Pharmacy

Out-of-Network Pharmacies (Plus Benefit)

• • Coverage for out-of-network pharmacy depends on your plan, so before you fill any prescriptions, take a few minutes to review your Evidence of Coverage (EOC) at kp.org/eoc.
  • If your Plus Benefit includes out-of-network pharmacy coverage, you have a set number of prescriptions you can fill at a pharmacy outside the Kaiser Permanente Network.
  • If your Plus Benefit doesn’t include pharmacy coverage, be sure to fill prescriptions at any Kaiser Permanente pharmacy, or one that is affiliated with your plan service area.*  Follow pharmacy guidelines or your Plus plan coverage.**
  • You’ll need to pay for prescriptions filled at a non-Kaiser Permanente pharmacy in full, and then submit your receipt and copy of the portion of the prescription label that contains the drug name/prescription information to the address below for reimbursement. Once we receive the documentation, you’ll be reimbursed for the cost of the drug, minus your Plus Benefit cost share.
  • If you’re a Denver/Boulder member, and you use a pharmacy that isn’t a Kaiser Permanente pharmacy located in one of our medical office buildings, the prescription cost will go toward your Plus Benefit. If you’re a Mountain, Northern or Southern Colorado member and you use a pharmacy that is not contracted with Kaiser Permanente, the prescription cost will go toward your Plus Benefit.
  • You will likely pay less if your physician refers to our formulary when prescribing a drug. To check if a medication is on the Kaiser Permanente formulary, go to kp.org/formulary, choose your region, and select the HMO Formulary link or access the HMO Drug Formulary.
  • Your non-Plan Provider can determine if a particular medication is on the Kaiser Permanente formulary or find a medication’s equivalent on the formulary by calling a Kaiser Permanente pharmacist at the Clinical Pharmacy Call Center, Monday through Friday, 8 a.m. to 6 p.m., Mountain time at:
    • Denver/Boulder: 303-338-4503 (TTY 711)
    • Northern and Southern Colorado: 1-866-244-4119 (TTY 711) 

    Send your itemized bill and receipts to the following address:
    Kaiser Foundation Health Plan of Colorado
    Claims Department
    PO Box 373150
    Denver, CO 80237-3150

*Subject to Kaiser Permanente formulary.

**Depending on your specific plan provisions, maintenance medication refills must be filled at one of our Kaiser Permanente Plan medical office pharmacies or through the Kaiser Permanente mail order program, or the maintenance medication will not be covered.

What if my 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.