Provider Manual - Kaiser Permanente
Provider Manual Member Eligibility and BenefitsDetermination Product Descriptions
WelcomeToKaiserPermanenteOur goal is to ensure members get the care they need when they need it, hasslefree! Our Member eligibility and benefit determination policies and procedureshelp guide you and your staff in assisting the member. This section provides aquick and easy resource complete with contact phone numbers, detailedprocesses and site lists for services related to Member eligibility and benefitdetermination. It also briefly describes our health plan products.If, at any time, you have a question or concern about the information outlinedin this section of the Provider Manual, you can reach our Member/ProviderServices Department by calling 303-338-3800 or 1-800-632-9700 forDenver/Boulder, Mountain Colorado and Northern Colorado and 1-888-6817878 for Southern Colorado.
SECTION 3: MEMBER ELIGIBILITY AND BENEFITS DETERMINATION . 43.1MEMBER ELIGIBILITY VERIFICATION . 43.2RETROACTIVE ELIGIBILITY CHANGES . 43.3BENEFIT COVERAGE VERIFICATION . 53.4.EXCLUSIONS AND LIMITATIONS . 53.5PRODUCTS AND ID CARDS . 53.5.1Health Maintenance Organization (HMO) .63.5.2Point-of-Service (“POS”) Product . 133.5.3Medicare Product . 173.5.4Self-Funded (SF) Product . 213.5.5Medicaid Product . 233.5.6PPO Product . 243.63.7DRUG BENEFITS . 283.6.1Service Areas . 283.6.2Mail Order Pharmacy . 303.6.3Specialty Pharmaceuticals . 303.6.4Drug Inclusions, Exclusions and Limitations . 303.6.5Exception Process . 323.6.6Formulary Addition/Deletion Requests. 323.6.7Prescription History. 323.6.8Pharmacy Benefits Manager (PBM) . 33VISITING MEMBERS (REQUIRED) . 33
Section 3: Member Eligibility and Benefits Determination3.1Member Eligibility VerificationYou are responsible to verify a Member’s eligibility each time the Member presents at youroffice for services. Do not assume that coverage is in effect because a person produces aKaiser Permanente Member ID card. The process for verifying eligibility is as follows:1 Request Kaiser Permanente Member ID card and check identity against a photo ID.2 Contact Kaiser Permanente by telephone, interactive voice response (IVR) system orby web (Affiliate Link), as described in Option #3 in the chart below.3 If you cannot verify eligibility because Kaiser Permanente’s eligibility verificationoffices are closed, you should verify eligibility on the next business day.4 If Kaiser Permanente is unable to verify eligibility or if services are requested afterhours, the Member must complete a financial responsibility form. Please explain thatthe Member will be responsible to pay for the services if it is later determined that heor she did not have coverage on the date of service. See Section 3.2 of the Manualregarding retroactive eligibility changes.OptionDescription#1Interactive Voice Response (IVR) System: The IVR can be accessed for member eligibility,copayment information, and the name of the PCP assigned to the member through theMember/Provider Services Department for Denver/Boulder and Northern Colorado (303) 3383800 or (800) 632-9700 and Southern Colorado (888) 681-7878, Mon-Sun from 8am to 5pm.Please have the member’s ID number and date of birth available when you call.#2Member/Provider Service Line: If you are unable to use the IVR system to confirm membereligibility or PCP assignment, you may speak with a customer service representative bycalling the Member/Provider Services Department Line for Denver/Boulder and NorthernColorado (303) 338-3800 or (800) 632-9700 and Southern Colorado (888) 681-7878 option 3,M-F from 8am to 5pm. Please provide the member’s name and member ID number, inclusiveof suffix, which is located on the Kaiser Permanente ID card.#3www.providers.kaiserpermanente.org/cod: Eligibility verification is available to providers viaAffiliateLink the Kaiser Permanente website at www.providers.kaiserpermanente.org/cod, asecure site, for which a user ID number and password are required. To obtain access, print &submit a Kaiser Permanente Affiliate Link Provider Website Application found on theCommunity Provider Portal Home Page of the aforementioned website.3.2Retroactive Eligibility ChangesKaiser Permanente may determine retroactively that a Member was not eligible for coverageon the date of service. This occurs, for example, when eligibility data is received late fromemployer groups, or is adjusted by employer groups. The applicable Payor is notKaiser Permanente Provider Manual20154Section 3: Health Plan Member Eligibilityand Benefits Determination
