Prescription Medicines

Prescription medicines are prescribed by your health care provider to help keep you healthy, or treat you when you are sick. Copays may apply. Please see the Copayment Schedule (PDF) for more information.

Keystone First CHC gives your health care provider a tool, called a drug formulary, to help him or her prescribe medicines for you. A drug formulary is a list of brand and generic medicines covered by Keystone First CHC. Keystone First CHC will let Participants know if they are impacted by changes to the drug formulary.

If you have questions about whether or not a medicine is covered, you can call your health care provider, pharmacist, or go to Find a Doctor, Medicine, or Pharmacy. If a certain medicine is not listed on the drug formulary, your health care provider or pharmacist may ask for it through the Keystone First CHC prior authorization process.

Getting your medicine approved (prior authorization)

Your medicine will need to be approved by Keystone First CHC before you get it. This is called prior authorization.

There may be times when you are trying to get your prescription filled, but it is still in the approval, or prior authorization, process. If it is still in process, you may get a temporary supply.

Temporary Supplies:

• If you have not already been taking the medicine, you will receive a 5-day temporary supply of the medicine, as long as the Pennsylvania Medical Assistance Program covers it, and the medicine is safe for you to take.
• If you have already been taking the medicine, you will receive a 15-day temporary supply of the medicine, as long as the Pennsylvania Medical Assistance program covers it, and the medicine is safe for you to take.

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 have a certain medicine before trying another, your doctor may ask for it by submitting a prior authorization to start the next medicine in line.

If you cannot find what you are looking for on our website, please call Participant Services at 1-855-332-0729 (TTY 1-855-235-4976), or take a look at our Participant handbook. Our Representatives are there to help you 24 hours a day, 7 days a week.