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Keystone Drug Formulary 04
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1
Pharmacy Services
Mission Statement
To provide
pharmaceutical
products and clinical
services in keeping
with the highest
quality of patient
care by incorporating
the principles of
Quality Management
in the most cost
effective manner.
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3
THE KEYSTONE MERCY
HEALTH PLAN DRUG FORMULARY
The Keystone Mercy Health Plan drug benefit has
been developed to cover medically necessary pre-
scription products. The pharmacy benefit design
provides for outpatient prescription services that
are appropriate, medically necessary, and are not
likely to result in adverse medical outcomes.
The Keystone Mercy Formulary and prior authori-
zation process are key components of the benefit
design. The medications included in the formulary
are reviewed and approved by the Pharmacy and
Therapeutics Committee and the Department of
Public Welfare (DPW). The Pharmacy and
Therapeutics Committee includes physicians and
pharmacists actively participating in the Keystone
Mercy provider network. The goal of the formulary
is to provide clinically efficacious, safe and cost-
effective pharmacologic therapies based on
prospective, concurrent, and retrospective peer
reviewed medical literature.
The Pharmacy and Therapeutics Committee meets
regularly to review and revise the formulary. All
providers (both participating pharmacies and
physicians) are sent copies of the Keystone Mercy
formulary and are periodically notified of formula-
ry updates. Providers may request addition of a
medication to the formulary. Requests must
include the drug name, rationale for inclusion on
the formulary, role in therapy and formulary med-
ications that may be replaced by the addition.
All requests should be forwarded in writing to:
Keystone Mercy Health Plan
Pharmacy and Therapeutics Committee
200 Stevens Drive
Philadelphia, PA 19113
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Physician State License Number
When processing a claim for a Member, an accurate
physician’s state license number is required. (This
is also a requirement of DPW.) Claims submitted
without a valid physician's state license number
will be rejected with NCPDP reject code 25
“Missing/Invalid Prescriber ID”. Please contact the
Keystone Mercy Pharmacy Services Department at
800-588-6767 for assistance.
Important Contact Information
Billing/Payment Inquiries:
Keystone Mercy Health Plan
Pharmacy Services Department
1-800-588-6767
Hours: M–F 8:30 a.m.–6:00 p.m.
Claim/Transmission Questions:
Argus Health Systems
1-800-522-7487
Hours: M–F 8 a.m.–1 a.m.
Sat 10 a.m.–6 p.m.
Sun 10 a.m.–6 p.m.
Holidays 10 a.m.–6 p.m.
Member Eligibility:
Keystone Mercy Member Services
1-800-521-6860
24 hours/day/ 7 days/week
Prior Authorization Requests:
Keystone Mercy Health Plan
Physician Prior Authorization Line
1-800-588-6767
M–F 8:30 a.m.–6:00 p.m.
1-800-521-6860
Sat, Sun, Holidays, and after hours
Mailing Address:
Keystone Mercy Health Plan
Pharmacy Services Department
200 Stevens Drive
Philadelphia, PA 19113
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Page 4
Covered Services
Covered services are those services related to dis-
pensing prescription and Over-the-Counter drugs
in accordance with the Member’s benefit plan and
Pennsylvania Medical Assistance Program.
Days Supply Dispensing Limitations
Depending on their benefit plan, Keystone Mercy
members may receive up to a 34-day supply or
150 units, whichever is less, of a pharmaceutical
product per prescription order or refill. A 34-day
supply shall be interpreted to mean consecutive
34-day supply, i.e. if a physician prescribes med-
ication b.i.d. (two times a day), a 34-day supply
corresponds to a quantity of 68. Quantities greater
than 150 units require prior authorization.
Certain formulary medications may have quantity
limits of less than 150 units or 34 days that are
based on FDA guidelines and accepted standards
of care. These products are notated in the formula-
ry and require prior authorization for greater
quantities.
The prescriber is urged to prescribe in amounts
that adhere to FDA guidelines and accepted stan-
dards of care. The day supply must be accurately
computed by the dispensing pharmacist to assure
compliance with Plan parameters.
Prescribed package sizes can not be altered unless
approved by the prescriber and must be within the
34 day limit.