responsible to pay for services in that case, but if you obtained a financial responsibility formfrom the Member, you may bill the Member directly for the services. If you have alreadyreceived payment for the services, the applicable Payor will notify you of the adjustment.Member eligibility may change retroactively in the following conditions: Kaiser Permanente receives delayed information, e.g., from Member’s employer, thatan individual is no longer a Member. The individual policy/benefit contract has been terminated. The Member decides not to purchase continuation coverage. The eligibility information received by Kaiser Permanente is later determined to befalse.If you have received payment on a claim(s) that is impacted by a retroactive eligibilitychange, a claim adjustment will be made. The reason for the claim adjustment will bereflected on the remittance advice.3.3Benefit Coverage VerificationYou are responsible for verifying that a Member has coverage under his or her MembershipAgreement for the services you will be providing, and for obtaining any required priorauthorization. See Section 4 of the Manual for information regarding authorizationrequirements. To determine a Member’s benefit coverage, choose an option below. 3.4.Contact the Member/Provider Services Department for Denver/Boulder, MountainColorado and Northern Colorado 303-338-3800 or 1-800-632-9700 and SouthernColorado 1-888-681-7878 to verify member benefit coverage.Access member benefit coverage via Affiliate Link website atwww.providers.kaiserpermanente.org/cod a secured site, for which a user ID numberand password are required. To obtain access, print & submit a Kaiser PermanenteAffiliate Link Provider Website Application found on the Community Provider Portalhome page of the aforementioned website.Exclusions and LimitationsThe benefits described in each Membership Agreement are subject to various limitations andexclusions. It is important to inquire about coverage before rendering a service so theMember can be informed of potential payment responsibility.Information can be obtained electronically or by calling for Denver/Boulder, MountainColorado and Northern Colorado 303-338-3800 or 1-800-632-9700 and Southern Colorado1-888-681-7878.3.5Products and ID CardsKaiser Permanente of Colorado offers different products to individuals and employer groups.The Member’s identification card will indicate which product he/she is enrolled in. KaiserKaiser Permanente Provider Manual20155Section 3: Health Plan Member Eligibilityand Benefits Determination
Permanente members should present their ID cards prior to services. Current member IDcard examples can be found in the Member Information section of the Community ProviderPortal at http://providers.kaiserpermanente.org/html/cpp cod/memberinfotoc.html?Additionally, it is recommended you obtain a copy of the card (front and back) each timeservices are rendered. This will assist you in referencing required insurance information. Youare contracted to treat Kaiser Permanente Members who are enrolled in the following plans:HMO Products:Traditional HMO ProductTraditional HMO Medicare Product(s)Deductible / Coinsurance HMO (DHMO)Deductible Product with Health Savings Account (DPHSA)HMO PlusDeductible Coinsurance HMO PlusMedicare Senior Advantage Plus Choice Plan (HMOPOS)Point of Service (POS) ProductsAdded Choice ProductsAdded Choice POS: HMO IndemnityAdded Choice Triple Option: HMO PPO IndemnityAdded Choice Deductible