Reimbursement for Medicine (Other than Co-Pay Amounts)

There may be times when you pay for your medicine. Keystone Mercy may reimburse you, if you are eligible to receive the medicine at the time you paid for it. This reimbursement process does not apply to co-payments.

Generally, reimbursement is NOT made for medicines that:

• Require prior authorization
• Are not covered by either Keystone Mercy or the Pennsylvania Medical Assistance Program
• Are not medically necessary
• Go over certain dose and supply limits set by the FDA
• Are re-filled too soon

To request reimbursement for medicines you paid for:

Your request for a refund must be in writing. You must send a detailed pharmacy receipt that includes:

• Date you bought the medicine
• Member's name
• Drug store name, address (city, state, zip code) and phone number
• Name, strength and quantity of medicine
• NDC number of medicine (if you are not sure about this information, ask the pharmacist to help you)
• Total amount you paid for each medicine

Write your name, address, phone number, and Keystone Mercy ID number on your receipt or another piece of paper. Send the above information to:

Pharmacy Department
Keystone Mercy Health Plan
200 Stevens Drive
Philadelphia, PA 19113-1570

It may take six to eight weeks before you receive payment.

NOTE: A receipt that does not include the above information will NOT be considered and will be returned to the member. Receipts should be turned in as soon as possible. Receipts older than 365 days will not be accepted. Please remember to keep a copy for your records.