Vacation Supplies
Keystone Mercy allows one vacation supply per
medication per Member per year without any prior
authorization. Vacation supplies may be obtained by
contacting Keystone Mercy at 800-588-6767. The
Member Services Department can enter the override
code to allow for the dispensing of a temporary
supply.
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However, if the medication is a controlled medica-
tion or the Member has already obtained one vaca-
tion supply, the request must be reviewed by the
Keystone Mercy Pharmacy Services Department.
Refill Frequency
The frequency with which a prescription can be
refilled is monitored by the Argus Claims
Processing System. Members may have their pre-
scriptions refilled when eighty-five percent (85%)
or more of the medication is utilized. Claims sub-
mitted for refills before 85% of the medication is
utilized, will be rejected with NCPDP reject code 79
“Refill Too Soon”.
If a claim is rejected because the dose of the
particular medication has been increased or
the day supply on the original prescription was
entered incorrectly, the Pharmacy must call
Keystone Mercy’s Pharmacy Services
Department at 800-588-6767 for prior
authorization.
Oral Contraceptives
A Member with oral contraceptive coverage may
receive one (1) cycle at a time.*
Generically Available Over-the-Counter
Medications
Certain generic over-the-counter medications are
covered by Keystone Mercy with a prescription
from the prescribing physician and are limited to a
34 day supply and include:
• Analgesics such as aspirin, acetaminophen and
nonsteroidal anti-inflammatory drugs
• Antacids
• Antidiarrheals such as loperamide and
kaolin-pectin combinations
• Antiflatulents such as simethicone
6
*Keystone Health Plan East will work with Argus Health Systems to
ensure payment for these products.
Page 6
• Antihistamines
• Antinauseants
• Bronchodilators
• Cough and cold preparations
• Contraceptives
• Hematinics not including long-acting products
• Insulin
• Laxatives and stool softeners
• Nasal Preparations
• Ophthalmic preparations
• Single and multiple ingredient topical products
such as antibacterials, anesthetics, antifungals,
dermatological baths, rectal preparations, tar
preparations (excluding soaps, shampoos, and
cleansing agents), wet dressings, scabicides,
corticosteroids and benzoyl peroxide.
• Single and multiple vitamins with and without
fluoride are covered for Members under 21 when
medically necessary
• Prenatal vitamins
• Quinine
• Oral electrolyte mixtures
• Tobacco cessation products
Generic Medications
Generic drugs are mandated when AB-rated generic
drugs are available. Requests for “Brand Necessary”
medications require prior authorization. The
request must include information to substantiate
medical necessity for a brand medication, such as
documentation of adverse effects of generic alter-
natives. Brand name products are covered without
authorization for the following drugs:
• Thyroid preparations
• Phenytoin
• Digoxin
• Carbamazepine
• Insulin
• Lithium
• Sustained Release
• Warfarin
Theophylline
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Behavioral Health Drugs
The following drugs may only be prescribed by a
behavioral health provider:
• Clozapine
• Olanzapine
• Naltrexone
• Naloxone
• Quetiapine
• Risperidone
• Disulfiram
• Thioridazine
• Ziprasidone
Physician Prior Authorization Program
Prior authorization is required for the follow-
ing products:
• All non-formulary medications
• All prescriptions that exceed plan limits
• All brand name medications where there is an
AB rated generic equivalent
• Limited use agents
• Regimens that are outside the parameters of use
approved by the FDA or accepted standards of
care
• Prescriptions that exceed $500.00
• Self-Injectable medications other than insulin,
Epipen, Haloperidol and Fluphenazine
• Prescriptions processed by non-network
pharmacies
• Extended duration of antibiotics in excess of 10
day supply for Cephalosporins, Pediazole,
Biaxin®, Augmentin® and Diflucan®
• Greater than 5 day supply for Zithromax® and
Avelox®
• Greater than 7 days for Tequin®
• Greater than 14 days for Cipro®
• Greater than 90 days treatment period of Proton
Pump Inhibitors
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• Compounded prescriptions
• Early refills
• Vacation supplies in excess of one vacation
supply per medication per year
Prior Authorization Procedure
The Pharmacy Services Department at Keystone
Mercy issues prior authorizations to allow process-
ing of certain prescription claims that would other-
wise be rejected. To contact the Pharmacy Services
Department by telephone, call 800-588-6767
between 8:30 a.m. and 6:00 p.m. Monday through
Friday (EST); and after business hours, Saturday,
Sunday and Holidays, the Member Services
Department at 800-521-6860.
The prior authorization procedure is as follows:
I
The physician or the dispensing pharmacist
contacts Keystone Mercy by telephone
(800-588-6767) or in writing by fax
(215-937-5018) to request prior authorization
for non-formulary, non-covered agents, or
those designated pharmaceutical agents out-
lined in the formulary. Member Services
Department may be contacted after business
hours, Saturdays, Sundays, and Holidays by
telephone at 800-521-6860.
II Utilizing criteria approved by both Keystone
Mercy’s Pharmacy and Therapeutics Committee
and DPW, (hereafter referred to as “Approved
Criteria”), a Keystone Mercy pharmacist reviews
the request.
A. When the prior authorization request meets
the Approved Criteria, the request is
approved and payment for the prescription
may be authorized for a period of up to six
months, or for the length of the physician’s
request, whichever is shorter.
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III When the prior authorization request does not
meet the Approved Criteria, the request is for-
warded to a Keystone Mercy Medical Director
for review. In evaluating the request, the
Medical Director generally relies upon informa-
tion supplied by the prescriber, guidelines pub-
lished in the Physicians Desk Reference, and
accepted clinical practice guidelines. In the
event of insufficient information provided by
the prescriber, a Keystone Mercy Pharmacist
will attempt to contact the prescriber to obtain
the necessary clinical information for review.
In addition, the decision will comply with the
following statutory and regulatory requirements:
• 55 Pa. Code 1121 (The Pennsylvania Code)
• Medical Assistance Bulletin 02-94-03
• The Social Security Act
• OBRA ’90 guidelines
• Any other applicable state and/or federal
statutory/regulatory provisions
A. If the request is for an ongoing medication,
Keystone Mercy will automatically authorize
a 15-day temporary supply of the requested
medication at the point-of-sale. If the
request is for a new medication and the
medication is covered by the Medical
Assistance Program, a 5 day temporary
supply of medication will automatically be
authorized at the point-of-sale.
B. Keystone Mercy will review requests for
prior authorization when a 5 or 15 day
temporary supply has been dispensed,
regardless of whether the prescriber formal-
ly submits a prior authorization request.
Keystone Mercy will review such prior
authorization requests and issue its deter-
mination within 24 hours. In the event that
Keystone Mercy cannot issue a written
denial notice within the 24 hour time-frame,
Keystone Mercy will authorize a temporary
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supply until such time that the member is
notified of Keystone Mercy’s determination.
For those requests that are approved by a
Keystone Mercy pharmacist, Keystone Mercy
will contact the Participating Pharmacy by
telephone to inform the Pharmacy of the
approval. Within one business day of being
notified by Keystone Mercy Health Plan of
the approval, the Participating Pharmacy
must contact the Member to let the Member
know that the prescription has been author-
ized and when the prescription will be ready
for pick-up.
C. For those requests that can not be approved
by a Keystone Mercy pharmacist, a Keystone
Mercy Medical Director will review each
request and make a determination within 24
hours of receipt. In the event of a denial,
Keystone Mercy will notify the physician,
the Primary Care Physician (PCP) and the
Member in writing within 24 hours and will
offer the physician a formulary approved
alternative. The correspondence will outline
specifically all Member and practitioner
appeal rights. If the request is approved by
the Medical Director, Keystone Mercy will
notify the prescribing physician that the
request has been approved.
D. The prescribing physician or PCP may dis-
cuss Keystone Mercy’s decision with a
Keystone Mercy Clinical Pharmacist or
Medical Director during regular business
hours. To speak with a Keystone Mercy
Clinical Pharmacist or Medical Director,
please call the Pharmacy Services
Department at 800-588-6767.
