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We offer Medicare Advantage (HMO) health plans in different areas of Washington state.
Medicare Advantage HMO Service Area (PDF)

2021 forms, policies, and resources

Kaiser Permanente Medicare Advantage (HMO) resources

2021 plan documents
Read or download 2021 Evidence of Coverage, Annual Notice of Changes, Summary of Benefits documents. .

Forms
Appointment of Representative Form (PDF)
Medicare Advantage Disenrollment Form (PDF)
Medicare Complaints Form
Member Reimbursement Form (PDF)
Online Member Appeals Request Form
Also see: Medical claim reimbursement process

Plan Information
Disenrollment Rights and Responsibilities
Medicare National Coverage Determinations (NCD)
Out of Network Coverage Rules
Part C Medical Care (Organization Determinations, Appeals, Grievances)
Multi Language Interpreter Services (PDF)
Privacy Notice (PDF)
Preferred Durable Medical Equipment (DME) List (PDF)
Medicare Star Quality Ratings (PDF)
Kaiser Permanente Washington Medicare Advantage HMO Service Area (PDF)

Supplemental benefits information
Optional Dental Benefits Flyer (PDF)
Routine Transportation Flyer (PDF)
Silver&Fit®1 Flyer (PDF)

Policies
Medicare Part C Standard and Expedited Reconsiderations (Appeals) Policy (PDF)
Medicare Part D Standard and Expedited Redeterminations (Appeals) Policy (PDF)
Medicare Part C and D Grievance Policy (PDF)
How to Obtain Information on Grievances, Appeals, and Exceptions
CMS Best Available Evidence Guidelines

Pharmacy Resources

Forms
Prescription Transfer Form (PDF)
Request for Prescription Information or Change (PDF)
Request for Medicare Prescription Drug Coverage Determination Form & Instructions (PDF)
Online Member Appeals Request Form
Drug Formulary Exception Request Form
Member Reimbursement Form for Prescription Drugs: For Members With Medicare But No Part D Coverage (PDF)
Member Reimbursement Form for Prescription Drugs for Members with Medicare With Part D Coverage (PDF)
Also see: Prescription drug reimbursement process

Plan Information
Part D Drug Formulary: Exceptions, Appeals, and Grievances
HMO Low Income Document (PDF)
Prior Authorization Drug List (PDF)
Step Therapy Requirements (PDF)

Policies Medicare Part D Grievance Policy (PDF)
Prescription Drug Transition Policy
Medication Therapy Management (MTM) Program Policy
Medicare Standard Appeals (PDF)
Out-of-Network Prescription Drug Access Policy (PDF)
Formulary Exception Policy

Learn about Medicare plans for group, state, and federal employees
If you are becoming eligible for Medicare and your employer offers a group retiree Medicare Advantage health plan through Kaiser Permanente Washington, call us at 1-800-581-8252 or TTY 711, from 8 a.m. to 5 p.m., Monday through Friday.

FEHB and PEBB members can also find information online: