2018 Forms, Policies, and Resources

Kaiser Permanente Medicare Advantage (HMO) Resources

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)

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)
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 C and 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 Change Policy (PDF)
Formulary Exception Policy
Drug Utilization Mgmt: Current and Retrospective (PDF)

Learn about group 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, talk to a Medicare sales specialist at 1-800-581-8252 or TTY WA Relay 1-800-833-6388 or 711, from 8 a.m. to 8 p.m., 7 days a week.

PEBB and FEHB members can also find information online: