Kaiser prescription insurance

Kaiser prescription insurance DEFAULT

Pharmacy

Prescriptions through MedImpact pharmacies.

  • You can fill prescriptions (written by any licensed provider) at MedImpact pharmacies.
  • Kaiser Permanente Insurance Company contracts with MedImpact to fill your outpatient prescription drugs at retail pharmacies across the country.
  • You can use any of the retail pharmacies nationwide in the MedImpact participating pharmacy network.

You can fill prescriptions at over 60,000 participating MedImpact pharmacies. Here’s a partial list: Walgreens, CVS, Rite Aid, Ralphs, Safeway, and Costco, plus hundreds of independent pharmacies nationwide.

Not all locations in a chain participate; some are independently contracted. To check on a specific pharmacy or for more information, call MedImpact Customer Service at 1-800-788-2949 (TTY 711) at any time or check the POS Pharmacy Locator Tool.

Prior Authorizationof Outpatient Prescription Drugs (for certain drugs, step therapies, age, and quantity limits for MedImpact Pharmacies):

Members will need to get prior authorization for certain outpatient prescription drugs. We’ve partnered with MedImpact to help ensure that outpatient prescription drugs ordered by your doctor are medically necessary, cost-effective, and the most appropriate treatment for your condition. MedImpact will facilitate the prior authorization process with the physician. MedImpact can be reached at 1-800-788-2949 (TTY 711), Monday through Friday, 7 a.m. to 5 p.m., Pacific time.

Find out what drugs are covered.

To find out if your prescription medications are on the Plan drug formulary, click the link below that applies to your coverage.

To determine which formulary applies to your plan, refer to your Certificate of Insurance (COI) or call Customer Service for assistance at 1-800-788-0710(TTY 711), Monday through Friday, 7 a.m. to 7 p.m., Pacific time.

Formulary with Specialty Drug Tier – MedImpact pharmacy (Non-grandfathered)

Standard Formulary – MedImpact pharmacy (Grandfathered)

Click here for the Pharmacy Claim form

Pharmacy Claims Address:
MedImpact Healthcare Systems, Inc.
PO Box 509098
San Diego, CA 92150-9098

For more information, refer to your Certificate of Insurance(COI) or call Customer Service for assistance at 1-800-788-0710(TTY 711), Monday through Friday, 7 a.m. to 7 p.m., Pacific time.

What if my pharmacy claim was denied?

If we have denied coverage for certain prescription drugs, in whole or in part, then you may request that we review this decision, also referred to as an “adverse benefit determination.” You, or a representative whom you formally appoint in writing, have the right to appeal our decision by asking that we review it.  To appeal the decision, please send your request for review in writing, to:

KPIC Pharmacy Administrator
Grievance & Appeals Coordinator  
10181 Scripps Gateway Court 
San Diego, CA 92131
(800) 788-2949

Or you can fax the letter to (858) 790-6060, Attn: KPIC Pharmacy Administrator Grievance and Appeals Coordinator.

In your request, please include:

(1) your name and, your medical record number
(2) your medical condition or symptom
(3) the specific prescription drug or supply that you are requesting, and
(4) the specific reason(s) for your request that we review our initial decision.

We must receive your request within 180 days of your receiving the notice of our adverse benefit determination.  Please note that we will count the 180 days starting 5 business days from the date of the notice to allow for mail delivery time, unless you can prove that you received the notice after that 5 business day period.

A decision about your appeal will be made within 30 days of receipt of your request for review at each level unless we inform you otherwise in advance.

If you disagree with our decision on your first level appeal, your first level appeal adverse decision notice will tell you how to submit a second level appeal.

Appointment of a Representative

If you would like to have someone act on your behalf during our review, you may appoint an authorized representative.  You must make this appointment in writing.  Please send the name, address and telephone contact information to KPIC Pharmacy Administrator Grievance and Appeals Coordinator at the address set forth above.

If you want to review the information that we have collected regarding your claim for this service, you may request, and we will provide without charge, copies of all relevant documents, records, and other information.

