Prescription Drug Benefits

Prescription Drug Benefits—What is Covered   |   Prescription Drug Limitations
96-Hour Urgent Temporary Supply Program   |   Prescription Drug Exclusions—What is Not Covered

Prescription drug benefits provided under this program are available for covered drugs and supplies dispensed because of a prescription order for the out-of-hospital use by the member.

Prescription Drug Benefits—What is Covered

1. Prescription drugs and maintenance prescription drugs prescribed by your child’s primary care physician or referred specialist and furnished by a participating pharmacy.
2. Insulin and disposable insulin needles, syringes and/or testing materials, lancets and glucometers.
3. Compounded preparations containing at least one prescription drug.
4. The quantity of a prescription drug dispensed from a pharmacy is limited to a 34 day supply or 120 dosage units, whichever is less. Up to a 90 day supply of a maintenance prescription drug may be obtained through the mail service pharmacy. For information on the mail service pharmacy call the Caring Foundation at 1-800-464-5437.
5. A member or member’s family shall pay to a participating pharmacy 100% of a non-covered drug or supply.

Prescription Drug Limitations

1. In certain cases, Keystone may determine that the use of certain covered prescription drugs for a member’s medical condition requires preapproval for medical necessity.
2. In certain cases where Keystone determines there may be Prescription Drug usage by a member that exceeds what is generally considered appropriate under the circumstances, Keystone shall have the right to direct that member to one pharmacy for all future covered prescription drugs.

96-Hour Urgent Temporary Supply Program

The 96-hour Urgent Temporary Supply Program applies to the following covered medications:

• Medications that require prior authorization
• Medications that are subject to age edits (requires preapproval for ages outside of recommended ranges)
• Migraine medications that require preapproval for amounts over the quantity level limits

Under the 96-Hour Urgent Temporary Supply Program if a child’s doctor writes a prescription for a drug that requires prior authorization, has an age edit or exceeds the quantity level limit for a migraine medication and prior authorization has not been obtained by the doctor, the following steps will occur:

1. The participating retail pharmacy will be instructed to release a 96-hour supply of the drug for your child.
2. By the next business day, Keystone’s pharmacy services department will contact your child’s doctor to request that they submit the necessary documentation of medical necessity or medical appropriateness for review.
3. Once the completed medical documentation is received by pharmacy services, Keystone’s review will be completed and the medication will be approved or denied.
4. If approved, the remainder of the prescription order will be filled.
5. If denied, notification will be sent to you and your child’s doctor.

This program is available to CHIP children for a one-time supply of medication in emergent situations only. Obtaining a 96-hour urgent temporary supply does not guarantee that the prior authorization request will be approved. Some medications are not eligible for the 96-hour Rx supply program due to packaging limitations (tube, 2-week or monthly supply). Additionally, certain drugs that must be specially ordered are not eligible for the 96-hour urgent temporary supply.

Prescription Drug Exclusions—What is Not Covered

The following are not covered under the prescription drug benefits of this program:

1. Devices or supplies of any type, except for blood glucose meters, test strips, lancits and insulin syringes.
2. Drugs that do not by federal or state law require a prescription order (i.e., over-the-counter or over-the-counter equivalents), except insulin and drugs specifically designated by Keystone, whether or not prescribed by a physician
3. Prescription refills resulting from loss or theft, or any unauthorized refills
4. Experimental drugs or investigational drugs or drugs prescribed for experimental (non-FDA approved) indications
5. Drugs used for cosmetic purposes, including, but not limited to, anabolic steroids, minoxidil lotion, or Retin A (tretinoin)
6. Pharmacological therapy for weight reduction or diet agents
7. Contraceptives for birth control purposes
8. Injectable drugs used for the primary purpose of treating infertility or injectable drugs for fertilization
9. Drugs prescribed and administered in the physician’s office (this would fall under the medical portion of the plan)
10. Medication for a member confined to a rest home, skilled nursing facility, sanitarium, extended care facility, hospital or similar entity (this would fall under the medical portion of the plan)
11. Medication furnished by any other medical service for which no charge is made to the member
12. Any covered drug which is administered at the time and place of the prescription order (this would fall under the medical portion of the plan)
13. Immunization agents, biological sera, blood or plasma, or allergy serum
14. Nicotine patches or gum or any other pharmacological therapy for smoking cessation
15. Prescription drugs not approved by Keystone or prescribed drug amounts exceeding the quantity level limits as conveyed by the FDA or FutureScripts^® Pharmacy and Therapeutics Committee
16. Human growth hormones (this would fall under the medical portion of the plan)