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Prescription drugs (Part D)

The following information can help you get the most from your prescription drug (Part D) coverage. Just click on the links below to learn more about your benefits or to request the forms you need. To find out more about the benefits in your plan simply log in at ibx.com/login.

Learn more:

Prescription drug formularies

A formulary is a list of covered medications. This list of drugs is carefully selected by the plan with the help of a team of doctors and pharmacists, and is reviewed and approved by Medicare. 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 prescription drug

To find covered prescription drugs, select your health plan below. You can search Independence Drug Formularies alphabetically by drug name and check for drugs recently added to or removed from the formulary.

2021 formularies for individual members

Scroll or swipe to reveal all table data.

2020 formularies for individual members

Scroll or swipe to reveal all table data.

2021 formularies for group members

 

2020 formularies for group members

You can contact us for the most recent list of drugs.

See the coverage determination section to learn how to obtain an exception to the plan's formulary.

For Utilization Management tool information please visit our quality assurance policies and procedures section. For Tiered Cost-Sharing information please view the prior authorization section.

The Independence pharmacy network

Independence Blue Cross contracts with FutureScripts® Secure to provide Medicare Part D prescription benefit management services.

The network includes:

  • national chain and independent retail pharmacies;
  • long-term care and home-infusion pharmacies;
  • Indian Health Service/Tribal/Urban Indian Health (I/T/U) Program pharmacies;
  • a network mail-order pharmacy service

Independence has contracts with pharmacies that meet or exceed Centers for Medicare & Medicaid Services (CMS) requirements for pharmacy access in your area.

In order to receive benefits through the plan, prescriptions generally must be filled at a network pharmacy.

Standard and preferred pharmacies

Some pharmacies contract with our plan to offer lower cost-sharing to plan members. This is known as preferred pharmacy cost-sharing. You may fill your prescriptions at either a preferred or standard pharmacy. You can save money on certain prescriptions by using a preferred pharmacy:

  • Tier 1 and 2 prescriptions (which include most generic drugs) will have lower copayments when you have them filled at preferred pharmacies.
  • Tier 3, 4 and 5 prescriptions (which include brand-name, specialty and high-cost generic drugs) will have the same copayments at both preferred and standard pharmacy locations.
Preferred pharmacies Standard pharmacies

CVS
Giant
ShopRite
Target
Walgreens
Wegmans
Other independent pharmacies

Acme
Costco
Kmart
Rite Aid
Sam's Club
Walmart
Other independent pharmacies

Find a network pharmacy

To locate or confirm that a pharmacy is currently in our network:

Find a pharmacy

Out-of-network coverage

Covered Part D drugs are available at out-of-network pharmacies in special circumstances, including illness while traveling outside of the plan's service area where there is no network pharmacy. We may cover your prescription at an out-of-network pharmacy for up to a 30-day supply if at least one of the following applies:

  • If the prescriptions are related to care for a medical emergency or urgent care;
  • If you are unable to obtain a covered drug in a timely manner within our service area because there are no network pharmacies within a reasonable driving distance that provide 24-hour service;
  • If you are trying to fill a prescription drug that is not regularly stocked at an accessible network retail or mail-order pharmacy (including high-cost and unique drugs).

You may have to pay more than your normal cost-sharing amount, and will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement. We will consider your request and make a coverage decision. If we decide that the drug is covered and you followed all the rules for getting the drug, we will pay for our share of the cost.

We cannot pay for any prescriptions that are filled by pharmacies outside the United States, even for a medical emergency.

How to submit a paper claim

When you go to a network pharmacy, your claim is automatically submitted to us by the pharmacy. However, if you go to an out-of-network pharmacy for one of the reasons listed above, the pharmacy may not be able to submit the claim directly to us. When that happens, you will have to pay the full cost of your prescription. When you return home, simply submit a claim form and your receipt. Please note that we can only reimburse up to our allowed amount. Please call the Member Help Team for more information on paper claims.

To request a reimbursement, please use the Direct Member Reimbursement Form.

To request a reimbursement specifically for a vaccine and/or a vaccine administration fee, please use the Vaccine and Administration Direct Member Reimbursement Form. This form is for Part D vaccines only and should not be used for Part B vaccines such as the flu shot.

For the Influenza Vaccine Reimbursement Form, please see the claim reimbursement forms section.