You may send us additional information including comments, documents, or additional medical records which you believe supports your claim.  If we had asked for additional information before and you did not provide it, we would still like to have that additional information for our review.  Please send all your additional information to:

KPIC Pharmacy Administrator
Grievance & Appeals Coordinator
10181 Scripps Gateway Court 
San Diego, CA 92131
(800) 788-2949

Or you can fax the letter to (858) 790-6060 Attn: KPIC Pharmacy Administrator Grievance and Appeals Coordinator

In addition, you may give testimony in writing or by telephone.  Please send your written testimony to KPIC Pharmacy Administrator Grievance and Appeals Coordinator at the address set forth above.  To arrange to give testimony by telephone, you should contact KPIC Pharmacy Administrator Grievance & Appeals Coordinator at the telephone number above. We will add all of the new information to your claim file and we will review it without regard to whether this information was submitted and/or considered in our initial decision.

We will share any additional information that we collect in the course of our review by sending it to you in advance of our decision.   If we believe on review that your request should not be granted, before we issue our final decision, we will also share with you in writing any new or additional reasons for that decision.  We will send you a letter explaining the new or additional information and/or reasons.  Our notices will tell you how you can respond to the information provided if you choose to do so.  If you do not respond before we must make our final decision, that decision will be based on the information already in your claim file.

Should you have any questions regarding your appeal rights, please contact KPIC Pharmacy Administrator Grievance and Appeals Coordinator at (800) 788-2949.

Sours: https://choiceproducts-california.kaiserpermanente.org/point-of-service/member-information/pharmacy/

Reducing Medication Costs

Topic Overview

Some health plans have their own pharmacies for their members. If you belong to one of those health plans, some of the advice in this topic may not apply to you.

How can you lower your medicine costs?

Trying to make some changes in your lifestyle might help reduce your need for medicines. Many chronic illnesses, including diabetes, high blood pressure, and low back pain, require fewer medicines if you can increase your activity level, lose weight, and improve your diet. Also, counseling, support groups, and other therapies may help with illnesses such as depression.

How can you save money on prescriptions?

Generic medicines are less expensive copies of brand-name medicines. Ask your doctor or pharmacist if you can take a generic equivalent for the brand-name medicine that you take now. Generic equivalents are made according to the same strict U.S. Food and Drug Administration (FDA) standards as brand-name drugs. So generics have the same quality, strength, purity, and stability as their more expensive brand names.

Unfortunately, generic equivalents are not available for every brand-name medicine. If there is not an equivalent, ask your doctor if there is a similar medicine in the same class that may be less expensive or that has a generic equivalent.

Shop around for the best deal on medicines. The retail cost can vary widely from pharmacy to pharmacy. Some pharmacies match the price that other pharmacies charge. Finding a good deal is important, but be sure that your pharmacist (or pharmacists) knows your medical history, including all the medicines you take—both prescription and over-the-counter (nonprescription) drugs as well as dietary supplements and herbs—even if you didn't get them at that particular pharmacy. That way he or she can provide valuable advice about any potential for drug interactions, side effects, or other problems.

Also, compare costs of buying medicines online. Some large drugstore chains have websites that offer savings. See a complete list of websites on the National Association of Boards of Pharmacy (NABP) site at www.nabp.net. Look for websites that display the NABP VIPPS (Verified Internet Pharmacy Practice Sites) seal, which means they meet state and federal requirements.

If you decide to buy your medicine on the Internet, be a smart shopper and learn how to buy drugs safely online.

Pill splitting is another strategy that can help you save money without losing drug effectiveness or safety. Some tablets are available at double the dose and at the same or almost the same cost as lower doses. By splitting the larger dose, you can essentially get two doses for the price of one. But many medicines should not be split, including timed-release pills and capsules.

Ask your doctor or pharmacist if any of your prescription medicines are sold at higher dosages and if it's possible to split them. Talk to your pharmacist about how to split pills with an inexpensive, easy-to-use pill splitter.