E. Prescribers and members may obtain prior
authorization criteria related to a specific
denial determination by submitting a writ-
ten request for the criteria to the Pharmacy
Services Department.
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Provider Complaint/Appeal Procedures
Participating providers of all provider types includ-
ing Participating Pharmacies have the opportunity
to request resolution of informal provider com-
plaints or formal provider appeals that have been
submitted to the appropriate internal Keystone
Mercy Health Plan Department.
Pharmacy Providers wishing to register an infor-
mal provider complaint should do so by contact-
ing the Provider Services Department at
800-521-6007, or the Pharmacy Services
Department at 800-588-6767. Provider or
Pharmacy Services Representatives will document
the complaint and coordinate resolution. The
Provider or Pharmacy Services Representative who
initially took the call is responsible for informing
the provider, either by telephone or written corre-
spondence, of the resolution.
Pharmacy Providers who are dissatisfied with the
resolution of an informal provider complaint may
request a formal provider appeal. Formal provider
appeals must be submitted in writing to the
Keystone Mercy Provider Appeals Department,
200 Stevens Drive, Philadelphia, PA 19113.
Physicians and Pharmacy Providers, with the
Member’s written consent, may file a grievance
on behalf of the Member by contacting Keystone
Mercy’s Member Services Department at
800-521-6860.
Temporary Supplies
Keystone Mercy and its Participating pharmacies
are required by DPW to dispense a temporary sup-
ply of medications when a prescription rejects for
prior authorization because the medication is not
on the formulary or is a formulary medication
requiring prior authorization. For new medication
therapies, a 5 day supply of the medication must
be dispensed and for ongoing medication therapies,
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a 15-day supply of medication must be dispensed.
In order to facilitate this mandate, Argus Health
Systems has automated these temporary supplies.
If you are having difficulty in transmitting a claim
for a temporary supply, please contact Keystone
Mercy Pharmacy Services Department at
800-588-6767 during normal business hours of
8:30-6:00 Monday to Friday, and Keystone Mercy
Member Services Department at 800-521-6860
after business hours, Saturdays, Sundays and
Holidays. A Member whose prescription rejects
for prior authorization because the medica-
tion is non-formulary or a formulary medica-
tion requiring prior authorization should not
be turned away at the pharmacy without
receiving a temporary supply of the medica-
tion unless the dispensing pharmacist, in
his/her professional opinion, feels that dis-
pensing the medication would jeopardize the
health and safety of the Member.
Medications Covered by Other Insurance
(Coordination of Benefits and Third Party
Liability)
As an agent of the Commonwealth of Pennsylvania
Medical Assistance Program, Keystone Mercy is
always the payor of last resort in the event that a
Member receives a medication that is covered by
another payor source. The claim must be billed to
the primary insurance, and subsequently billed on-
line or submitted on a Universal Claim Form (UCF)
to Keystone Mercy for any outstanding balance.
Non-Covered Medications
The following is a list of non-covered medications
under the Medical Assistance Program:
• Drugs and other items prescribed for any of the
following: obesity, anorexia, weight loss, weight
gain or appetite control unless the drug or item
is prescribed for any medically accepted indica-
tion other than obesity, anorexia, weight loss,
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weight gain or appetite control.
• Hair growth or other cosmetic purposes
• Drugs which promote fertility
• Nonlegend drugs in the form of troches,
lozenges, throat tablets, cough drops, chewing
gum, mouthwashes and similar items with the
exception of products for tobacco cessation.
• Pharmaceutical services provided to a hospital-
ized person.
• Single entity and multiple vitamin preparations
except for those listed above.
• Drugs and devices classified as experimental by
the FDA or not approved by the FDA.
• Placebos.
• Nonlegend soaps, cleansing agents, dentifrices,
mouthwashes, douche solutions, diluents, ear
wax removal agents, deodorants, liniments, anti-
septics, irrigants, and other personal care and
medicine chest items.
• Nonlegend aqueous saline solution
• Nonlegend water preparations
• Nonlegend drugs not covered by the
Pennsylvania Medical Assistance Program.
• Items prescribed or ordered by a physician who
has been barred or suspended from participating
in the Medical Assistance Program.
