Keystone First covers medically needed Food and Drug Administration (FDA)-approved medicines. These medicines are prescribed by your health care provider to help keep you healthy, or treat you when you are sick. Keystone First gives your health care provider a tool, called a drug formulary, to help him or her prescribe medicines for you.
Full Answer
What drugs does Keystone first VIP choice cover?
For certain drugs, Keystone First VIP Choice limits the amount of the drug that the plan will cover. For example, our plan provides 9 tablets per 30 days of a prescription for sumatriptan succinate. ST:Step Therapy. In some cases, Keystone First VIP Choice requires you to first try certain
Does Keystone First follow the DHS PDL?
(PDF). Keystone First follows the DHS PDL for drugs and drug classes that are included on the PDL. Keystone First will also cover additional medications that are not on the DHS PDL as a part of our Supplemental Formulary. Please use the following links to find additional information on the DHS PDL and the Keystone First Supplemental Formulary:
When do Keystone first VIP Choice benefits change?
Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2022, and from time to time during the year. What is the Keystone First VIP Choice Formulary? A formulary is a list of covered drugs selected by Keystone First VIP Choice in consultation with
Does Keystone first cover mini implants?
Fixed bridges and all other dental implants, except for mini-implants, are not covered.
Is Keystone first considered Medicare?
Do you also have Medicare? Keystone First has a Medicare plan called Keystone First VIP Choice. You can find out more about our Medicare plan at the Keystone First VIP Choice website Opens a new window.
Is Keystone first HMO or PPO?
We offer Keystone First VIP Choice (HMO-SNP) and Keystone First Community HealthChoices (CHC) as options. Visit the COMPASS website for more information on Community HealthChoices eligibility.
Is Keystone First Pennsylvania Medicaid?
Putting you first. Keystone First is Pennsylvania's largest Medical Assistance (Medicaid) managed care health plan serving more than 400,000 Medical Assistance recipients in southeastern Pennsylvania including Bucks, Chester, Delaware, Montgomery, and Philadelphia counties.
Does Keystone first cover freestyle Libre?
Keystone First considers the long-term use of a Food and Drug Administration-approved continuous glucose monitoring device (Freestyle Libre®) to be clinically proven and, therefore, medically necessary for the Page 4 CORP- CCP.1366 4 detection of patterns and trends in glucose levels when all of the following criteria ...
Is Independence Blue Cross the same as Keystone first?
In 2012, backed by parent companies Independence Blue Cross and Blue Cross Blue Shield of Michigan, Keystone Mercy became Keystone First. Today, Keystone First serves more than 300,000 Medical Assistance recipients in the five-county Greater Philadelphia area.
Which is better PPO or HMO?
HMO plans typically have lower monthly premiums. You can also expect to pay less out of pocket. PPOs tend to have higher monthly premiums in exchange for the flexibility to use providers both in and out of network without a referral. Out-of-pocket medical costs can also run higher with a PPO plan.
What is PPO good for?
PPO stands for preferred provider organization. Just like an HMO, or health maintenance organization, a PPO plan offers a network of healthcare providers you can use for your medical care. These providers have agreed to provide care to the plan members at a certain rate.
What is Medicaid called in PA?
Medical AssistancePennsylvania's Medicaid program, also known as "Medical Assistance", provides comprehensive health care coverage for vulnerable populations and people with limited incomes.
Is Medicare and Medicaid the same?
The difference between Medicaid and Medicare is that Medicaid is managed by states and is based on income. Medicare is managed by the federal government and is mainly based on age. But there are special circumstances, like certain disabilities, that may allow younger people to get Medicare.
Is Keystone First an MCO?
Enrollment Process Keystone First is informed on a daily basis of eligible recipients who have selected Keystone First as their PH-MCO.
Does Keystone first cover tubal ligation reversal?
Infertility diagnosis and treatment services, including sterilization reversals and related office (medical or clinical) drugs, laboratory, radiological and diagnostic and surgical procedures are not covered.
How long does it take to get a receipt from Keystone?
It may take 6 to 8 weeks before you get your payment. NOTE: A receipt that does not have all of the above information will NOT be reimbursed and will be returned to you. Receipts should be sent to Keystone First as soon as possible. Receipts older than 365 days will not be accepted.
Is PA medical assistance covered by Keystone First?
Generally, reimbursement is NOT made for medicines that: Need prior authorization. Are not covered by either Keystone First or the Pennsylvania Medical Assistance program. Are not medically necessary. Go over certain dose and supply limits set by the FDA. Are re-filled too soon.
What is keystone first?
Keystone First follows the DHS PDL for drugs and drug classes that are included on the PDL. Keystone First will also cover additional medications that are not on the DHS PDL as a part of our Supplemental Formulary.
What is a prior authorization for a drug?
Pharmacy prior authorizations are required for pharmaceuticals that are not in the formulary, not normally covered, or which have been indicated as requiring prior authorization. Pharmacy prior authorization criteria (PDF) Opens a new window.
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.
Medication therapy management (MTM)
Keystone First VIP Choice has partnered with PerformRx SM to offer MTM programs at no additional cost for members who:
2022 medication therapy management
These programs may have limited eligibility criteria and are not considered a benefit; they are available for the following conditions:
