Prior Authorization

Certain covered drugs, that have been approved by the U.S. Food and Drug Administration (FDA) for specific medical conditions require prior authorization. The approval criteria were developed and endorsed by our Pharmacy and Therapeutics Committee and are based on information from the FDA, manufacturers, medical literature, actively practicing consultant physicians, and appropriate external organizations.

To request coverage for drugs not on the formulary: refer to the tiered cost-sharing exceptions at the bottom of this page.

A request form must be completed for all medications requiring prior authorization. Current prior authorization medications are:

How to Submit a Prior Authorization Request

Providers:

  1. When filling out a prior authorization form, all requested information must be supplied. Incomplete requests will be faxed back to your office for completion, which will delay the review process.
  2. Fax completed forms to FutureScripts® Secure for review. Make sure you include your office telephone and fax numbers on the form.
  3. You will be notified by fax if the request is approved. You and your patient will receive a denial letter if the request is denied.
  4. If you have not received a response 72 hours after submitting complete information, contact FutureScripts Secure.

Members:

  1. Take the appropriate request form to your physician to be completed.
  2. You or your physician may fax the completed form to FutureScripts Secure for review.
  3. If you have not received a response from your provider after two business days, contact the provider who requested the prior approval on your behalf.
  4. If you have questions, please contact Customer Service.

FutureScripts Secure fax numbers:

  • 215-241-3073, inside local Philadelphia area
  • 1-888-671-5285, toll-free outside the local calling area

Tiered cost-sharing exceptions

Physicians, on behalf of members, may request coverage of a non-formulary medication, at the preferred formulary copay. The physician should complete the PDF icon Non-formulary Exception Request Form providing detail to support use of the non-preferred medication and fax the request to 215-241-3073 or 1-888-671-5285. The Non-preferred Exception Request Form can also be obtained by calling 1-888-678-7015 (Option #3).

If the non-preferred request is approved, the drug will be processed at the appropriate formulary benefit copay. If the request is denied, the member and physician will receive a denial letter that explains the appeal process. The member may still receive benefits for the drug at the non-preferred copay or coinsurance.

Coverage Determination

A decision from your Medicare drug plan about whether a drug prescribed for you is covered by the Plan and the amount, if any, you are required to pay for the prescription. In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn’t covered under your plan, that isn’t a coverage determination. You need to call or write to your plan to ask for a formal decision about the coverage if you disagree.

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

Search the 2012 IBC Drug Formulary to see if a drug is covered.
Search the 2012 IBC Drug Formulary
Find a network pharmacy near you.
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