• DESI drugs and identical, similar or related prod-
ucts or combinations of these products.
• Legend or nonlegend drugs that the manufactur-
er seeks to require as a condition of sale that
associated tests or monitoring services be pur-
chased exclusively from the manufacturer or its
designee.
• Prescriptions or orders filled by a pharmacy
other than the one to which a recipient has been
restricted because of misutilization or abuse.
• Nonlegend impregnated gauze and any identical,
similar, or related nonlegend products
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• Any pharmaceutical product marketed by a drug
company which has not entered into a rebate
agreement with the Federal Government as pro-
vided under section 4401 of the Ominibus
Budget Reconciliation Act of 1990.
Drug Utilization Review
Keystone Mercy’s pharmacy drug utilization pro-
gram is coordinated with Keystone Mercy quality
assurance programs to achieve quality care
through a disease management approach.
The Drug Utilization Program is designed to identi-
fy and correct potentially harmful prescribing pat-
terns, enhance community prescribing standards,
and detect patterns of fraud and abuse. The policy
and procedures meet federal statute/regulation
citation Section 4401 (g) of OBRA ’90 and 42 CFR
456 as well as NCQA guidelines. Keystone Mercy’s
continuous quality improvement philosophy allows
for annual evaluation and assessment of the pro-
gram, resulting in the implementation of improved
programs that are responsive to the needs of our
members and providers.
The Prospective Drug Utilization Review (DUR)
system provides Keystone Mercy with the ability
to minimize the number of potentially dangerous
conditions that result from improper drug
utilization.
The system achieves this objective by:
• Reviewing prescription drug claims for
therapeutic appropriateness prior to medication
dispensing
• Using criteria that include the patient’s medical
history and clinical parameters
• Focusing on those Members with conditions that
place them at the highest level of risk for poten-
tially harmful outcome
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At the point of sale, the prescription is reviewed
against the therapeutic criteria file catalogues, and
therapeutic problems are monitored that are sig-
nificant to Keystone Mercy’s prescription drug pro-
gram. The therapeutic file includes approximately
228 AHFS primary classes of drugs. Further, the
criteria address disease categories that may predis-
pose patients to inappropriate and potentially
harmful drug use situations.
The system evaluates each incoming drug claim
when the pharmacist enters the information for
the prescription with respect to the Member’s drug
and medical history. The system identifies poten-
tial drug therapy problems. Monitoring is accom-
plished through an on-line alert message system
transmitted in conjunction with claim adjudica-
tions that may present potential therapeutic prob-
lems. When appropriate, the pharmacist receives
advice, then takes additional steps to evaluate the
order (e.g., calling the prescribing physician).
The file also incorporates the following, eleven
drug therapy problem types:
• Excessive drug dosage (age-specific)
• Insufficient drug dosage (age-specific)
• Drug pregnancy contraindications
• Excessive quantity dispensed
• Early refill (over-utilization)
• Late refill (under-utilization)
• Drug age contraindications
• Drug drug interactions
• Therapeutic duplications
• Generic product availability
All criteria are rated using the following severity
indicators:
• Cause serious harm to relatively few people
(high risk and low incidence)
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• Cause relatively minor harm to a large number
of people (low risk and high incidence)
• Significantly increase the cost of health care by
increasing hospitalizations or the use of other
treatment modalities.
A claim that is submitted either on-line (or previ-
ously approved for paper, via paper claim) by a
participating pharmacy and subsequently
approved for payment that includes DUR messages
is subject to post – payment audit and recoupment
if written documentation is not maintained that
pertains to the message(s) returned with the claim.
If a message is returned saying that the approved
claim has a dosage that exceeds standards devel-
oped by a national database company, and no
notation is retrievable that documents a discussion
between the pharmacist and the prescriber verify-
ing the high dose, the claim is subject to reversal
upon audit. Likewise, a claim paid but returned
with a duplicate therapy message is subject to
reversal without documentation demonstrating
that the prescriber spoke with the dispensing phar-
macist and approved the concurrent administra-
tion of both drugs involved.
