2021 2 Tier Standard - Keystone First VIP Choice 2021 Member Formulary Formulary ID 21350 CURRENT AS OF 1/1/2021 Name of Drug Drug Tier Necessary actions, restrictions, or limits on use Analgesics - Treatment Of Pain Analgesics, Other acetaminophen-codeine #2 oral tablet 300-15 mg 1 MME acetaminophen-codeine #3 oral tablet 300-30 mg 1 MME Keystone First Community HealthChoices (CHC) may reimburse you, or pay you back. A formulary is a list of covered drugs selected by Keystone First VIP Choice in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Please use the following link to find additional information on the Pennsylvania Medical Assistance Program Preferred Drug List (PDL) (includes PDF of DHS PDL) Important Formulary Update: Not all participants will qualify for all Keystone First Community HealthChoices (KF-CHC) pharmacy services. Prescription medicines. Medicaid LTSS Participants: Please use the following links to find additional information on the DHS PDL and the Keystone First CHC Supplemental Formulary: Important Formulary Update: Prescribers: Click here to Submit a Prior Authorization Request Online. This information is not a complete description of benefits. If you have questions about, please call Participant Services at 1-855-235-5115 (TTY 1-855-235-5112) to talk to a Participant Services Representative 24 hours a day, 7 days a week. Enrollment in Keystone First VIP Choice depends on contract renewal. Reimbursement for medicine. Keystone First CHC will work with our Participants to help them get the care they need, when they need it, and where they need it If you have Keystone First CHC as a secondary coverage, use our list of covered over-the-counter medicines. Call 1-800-450-1166 (TTY/TDD 711), 8 a.m. to 8 p.m., seven days a week for more information. If you have questions about, please call Participant Services at 1-855-332-0729 (TTY 1-855-235-4976) to talk to a Participant Services Representative 24 hours a day, 7 days a week. There may be times when you pay for your medicine. For more detailed information about your Keystone First prescription drug coverage, please review your Member Handbook and other plan materials.. If you have Keystone First VIP Choice, use our Medicare Part D formulary. If you have questions about Keystone First, please call Member Services at 1-800-521-6860, TTY users should call 1-800-684-5505. Important Formulary Update: Prescribers: Click here to Submit a Prior Authorization Request Online. Important Formulary Update: Not all participants will qualify for all Amerihealth Caritas Pennsylvania (PA) Community HealthChoices (CHC) pharmacy services. Keystone First CHC Searchable Formulary; Keystone First CHC Supplemental Formulary (PDF) Machine-readable formulary. 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