Part D drug formulary: Exceptions, appeals, and grievances

Exceptions to the formulary

You can ask us to cover a non-formulary drug; or to waive coverage restrictions or limits on a drug. For example, for certain drugs, Kaiser Foundation Health Plan of Washington limits the amount of the drug that we will cover. If the prescribed drug has a quantity limit, you can ask us to waive the limit and cover more.

A formulary exception may be requested by you, your appointed representative (see details below), or the prescribing physician. A request can be submitted by phone, fax, mail, or online.

Kaiser Permanente will have 72 hours for a standard request to notify you of our decision. If you or your prescriber believe that waiting 72 hours for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision using the Request for Medicare Prescription Drug Coverage Determination (PDF). If your prescriber indicates that waiting 72 hours could seriously harm your health, we will automatically give you a decision within 24 hours. If you do not obtain your prescriber's support for an expedited request, we will decide if your case requires a fast decision. You cannot request an expedited coverage determination if you are asking us to pay you back for a drug you already received.

Requesting an exception (members)

Online
You can fill out a form online, but to protect the security of personal information, you must sign in to the Kaiser Permanente member website.

Drug formulary exception request form

By mail or fax

  • Download and print the Request for Medicare prescription drug coverage determination (PDF), or call Member Services and request that the form be sent to you. Also see: Form Instructions (PDF)
  • Complete the entire form and submit either by fax or mail.
  • Your physician must submit a statement that none of the drugs used to treat your condition in Kaiser Permanente's formulary would be as effective, and/or that all of the formulary drugs have caused you adverse effects.
  • To check the status of your exception request, please contact Member Services.

Fax number
1-866-510-1765 (toll-free fax)
206-630-7923 (fax)

Mailing address
Kaiser Foundation Health Plan of Washington
Pharmacy Drug Benefit Help Desk
P.O. Box 34990
Seattle, WA 98124-1990

For coverage requests after an initial denial, you will need to use this form:
Request for Redetermination of Medicare Prescription Drug Denial (PDF)

Requesting an exception (physicians)

  • Download and print the Request for Medicare prescription drug coverage determination (PDF). Also see: Form Instructions (PDF) Or provide a statement that none of the drugs used to treat your patient's condition in Kaiser Permanente's formularies would be as effective, and/or that all of the formulary drugs have caused adverse effects for your patient.
  • Submit all materials either by fax or mail.
  • To check the status of your exception request, please contact the Kaiser Permanente Pharmacy Solution Center at the number below.

Fax number
206-901-4617
1-866-510-1765 (toll-free)

Mailing address
Kaiser Foundation Health Plan of Washington
Pharmacy Solution Center
P.O. Box 34589
Seattle, WA 98124-1589

Phone
206-901-4196, 1-888-301-1915 (toll-free)

See also: Formulary exception policy as described above.

For coverage requests after an initial denial, use this form: Request for Redetermination of Medicare Prescription Drug Denial (PDF)

How to request an appeal/redetermination

If Kaiser Permanente denies a request for coverage of a drug, you have the right to request an appeal. You must request this appeal within 60 days from the date notice of the denial, reduction or discontinuation of coverage.

An appeal may be requested by a patient or an authorized representative (see details below) and the prescribing physician. Please include: Member name, address, member ID number, reasons for requesting an exception, and any evidence you wish to attach. A request for an appeal redetermination may be submitted by fax or mail.

Online
Alternatively, you can fill out a form online, but to protect the security of personal information, you must sign in to the Kaiser Permanente member website.

Online Member Appeals Request form

Fax
206-901-7340

Mail
Kaiser Foundation Health Plan of Washington
Kaiser Permanente Member Appeals Department
Attn.: Appeals Coordinator
P.O. Box 34593
Seattle, WA 98124-1593

Once Kaiser Permanente receives the request for an appeal, we have 7 days (for a standard request for coverage or for a request to pay the member back) or 72 hours (for an expedited request for coverage) to notify the member of our decision. The member's request will be expedited if a physician confirms that your life or health will be seriously jeopardized by waiting for a standard decision.