Mail-order pharmacy service

Your benefit includes the option to receive prescription drugs shipped to your home through our network mail-order delivery program administered by FutureScripts® Secure. Whether it’s a new prescription or one you have been filling for years, mail order is an easy way to get the medications you take regularly.

Mail order offers you:

  • Cost savings. You may pay less than retail.
  • Convenience. Up to a 90-day supply of maintenance medications and free shipping.
  • 24/7 access. Speak to a pharmacist at any time, any day.

How do I order prescriptions?

If you are filling a prescription at a retail pharmacy and would like to switch to mail order:

  • Call 1-888-678-7015 (TTY:TDD:711) to find out if the prescription is eligible for mail order and ask to change to mail order.
  • Provide your name, address, prescription number (located on your prescription bottle), and billing information.

If you have a new prescription:

  • Ask your doctor to send the prescription to be filled by the FutureScripts pharmacy - OptumRx® home delivery.
  • OptumRx® home delivery will call you to confirm any details. Pharmacies must get consent prior to shipping or delivering any prescriptions that your prescriber sends.

If you need to refill a mail order prescription:

  • Call 1-888-678-7015 (TTY:TDD:711) and request a refill.
  • Confirm your information.
  • Please note, FutureScripts does not offer automatic refills.

You can also fill out and send in the Prescription Mail-order Form.

Your prescriptions from FutureScripts should arrive within 7 to 10 business days after we receive the complete order.

Questions? Please call FutureScripts at 1-888-678-7015 (TTY:TDD:711), 7 days a week, 24 hours a day.


Prior authorization and coverage determination for Part D drugs

For certain drugs, the plan requires additional information from your provider to approve coverage. This is called "prior authorization." This requirement helps to guide appropriate use of certain drugs.

Please reference your plan's formulary for a list of drugs that require prior authorization.

Prior authorization approval criteria are developed and endorsed by our Pharmacy and Therapeutics Committee and based on information from the FDA, manufacturer guidelines, medical literature, actively practicing consultant physicians, and appropriate external organizations.

Step therapy

Step therapy is another type of coverage determination that applies to certain drugs. Step therapy is when you must first try certain drugs to treat your medical condition before the plan will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Independence may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Independence will then cover Drug B.

How to submit a prior authorization/step therapy request

You may submit a request form for medications requiring prior authorization. Our pharmacy benefits manager, FutureScripts® Secure, reviews all requests. If you, your appointed representative, or your prescriber would like to initiate a prior authorization request, please submit a coverage determination. A standard coverage decision takes 72 hours after we receive a request. An urgent coverage decision means we will answer within 24 hours after we receive a request.

2021 prior authorization and coverage determination process

  • For more information on Keystone 65 Rx HMO’s prior authorization process and what services require prior authorization, please reference Chapter 5, Section 4.2 on page 127 in your EOC or view Keystone 65 Rx HMO Part D Prior Authorization.
  • For more information on Personal Choice 65SM Rx PPO's prior authorization process and what services require prior authorization, please reference Chapter 5, Section 4.2 on page 131 in your EOC or view Personal Choice 65 Rx PPO Prior Authorization.

2020 prior authorization and coverage determination process

  • For more information on Keystone 65 Rx HMO’s prior authorization process and what services require prior authorization, please reference Chapter 5, Section 4 on page 58 in your EOC or view Keystone 65 Rx HMO Part D Prior Authorization.
  • For more information on Personal Choice 65SM Rx PPO's prior authorization process and what services require prior authorization, please reference Chapter 5, Section 4 on page 55 in your EOC or view Personal Choice 65 Rx PPO Prior Authorization.

Non-formulary exception and quantity limit exception

If your drug is not on the plan's List of Covered Drugs (Formulary) or is on the list but has a quantity limit, you can request an exception and ask the plan to cover the drug or cover a greater quantity of the drug than what the plan allows. You and your provider can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If your provider says that you have medical reasons that justify asking us for a quantity limit exception, your provider can help you request an exception to the rule. Drugs approved for formulary exception will always pay at the non-preferred tier and cannot be approved for tier exception.

Tier cost-sharing

The plan puts each covered drug into one of several different cost-sharing tiers. How much you pay for your prescription depends on which cost-sharing tier your drug is in. If your drug is in the non-preferred tier, you or your provider can ask the plan to make an exception to allow the drug at the preferred tier so you pay less for it. If your provider says that you have medical reasons that justify asking us for an exception, your provider can help you request an exception to the non-preferred tier. See instructions below for requesting an exception.

