Pharmacy
Prescription medicine coverage is part of your Choice Products plan. Where you choose to have your outpatient prescription drugs filled will determine how much you pay for your medicines. You have two pharmacy Tiers: Kaiser Permanente Pharmacies and Participating Pharmacies (MedImpact Pharmacies), and Non-Participating Pharmacies. You can choose any pharmacy Tier regardless of the prescribing provider’s tier status.
Kaiser Permanente Pharmacies
You can fill prescriptions (written by any provider) at pharmacies located in Kaiser Permanente medical offices and participating MedImpact pharmacies. You will always pay the lowest out-of-pocket costs at these pharmacies. Choose how to fill your prescriptions:
- At Kaiser Permanente medical offices. Most Kaiser Permanente medical offices across the region have pharmacies. Kaiser Permanente doctors can send most prescriptions electronically to the pharmacy—or you can present your prescription with your ID card.
- Online. Register at kp.org/register to order most refills online and have the medicine mailed to you.
- Through the Refill phone line. Call us at 770-434-2008, 24 hours a day, and have the medicine mailed to you or available for pick up at any medical facility.*
To choose the Kaiser Permanente medical office where you’d like to pick up your prescription, visit kp.org/facilities.
Find out what drugs are covered.
To find out if your prescription medications are on the Plan drug formulary, you can access the Choice Products Formulary (Five Tier Plan Formulary) for a list of approved drugs.
*A program operated or arranged by health plan that distributes prescription drugs to members via mail. Some medications are not eligible for the Mail Service Delivery Program. These may include, but are not limited to, drugs that are time or temperature sensitive, drugs that cannot legally be sent by U.S. mail, and drugs that require professional administration or observation.
Participating Pharmacies (MedImpact Pharmacies)
Prescriptions through participating retail pharmacies.
- You can fill prescriptions (written by any provider) at MedIimpact pharmacies.
- Kaiser Permanente Insurance Company contracts with MedImpact to fill your outpatient prescription drugs at retail pharmacies across the country.
- You can use any of the retail pharmacies nationwide in the MedImpact participating pharmacy network.
You can fill prescriptions at any participating MedImpact pharmacy. Here’s a partial list:
- Rite Aid
- Walgreens
- Kroger
Not all locations in a chain participate; some are independently contracted. To check on a specific pharmacy or for more information, call MedImpact Customer Service at 1-800-788-2949 (TTY 711) at any time or check the MedImpact Participating Pharmacy Directory.
Find out what drugs are covered.
- To find out if your prescription medications are on the Plan drug formulary, you can access the Choice Products Formulary (Five Tier Plan Formulary) for a list of approved drugs.
Submit Pharmacy Claims to:
MedImpact Healthcare Systems, Inc.
P.O. Box 509098
San Diego, CA 92150-9098
Expected pharmacy review turnaround times for prescriptions that require prior authorization:
Urgent Requests: 24 hours
Standard Requests: 48 hours
What if my pharmacy claim is denied?
If we have denied coverage for certain prescription drugs, in whole or in part, then you may request that we review this decision, also referred to as an “adverse benefit determination.”
You, or a representative whom you formally appoint in writing, have the right to appeal our decision by asking that we review it. To appeal the decision, please send your request for review in writing, to:
KPIC Pharmacy Administrator
Grievance & Appeals Coordinator
10181 Scripps Gateway Court
San Diego, CA 92131
(800) 788-2949
Or you can fax the letter to (858) 790-6060, Attn: KPIC Pharmacy Administrator Grievance and Appeals Coordinator.
In your request, please include:
(1) your name and, your medical record number
(2) your medical condition or symptom
(3) the specific prescription drug or supply that you are requesting, and
(4) the specific reason(s) for your request that we review our initial decision.
We must receive your request within 180 days of your receiving the notice of our adverse benefit determination. Please note that we will count the 180 days starting 5 business days from the date of the notice to allow for mail delivery time, unless you can prove that you received the notice after that 5 business day period.
A decision about your appeal will be made within 30 days of receipt of your request for review at each level unless we inform you otherwise in advance.
If you disagree with our decision on your first level appeal, your first level appeal adverse decision notice will tell you how to submit a second level appeal.
Appointment of a Representative
If you would like to have someone act on your behalf during our review, you may appoint an authorized representative. You must make this appointment in writing. Please send the name, address and telephone contact information to KPIC Pharmacy Administrator Grievance and Appeals Coordinator at the address set forth above.
If you want to review the information that we have collected regarding your claim for this service, you may request, and we will provide without charge, copies of all relevant documents, records, and other information.
You may send us additional information including comments, documents, or additional medical records which you believe supports your claim. If we had asked for additional information before and you did not provide it, we would still like to have that additional information for our review. Please send all your additional information to:
KPIC Pharmacy Administrator
Grievance & Appeals Coordinator
10181 Scripps Gateway Court
San Diego, CA 92131
(800) 788-2949
Or you can fax the letter to (858) 790-6060 Attn: KPIC Pharmacy Administrator Grievance and Appeals Coordinator
In addition, you may give testimony in writing or by telephone. Please send your written testimony to KPIC Pharmacy Administrator Grievance and Appeals Coordinator at the address set forth above. To arrange to give testimony by telephone, you should contact KPIC Pharmacy Administrator Grievance & Appeals Coordinator at the telephone number above. We will add all of the new information to your claim file and we will review it without regard to whether this information was submitted and/or considered in our initial decision.
