente Medicare Advantage (HMO or HMO-POS) member with limited income and resources, you may qualify for Extra Help, a Medicare program that helps you pay for prescription drugs.
If you’re eligible, Medicare could pay for some or most of your drug costs, including monthly prescription drug premiums, annual deductibles, and coinsurance.
Some people who qualify for Extra Help are automatically enrolled and don’t need to apply. Medicare will mail them a letter to let them know. To find out if you qualify, you can do one of the following:
Here’s what your monthly plan premium will be if you get Extra Help. The premiums listed are for both medical services and prescription drug benefits. This does not include a Medicare Part B premium.
| Medicare Advantage High Option – MD | Medicare Advantage Standard Option – MD | Medicare Advantage Value Option – Balt. and MD | Medicare Advantage Care Plus MD |
| $83.80 | $21 | $0 | $27 |
| Medicare Advantage High Option – VA | Medicare Advantage Standard Option – VA | Medicare Advantage Value Option – VA | Medicare Advantage Care Plus - VA |
| $106.30 | $0.50 | $0 | $7.60 |
| Medicare Advantage High Option – DC | Medicare Advantage Standard Option – DC | Medicare Advantage Value Option – DC |
| $85.20 | $30 | $0 |
$0 deductible
$0 deductible
$1.55 for generics and brands that are treated as generics
$4.60 for brand-name drugs
$4.50 for generics and brands that are treated as generics
$11.20 for brand-name drugs
$0 deductible
$0 deductible
$1.60 for generics and brands that are treated as generics
$4.80 for brand-name drugs
$4.90 for generics and brands that are treated as generics
$12.15 for brand-name drugs
Note: If the amount listed in your Evidence of Coverage Rider for People Who Get Extra Help Paying for Their Prescription Drugs is less than the amount listed above, you’ll pay the lower amount. Please refer to this document for more details.
If you’re eligible for Extra Help, or you believe you’re eligible, and you think you aren’t paying the correct premium or drug costs, you may be able to correct your records by giving us information known as Best Available Evidence (BAE).
Examples of BAE include:
For more information on what qualifies as BAE, or to learn how to submit it to us, please refer to your Evidence of Coverage. You can also call Member Services at 1-888-777-5536 (TTY 711), 8 a.m. to 8 p.m., 7 days a week.
You can also visit the CMS Best Available Evidence page.
Kaiser Permanente has quality assurance measures that are meant to prevent medication errors, harmful drug interactions, and to improve medication use.
Our pharmacy policies and procedures meet state and federal laws and include:
If you have a complaint about your Kaiser Permanente care:
Livanta
BFCC-QIO Program
10820 Guilford Road, Suite 202
Annapolis Junction, MD 20701-1105
Or call the QIO at 1-888-396-4646 (TTY 711).
Kaiser Permanente has requirements, restrictions, or limits on some covered prescription drugs. These are established by a team of doctors and pharmacists to prevent waste, manage member costs, ensure safe and effective drug use, and to comply with FDA and Medicare guidelines. For example, there are limits on opioid prescriptions, such as lower doses and shorter courses, to ensure your prescribed drug is safe, appropriate and medically necessary.
You may need to get preapproval (prior authorization) from us before you fill certain prescriptions. If you don’t get preapproval, we may not cover the drug.
Drugs needing our approval† could be covered under Medicare Part B or Part D, depending on your medical diagnosis. More details from your prescriber might be required to make that decision.
You may need to get an approval for certain Part D drugs if you’re admitted to hospice. Hospice providers can complete this form† if necessary.
For more information, please see the Kaiser Permanente comprehensive formulary.†
Let us know right away if you have questions, concerns, or problems related to your covered services or care by calling Member Services at 1-888-777-5536 (TTY 711), 8 a.m. to 8 p.m., 7 days a week.
A representative will help determine whether your concern should be handled as a grievance, coverage determination, or an appeal. Here’s the difference:
A Member Services representative can help you file a grievance, coverage determination, and/or appeal. You can also refer to your Evidence of Coverage for more information about the process.
You, your appointed representative, your Kaiser Permanente or affiliated doctor, or another prescriber can request a coverage determination. The CMS coverage determination form† makes it easy to provide evidence supporting your request. You don’t have to use the form, but your request must include all the information from the form.
If you appoint a representative to act on your behalf, you both must sign and date a Disclosure Authorization form along with your Medicare Authorized Representative statement, which gives that person legal permission to act as your appointed representative.†
You can ask for a coverage determination in the following ways:
You can appoint a representative to help you. Your representative can be a family member, friend, advocate, attorney, doctor, or someone else who will act on your behalf. Fill out an Appointment of Representative form† and send it in with your appeal.
A standard decision will be made within 72 hours. For exception requests, the timeframe begins when your doctor or other prescriber provides a supporting statement.
