The IBC Drug Formulary

The IBC Drug Formulary is a list of FDA-approved drugs we cover. Our Pharmacy and Therapeutics Committee has carefully chosen these drugs for their medical effectiveness and value.

We may periodically add or remove covered drugs, change coverage limitations on certain drugs, or change how much you pay for a drug.

Find a Drug on the Formulary

Search the IBC Drug Formulary alphabetically by drug name or by drug class. You can also check the formulary for drugs recently added to or removed from the formulary.

• Keystone 65 Preferred and Personal Choice 65 Formulary
• Keystone 65 Select Formulary

See Exceptions and Appeals to learn how to obtain an exception to the plan’s formulary.

Download a 2012 Formulary:

• 2012 Keystone 65 HMO and Personal Choice 65 PPO FormularyY0041_HM12_14 File & Use 09/03/2011
  No changes made since 09/2011
• 2012 Keystone 65 Select HMO Formulary Y0041_H3952_KS12_11 File & Use 08/31/2011
  No changes made since 09/2011

Formulary Changes
We regularly review the formulary to ensure its continued effectiveness. The formulary may change during the year. We may remove drugs from the formulary, or add prior authorizations, quantity limits, restrictions on a drug, or move a drug to a higher cost-sharing tier.

If a prescription you’re taking is affected by a formulary change, we will notify you, in writing, at least 60 days before the date it takes effect.

If we don’t notify you in advance of the change, you will get a 60-day supply of the drug when you request a refill of the drug.

In case of a market recall, we will not give you 60 days’ notice before removing the drug. Instead, we will remove the drug from our formulary immediately and notify members about the change as soon as possible.

You must continue to pay your Medicare Part B premium.

The Medicare Contract is renewed annually, and the availability of coverage beyond the end of the current year is not guaranteed.

The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change January 1, 2013. Members may enroll in the plan during specific times of the year. Contact the plan for more information. Please reference the Evidence of Coverage for information on premiums, cost-sharing, out-of-network coverage, rights and responsibilities upon disenrollment and any applicable conditions associated with using the plan benefits, as well as limitations, copayments, and restrictions. Members must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity limitations and restrictions may apply.

You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call:

• 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week;
• The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or
• Your State Medicaid Office.

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay for up to seventy-five (75) percent or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users should call 1-877-486-2048.”

You must use plan providers except in emergency or urgent care situations or for out-of-are renal dialysis or other services. You must use plan providers except in emergency or urgent care situations or for out-of-are renal dialysis or other services. If you obtain routine care from out-of-network providers neither Medicare nor Keystone 65 HMO or Personal Choice 65 PPO will be responsible for the costs.

Please contact Keystone 65 HMO or Personal Choice 65 PPO Customer Service for more information.

Y0041_HM_12_300a Pending CMS Approval