For information on the status of your appeal redetermination request, please contact the Kaiser Permanente Appeals Department at 206-901-7359 or toll-free 1-866-458-5479.

Filing a grievance

A grievance is any complaint or dispute regarding an organization's or a provider's operations, activities, or behavior. Grievances do not include denial or discontinuation of health care services, or denial of claims.

Examples or possible subjects of grievances:

  • Complaints concerning the quality of care or services provided (not related to payment or coverage)
  • Interpersonal aspects of care, such as rudeness by a provider or staff member
  • Failure to respect a patient's rights
  • Complaints regarding copays
  • Membership, enrollment, or premium issues

To file a grievance, contact Kaiser Permanente Member Services at or TTY WA Relay 1-888-901-4600 toll free or TTY WA Relay 711, or send a fax to 206-901-6205. Hours are 8 a.m. to 8 p.m., 7 days a week.

You can also contact us by mail:

Kaiser Foundation Health Plan of Washington
Member Services
P.O. Box 34590
Seattle, WA 98124-1590

Grievances must be filed no later than 60 days after the incident in question.

Kaiser Permanente will review the complaint and respond as quickly as the case requires, but no later than 30 days after the grievance is received. A 14-day extension is allowed if you request it, or if Kaiser Permanente needs time to gather more information and can show that the delay is in your interest. Kaiser Permanente must notify you of the delay in writing.

Kaiser Permanente will respond within 24 hours to these types of grievances:

  • Complaint about Kaiser Permanente's refusal to grant a request for an expedited coverage decision and you have not yet purchased or received the drug in question.
  • Complaint involving Kaiser Permanente's decision to extend the deadline (up to 14 days) to respond to a grievance.

Authorized representatives

You can ask anyone you want to help you with your Medicare prescription drug plan. If this person agrees to help you in this way, she or he is your authorized representative. Your authorized representative can be someone appointed to make decisions for you, such as a guardian or health care proxy, or attorney-in-fact.

If someone else will be filing a grievance or requesting an exception or an appeal on your behalf, please complete the following form and submit along with other supporting documentation.

2019 evidence of coverage documents (EOCs)

For complete information on grievance, coverage determination (including exceptions), and appeals processes, you can refer to your Evidence of Coverage.

Read or download the Evidence of Coverage for your plan.

Medicare complaint form

Use this electronic form if you wish to file a complaint directly with Medicare, instead of with Kaiser Permanente. You can also contact 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week, for assistance with complaints, grievances and information requests.

For more information

Please contact Member Services at 1-888-901-4600 (TTY 711), 8 a.m. to 8 p.m., 7 days a week

You can also refer to your Evidence of Coverage (EOC).

If you have questions about the process, or about the status of your exception request, grievance or appeal, please call Member Services. Providers may call the Provider Assistance Unit at 509-241-7206.

To obtain information on the aggregate number of grievances, appeals, and exceptions filed with us, contact Member Services at the numbers above.

Also see: Medicare Advantage Part D drug formulary

Call Member Services

Questions? Call us

Prospective members
8 a.m. to 8 p.m., 7 days a week
1-800-446-8882
TTY WA Relay 711

Current members
MEMBER SERVICES
8 a.m. to 8 p.m., 7 days a week
1-888-901-4600
TTY WA Relay 711

Medicare Star Quality Ratings

Our Medicare Advantage health plan in Washington was rated 4.5 out of 5 stars for 2019. Our 4.5 out of 5 star rating is based on quality, service, and member satisfaction, so you get the peace of mind that comes with knowing you're getting high-quality care. 1

NCQA quality rating

Kaiser Permanente Washington Medicare Advantage (HMO) plan was rated 5 out of 5 in the National Committee for Quality Assurance (NCQA) Medicare Health Insurance Plan Ratings 2017-2018.2