Coinsurance: DHMO PPO IndemnityMultiChoice POSPPO Products:Traditional PPOPPO with Health Savings Account (HSA)Out-of-Area PPOCost Share Products:High Deductible Health Plan (HDHP)KP Select Products:SoCo KP Select Traditional HMO Plan (KH)SoCo KP Select Deductible/Coinsurance HMO Plan (KD)SoCo KP Select HSA-Qualified Deductible HMO Plan (KC)3.5.1 Health Maintenance Organization (HMO) ProductsTraditional HMO ProductWith this product our members choose Primary Care Physicians within the ColoradoPermanente Medical Group and receive almost all of their care within the Kaiser Permanentetraditional Group Model System. A referral from a CPMG physician is required to obtainservices outside of the traditional system. Within this product, Kaiser Permanente offers awide selection of benefit choices. To verify eligibility and benefit information only, contactMember Services for Denver/Boulder, Mountain Colorado and Northern Colorado 303--3383800 or 1-800-632-9700 and Southern Colorado 1-888-681-7878 or r Permanente Provider Manual20156Section 3: Health Plan Member Eligibilityand Benefits Determination
Deductible / Coinsurance HMO Product (DHMO). DHMO products are based on our coreHMO plan but with a deductible that results in a lower monthly premium. Members haveaccess to any Kaiser Permanente Providers.Deductible Coinsurance HMO PlusDeductible Coinsurance HMO Plus provides members all the benefits and resources ofKaiser Permanente’s DHMO plan, plus the convenience to receive care from any licensedcommunity/network physician at any time, up to a set dollar amount each year. The setannual amount of the Plus benefit is based on Kaiser Permanente’s contribution amount.Once the member reaches his Plus benefit limit, only the Deductible Coinsurance HMOportion of the coverage will remain. Deductible Coinsurance HMO Plus is available to bothlarge and small groups.Deductible Product with HSA Option (DPHSA)For Denver/Boulder and Northern Colorado, the product is offered to large group, smallgroup and individual lines of business. In Southern Colorado, the product is offered to bothsmall group and large group lines of business. Members are responsible for all medicalcosts, excluding preventive which is covered at no cost, until reaching their deductible.Deductibles and coinsurance apply to the out-of-pocket maximum.Member ID Card for Traditional HMO Plans (DH)FrontBackKaiser Permanente Provider Manual20157Section 3: Health Plan Member Eligibilityand Benefits Determination
Member ID Card for D/B Traditional HMO Plus Plan (DX)FrontBackKaiser Permanente Provider Manual20158Section 3: Health Plan Member Eligibilityand Benefits Determination
Member ID Card for D/B Deductible/Coinsurance HMO Plan (DD)FrontBackKaiser Permanente Provider Manual20159Section 3: Health Plan Member Eligibilityand Benefits Determination
Member ID Card for D/B Deductible/Coinsurance HMO Plus Plan (DE)FrontBackKaiser Permanente Provider Manual201510Section 3: Health Plan Member Eligibilityand Benefits Determination
Member ID Card for D/B HSA-Qualified Deductible HMO Plan (HD)FrontBackKaiser Permanente Provider Manual201511Section 3: Health Plan Member Eligibilityand Benefits Determination
3.5.2 KP Select Member ID Card (SoCo area only)SoCo KP Select Traditional HMO Plan (KH)SoCo KP Select Deductible/Coinsurance HMO Plan (KD)Kaiser Permanente Provider Manual201512Section 3: Health Plan Member Eligibilityand Benefits Determination
SoCo KP Select HSA-Qualified Deductible HMO Plan (KC)3.5.3 Digital Membership CardsThe digital membership card provides convenient, secure access to members’ Kaiser Permanentemembership information anytime, anywhere so members can check in for appointments and pickup prescriptions at Kaiser Permanente facilities, and can access their family’s membershipinformation.3.5.4 Point-of-Service (“POS”) ProductsMembers seeking services from providers outside of the Kaiser Permanente system can selfrefer to providers of their choice at the time of medical need, or at the "point of service". Theywill have a Kaiser Permanente POS membership ID card."In-Plan" If the POS member stays in-plan (using the HMO tier of his plan), obtain referralinformation and bill Kaiser Permanente in your usual manner."Out-of-Plan" If the Added Choice member receives treatment without an HMO referralauthorization, they have elected to go out-of-plan. Payment is made under the PPO orindemnity contract and all contracted discounts apply. Bill Kaiser Permanente indicating thePOS member’s ID number. Kaiser Permanente will send remittance advice to both you andthe member itemizing the member's balance due.For all POS plans, pre-certification is required for the following services or treatments underthe PPO Tier and Out-of-Network Tier: Hospital Confinements, including preadmission testing Treatment, services, and supplies related to Birth Services Magnetic Resonance Imaging (MRI’s), Computerized Axial Tomography (CAT scans), andPositron Emission Tomography (PET scans) Home Health services Facility-based Hospice Care Hospitalization and anesthesia for dental procedures (covered for children under theage of 5)Kaiser Permanente Provider Manual201513Section 3: Health Plan Member Eligibilityand Benefits Determination
Craniofacialreconstruction (including cleft lip repair)testing Orthognathic surgery Abdomenoplasty Non-cosmetic blepharoplasty (eyelid surgery) Septoplasty Reconstructive surgery NeuropsychologicalThe patient (or his/her doctor) must call Permanente Advantage for pre-certification at least 3days prior to any scheduled hospital admission, unless admitted in an emergency. Precertification for emergency admissions must be obtained within 3 days following theadmission. To obtain pre-certification, call 1-888-525-1553. Both the member and providerwill receive written authorization confirming medical necessity.MultiChoice POSMultiChoice is a 3-tier Point-of-Service product. MultiChoice members have three tiers ofbenefits – a deductible coinsurance HMO coverage for those who seek care with KaiserPermanente or affiliated healthcare providers and medical offices, Preferred Providercoverage within the Private Healthcare Systems (PHCS) network, and Out-of-Network.Copays for office visits, deductibles, coinsurance, and out-of-pocket maximums now matchbetween the plan’s HMO and PPO coverage tiers, to reduce or eliminate benefit disparitybetween these networks.Member ID Card for D/B Added Choice 2-Tier POS Plan (DP)FrontKaiser Permanente Provider Manual201514Section 3: Health Plan Member Eligibilityand Benefits Determination
BackMember ID Card for D/B Added Choice Triple Option Plan (DT)FrontBackKaiser Permanente Provider Manual201515Section 3: Health Plan Member Eligibilityand Benefits Determination
Member ID Card for D/B MultiChoice POS Plan (DI)FrontBackKaiser Permanente Provider Manual201516Section 3: Health Plan Member Eligibilityand Benefits Determination
3.5.5 Medicare ProductsTraditional HMO Medicare ProductsKaiser Permanente has contracted with the Centers for Medicare & Medicaid Services(CMS) to offer Medicare Advantage (MA) plans to Medicare beneficiaries. These plans areknown as Senior Advantage. Kaiser Permanente offers five individual MA plans; SeniorAdvantage Core, Silver, Gold, Plus Choice, and our Special Needs Plan. The Special NeedsPlan is for individuals with both Medicare and Medicaid. These plans provide comprehensive,high-quality healthcare, including Medicare Part D prescription-drug benefits. Based on thecontract between Kaiser Permanente and CMS, Senior Advantage covers all Medicarebenefits and more. Senior Advantage is available to Medicare beneficiaries who are eligiblefor Medicare Part A and are enrolled in Medicare Part B.In addition to our four individual plans, Kaiser Permanente offers Senior Advantage to theemployer group market.Medicare Senior Advantage Plus Choice Plan (HMOPOS)Senior Advantage Plus Choice is a Medicare Advantage HMOPOS plan with KaiserPermanente HMO benefits and a limited out-of-network point of service (POS) benefit forout-patient services. Under the limited POS benefit Plus Choice members can self-refer toan out-patient Medicare-approved provider whether or not the provider is contracted withKaiser Permanente. Orders written for a Plus Choice member may be performed at KaiserPermanente medical offices; there are laboratory and radiology order forms for you tocomplete and fax if the member prefers to return to Kaiser Permanente for these services.Prescription drug orders must be filled at a Kaiser Permanente or affiliated pharmacy for themember to receive the prescription under their Part D plan benefit. The limited annualamount of the POS benefit is based on Kaiser Permanente's contribution amount. Once themember reaches his POS benefit limit, only the HMO portion of the coverage will remain.Senior Advantage Plus Choice is only available to individuals.Kaiser Permanente Provider Manual201517Section 3: Health Plan Member Eligibilityand Benefits Determination
Member ID Card for D/B Medicare Part D (DBMMA)FrontBackMember ID Card for D/B Medicare Non-Part D (DBMA)FrontBackKaiser Permanente Provider Manual201518Section 3: Health Plan Member Eligibilityand Benefits Determination
Member ID Card for D/B Medicare Plus Choice (DBMMX)FrontBackKaiser Permanente Provider Manual201519Section 3: Health Plan Member Eligibilityand Benefits Determination
Member ID Card for D/B Medicare HMO-SNP (DBMMS)FrontBackKaiser Permanente Provider Manual201520Section 3: Health Plan Member Eligibilityand Benefits Determination
3.5.6 Self-Funded (SF) ProductsRefer to www.providers.kaiserpermanente.org/cod to obtain information regarding the SelfFunded products.Member ID Card for D/B Self Funded EPO PlanFrontBackKaiser Permanente Provider Manual201521Section 3: Health Plan Member Eligibilityand Benefits Determination
Member ID Card for D/B Self Funded PPO PlanFrontBackKaiser Permanente Provider Manual201522Section 3: Health Plan Member Eligibilityand Benefits Determination
Member ID Card for D/B Self Funded POS PlanFrontBack3.5.7 Medicaid ProductsKaiser Permanente no longer pays you for services you provide to Medicaid clients (PCPP)as a result of a referral from a Kaiser Permanente provider. You will need to bill the StateMedicaid Program directly in order to receive reimbursement, and collect the appropriatecopayment from the client.Kaiser Permanente continues to offer medical services to these Medicaid clients as a fee forservice provider under the State’s Primary Care Provider Program (PCPP). Our MedicaidKaiser Permanente Provider Manual201523Section 3: Health Plan Member Eligibilityand Benefits Determination
provider number is 30478251. This number must be included as the referring physician onyour claim to the State.Member ID Card for Denver/Boulder Medicaid Program (MD)FrontBack3.5.8 PPO ProductsTraditional PPOOur traditional PPO product allows the member to take advantage of Kaiser Permanente’spreferred provider network, Private Healthcare Systems (PHCS), with nearly 450,000physicians and more than 4,000 facilities nationwide. Or if the member prefers, he can go toany other licensed practitioner or hospital he chooses. If the member gets care from withinthe preferred provider network, he will reduce costs through copayments for office visits(including diagnostic x-rays and lab work performed in the doctor’s office), as well as lowerdeductibles and reduced coinsurance rates for other services. If the provider is outside thenetwork, the member will pay higher deductibles & coinsurance, may be required to make hisown financial arrangements, and may need to submit receipts or claims for reimbursement.Kaiser Permanente Provider Manual201524Section 3: Health Plan Member Eligibilityand Benefits Determination
Also, members are responsible for paying the difference between the amount billed & theamount that KP can reimburse.Out-of-Area PPOThis plan is similar to our traditional PPO plan but is available to small group members only.This plan is available to members outside of Kaiser Permanente’s service area who are noteligible for the HMO plan.PPO Plan with Health Savings Account (HSA) OptionWith this plan, the member can take advantage of Kaiser Permanente’s Preferred ProviderNetwork, Private Healthcare Systems (PHCS), or if the member prefers, he can go to anyother licensed practitioner or hospital he chooses. In addition, the member can set up aHealth Savings Account (HSA) which he can use to pay for qualified medical expenses, taxfree. Kaiser Permanente has named Wells Fargo as a preferred partner, although memberscan have an HSA with any accredited financial institution. The PPO Plan with Health SavingsAccount (HSA) is available to large group members only.Member ID Card for D/B PPO Plan (NP)FrontBackKaiser Permanente Provider Manual201525Section 3: Health Plan Member Eligibilityand Benefits Determination
Member ID Card for D/B HSA-Qualified PPO Plan (PH)FrontBackKaiser Permanente Provider Manual201526Section 3: Health Plan Member Eligibilityand Benefits Determination
SoCo KP Select Traditional HMO Plan (KH)SoCo KP Select Deductible/Coinsurance HMO Plan (KD)SoCo KP Select HSA-Qualified Deductible HMO Plan (KC)Kaiser Permanente Provider Manual201527Section 3: Health Plan Member Eligibilityand Benefits Determination
3.5.9 Digital Membership CardsThe digital membership card provides convenient, secure access to members’ KaiserPermanente membership information anytime, anywhere so members can check in forappointments and pick up prescriptions at Kaiser Permanente facilities, and can access theirfamily’s membership information.3.6 Drug BenefitsKaiser Permanente offers supplemental drug coverage with many of its benefit plans. Toverify a Member’s drug coverage, obtain or view our drug formularies, identify availablepharmacies, or for general questions, please use the following options below.1. Contact Member Services at 303-338-3800 or 1-800-632-9700 or 1-888-681-7878, or711 TTY2. Use the Kaiser Permanente Community Provider Portal at:http://providers.kaiserpermanente.org/html/cpp cod/pharmacytoc.html?3.6.1 Service AreasKaiser Permanente offers benefits in four different service areas across the Front Range.These service areas include: 1) the Denver/Boulder metropolitan areas, 2) the NorthernColorado areas generally north of Loveland, CO, 3) the Southern Colorado areas south ofLarkspur, CO and 4) beginning in January 2016, Mountain Colorado which includes Summitand Eagle Counties). There are many similarities and a few differences between the serviceareas, which are described in the following sub sections.Pharmacy NetworksHMO and Medicare Part D BenefitsDenver/Boulder – utilizes Kaiser Permanente owned and operated retail pharmacies with afew select Hospital and Long Term Care pharmacies, and the Kaiser Permanente Mail OrderPharmacy located in Aurora, ColoradoNorthern Colorado – utilizes Kaiser Permanente owned and operated pharmacies, a fewselect Hospital, Long Term Care, select affiliate retail pharmacies, and the KaiserPermanente Mail Order Pharmacy located in Aurora, ColoradoSouthern Colorado - utilizes Kaiser Permanente owned and operated pharmacies, a fewselect Hospital, Long Term Care, hundreds of affiliate retail pharmacies, and the KaiserPermanente Mail Order Pharmacy located in Aurora, Colorado.EPO (Self Funded) plansDenver/Boulder, Northern Colorado and Southern Colorado – all three service areas utilizeKaiser Permanente owned and operated retail pharmacies, hundreds of affiliate retailKaiser Permanente Provider Manual201528Section 3: Health Plan Member Eligibilityand Benefits Determination
