Drug Management Programs: Part D Quality Assurance

Keystone First VIP Choice (HMO-SNP) has created special programs to help you access your prescriptions safely, at the lowest cost to you.

Utilization management

For some prescription drugs, Keystone First VIP Choice has extra requirements for coverage or limits on coverage. This is called Utilization Management. The requirements and limits ensure that members use these drugs in the most effective way and help control drug costs. They were designed by a team of doctors and pharmacists.

Examples of utilization management tools are:

  1. Prior authorization
    Keystone First VIP Choice requires you to get prior authorization for certain drugs. This means that prescribers will need to get approval from us before you fill your prescription. If they do not get approval, we may not cover the drug.
  2. Quantity limits
    For certain drugs, Keystone First VIP Choice limits the amount of the drug that we will cover per prescription or for a defined period of time.
  3. Step therapy
    In some cases, we require you to first try one drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.
  4. Generic substitution
    When there is a generic version of a brand name drug available, network pharmacies will automatically give you the generic version, unless your doctor has told Keystone First VIP Choice that you must take the brand name drug and has obtained a prior authorization.

Medication therapy management (MTM)

Keystone First VIP Choice has partnered with PerformRxSM to offer MTM programs at no additional cost for members who:

  • Have multiple medical conditions.
  • Are taking many prescription drugs.
  • Have high drug costs.

A team of pharmacists and doctors developed these MTM programs to help provide better prescription drug coverage for plan members. For example, these programs help us ensure that our members are using the proper drugs to treat their medical conditions and help Keystone First VIP Choice spot possible medication errors.

Keystone First VIP Choice offers MTM programs for members who meet certain criteria. As a Keystone First VIP Choice member, we may notify you of being enrolled in the program. Keystone First VIP Choice hopes that you will participate in any program offered to help you manage your medications. Remember, you do not need to pay anything extra to participate. If you are selected as an eligible participant for an MTM program, Keystone First VIP Choice will send you information about the specific program, including how to disenroll if you choose not to take part.

If you wish to participate in the program, our pharmacy benefits manager, PerformRx, will be reaching out to you. You will be contacted either via phone by our clinical staff or via direct mail with informational materials. Our outreach to you should take less than 30 minutes to complete. You will be eligible for both the comprehensive medication review, which will be a review of all your medications and therapy programs, and a targeted medication review, which will target your specific conditions.

We will provide you an overview of the MTM program, a personal medication list (PDF — January 18, 2023), a recommended to-do list (PDF — January 18, 2023) based on your medications and educational information based on the specific conditions which you have. If you opt into this program, we will also be contacting your primary care provider (PCP) to discuss your current treatments to work to improve your conditions and outcomes. You will be able to get any information we receive from our consultations with your physicians.

Every three months, we will send you materials for you to review. We ask that you review this information and provide us any updates so that we are aware of your current information. At your request we will also provide a comprehensive medication review. You may also receive additional information targeted at your specific conditions. These reviews can be helpful in reviewing your current drug treatment to ensure that you are receiving the best care.

To learn more, or to obtain MTM documents, call PerformRx at 1-888-349-0501 (TTY 1-888-765-6351) 8:30 a.m. to 5 p.m., Monday through Friday.

2024 medication therapy management

You are eligible for the Drug Management Program based on the Centers for Medicare and Medicaid Services (CMS) guidelines. These programs may have limited eligibility criteria and are not considered a benefit; they are available for the following conditions:

Having at least three of the following disease states:

  • Rheumatoid arthritis
  • Chronic heart failure (CHF)
  • Diabetes
  • Dyslipidemia.
  • End-stage renal disease (ESRD)
  • Hypertension
  • Chronic and/or disabling mental health conditions
  • Asthma
  • Chronic obstructive pulmonary disease (COPD)
  • Osteoporosis

Being on at least five different medications from the following list to treat those disease states:

  • Angiotensin-converting enzyme (ACE) inhibitors
  • Angiotensin II receptor blockers (ARBs)
  • Antidepressants
  • Antihyperlipidemics
  • Antihypertensives
  • Antipsychotics
  • Beta blockers
  • Bisphosphonates
  • Bronchodilators
  • Calcimimetic
  • Calcium channel blockers
  • Cardiac glycosides
  • Colony stimulating factors
  • Disease-modifying anti-rheumatic drugs (DMARDs)
  • Diuretics
  • Glucagon-like peptide-1 receptor agonists
  • Inhaled corticosteroids
  • Insulins
  • Neprilysin inhibitors
  • Nonsteroidal anti-inflammatory drugs NSAIDs
  • Oral hypoglycemics
  • Phosphate binders
  • Selective serotonin reuptake inhibitors (SSRIs)
  • Vitamin D analogs

Drug costs of $5,330 per year are likely to be incurred.

To learn more, or to obtain MTM documents, call PerformRx at 1-888-349-0501 (TTY/TDD 1-888-765-6351) 8:30 a.m. to 5 p.m., Monday through Friday.