Pharmacy Services
Flexible Choice offers members options about how and where to have their prescriptions filled for maximum convenience and to manage their costs. As a provider, here’s what you need to know about how pharmacy services are managed for Flexible Choice.
Pharmacy services options.
Members have three options where to fill their prescriptions:
1. Kaiser Permanente Pharmacies: Members can choose a Kaiser Permanente pharmacy at kp.org/facilities for prescriptions ordered by Option 1, 2 or 3 providers. Filling prescriptions at KP Pharmacies is usually the most economical way. Mail order is available at Kaiser Permanente pharmacies only.
2. Network Community Pharmacies:
- Flexible Choice members can bring a prescription from a PHCS or non-participating provider to be filled at a network pharmacy.
- MedImpact is the pharmacy benefit manager (PMB), who administers the pharmacy benefit for network and out-of-network pharmacies.
3. Out-of-Network Pharmacies: Members can choose any pharmacy outside KP and MedImpact networks to fill prescriptions from a Kaiser Permanente, PHCS or non-participating provider. Members will pay full out-of-pocket costs for prescriptions filled at out-of-network pharmacies and will need to submit claims for reimbursement.
Members can fill a prescription at any pharmacy Option (KP, Network Pharmacy of Out-Of-Network), no matter if prescribed by Option 1, 2 or 3 provider.
- Applicable copay will apply based on whether the medication is generic, preferred brand or non-preferred brand (or specialty where applies) and if it is being field at an Option 1, 2 or 3 pharmacy.
- Members can fill prescriptions that they get from out-of-network physicians at Kaiser Permanente medical center pharmacies, where they will usually pay the lowest copay.
The MedImpact Network
- 70,000 independent pharmacies nationwide.
- Pharmacy chains include CVS, Kmart, Raley’s, Rite Aid, Safeway, Vons, Costco, Target, and Walgreens
- Not all locations within a pharmacy chain company are contracted with MedImpact.
Rx Generic and Brand Drug Rules
Members can request any drug tier:
- There are no restrictions on the drug tier that a member can request.
- Even if the member is prescribed a Generic drug, he/she can request a preferred brand name product if they so choose, but will pay the higher cost share.
- This rule does not differ between the pharmacy options.
The Flexible Choice product uses an open formulary for prescriptions from options 2 and 3 providers.
- There is no requirement for medical necessity review for non-preferred/non-formulary products to be dispensed instead of the covered generic.
- For example, if a PHCS provider writes for a generic but the member goes to the pharmacy and requests the non-preferred brand drug, he/she will simply pay the higher non-preferred brand copayment.