pharmacies, with a few select Hospital and Long Term Care pharmacies, and the KaiserPermanente Mail Order Pharmacy located in Aurora, Colorado.PPO and POS (Tiers 2 & 3) BenefitsDenver/Boulder, Northern Colorado and Southern Colorado – all three service areas utilizeaffiliated retail pharmacies and Walgreens Mail Order pharmacies.Drug FormulariesHMO BenefitsDenver/Boulder and Northern Colorado – follow a closed formulary titled ColoradoDenver/Boulder/Northern Areas formulary – HMOSouthern Colorado – follow the drug formulary titled Southern Colorado formulary – HMOMarketplace plansDenver/Boulder, Northern Colorado and Southern Colorado – all three service areas followthe formulary titled the Marketplace Exchange Drug FormularyEPO (Self Funded) plans and Federal Employee Commercial GroupsDenver/Boulder, Northern Colorado and Southern Colorado – all three service areas followthe formulary titled the EPO/Federal Group Commercial FormularyMedicare Part D BenefitsDenver/Boulder, Northern Colorado and Southern Colorado – all three service areas followthe open formulary titled the Kaiser Permanente Medicare Part D formularyPPO and POS (Tiers 2 & 3) BenefitsDenver/Boulder, Northern Colorado and Southern Colorado – all three service areas followthe open formulary titled the Denver/Boulder/Northern/Southern Colorado Preferred ProductListThese drug formularies and preferred products lists can be found within the CommunityProvider Portal at http://providers.kaiserpermanente.org/html/cpp cod/pharmacytoc.html?Or you may obtain a copy of any of our drug formularies by contacting Member Services at1-800-632-9700 or 1-888-681-7878.Kaiser Permanente Provider Manual201529Section 3: Health Plan Member Eligibilityand Benefits Determination
3.6.2 Mail Order PharmacyHMO, Medicare Part D Benefits, Marketplace and EPO (Self Funded) plansKaiser Permanente Mail Order Pharmacy16601 E. Centretech ParkwayAurora, CO. 80011Phone for Providers:1-866-523-6059Fax for new prescriptions: 1-866-551-9628Hours of Operation: Monday through Friday, 8:00 a.m. to 6:00 p.m.PPO and POS (Tiers 2 & 3) BenefitsWalgreens Mail Service PharmacyP.O. Box 29061Phoenix, AZ 85038-9061Phone for Providers:1-855-899-6012Fax for new prescriptions: 1-800-332-9581Hours of Operation: Monday through Friday, 6:00 a.m. to 8:00 p.m.Saturday & Sunday, 6:00 a.m. to 3:00 p.m.In Southern Colorado most HMO/Marketplace plans have a Mandatory Mail Order or KPbenefit design in place for maintenance medications. This means that the first fill of amaintenance medication may be dispensed from any pharmacy within the network, howeverthe subsequent dispenses must be from a Kaiser Permanente outpatient pharmacy or theKaiser Permanente Mail Order pharmacy.3.6.3 Specialty PharmaceuticalsKaiser Permanente utilizes a list of medications which are considered to be specialty drugs.These medications are typically medications which require special dispensing and/ormonitoring or are high cost medications. Some prescription drug plans may have a definedcopay/coinsurance tier for specialty drugs, and these drugs may be limited to a 30 daysupply. To verify a Member’s drug coverage, or to obtain or view the Kaiser PermanenteSpecialty Drug List please refer to the Community Provider Portal at:http://providers.kaiserpermanente.org/html/cpp cod/pharmacytoc.html?3.6.4 Drug Inclusions, Exclusions and LimitationsKaiser Permanente’s outpatient prescription drug coverage is determined by the specificdrug formularies, however many drug plans have specific exclusions, copays orcoinsurances that are not reflected in the drug formularies. A general summary of inclusions,exclusions, limitations and rules for the HMO Commercial and Marketplace plans can befound in the following sections. Medicare Part D plans follow the rules set forth by theKaiser Permanente Provider Manual201530Section 3: Health Plan Member Eligibilityand Benefits Determination
Centers for Medicare and Medicaid Services (CMS). EPO (Self Funded) plans follow rulesset forth by the funding entity.InclusionsKaiser Permanente’s outpatient prescription drug plans generally cover FDA ap
3.5.3 Digital Membership Cards The digital membership card provides convenient, secure access to members’ Kaiser Permanente membership information anytime, anywhere so members can check in for appointments and pick up prescriptions at Kaiser Permanente facilities, and can acces
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