Prescription Drug Coverage
How do I get prescription drug coverage through Keystone First VIP Choice (HMO-SNP)?
While you are a member of our plan, you must use your plan membership card as well as your Medical Assistance (state Medicaid) card to get prescriptions at our network pharmacies. This helps to make sure you have proper drug coverage and limit, if any, cost-sharing responsibility.
What to do if you don't have your membership card at the pharmacy:
- If you don't have your plan membership card with you when you fill your prescription, ask the pharmacy to call the plan to get the information.
- If the pharmacy is not able to get your card information, you may have to pay the full cost of the prescription when you pick it up. (You can then ask us to reimburse you for our share.)
How much will I have to pay for prescriptions?
The amount you pay for prescription drugs may depend on which pharmacy you use. Keystone First VIP Choice has a network of pharmacies. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies.
Need help paying for your drugs? You may qualify for help with a low-income subsidy.
What are "network pharmacies"?
A network pharmacy is a pharmacy that has agreed to fill covered prescriptions for our plan members. It is important to use a network pharmacy because, with few exceptions, you must get your prescriptions filled there if you want our plan to cover the cost. Find a pharmacy in our network to fill your prescriptions.
How do I use the formulary to see if my drugs are covered?
The plan has a list of covered drugs (formulary). We call it the "drug list" for short. In addition to the drugs covered by Part D, some prescription drugs are covered for you under your Medicaid benefits. The drug list tells you how to find out which drugs are covered under Medicaid. It tells you if there are any rules that restrict coverage for your drugs.
The plan will generally cover your drugs as long as you follow these basic rules:
- You must have a provider (a doctor or other prescriber) write your prescription. Find a provider.
- You must use a network pharmacy to fill your prescription. Find a pharmacy.
- Your drug must be on the plan's list of covered drugs (formulary) Search for a prescription drug.
Remember, your drug must be used for a medically accepted indication.
What is a "medically accepted indication"?
- A "medically accepted indication" is a use of the drug that is one of the following:
- Approved by the Food and Drug Administration (FDA). This means that the FDA has approved the drug for the diagnosis or condition for which it is being prescribed.
- Supported by certain reference books. These reference books are the American Hospital Formulary Service Drug Information (AHFS-DI) and the DRUGDEX® Information System. Exceptions may be possible when used as part of an anti-cancer chemotherapeutic regimen.
Are there any restrictions on the drugs I can get?
Our plan uses different types of restrictions to help our members use drugs in the most effective ways. If there is a restriction on the drug you want to take, you should contact Member Services to learn what you or your provider would need to do to get coverage for the drug.
If you want us to waive the restriction for you, you will need to use the Coverage Determination process and ask us to make an exception. We may or may not agree to waive the restriction for you. For more information, see the prescription drug frequently asked questions (FAQ).
Types of restrictions we use for certain drugs:
- Restricting brand name drugs when a generic version is available. A generic drug works the same way as a brand name drug and usually costs less. In most cases, our network pharmacies will try to use a generic version of a brand name drug if available. We usually will not cover the brand name drug when a generic version is available. However, if your provider has told us the medical reason that the generic drug will not work for you, then we will cover the brand name drug. (Your share of the cost may be greater for the brand name drug than for the generic drug.)
- Getting plan approval in advance. For certain drugs, you or your provider need to get approval from the plan before we will agree to cover the drug for you. This is called "prior authorization." Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. If you do not get this approval, your drug might not be covered by the plan.
- Trying a different drug first. This requirement encourages you to try drugs that are less costly but just as effective before the plan covers another drug. For example, if Drug A and Drug B treat the same medical condition, the plan may require you to try Drug A first. If Drug A does not work for you, the plan will then cover Drug B. This requirement to try a different drug first is called "step therapy."
- Quantity limits. For certain drugs, we limit the amount of the drug that you can have. The plan might limit how many refills you can get, or how much of a drug you can get each time you fill your prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day.