Buying prescriptions in bulk can also save you money. Ask your doctor to write a prescription for several months' supply of medicines that you take consistently. Keep in mind that your insurance company may limit the amount of medicine you can get at one time. Sometimes the price for a 3-month supply of medicine is less costly than if you were to pay an insurance copay each month for three months. Mail-order services can often save you money on large orders. But be sure to use only trusted, reliable pharmacy websites.

If you are trying a medicine for the first time, don't get more than a 30-day supply. That way, if you have concerns about side effects, you can talk to your doctor about trying another medicine. And you may save money by not getting more than you needed.

For more ideas about how to pay for medicines, how to remember to take them, and when to call your doctor, see Quick Tips: Taking Medicines Wisely.

How can your insurance plan help you save money?

Take time to find out about how your medical insurance or managed health care plan covers medicine costs. Some insurance companies cover only generic medicines if they are available. With some insurance plans, you may have to pay more for medicines that are not on the plan's list of preferred medicines (also known as a formulary). Some insurers cover medicines that are bought only at participating pharmacies. Your insurance company also may not pay for certain medicines such as weight-loss and hair-growth drugs. Ask the customer service representative whether your medicines are covered, whether you need to buy at certain pharmacies, and about your copayment. Many insurance companies also list this information on their websites.

If you have a choice between plans, check what your copayment for prescription drugs will be, the maximum amount the plan will pay in a year, and other details. Choose the plan that best suits your needs. When you buy medicines, find out which payment option will be the least expensive. Some things to consider include whether there is a generic version of a preferred medicine and whether an over-the-counter equivalent costs less than your copayment. Bring a copy of your health care plan's list of preferred prescription drugs to your next doctor appointment. And keep the list with your chart. That way, you and your doctor can see which medicines cost the least on your plan. Remember, having the right information can save you time and money.

To learn more about insurance, see the topic Understanding Health Insurance.

Are prescription medicines always needed?

There may be an over-the-counter alternative for your prescription medicine. For example, nonprescription naproxen (Aleve) is a fraction of the cost of the prescription equivalent Naprosyn. (Generic versions of over-the-counter medicines can save you even more money.) Often nonprescription equivalents of prescription medicines come in lower strengths, so get instructions from your doctor or pharmacist on how to take them.

In the case of antibiotics, research has found that they are not always needed. For example, up to two-thirds of people who have acute sinusitis improve on their own without antibiotic treatment. footnote 1Your doctor might advise you to take a wait-and-see approach before you buy expensive antibiotics.

Can you save money by purchasing prescription medicines from Canada? Is it safe?

The answer to the first question is "Yes." Many brand-name prescription medicines, either over the Internet, by mail order, or in person, cost less from Canadian pharmacies than from their U.S. counterparts. Whether it is legal to buy them remains controversial.

The FDA warns that the safety of drugs bought from other countries cannot be ensured. But many doctors say that Canada also demands safety and efficacy for medicines. These doctors say they would rather have their patients buy medicines from Canada than skip doses because they can't afford their medicines. U.S. citizens have been buying medicines in Canada for years, although federal law prohibits the practice.

Talk to your doctor if you decide to import your medicines. And be sure to buy only from licensed Canadian pharmacies and wholesalers.

How can your doctor help?

To get your doctor to help, tell him or her that your prescription medicine bill is a financial burden. Ask for drugs that are less expensive but that work just as well. Often, a condition can be treated with one of several different medicines, and your doctor may be able to prescribe one that costs less.

You might ask your doctor if he or she has medicine samples, vouchers, or other resources for you, especially when you are trying out a new medicine to see whether it will work.

What about the Medicare drug program?

The Medicare Part D prescription drug benefit began in January 2006. For the most current information about what the Medicare Part D Act means for you, go to www.medicare.gov or call 1-800-MEDICARE. Your doctor, pharmacist, or social worker may also be able to help you know about your Medicare benefits.

What other resources are available?

