Disclosure form and evidence of coverage - Kaiser Permanente ...

Member Service Contact Center: toll free 1-800-443-0815 (TTY users call 711) seven days a week 8 a.m.–8 p.m.
Other outpatient drugs, supplies, and
supplements
If a drug, supply, or supplement is not covered by
Medicare Part B or D, we cover the following additional
items in accord with our non–Part D drug formulary:
• Drugs for which a prescription is required by law that
are not covered by Medicare Part B or D. We also
cover certain drugs that do not require a prescription
by law if they are listed on our drug formulary
applicable to non–Part D items
• Diaphragms, cervical caps, contraceptive rings, and
contraceptive patches
• Disposable needles and syringes needed for injecting
covered drugs, pen delivery devices, and visual aids
required to ensure proper dosage (except eyewear),
that are not covered by Medicare Part B or D
• Inhaler spacers needed to inhale covered drugs
• Ketone test strips and sugar or acetone test tablets or
tapes for diabetes urine testing
• Continuity non–Part D drugs: If this Evidence of
Coverage is amended to exclude a non–Part D drug
that we have been covering and providing to you
under this Evidence of Coverage, we will continue to
provide the non–Part D drug if a prescription is
required by law and a Plan Physician continues to
prescribe the drug for the same condition and for a
use approved by the federal Food and Drug
Administration
Cost Sharing for other outpatient drugs, supplies, and
supplements. The Cost Sharing for these items is as
follows:
• Generic items (other than those described below in
this "Cost Sharing for outpatient drugs, supplies, and
supplements" section) at a Plan Pharmacy: a
$5 Copayment for up to a 30-day supply, a
$10 Copayment for a 31- to 60-day supply, or a
$15 Copayment for a 61- to 100-day supply
• Generic items (other than those described below in
this "Cost Sharing for outpatient drugs, supplies, and
supplements" section) through our mail-order service:
a $5 Copayment for up to a 30-day supply or a
$10 Copayment for a 31- to 100-day supply
• Brand-name items, specialty drugs, and compounded
products (other than those described below in this
"Cost Sharing for outpatient drugs, supplies, and
supplements" section) at a Plan Pharmacy: a
$25 Copayment for up to a 30-day supply, a
$50 Copayment for a 31- to 60-day supply, or a
$75 Copayment for a 61- to 100-day supply
• Brand-name items, specialty drugs, and compounded
products (other than those described below in this
"Cost Sharing for outpatient drugs, supplies, and
supplements" section) through our mail-order service:
a $25 Copayment for up to a 30-day supply or a
$50 Copayment for a 31- to 100-day supply
• Drugs prescribed for the treatment of sexual
dysfunction disorders: 25 percent Coinsurance for
up to a 100-day supply
• Amino acid–modified products used to treat
congenital errors of amino acid metabolism (such as
phenylketonuria) and elemental dietary enteral
formula when used as a primary therapy for regional
enteritis: no charge for up to a 30-day supply
• Continuity drugs: 50 percent Coinsurance for up to
a 30-day supply in a 30-day period
• Diabetes urine-testing supplies: no charge for up to a
100-day supply
• Diaphragms and cervical caps: a $25 Copayment per
item
Non–Part D drug formulary. Our non–Part D drug
formulary includes the list of drugs that have been
approved by our Pharmacy and Therapeutics Committee
for our Members. Our Pharmacy and Therapeutics
Committee, which is primarily composed of Plan
Physicians, selects drugs for the drug formulary based on
a number of factors, including safety and effectiveness as
determined from a review of medical literature. The
Pharmacy and Therapeutics Committee meets quarterly
to consider additions and deletions based on new
information or drugs that become available. If you would
like to request a copy of our non–Part D drug formulary,
please call our Member Service Contact Center. Note:
The presence of a drug on our drug formulary does not
necessarily mean that your Plan Physician will prescribe
it for a particular medical condition.
Our drug formulary guidelines allow you to obtain
nonformulary prescription drugs (those not listed on our
drug formulary for your condition) if they would
otherwise be covered and a Plan Physician determines
that they are Medically Necessary. If you disagree with
your Plan Physician's determination that a nonformulary
prescription drug is not Medically Necessary, you may
file an appeal as described in the "Coverage Decisions,
Appeals, and Complaints" section. Also, our non–Part D
formulary guidelines may require you to participate in a
behavioral intervention program approved by the
Medical Group for specific conditions and you may be
required to pay for the program.
Certain intravenous drugs, supplies, and
supplements
We cover certain self-administered intravenous drugs,
fluids, additives, and nutrients that require specific types
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