2019 forms, policies, and resources

Kaiser Permanente Medicare Advantage (HMO) resources

2019 plan documents
Read or download Evidence of Coverage, Annual Notice of Changes, Summary of Benefits documents. .

Forms
Appointment of Representative Form (PDF)
Online Member Appeals Request Form
Medicare Complaints Form
Drug Coverage Determination Form (PDF)

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
Preferred Durable Medical Equipment (DME) List (PDF)
Medicare Star Quality Ratings (PDF)
Kaiser Permanente Washington Medicare Advantage HMO Service Area (PDF)
Health Plans to Help You Thrive: Puget Sound Region (PDF)
Health Plans to Help You Thrive: Northwest Washington Counties (PDF)
Health Plans to Help You Thrive: Spokane County (PDF)

Policies
Medicare Part C Standard and Expedited Reconsiderations (Appeals) Policy (PDF)
Medicare Part C Grievances and Appeals (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)
Request for Redetermination of Medicare Prescription Drug Denial Form & Instructions (PDF)
Online Member Appeals Request Form
Drug Formulary Exception Request Form
Member Reimbursement Form for Prescription Drugs: For Members With Medicare Part D Coverage - for fill date on or after 1/1/2017 (PDF)
Member Reimbursement Form for Prescription Drugs: For Members With Medicare Part D Coverage - for fill date prior to 1/1/2017 (PDF)
Member Reimbursement Form for Prescription Drugs: For Members With Medicare But No 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 Grievances and Appeals (PDF)
Medicare Part D Standard and Expedited Redeterminations (Appeals) 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 Medicare Advantage plan through Kaiser Permanente Washington, call us at 1-800-581-8252 or TTY WA Relay 711, from 8 a.m. to 5 p.m., Monday through Friday.

PEBB and FEHB members can also find information online: