Transparency in Coverage

Certain services require authorization before you get them. In these cases, your participating provider can help you get authorization for care he or she considers medically necessary. We determine when covered services are medically necessary based upon certain standards that take into account your medical condition as well as generally accepted standards of care.

When you receive covered services for which you do not have prior authorization or that you receive from non-participating providers or from non-Plan Facilities that have not been approved by us in advance, we will not pay for them except in an emergency.

Some services need special approval through a utilization review. If you need services that require a review and your participating provider believes they’re medically necessary, he or she may submit a request for a utilization review for you, or you may submit a request. We will respond to your request within 14 calendar days.

If the request is denied, Kaiser Permanente will send you a letter. It will explain the reason for our decision and give instructions for filing an appeal if you don’t agree with the determination.

When you get care from participating providers, you won’t be responsible for paying any amounts except for any cost sharing (deductibles, copayments or coinsurance) amounts that you owe. However, you will need to pay for any noncovered services you receive, whether you get them from a participating or a non-participating provider.

If you get covered services without prior authorization — or if you get them from a non-participating provider we haven’t approved in advance — we won’t pay for them, except in an emergency. Charges for these services will be your financial responsibility, and you may be billed directly by the provider for any balance you owe.

If you have chosen for Kaiser Permanente to receive advance payments of your premium tax credit, your monthly premium payment will be reduced by that amount. You need to pay any part of the premium that isn’t covered by the advance payment. If we don’t get your portion of the monthly premium by the due date, you’ll have a 3-month grace period in which to pay the late premium as well as the premiums owed for the additional 2 months of the grace period. A grace period is a time period when your plan will not terminate even though you did not pay your premium. Any claims submitted for you during that grace period will be pended. When a claim is pended, that means no payment will be made to the provider until your delinquent premium is paid in full.

If you qualify for a grace period, we’ll send you a notice with details. During the first month of the grace period, we’ll pay all appropriate claims for covered services. For the second and third months, we may choose not to pay for services if we don’t get your payment for any outstanding premiums by the end of the grace period. However, you generally won’t have to file a claim if a Kaiser Permanente provider provides the services. A participating provider will send the bill/claim directly to Kaiser Permanente, and we’ll process the claim unless you don’t pay your premium and we have indicated to your participating provider that we may not pay their claim (pended the participating provider’s claim).

In certain cases, a claim may be denied retroactively — for example, if you fail to pay your premium or you get services after your membership ends. In the event of a retroactive denial, you’ll be financially responsible for the covered services you received. To ensure a claim is not retroactively denied, premiums must be paid on time. If you have questions about a claim that’s been denied, please contact Member Services.

If we terminate your membership, we’ll refund any premium payments you made after your membership ended. We’ll also pay you any amounts we owe for claims while you were a member. When making these payments, we may deduct any amounts you owe Kaiser Permanente or any participating providers. Refunds for overpayment of premium are provided based on the method of payment used by the member. If you believe you have overpaid your premium and are due a refund, please contact Member Services.

Selected prescription drugs require step therapy. Step therapy defines how and when a particular outpatient prescription drug can be dispensed and establishes the specific sequence in which prescription drugs for a specified condition are deemed medically appropriate. Step therapy requires the use of one or more prerequisite drugs (first line agents), as identified through Your drug history, prior to the use of another drug (second line agent) when prescribed for Your condition. The step therapy process encourages safe and cost-effective medication use. Under this process, a “step” approach is required to receive coverage for certain medications. This means that to receive coverage you may first need to try a proven, cost-effective medication different than the one prescribed.

Your prescribing Plan Provider should prescribe a first-line medication appropriate for Your condition. If Your prescribing Provider determines that a first-line drug is not appropriate or effective for You, a second line drug may be covered if You qualify for a step therapy exception. Treatment decisions are always between You and Your Prescribing Provider.

Refer to Our formulary for a complete list of medications requiring step therapy. You may access Our formulary at www.kp.org or by calling Our Member Services Department Monday through Friday from 7 a.m. to 7 p.m. at (404) 261-2590 (local) or 1-888-865-5813 (long distance).

A step therapy exception may be granted if Your prescribing Plan Provider's submits justification and supporting clinical documentation that demonstrates that another drug (second line agent) is Medically Necessary. The exception process may be initiated by contacting the Health Plan at the number located on the back of Your card. This exception process only applies to prescription drugs that are covered under this Plan.

We will respond to Your exception request within two (2) business days from the date such request is submitted in a nonurgent health care situation.

We will respond to Your urgent exception request within 24 hours from the time such request is submitted in an urgent health care situation.

If We fail to respond within the stated time frame, Your step therapy exception will be deemed approved.

If Your exception request is denied, You may appeal Our decision. Our Appeals process is further described in SECTION 4 in your EOC – Getting Assistance, Filing Claims, and Dispute Resolution.

