Pharmacy (Prescription) Benefits

On January 1, 2020, the Pennsylvania Department of Human Services (DHS) made changes in the way that some medicines are covered. All Pennsylvania Medical Assistance (Medicaid) health plans were required to move to a statewide preferred drug list (PDL). If you have any questions about this change, please call Member Services at 1-800-521-6860 (TTY 1-800-684-5505).

Keystone First members younger than 21 years old have prescription coverage. Some members who are 21 years or older may have prescription coverage too. For members over 18 years old, copays may apply to prescriptions.

How does the prescription benefit work?

When you need medicine or over-the-counter items, your health care provider will write a prescription for you to take to the pharmacy. The following areas will help you learn more about the different prescription benefits you may be eligible for.

The member copayment schedule (PDF) will show you the different costs on your prescriptions. You may also call Member Services at 1-800-521-6860 to find out what prescription benefits you are eligible for.

Monthly prescription limits

Some medicines may have monthly limits on the number of prescriptions or refills. This is shown in the drug formulary. To request a prescription limit prior authorization, the doctor who prescribed the medicine should contact Keystone First’s Pharmacy Services at 1-800-588-6767, or fax it to 1-215-937-5018.

Generic substitution and step therapy

There may be times when a generic medicine is used in place of a brand-name medicine. This may happen if the generic medicine has the same therapeutic properties as the brand-name medicine. This is called generic substitution. Talk with your doctor or pharmacist if you have questions about your medicines.

In some cases, we require you to try certain drugs first to treat your medical condition before another drug for that condition will be covered. For example, if drug A and drug B both treat your medical condition, we may not cover drug B unless you try drug A first.

If drug A does not work for you, we will then cover drug B. The drug formulary shows which drugs this applies to. If your provider thinks that you need to a have certain medicine before trying another, your doctor may ask for it by submitting a prior authorization to start the next medicine in line.

Do more online. Don’t wait until you run out. Get automatic refill reminders in the member portal.

Members