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

of parenteral-infusion (such as an intravenous or
intraspinal-infusion) at no charge for up to a 30-day
supply. In addition, we cover the supplies and equipment
required for the administration of these drugs at
no charge.
Drug utilization review
We conduct drug utilization reviews to make sure that
you are getting safe and appropriate care. These reviews
are especially important if you have more than one
doctor who prescribes your medications. We conduct
drug utilization reviews each time you fill a prescription
and on a regular basis by reviewing our records. During
these reviews, we look for medication problems such as:
• Possible medication errors
• Duplicate drugs that are unnecessary because you are
taking another drug to treat the same medical
condition
• Drugs that are inappropriate because of your age or
gender
• Possible harmful interactions between drugs you are
taking
• Drug allergies
• Drug dosage errors
If we identify a medication problem during our drug
utilization review, we will work with your doctor to
correct the problem.
Medication therapy management programs
We offer medication therapy management programs at
no additional cost to Members who have multiple
medical conditions, who are taking many prescription
drugs, and who have high drug costs. These programs
were developed for us by a team of pharmacists and
doctors. We use these medication therapy management
programs to help us provide better care for our members.
For example, these programs help us make sure that you
are using appropriate drugs to treat your medical
conditions and help us identify possible medication
errors.
If you are selected to join a medication therapy
management program, we will send you information
about the specific program, including information about
how to access the program.
ID card at Plan Pharmacies
You must present your Kaiser Permanente ID card when
obtaining covered items from Plan Pharmacies, including
those that are not owned and operated by Kaiser
Permanente. If you do not have your ID card, the Plan
Pharmacy may require you to pay Charges for your
covered items, and you will have to file a claim for
reimbursement as described in the "Requests for
Payment" section.
Notes:
• If Charges for a covered item are less than the
Copayment, you will pay the lesser amount
• Durable medical equipment used to administer drugs,
such as diabetes insulin pumps (and their supplies)
and diabetes blood-testing equipment (and their
supplies) are not covered under this "Outpatient
Prescription Drugs, Supplies, and Supplements"
section (instead, refer to "Durable Medical Equipment
for Home Use" in this "Benefits and Cost Sharing"
section)
• Except for vaccines covered by Medicare Part D,
drugs administered to you in a Plan Medical Office or
during home visits are not covered under this
"Outpatient Prescription Drugs, Supplies, and
Supplements" section (instead, refer to "Outpatient
Care" in this "Benefits and Cost Sharing" section)
• Drugs covered during a covered stay in a Plan
Hospital or Skilled Nursing Facility are not covered
under this "Outpatient Prescription Drugs, Supplies,
and Supplements" section (instead, refer to "Hospital
Inpatient Care" and "Skilled Nursing Facility Care" in
this "Benefits and Cost Sharing" section)
Outpatient prescription drugs, supplies, and
supplements limitations
Day supply limit. Plan Physicians determine the amount
of a drug or other item that is Medically Necessary for a
particular day supply for you. Upon payment of the Cost
Sharing specified in this "Outpatient Prescription Drugs,
Supplies, and Supplements" section, you will receive the
supply prescribed up to a 100-day supply in a 100-day
period. However, the Plan Pharmacy may reduce the day
supply dispensed to a 30-day supply in any 30-day
period at the Cost Sharing listed in this "Outpatient
Prescription Drugs, Supplies, and Supplements" section
if the Plan Pharmacy determines that the drug is in
limited supply in the market or a 31-day supply in any
31-day period if the item is dispensed by a long term care
facility's pharmacy. Plan Pharmacies may also limit the
quantity dispensed as described under "Utilization
management." If you wish to receive more than the
covered day supply limit, then the additional amount is
not covered and you must pay Charges for any
prescribed quantities that exceed the day supply limit.
The amount you pay for noncovered drugs does not
count toward reaching the Catastrophic Coverage Stage.
Page 50