Send Your Appeal to:
2Kaiser Permanente
Appeals Department
Nine Piedmont Center
3495 Piedmont Road, N.E.
Atlanta, GA 30305-1736
(404) 364-4862

We will respond to Your appeal within two (2) business days from the date of the appeal is submitted in a nonurgent health care situation.

We will respond to Your urgent appeal within 24 hours from the time of the appeal is submitted in an urgent health care situation.

If We fail to respond to Your appeal within the stated time frame, Your appeal will be deemed approved.

Nothing in this provision shall be construed to prevent Health Plan from (1) requiring a Member to try a generic equivalent prior to providing coverage for the equivalent branded prescription drug; (2) requiring a Member to try an interchangeable biological product prior to providing coverage for the biological product; or (3) substituting a generic drug for a brand name drug.

Certain prescription drugs require review and prior authorization prior to dispensing. Your Plan Provider must obtain this review and prior authorization. The list of prescription drugs requiring review and authorization is subject to periodic review and modification by Our Pharmacy and Therapeutics Committee.

If You would like information about:

• whether a particular drug is included in Our drug formulary,
• obtaining a formulary brochure that lists the formulary drugs and provides more information about our drug formulary, or
• whether a drug requires authorization,

Please call Our Member Services Department, Monday through Friday from 7 a.m. to 7 p.m. at (404) 261-2590 (local) or 1-888-865-5813 (long distance).

Sometimes you may need a prescription drug that is not covered on Kaiser Permanente’s formulary (list of covered drugs). If you request a prescription for a non-formulary drug, and your Kaiser Permanente provider does not give you the prescription, then you may request review through the internal non-formulary exception review process. You or your Kaiser Permanente provider may submit the request to us with information as to why the non-formulary drug is medically necessary so that we may review your request.

To submit a non-formulary exception request to Kaiser Permanente, calling Our Member Services Department Monday through Friday from 7 a.m. to 7 p.m. at (404) 261-2590 (local) or 1-888-865-5813 (long distance). You must submit medical information supporting your request in order for us to complete our review. For most requests (standard requests), we will respond within 72 hours, but when exigent circumstances exist (i.e., your life, health or ability to regain maximum function would be seriously jeopardized without the non-formulary drug, or when you are already taking the non-formulary drug), then we will expedite your review request and respond to your request within 24 hours after our receipt of the request. If we grant your request, we will cover the non-formulary drug for the duration of the prescription, including refills. If exigent circumstances exist, we will cover the non-formulary drug for the duration of the exigent circumstance.

If after our review of your non-formulary drug exception request, you feel that we have denied your request for the non-formulary drug incorrectly, you may ask us to submit the case for external review. This external review may be requested by you, your authorized representative or the prescribing provider by sending your written request for external review to:

MAXIMUS Federal Services
3750 Monroe Avenue, Suite 705
Pittsford, NY 14534

Or, you may fax your request to 1-888-866-6190 or submit your request online at www.externalappeal.com. If you have any questions or concerns during the external review process, you may call toll free 1-888-866-6205.

An independent review organization will review your external review request within 72 hours, or 24 hours for exigent circumstances. If the external review results in your non-formulary drug being approved, we will cover it for the either duration of the exigent circumstances or the duration of the prescription, as applicable.

An Off-Label Drug is one that is prescribed for a use that is different from the use for which that drug has been approved for marketing by the Federal Food and Drug Administration.

We will cover Off-Label use of covered prescription drugs when prescribed for an individual with a life-threatening or chronic and disabling condition or disease. Coverage is also provided for Medically Necessary services associated with the administration of such a drug.

• Unless an exception is made by Health Plan, drugs not approved by the Food and Drug Administration and in general use as of March 1 of the year immediately preceding the year in which this EOC became effective or was last renewed are not covered.

• Immunizations and other drugs and supplies needed solely for travel are not covered.

• If a Service is not covered under this EOC, any drugs and supplies needed in connection with that service are not covered.

• Drugs and injectables used in connection with cosmetic Services are not covered.

• Drugs and injectables for the treatment of sexual dysfunction disorders are not covered.

• Drugs and injectables for the treatment of involuntary infertility are not covered.

An Explanation of Benefits (EOB) is a summary of services you’ve received during a specific period. It shows the charges, the date of your visit, and the name of the provider you visited. An EOB is not a bill. It’s available to help you understand the payments made for your covered services and to help you keep track of your expenses. EOBs are sent at least once a month after the member receives services and the claim is received by Kaiser Permanente to be processed.

If you have health coverage under more than one plan, the Coordination of Benefits process helps you make the most of your coverages to make sure you get the care you need. It determines the order in which different plans pay for services, which can make it easier to get and pay for care.

The plan that pays first is the primary plan. It’s responsible for paying first regardless of whether another plan covers some expenses so long as the care is covered. The secondary plan pays next. Based on how much the primary plan pays, it may reduce what it pays so the amounts from both plans don’t total more than the allowable expense for specific services.

If you have any questions or want more information about any of the topics covered here, please contact Member Services. One of our representatives will be happy to help.