Out of Network Coverage Rules

Our Plan Network

The Provider and Pharmacy Directory lists the providers and pharmacies that are part of Kaiser Permanente's network. You may ask Member Services for more information about our network providers and pharmacies.

Medical Care

You must use plan providers except in emergency or urgent care situations or for out-of-area renal dialysis.

If your primary care provider determines that you need Medicare-required medical care that is not available within our network, your primary care provider will obtain plan authorization for you to see an out-of-network provider. You must have plan authorization prior to seeking care from an out-of-network provider for services to be covered. You will pay the same for authorized out-of-network services as you would pay if you got the care from a network provider. If you obtain routine care from out-of-network providers neither Medicare nor Kaiser Permanente will be responsible for the costs.

Prescription Drugs

If your plan pays for prescription drugs, in most cases, your prescriptions are covered only if they are filled at the plan’s network pharmacies. However, we will reimburse you for Part D drugs purchased from an out-of-network pharmacy if:

  • The prescription is related to care for a medical emergency or for urgently needed care.
  • You become ill or run out of a prescription drug while traveling within the United States and you are outside of the plan's service area with no network pharmacy available to fill your prescription. In this case, you must follow the other coverage rules outlined in the Out of Network Prescription Drug Access Policy (PDF)
  • You are not able to get a covered drug in a timely manner within our service area because there are no network pharmacies within a reasonable driving distance that provide 24-hour service.
  • You are trying to fill a prescription for a covered drug that is not regularly stocked at a network pharmacy or mail-order pharmacy.

If you use an out-of-network pharmacy, you will generally have to pay the full cost, instead of your normal share of the cost, when you fill the prescription. You can ask us to reimburse you for your share of the cost by filling out and submitting the Member Reimbursement Form for Prescription Drugs (PDF) and your receipt.

Usually we do not allow more than a 30-day supply of medicine to be filled by an out-of-network pharmacy, except for unusual circumstances — including federal emergency declarations. Requests are reviewed on a case-by-case basis. Prescription drug claims dispensed at a pharmacy outside the USA are not covered under Medicare Part D.

Questions? Call Us:

Prospective members
(to be directed to a licensed sales specialist)
8 a.m. - 8 p.m., 7 days a week
1-800-446-8882
TTY WA Relay 1-800-833-6388 or 711

Current members
MEMBER SERVICES
8 a.m. - 8 p.m., 7 days a week
1-888-901-4600
TTY WA Relay 1-800-833-6388 or 711