An expedited (fast) decision will be made within 24 hours. For exception requests, the timeframe begins when your doctor or other prescriber provides a supporting statement.
An expedited decision will only be allowed if your doctor confirms that waiting 72 hours could seriously harm your health.
If your request for an expedited decision isn’t approved, we’ll make our decision in the standard 72-hour time frame.
If we deny your expedited review by phone and you disagree with our decision, you can ask for a 24-hour expedited grievance at that time. Otherwise, we’ll send a letter within 3 calendar days explaining how to file the expedited grievance. It’ll also explain that we’ll automatically give you an expedited decision if you get the prescribing Kaiser Permanente or affiliated doctor’s support for an expedited review.
If you believe you were incorrectly charged through our coverage determination process, you may submit a reimbursement request. Once we receive it, we’ll respond within 14 calendar days. If approved, payment will be made within 14 calendar days.
To ask questions or to check on the status of a request, call Member Services at 1-888-777-5536 (TTY 711), 8 a.m. to 8 p.m., 7 days a week.
If you disagree with our coverage determination, you have the right to file an appeal called a plan redetermination. You must ask for it within 60 days from the date of our denial notice, unless you can show good cause for the delay.
You can file your request for a plan redetermination in writing by mailing it to the address on your denial notice. An expedited request may also be filed in writing, or by contacting us by telephone or fax at the numbers provided in your coverage determination denial letter.
You can also complete the coverage redetermination form† and fax it to Appeals and Grievances at 1-866-640-9826. Or mail it to the following address:
Kaiser Permanente Member Services
3495 Piedmont Road, NE
Atlanta, GA 30305-1736
You also have the right to give us new information supporting your appeal in writing, by telephone, by fax, or by hand-delivering it to your local Member Services department.
A standard appeal decision will be made within 7 calendar days. For pre-service exception requests, the timeframe begins when your doctor or other prescriber provides a supporting statement, if not provided during the initial review. If our decision is fully in your favor, we must authorize the service within 7 days and/or make the payment within 14 calendar days.
If waiting for a standard decision could seriously harm your health or compromise your ability to regain maximum function, you or your prescribing Kaiser Permanente or affiliated doctor may request an expedited appeal for a decision within 72 hours. For exception requests, the timeframe begins when your doctor or other prescriber provides a supporting statement, if not provided during the initial review. This process doesn’t apply to denied claims for payment.
If you have questions or concerns about services or your care, problems with a particular Medicare Part D drug, or need help getting a representative to handle your coverage determination or appeal, you may submit a complaint online or call Member Services at 1-888-777-5536 or (TTY 711), 8 a.m. to 8 p.m., 7 days a week.
For additional assistance, you can also visit the Member Services department at your local Kaiser Permanente facility.
To send a complaint directly to Medicare, you may use the online Medicare Complaint Form.
You can get a summary of the appeals and grievances other plan members have filed with Kaiser Permanente by calling Member Services.
We encourage anyone to let us know if anything happens at Kaiser Permanente that could be unlawful. If we know about it, we can take action.
If you believe you’ve experienced fraud, or you become aware of fraud, waste, or abuse involving Kaiser Permanente members or resources, please contact Member Services at 1-888-777-5536 (TTY 711), 8 a.m. to 8 p.m., 7 days a week.
You can also contact Medicare for fraud-related questions and concerns at:
1-800-HHS-TIPS (1-800-447-8477)
TTY: 1-800-377-4950
Fax: 1-800-223-8164
Mail:
U.S. Department of Health and Human Services Office of Inspector General
Attn: OIG HOTLINE OPERATIONS
P.O. Box 23489
Washington, DC 20026
For general information about Kaiser Permanente: Please call Member Services at 1-888-777- 5536 or (TTY 711), 8 a.m. to 8 p.m., 7 days a week.
Or you can mail a letter to:
Kaiser Permanente
2101 E. Jefferson St.
Rockville, MD 20852
If you have questions about your medicines: Please talk to your Kaiser Permanente or affiliated doctor, or to someone in your Kaiser Permanente or affiliated pharmacy.
For more information about Medicare prescription drug coverage: Call 1-800-MEDICARE (1-800-633-4227) or (TTY 1-877-486-2048), 24 hours a day, 7 days a week. Or visit the Medicare website.
†You will need the free Adobe Acrobat Reader to read this file. Kaiser Permanente is not responsible for the content or policies of external websites. Details.
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Kaiser Permanente is an HMO and HMO-POS plan with a Medicare contract. Enrollment in Kaiser Permanente depends on contract renewal. You must reside in the Kaiser Permanente Medicare health plan service area in which you enroll.
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Page last updated on December 8, 2024 at 12 a.m. EST
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