See whether the pharmaceutical company that makes your medicine has a patient assistance program. Some companies offer free or discounted drugs for people who cannot afford them. These companies often require that your doctor contact them first about your case. Your doctor will need to be involved, and the application process can be complex. You may need to provide documentation to verify your income. The Partnership for Prescription Assistance provides doctors and other health care providers with the information they need to access these programs. You can find out more at www.pparx.org.

Some states have programs for seniors and people with disabilities or low incomes.

If you have a rare disease, you may qualify for a National Organization for Rare Disorders (NORD) medication assistance program. NORD's assistance programs help people with rare diseases whose income is too high to qualify for Medicaid but too low to pay for their prescribed medicines. For more information, visit www.rarediseases.org/patients-and-families/patient-assistance.

Most veterans know that the Veterans Administration offers prescription drug coverage for retired veterans. But many people don't know that the same service is available for their families and survivors. Call the VA Health Revenue Center toll-free at 1-877-222-VETS (8387), or go to www.va.gov/health.

Some organizations offer special discounts on prescription drugs for their members. For example, AARP and AAA offer savings. Many pharmacies offer some form of a discount plan for seniors. Community health clinics or programs may have low- or no-cost prescription drugs for those who qualify. Also, some pharmacies offer a set price for some medicines—for example, $5 for a 30-day supply of certain generic medicines.

References

Citations

  1. Ah-See K (2015). Sinusitis (acute rhinosinusitis). BMJ Clinical Evidence. http://clinicalevidence.bmj.com/x/systematic-review/0511/overview.html. Accessed April 14, 2016.

Other Works Consulted

  • Kass-Bartelmes BL, Bosco L (2002). Prescription Drug Therapies: Reducing Costs and Improving Outcomes. Research in Action Issue No. 8 (AHRQ Publication No. 02-0045). Rockville, MD: Agency for Health Care Research and Quality.
  • Kesselheim AS, Choudhry NK (2008). The international pharmaceutical market as a source of low-cost prescription drugs for U.S. patients. Annals of Internal Medicine, 148(8): 614–619.
  • Tablet splitting (2009). Medical Letter on Drugs and Therapeutics, 51(1318): 62–63.
  • U.S. Food and Drug Administration (2011). Coverage of personal importations. Regulatory Procedures Manual 2011, chap. 9. Available online: http://www.fda.gov/downloads/ICECI/ComplianceManuals/RegulatoryProceduresManual/UCM074300.pdf.

Credits

Current as of: February 11, 2021

Author: Healthwise Staff
Medical Review:
Adam Husney MD - Family Medicine
E. Gregory Thompson MD - Internal Medicine

Sours: https://healthy.kaiserpermanente.org/health-wellness/health-encyclopedia/he.reducing-medication-costs.te7832
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Pharmacy

Kaiser Permanente Pharmacies

Prescriptions through Kaiser Permanente pharmacies.

You can fill prescriptions (written by any provider) at pharmacies located in Kaiser Permanente medical centers. You will always pay the lowest out-of-pocket costs at these pharmacies. Choose how to fill your prescriptions:

  • At Kaiser Permanente medical centers. All 30+ medical centers across the region have pharmacies. Permanente doctors can send most prescriptions electronically to the pharmacy—or you can present your prescription with your membership ID.
  • Online. Register at kp.org/register to order most refills online and have the medicine mailed to you or pick it up at a medical center pharmacy.
  • Through EZ Refill phone line. Call us at 800-700-1479 (TTY 711), 24 hours a day, and have the medicine mailed to you or available for pick up at any medical center pharmacy.*

To choose the Kaiser Permanente pharmacy where you’d like to pick up your prescription, visit kp.org/facilities.

 

 

* A program operated or arranged by Health Plan that distributes prescription drugs to Members via mail. Some medications are not eligible for the Mail Service Delivery Program. These may include, but are not limited to, drugs that are time or temperature sensitive, drugs that cannot legally be sent by U.S. mail, and drugs that require professional administration or observation. The Mail Service Delivery Program can mail to addresses in MD, VA, D.C., and certain locations outside the service area.

Sours: https://choiceproducts-midatlantic.kaiserpermanente.org/flexible-choice/member-information/pharmacy/
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