If we approve the non-preferred request, the drug will be processed at the appropriate preferred formulary benefit cost-sharing. If we deny the request for access at the preferred tier, you and your physician will receive a denial letter that explains the appeal process. You may still receive benefits for the drug at the non-preferred cost-sharing level.

Please note that certain drugs in some of our cost-sharing tiers are not eligible for this type of exception. Such scenarios include:

  • Generic drugs that are already on our lowest generic tier (preferred generic)
  • Brand drugs that are already on our lowest brand tier (preferred brand)
  • Drugs that are on our specialty tier
  • Cost-share based on coverage phases, such as the Coverage Gap
  • Drugs that were already approved through the formulary exception process

How to submit a tier cost-sharing or formulary exception request

You may submit a request for an exception request. Our pharmacy benefits manager, FutureScripts® Secure, reviews all requests. If you, your appointed representative, or your prescriber would like to initiate an exception request, please submit a coverage determination. Please note that if you are approved for a formulary exception, you are not permitted to also request a tier exception for that same drug. For more information on coverage determinations, including how to submit, please reference the coverage determination section.

Medicare Part B vs. Part D determinations

CMS limits coverage of some drugs to either the Part B or Part D benefit depending on how the drug is prescribed, dispensed and/or administered. Please refer to the appropriate formulary to determine if your drug requires a Medicare Part B vs. Part D determination. Please complete the Medicare Administrative Prior Authorization for Part B/D coverage form if needed. This drug may be covered under Medicare Part B or D depending upon the circumstances. You may need to describe information such as the use and setting of the drug so we can make the determination.

Certain drugs are generally covered only under the Part B benefit. These drugs typically will not be listed on the formulary. However, some Part B drugs require precertification. Please see the attachment below to determine if precertification is required:

Specialty Drugs Requiring Precertification under Medicare Part B

Your physician may refer to the Direct Ship Injectables Program for more information about certain injectable drugs covered under the Medicare Part B benefit.

Hospice Medicare coverage

CMS requires Medicare beneficiaries with Part D coverage who are under hospice care to get prior authorization for prescriptions that fall under these four classes of medications: analgesics (drugs used for pain), antiemetics (drugs used for nausea), laxatives, and antianxiety drugs. These medications will be covered under Medicare Part D only if they are prescribed for diagnoses unrelated to the member's terminal illness.

If you, your appointed representative, or your prescriber would like to initiate a prior authorization request, please fill out the necessary information using the Hospice Information for Medicare Part D request form. Our pharmacy benefits manager, FutureScripts® Secure, reviews all requests.

Providers:

  • You may print and fax your completed Hospice Information for Medicare Part D request form to FutureScripts® Secure at 1-888-671-5285.
  • When filling out a prior authorization form, please supply all the requested information. Incomplete requests will require an outreach to your office to obtain additional information.
  • Fax completed forms to FutureScripts® Secure for review at 1-888-671-5285. Make sure to include your office telephone and fax numbers on the form.
  • You will be notified by fax if the request is approved or denied. You and your patient will also receive a denial letter if the request is denied.
  • If you have not received a response 72 hours after submitting complete information, contact FutureScripts® Secure at 1-888-678-7015, Option 1.

Members:

  • You, your authorized representative, or your physician may fax the Hospice Information for Medicare Part D request form to FutureScripts® Secure for review at 1-888-671-5285.
  • Complete the prior authorization form. Please supply all requested information. Note: FutureScripts® Secure may need to reach out to your provider for additional information.
  • You may take the appropriate request form to your physician to complete and fax to FutureScripts® Secure for review at 1-888-671-5285. If you have not received a response from FutureScripts® Secure after 72 hours, you may contact the provider who made the request on your behalf or FutureScripts® Secure directly at 1-888-678-7015.
  • If you have questions, please contact our Member Help Team.

 


Coverage determination for Part D drugs

Coverage determination is the process by which the plan makes a decision about whether a Part D drug prescribed for you is covered and the amount, if any, you are required to pay. An initial coverage decision about your Part D drugs is called a coverage determination. You, your doctor, or someone you've authorized may make an oral or written, standard or expedited request.