We will share any additional information that we collect in the course of our review by sending it to you in advance of our decision. If we believe on review that your request should not be granted, before we issue our final decision, we will also share with you in writing any new or additional reasons for that decision. We will send you a letter explaining the new or additional information and/or reasons. Our notices will tell you how you can respond to the information provided if you choose to do so. If you do not respond before we must make our final decision, that decision will be based on the information already in your claim file.
Should you have any questions regarding your appeal rights, please contact KPIC Pharmacy Administrator Grievance and Appeals Coordinator at (800) 788-2949.
Non-Participating Pharmacies
Fill your prescription (written by any provider) at any pharmacy.
- You will pay full out-of-pocket costs for prescriptions filled at Non-Participating pharmacies and then submit the Drug Reimbursement Form for reimbursement.
Find out what drugs are covered.
- To find out if your prescription medications are on the Plan drug formulary, you can access the Choice Products Formulary (Five Tier Plan Formulary) for a list of approved drugs.
What if my pharmacy claim is denied?
If we have denied coverage for certain prescription drugs, in whole or in part, then you may request that we review this decision, also referred to as an “adverse benefit determination.”
You, or a representative whom you formally appoint in writing, have the right to appeal our decision by asking that we review it. To appeal the decision, please send your request for review in writing, to:
KPIC Pharmacy Administrator
Grievance & Appeals Coordinator
10181 Scripps Gateway Court
San Diego, CA 92131
(800) 788-2949
Or you can fax the letter to (858) 790-6060, Attn: KPIC Pharmacy Administrator Grievance and Appeals Coordinator.
In your request, please include:
(1) your name and, your medical record number
(2) your medical condition or symptom
(3) the specific prescription drug or supply that you are requesting, and
(4) the specific reason(s) for your request that we review our initial decision.
We must receive your request within 180 days of your receiving the notice of our adverse benefit determination. Please note that we will count the 180 days starting 5 business days from the date of the notice to allow for mail delivery time, unless you can prove that you received the notice after that 5 business day period.
A decision about your appeal will be made within 30 days of receipt of your request for review at each level unless we inform you otherwise in advance.
If you disagree with our decision on your first level appeal, your first level appeal adverse decision notice will tell you how to submit a second level appeal.
Appointment of a Representative
If you would like to have someone act on your behalf during our review, you may appoint an authorized representative. You must make this appointment in writing. Please send the name, address and telephone contact information to KPIC Pharmacy Administrator Grievance and Appeals Coordinator at the address set forth above.
If you want to review the information that we have collected regarding your claim for this service, you may request, and we will provide without charge, copies of all relevant documents, records, and other information.
You may send us additional information including comments, documents, or additional medical records which you believe supports your claim. If we had asked for additional information before and you did not provide it, we would still like to have that additional information for our review. Please send all your additional information to:
KPIC Pharmacy Administrator
Grievance & Appeals Coordinator
10181 Scripps Gateway Court
San Diego, CA 92131
(800) 788-2949
Or you can fax the letter to (858) 790-6060 Attn: KPIC Pharmacy Administrator Grievance and Appeals Coordinator
In addition, you may give testimony in writing or by telephone. Please send your written testimony to KPIC Pharmacy Administrator Grievance and Appeals Coordinator at the address set forth above. To arrange to give testimony by telephone, you should contact KPIC Pharmacy Administrator Grievance & Appeals Coordinator at the telephone number above. We will add all of the new information to your claim file and we will review it without regard to whether this information was submitted and/or considered in our initial decision.
We will share any additional information that we collect in the course of our review by sending it to you in advance of our decision. If we believe on review that your request should not be granted, before we issue our final decision, we will also share with you in writing any new or additional reasons for that decision. We will send you a letter explaining the new or additional information and/or reasons. Our notices will tell you how you can respond to the information provided if you choose to do so. If you do not respond before we must make our final decision, that decision will be based on the information already in your claim file.
Should you have any questions regarding your appeal rights, please contact KPIC Pharmacy Administrator Grievance and Appeals Coordinator at (800) 788-2949.
Prescription Drugs Copayment Coupons
For outpatient prescription drugs and/or items that are covered under the Outpatient Prescription Drug section and obtained at a pharmacy owned and operated by Kaiser Foundation Health Plan, you may be able to use approved manufacturer coupons, after you satisfy your Plan’s required deductible, as a form of payment for the prescription Cost Sharing that you owe, as allowed under Kaiser Permanente’s coupon program. You will owe any additional amount if the coupon does not cover the entire amount of Your Cost Sharing for Your prescription. When you use an approved copay coupon for payment of Your Cost Sharing, the coupon amount and any additional payment that you make will accumulate to Your Out-of-Pocket Maximum. Certain health plan coverages are not eligible for coupons. [You can get more information regarding the Kaiser Permanente copay coupon program rules and limitations at www.kp.org/rxcoupons.
How to save money on prescriptions.
- You can fill prescriptions you get from Out-of-Network Providers at Kaiser Permanente medical offices, where you’ll usually pay the lowest copay.
- Just bring your prescription and your ID card to the medical office. To find medical offices, go to kp.org/facilities.
- If you are registered at kp.org, you’ll be able to order refills online or by phone and have them delivered, with no cost for postage (applies to most drugs).
- If you present a prescription for a drug that is not on the Kaiser Permanente formulary, the Kaiser Permanente pharmacist will likely check with the prescribing physician to determine if a therapeutic equivalent from the Kaiser Permanente formulary can be substituted.
- Information will become part of your Kaiser Permanente medical record, for better coordinated care.