Prescription Drug Frequently Asked Questions (FAQ)
- What if my drug is not on the formulary?
- What is a coverage determination?
- What can I do if my coverage determination is denied?
- Can the formulary change?
- What is prior authorization?
- How do I request an exception to the Keystone First VIP Choice formulary?
- How do I get reimbursed for my prescription expenses?
- What is the Keystone First VIP Choice transition policy?
- Does the plan have mail-order delivery services?
What if my drug is not on the formulary?
First, contact Member Services and ask if your drug is covered. If Member Services says your drug is not covered, you have two options:
- You can ask Member Services for a list of similar drugs that are covered by Keystone First VIP Choice (HMO-SNP). When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Keystone First VIP Choice.
- You can ask Keystone First VIP Choice to make an exception and cover your drug. For more information, please see the section below titled How do I request an exception to the Keystone First VIP Choice Formulary?
What is a coverage determination?
A coverage determination is any decision (an approval or denial) that Keystone First VIP Choice makes when you ask for coverage or payment of a drug that you believe Keystone First VIP Choice should provide.
- You or your primary care provider (PCP) and other prescribers can ask for a coverage determination.
- You can also appoint someone (such as a relative) to request a coverage determination for you.
- You can ask for a standard coverage determination. Keystone First VIP Choice will give you a decision in 72 hours.
- You can also ask for a fast coverage determination (also called an "expedited" determination) if you or your physician or other prescriber believes that your health could be seriously harmed by waiting up to 72 hours for a decision. Keystone First VIP Choice will give you an answer in 24 hours.
How to contact us when you are asking for a coverage decision about your Part D prescription drugs:
Request for Medicare prescription drug coverage determination
Submit online or fill out the paper form (PDF).
Fax standard: 1-855-516-6380
Fax urgent: 1-855-516-6381
Call: 1-866-828-0021 (TTY 711), 24 hours, seven days a week
Write:
Keystone First VIP Choice
Attn: Pharmacy Prior Authorization/Member Prescription Coverage
200 Stevens Drive
Philadelphia, PA 19113
What can I do if my coverage determination is denied?
If Keystone First VIP Choice denies your coverage determination you have the right to request a redetermination appeal. Please see our section on appeals and grievances for information about your appeal rights.
Can the formulary change?
Generally, if you are taking a drug on our 2024 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2024 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Please check the webpage for the most up to date version of the drug list.
If we remove drugs from our formulary or add prior authorization requirements, quantity limits, or step therapy restrictions on a drug, we must notify affected members of the change at least 30 days before the change happens, or at the time the member requests a refill of the drug, at which time the member will receive a 30-day supply of the drug.
If the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or the drug's manufacturer removes the drug from the market, we will remove the drug from our formulary and provide notice to members who take the drug.
What is prior authorization?
Prior authorization means that you will need to get approval from Keystone First VIP Choice before you fill your prescriptions for some drugs. If you do not get approval, Keystone First VIP Choice may not cover the drug. You can find out which drugs require prior authorization by reviewing the Keystone First VIP Choice formulary (PDF — posted December 1, 2024). Usually, your physician or other prescribers will have to give us information about your medical condition or previous prescriptions to receive prior authorization.
- Members and physicians: Download the coverage determination request form (PDF).
Mail or fax the completed form to:
Keystone First VIP Choice
Attn: Prior Authorization
200 Stevens Drive
Philadelphia, PA 19113
Fax standard: 1-855-516-6380
Fax urgent: 1-855-516-6381
How do I request an exception to the Keystone First VIP Choice formulary?
Prior authorization exception
You and/or your PCP or other prescriber can request an exception to the Keystone First VIP Choice formulary (PDF — posted December 1, 2024). Generally, your PCP or other prescriber must provide a statement of medical necessity that explains why the formulary drug would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
- Members and physicians: Download the coverage determination request form (PDF).
Mail or fax the completed form to:
Keystone First VIP Choice
Attn: Pharmacy Prior Authorization/Member Prescription Coverage
200 Stevens Drive
Philadelphia, PA 19113
Fax standard: 1-855-516-6380
Fax urgent: 1-855-516-6381
How do I get reimbursed for my prescription expenses?
In-network pharmacy claims: Direct member reimbursement
Please read the instructions on the form carefully, complete the prescription claim form (PDF), and mail it to:
Keystone First VIP Choice - Part D Drugs
Attention: Direct Member Reimbursement
P.O. Box 516
Essington, PA 19029
Out-of-network pharmacy claims: Direct member reimbursement
Generally, we only cover drugs filled at an out-of-network pharmacy in limited, non-routine circumstances when a network pharmacy is not available. Before you fill your prescription at an out-of-network pharmacy, call Member Services to see if there is a network pharmacy in your area where you can fill your prescription. You may also access the Keystone First VIP Choice pharmacy directory.
If you do go to an out-of-network pharmacy you may have to pay the full cost for the drug (rather than paying just your co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a direct reimbursement claim form (PDF).
However, even after we reimburse you for our share of the cost, you may pay more for a drug purchased at an out-of-network pharmacy because the out-of-network pharmacy's price may be higher than what a network pharmacy would have charged.
You should always submit a claim to us if you fill a prescription at an out-of-network pharmacy, since any amount you pay, consistent with the circumstances listed above, will help you qualify for catastrophic coverage.
Please read the instructions on the reimbursement form (PDF) carefully, complete the form, and mail it to:
Keystone First VIP Choice - Part D Drugs
Attention: Direct Member Reimbursement
P.O. Box 516
Essington, PA 19029
What is the Keystone First VIP Choice transition policy?
View the 2024 transition policy.
Does the plan have mail-order delivery services?
Yes. For certain kinds of drugs, you can use the plan's network mail-order services. Generally, the drugs available through mail order are drugs that you take on a regular basis, for a chronic or long-term medical condition. The drugs available through our plan's mail-order service are marked as "mail-order" drugs in our drug list. Our plan's mail-order service requires you to order a 90-day supply. If you use a mail-order pharmacy not in the plan's network, your prescription will not be covered. Usually a mail-order pharmacy order will get to you in no more than 10 days.
However, sometimes your mail order may be delayed. If you need to start your medications right away, but the mail order is delayed, ask your doctor for a 30-day supply (prescription) to be filled at your local pharmacy.
View the mail order form (PDF) and brochure and directions (PDF).