In the event a medication requires prior authoriza-
tion, a system alert message will appear, advising
the pharmacist to call the Keystone Mercy
Physician Prior Authorization Line.
Keystone Mercy Health Plan produces selected ret-
rospective review reports for clinical analysis and
physician intervention services utilizing Argus
Health System’s RX Focus computer program. This
provides screening and trending of prescription
claims data, using therapeutic criteria standards,
to identify patterns of inappropriate drug utiliza-
tion and to evaluate the total cost of care.
Keystone Mercy reviews the information and sub-
mits reports to its Pharmacy and Therapeutics
Committee for review and development of quality
improvement programs. These will include but are
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not limited to outcomes research activities,
provider education and member education
programs.
Recipient Restriction
Keystone Mercy participates in DPW's Recipient
Restriction Program. Under this program, Members
that are identified by Keystone Mercy and DPW as
misutilizing and/or abusing services or defrauding
Keystone Mercy or the Medical Assistance Program
are restricted to one physician and one
Participating Pharmacy for a period of five (5)
years. Keystone Mercy contacts the Member’s
physician and Participating Pharmacy of choice to
ask if the provider is willing to accept the restrict-
ed Member. The restriction is not enforced in cases
of emergency. Please contact Keystone Mercy at
800-588-6767 in such cases. If you suspect
Member misutilization, abuse and/or fraud, please
contact Keystone Mercy’s Recipient Restriction
Coordinator at 215-937-5020 or our Pharmacy
Services Department at 800-588-6767.
Compounded Prescriptions
A claim for a compound prescription should be
submitted using the NDC of the most expensive
legend ingredient (one of the ingredients must be a
legend drug). The pharmacy’s software should be
able to flag the prescription as a “Compound
Prescription” and the compound ingredient cost
must be manually entered by the pharmacy. The
claim may be submitted via paper claim if the
Participating Pharmacy is unable to process com-
pound prescriptions on-line.
Quantity
For liquids or topical medications, the metric
quantity of the medication should be reported as
the number of grams (gms) or milliliters (mls). If
the metric quantity is a fraction, round up to the
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nearest whole number (i.e. for 42.4 gms round up
to 43). All topical medications are limited to the
smallest available size.
Durable Medical Equipment (DME)
Supplies
Certain DME supplies under $500.00, such as
blood glucose test strips, lancets, alcohol swabs
and generic diapers are covered by Keystone
Mercy’s DME Program and may be billed on-line by
the Participating Pharmacy if the Participating
Pharmacy has executed an Keystone Mercy
Participating Pharmacy Agreement Addendum to
dispense such DME supplies.
Blood Glucose Monitors
Providers may call 888-744-3671 to order a blood
glucose monitor for Keystone Mercy Members. The
monitor will be shipped directly to the Member’s
home.
Additional Information
Pharmacies who have additional questions not
addressed by the formulary preface should contact
the Keystone Mercy Pharmacy Services Department
at 800-588-6767.
Available Web Information
The following reference materials are available on
the Keystone Mercy Health Plan website:
www.keystonemercyhp.com
• Keystone Mercy Formulary
• Keystone Mercy Prior Authorization Form
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Self-Injectable Medications
Certain self-injectable products require an authori-
zation from Keystone Mercy prior to dispensing.
To obtain the authorization, the treating physician
must complete the Prior Authorization Form and
return it to the Keystone Mercy Pharmacy Services
Department via fax at 888-981-5202. Additional
supportive information, such as objective patient
findings and clinical laboratory results, may be
requested by Keystone Mercy to support the
request for prior authorization.
Upon receipt of a completed Prior Authorization
Form, a determination to approve or deny cover-
age for the requested self-injectable product will
be made by Keystone Mercy within 24 hours of
receipt of all information reasonably necessary to
make a determination. The prior authorization
decision will be communicated in writing to both
the requesting provider and the member.
Smoking Cessation Benefit
Members with pharmacy coverage are entitled to
receive up to 6 months of smoking cessation prod-
ucts per calendar year. This would include generic
nicotine replacement patches and Zyban, which do
not require prior authorization. If you have ques-
tions about the smoking cessation benefit, contact
Pharmacy Services at 800-588-6767.
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