If you are a Keystone 65 Rx HMO or Personal Choice 65SM Rx PPO member, you can file a coverage determination by using one of the methods below.

  • Submit an online request.
  • Print and mail or fax the drug-specific coverage determination form.
    If you do not see a specific form for your request, please utilize our generic coverage determination request form.
  • Call 1-888-678-7015 (TTY/TTD 711).
    Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 through September 30, your call may be sent to voicemail.
  • Fax 1-888-671-5285.
  • Write FutureScripts® Secure
    1650 Arch Street
    Suite 2600
    Philadelphia, PA 19103

As part of the coverage determination process, you can ask us to make an exception, including requesting coverage of drug that is not on the formulary, waiving restrictions on the plan's coverage for a drug or asking to pay a lower-cost sharing amount. This process is called a formulary or tier cost-sharing exception. You may use the Coverage Determination Form to request an exception.

Coverage determination process

2021 coverage determination

2020 coverage determination

 


Part D appeals

If you, your doctor, or your representative do not agree with the outcome of the initial coverage determination, appeal the decision by requesting a redetermination.

If you are a Keystone 65 HMO member, you can file a standard or expedited Part D appeal by using one of the methods below.

If you are a Personal Choice 65SM PPO member, you can file a standard or expedited Part D appeal by using one of the methods below.

If our answer is yes to part or all of what you requested:

  • If we approve a request for coverage, we must provide the coverage we have agreed to provide as quickly as your health requires, but no later than 7 calendar days after we receive your appeal.
  • If we approve a request to pay you back for a drug you already bought, we are required to send payment to you within 30 calendar days after we receive your appeal request.
  • If we approve an expedited (or fast) request for coverage, we must provide the coverage we have agreed to provide as quickly as your health requires, but no later than 72 hours after we receive your appeal.

If our answer is no to part or all of what you requested:

  • We will send you a written statement that explains why we said no and how to appeal our decision.

2021 Part D appeals process

2020 Part D appeals process

 


Part D grievances

You may file a grievance if you have a complaint other than one that involves a coverage determination (see Part D Appeals above). You would file a grievance for any type of problem you might have with us or one of our network pharmacies.

If you are a Keystone 65 HMO member, you can file a standard or expedited Part D grievance by using one of the methods below.

  • Call 1-800-645-3965 (TTY/TTD 711).
    Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 through September 30, your call may be sent to voicemail.
  • Fax 1-888-289-3008.
  • Write Keystone 65 HMO
    Medicare Member Appeals Unit
    PO Box 13652
    Philadelphia, PA 19101-3652

If you are a Personal Choice 65SM PPO member, you can file a standard or expedited Part D grievance by using one of the methods below.

  • Call 1-888-718-3333 (TTY/TTD 711).
    Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 through September 30, your call may be sent to voicemail.
  • Fax 1-888-289-3008.
  • Write Personal Choice 65 PPO
    Medicare Member Appeals Unit
    PO Box 13652
    Philadelphia, PA 19101-3652

2021 Part D grievances process

2020 Part D grievances process

Appointment of a representative

If you have someone appealing our decision for you other than your physician, your appeal must include an Appointment of Representative form.

For claims and reimbursement

Keystone 65 HMO, Personal Choice 65 PPO and Select Option PDP:

FutureScripts Secure
PO Box 650287
Dallas, TX 75265

Contact information

Members and providers who have questions about the exceptions and appeals processes, would like to inquire about the status of a coverage determination or appeal request please contact the Member Help Team.

To obtain an aggregate number of grievances, appeals, and exceptions filed with Independence Blue Cross, please mail a written request to:

Medicare Member Appeals Unit
PO Box 13652
Philadelphia, PA 19101-3652

If you prefer to file a grievance through CMS, please complete the Medicare Complaint Form.


Transition supply process

What if my current prescription drugs are not on the formulary or are limited on the formulary?

Under certain circumstances, IBX can offer a temporary transition supply of a drug to you when your drug is not on the Drug Formulary or when it is restricted in some way. Doing this gives you time to talk with your doctor about the change in coverage, while figuring out what to do. Please note that not all medications qualify for a transition supply.

IBX can only offer a temporary transition supply of drugs that are eligible for coverage under Medicare Part D. Drugs that are excluded from Part D coverage are not eligible for a transition supply.

For more information on excluded drugs, please reference your Evidence of Coverage (EOC).

For new members

As a new member in our plan, you might currently be taking a drug that is not on our formulary. Or, the drug is on our formulary but your ability to get it is limited. In instances like these, you should talk with your doctor about appropriate alternative therapies available on our formulary. If there are no appropriate alternative therapies on our formulary, you or your doctor can request a coverage determination. If the exception is approved, you will be able to obtain the drug you are taking for a specified period of time. While you are talking with your doctor to determine your course of action, you may be eligible to receive an initial 30-day transition supply of the drug anytime during the first 90 days you are a member of our plan.

For each of your drugs that are not on our formulary, or for situations where your ability to get your drugs is limited, we will cover a temporary supply when you go to a network pharmacy. This temporary supply will be for a maximum of 30 days. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 30-days of medication. After your first 30-day transition supply, we may not continue to pay for these drugs under the transition policy. You are reminded to discuss with your doctor appropriate alternative therapies on our formulary. If there are none, you or your doctor may request a coverage determination.

If you are a resident of a long-term care facility, we will cover a temporary, 31-day transition supply(unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan, up to a maximum of 98 days of medication. If you need a drug that is not on our formulary, or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a coverage determination.

For continuing members

If you already are a member in the plan, you should have received your Annual Notice of Change (ANOC) by September 30. You may notice that a formulary medication that you are currently taking is either not on the upcoming year's formulary or that coverage is limited in the upcoming year. In this case, we will provide a transition period consistent with the above transition process for new enrollees.

If you have any questions about our transition policy or need help asking for a coverage determination, call the Member Help Team at the number printed on the back of your ID card.


Quality assurance policies and procedures

Independence Blue Cross (IBX) has developed a system of checks and balances to help ensure you get the right medications, in the right amounts, at the right times. Our goal is to avoid potential health risks to you, to keep the plan affordable, and to help those who need it the most to manage their medications. IBX offers these quality assurance programs:

Drug utilization review

Avoiding problems with your prescribed medicines
We conduct Drug Utilization Reviews (DUR) for our members. These reviews are especially important for members with more than one doctor prescribing their medications.

Each time you fill a prescription, we check:

  • possible medication or dosage errors
  • possible harmful interactions
  • drug allergies
  • duplication of drugs
  • drugs that are inappropriate because of your age or gender.

How the DUR system works
Your pharmacist enters your prescription online, where it is reviewed against all your previous prescriptions from the various pharmacies that are in the system. If we identify a potential medication problem, we will discuss it with your pharmacist and/or doctor to correct the problem. Your pharmacist or doctor may also call you.

The following checks are completed online, in real time, as a prescription is being dispensed:

  • duplicate drug therapy
  • too-early refill
  • low-dose/high-dose alert
  • incorrect daily dosage
  • excessive or questionable days' supply
  • drug-to-drug interaction
  • drug age/gender interaction
  • drug-pregnancy interaction

Helping your doctor(s) manage your medicines
We may notify physicians about potential problems with certain drugs. A targeted drug utilization review helps identify members who may be:

  • receiving improper medicines or high doses;
  • getting the wrong combinations of products;
  • abusing narcotics.

Independence complies with the Centers for Medicare and Medicaid Services (CMS) requirement to apply additional safety measures to opioid products.

Members new to an opioid medication will be limited to a 7 day supply for their first fill. All other prescription fills for opioid medications will be limited to a 30-day supply.

Please note that individual pharmacies may have additional limitations on opioid medications. Future Scripts Home Delivery requires that you must use 90 percent of your opioid medication before it may be refilled.

Independence limits the total daily dose of opioids through a measurement called the Morphine Milligram Equivalent (MME) dose. MME is a number that is calculated from the number of opioid drugs, their potencies and the duration of therapy. It is used to determine and compare the potency of opioid medications, and helps to identify when additional caution is needed.

There are two safety interventions at the pharmacy based upon the MME dose:

  • The first intervention produces a claim rejection at 90 MME that does not require a prior authorization, but may require intervention from your pharmacist.
  • The second intervention produces a claim rejection at 200 MME or greater, and requires a prior authorization.

Utilization management

Addressing the Increasing Cost of Drugs
A team of doctors and pharmacists developed requirements and limits on certain drugs to help the plan manage drug usage. The idea of utilization management is to continue to provide access to prescription drugs you need, while keeping plan costs down.

