Documents and Forms
Looking for information about your OOA Plan? View, download, or print commonly used forms, reference guides, and other documents here.
Links to important forms and documents.
Member Resources:
Provider Directories
Drug Formulary
POS Formulary with Specialty Drug Tier – MedImpact Pharmacy (Non-grandfathered)
POS Standard Formulary – MedImpact Pharmacy (Grandfathered)
Claim forms
MedImpact Prescription Drug Claim Form
Other documents and forms
Walgreens Home Delivery Prescription Services
Walgreens Home Delivery Prescription Services en Espanol
Filling Prescriptions at MedImpact Retail Pharmacies
Filling Prescriptions at MedImpact Retail Pharmacies, en Espanol
MedImpact Standard Commercial Guidelines
Permanente Advantage – Precertification and Care Management
Permanente Advantage – Precertification and Care Management, en Espanol
Permanente Advantage Precertification Request Form
Member Care Transition Form, en Espanol
Confidential Communication Request Form (English)
Confidential Communication Revocation Form (English)
Your Rights and Protection Against Surprise Medical Bills
KPIC Notice of Language Assistance
KPIC Notice of Non-Discrimination