If we approve an exception through this exception process, then we will cover the drug or supply at the applicable Cost Share shown in the “Prescription drugs, insulin, and diabetic supplies” section in the Benefit Summary. If we do not approve the Formulary exception request, we will send you a letter informing you of that decision. You may request a review by an independent review organization. The process is explained in our denial letter and under “External Review” in the “Grievances, Claims, Appeals, and External Review” section. Emergency Fill For purposes of this section, “emergency fill” means a limited dispensed amount of the prescribed drug that allows time for the processing of a prior authorization request. You may have the right to receive an emergency fill of a prescription drug that requires prior authorization under the following circumstances:  The Participating Pharmacy is unable to reach Kaiser’s prior authorization department by phone, as it is outside the department’s business hours; or  The Participating Pharmacy is unable to reach the prescribing Participating Provider for full consultation, and  Delay in treatment would result in imminent emergency care, hospital admission or might seriously jeopardize the life or health of the patient or others in contact with the patient. An emergency fill must be received at a Participating Pharmacy and is subject to the applicable Cost Share shown in the “Benefit Summary.” An emergency fill is limited to no more than a seven-day supply or the minimum packaging size available. Your Prescription Drug Rights You have the right to safe and effective pharmacy Services. You also have the right to know what drugs are covered under this Plan and the limits that apply. If you have a question or a concern about your prescription drug benefits, please contact Member Services or visit us online at kp.org. If you would like to know more about your rights, or if you have concerns about your Plan you may contact the Washington State Office of Insurance Commissioner at 1-800-562-6900 or www.insurance.wa.gov. If you have a concern about the pharmacists or pharmacies serving you, please contact the Washington State Department of Health at 360-236-4700, www.doh.wa.gov, or [email protected]. Medication Management Program The Medication Management Program is available at no extra cost to Members who use Participating Pharmacies. The program’s primary focus is on reducing cardiovascular risk by controlling lipid levels and high blood pressure. Providers, including pharmacists, nurse care managers, and other staff, work with Members to educate, monitor, and adjust medication doses. Outpatient Prescription Drugs and Supplies Limitations  If your prescription allows refills, there are limits to how early you can receive a refill. In most cases, we will refill your prescription when you have used at least 70 percent of the quantity. Prescriptions for controlled substances cannot be refilled early refill. Please ask your pharmacy if you have questions about when you can get a covered refill.  The Participating Pharmacy may reduce the day supply dispensed at the applicable Cost Share to a 30-day supply in any 30-day period if it determines that the drug or supply is in limited supply in the market or for certain other items. Your Participating Pharmacy can tell you if a drug or supply you use is one of these items.  For certain drugs or supplies we may limit the amount of a drug or supply that is covered for a specified time frame. Quantity limits are in place to ensure safe and appropriate use of a drug or supply. Drugs and EWCLGDED1983ACT0124 62 WAPEBB-CL-ACT