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

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 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 an expedited 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 the formulary drugs have caused you adverse effects.
  • To check the status of your exception request, please contact Member Services.

Fax number
206-630-7923 or 1-866-510-1765

Mailing address
Kaiser Foundation Health Plan of Washington
Pharmacy Drug Benefit Help Desk
P.O. Box 34990
Renton, WA 98123-1990

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 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
206-630-7923 or 1-866-510-1765

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

Phone
206-901-4196 or 1-888-301-1915

Also see: 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 of the denial, reduction, or discontinuation of coverage notice.

Either you, an authorized representative (see details below), or the prescribing physician may request a standard appeal or an expedited appeal. The appeal should include member name, address, member ID number, reasons for requesting an exception, and any evidence you wish to attach.

You can request a standard appeal or redetermination by fax, mail, or online:

Fax
206-630-1859

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

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

You, an authorized representative, or the prescribing physician can request an expedited appeal or redetermination by calling the Kaiser Permanente Appeals Department at 206-901-7359 or 1-866-458-5479. Your request will be expedited if a physician confirms that your life or health will be seriously jeopardized by waiting for a standard decision.

Once Kaiser Permanente receives your request for an appeal, we will notify you about our decision within:

  • 7 days for a standard request for coverage
  • 14 days for a reimbursement
  • 72 hours for an expedited request for coverage

For information on the status of your appeal redetermination request, please call the Kaiser Permanente Appeals Department at 206-901-7359 or 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, call Kaiser Permanente Member Services at 1-888-901-4600 (TTY 711), 8 a.m. to 8 p.m., 7 days a week, or send a fax to 206-630-1859.

You can also contact us by mail:

Kaiser Foundation Health Plan of Washington
Member Services
P.O. Box 34593
Seattle, WA 98124-1593

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 if you have a complaint about a refusal to grant a request for an expedited coverage decision and you have not yet purchased or received the drug in question.

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 it along with other supporting documentation.

2022 Evidence of Coverage (EOC) documents

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 health 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

Call 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
1-800-446-8882 (TTY 711)
8 a.m. to 8 p.m., 7 days a week

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

Medicare Star Quality Ratings

Kaiser Permanente Medicare Advantage (HMO) health plan is rated 5 out of 5 Stars in Washington for 2022. The Medicare Star Rating is based on quality, service, and member satisfaction. Our high rating means you can have peace of mind knowing that you're getting high-quality care and coverage — all in a single plan at a great value.1

NCQA Quality Rating

Kaiser Permanente Washington Medicare Advantage (HMO) plan was rated 4.5 out of 5 in the National Committee for Quality Assurance (NCQA) Medicare Health Plan Ratings 2021.3