Out-of-Area Plan
Documents and Forms
Looking for information about your Choice Out-of-Area plan? View, download, or print commonly used forms, reference guides, and other documents here.
Links to important forms and documents.
Member Resources:
Drug Formulary
Claims Forms
- Medical: Choice Products Medical Claim Form
- Pharmacy: Drug Reimbursement Form
Prior Approval and Pre-certification Forms
- Medical: Pre-Certification Request Form (Coming Soon)
- Pharmacy: Pharmacy Prior Authorization Request Form (KPIC MRF)
- Step Therapy: Step Therapy Process
Selected prescription drugs require step therapy. Step therapy is the protocol that requires you to use a particular outpatient prescription drug or sequence of prescription drugs, other than the drug that your provider recommends for your treatment before we provide coverage for the recommended prescription drug. - Oncology Step Regulation PA Guidelines
- Exception Requests for Prior Authorization and Step Therapy
- You or your authorized representative or the prescribing provider may request an exception or a waiver to the Outpatient Prescription Drug Prior Authorization Request and Step Therapy process described above if you are already being treated for a medical condition and currently under medication of a drug subject to prior authorization or step therapy, provided the drug is appropriately prescribed and is considered safe and effective for your condition. To request an exception or waiver to the Outpatient Prescription Drug Prior Authorization or Step Therapy process please call 1-800-788-2949 (Pharmacy Help Desk).
Other Documents and Forms
- Choice Out-of-Area New Member Guidebook (Coming Soon)
- Walgreens Home Delivery Prescription Services (Coming Soon)
- Filling Prescriptions at MedImpact Retail Pharmacies (Coming Soon)
- Permanente Advantage – Pre-certification and Care Management (Coming Soon)
- Member Care Transition Form (Coming Soon)
- Your Rights and Protection Against Surprise Medical Bills