How utilization management may affect you:

  • Prior authorization. This means that physicians will need to get approval from us before you fill your prescription for certain drugs. If they don’t get approval, we may not cover the drug.
  • Quantity limits. For certain drugs, we limit the amount of the drug that we will cover per prescription or for a defined period of time.
  • Generic substitution. When there is a generic version of a brand-name drug available, our network pharmacies will automatically give you the generic version unless your provider writes no substitutions on the script.
  • Step therapy. This requirement encourages you to try less costly but just as effective drugs before the plan covers another drug. For example, if Drug A and Drug B treat the same medical condition, the plan may require you to try Drug A first. If Drug A does not work for you, the plan will then cover Drug B.

You can find out if your drug is subject to these additional requirements or limits by looking in the IBX Drug Formulary. If your drug does have these additional requirements or limits, you can ask us to make an exception to our coverage rules. View the coverage determination section for more information.

For More Information, contact the Member Help Team.
If you are a member and have questions, contact the Member Help Team at 1-800-645-3965 for Keystone 65 HMO and 1-888-718-3333 for Personal Choice 65 PPO (711 for the speech- and hearing-impaired), 8 a.m. to 8 p.m., seven days a week. However, please be aware that on weekends and holidays from April 1 through September 30, your call may be sent to voicemail.


Medication Therapy Management (MTM) program

In collaboration with PerformRX, we offer a Medication Therapy Management (MTM) program to ensure that you are receiving the most effective medications, while also helping to reduce the risk of side effects and interactions as well as your out-of-pocket costs. The program is paid in full by your plan, at no cost to you. This program is not considered a benefit. There is no change to insurance benefits, co-pays, prescription coverage, or available doctors or pharmacies. Specially trained pharmacists will work closely with you and your doctors to solve any problems related to medicines and to help you get the best results.

Who is eligible for the MTM program?

The MTM program is designed to help you get the most from your medications if you meet all of the following criteria:

  • You have 3 or more chronic diseases including:
    • Bone/Joint Disease (i.e., Osteoporosis)
    • Chronic Heart Failure (CHF)
    • Diabetes
    • High Cholesterol
    • Chronic Obstructive Pulmonary Disease (COPD)
    • Anticoagulation
    • Cancer
    • Multiple Sclerosis or
    • Atrial Fibrillation
  • You take 6 or more maintenance medications for chronic conditions
  • You spend $4,376 or more per year on Medicare Part D covered medications

What happens if you qualify for the program?

1. You will be sent an introduction letter describing the program to you.

2. You will receive a full medication review:

  • A specially trained clinical pharmacist will contact you for an interactive person-to-person medication consultation to review all of your medications and answer any questions that you may have.
  • Following the consultation, you will be sent a summary of your Comprehensive Medication Review. The summary will contain a medication action plan for you to take notes or write down any follow-up questions.
  • Personal Medication List
  • Medication Action Plan

3. Your medications will be reviewed on an ongoing basis

  • A Comprehensive Medication Review (CMR) will be offered once a year
  • At least every 3 months, your medicines will be reviewed and your MTM pharmacist will work with you, your doctor(s), if any changes are needed

Medicare requires that MTM programs automatically enroll those who qualify throughout the calendar year, but participation is voluntary, and you have the opportunity to opt out at any time. Once you have been enrolled, you will remain enrolled through the calendar year unless you opt-out or leave our plan.

If you have any questions about the MTM program, please call PerformRx at 1-888-349-0501 or 1-888-765-6351 (TDD/TTY) between 8:30 a.m. and 5 p.m. (EST), Monday through Friday.

Contact information

For more information, contact the Member Help Team.

If you are a member and have questions, contact the Member Help Team at 1-800-645-3965 for Keystone 65 HMO and 1-888-718-3333 for Personal Choice 65 PPO (711 for the speech- and hearing-impaired), 8 a.m. to 8 p.m., seven days a week. However, please be aware that on weekends and holidays from April 1 through September 30, your call may be sent to voicemail.


Understanding the donut hole

If you're enrolled in a Medicare Part D prescription plan, you've likely heard about the coverage gap — sometimes called the 'donut hole'. It’s one of the four phases of Part D coverage, and it's important to understand how it works and when it could apply to you. View our infographic to learn more about the Medicare Part D coverage phases.

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Website last updated: 11/9/2020