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Prior Authorization*
Independence Blue Cross requires prior authorization of certain covered drugs that have been approved by the Food and Drug Administration (FDA) for specific medical conditions. The approval criteria was developed and endorsed by the FutureScripts® Pharmacy and Therapeutics Committee and is based on information from FDA and manufacturers, medical literature, actively practicing consultant physicians, and appropriate external organizations.
A request form must be completed for all medications requiring prior authorization. The forms below are available in PDF format for manual submission or may be submitted by providers electronically via NaviNet®.
 Analgesic Medications (Celebrex®, Mobic®, Ultram ER®, Flector patch®, Voltaren gel®, Ryzolt®and Zipsor®)- Anti-Infective Agents (Avidoxy®, Avidoxy DK®, Zmax®, Zyvox®, Noxafil®, Oracea®, and Nutridox®)
- Arthritis/Psoriasis Agents (Enbrel®, Kineret®, Humira®, Amevive®, Raptiva®, Simponi®, Cimzia®, and Actemra®)
- Bisphosphonate Agents
- Botulinium Toxins (Type A & B)
- Diabetic Agents (Byetta®, Exubera®, Glumetza®, Janumet®, Januvia®, Prandimet®, Onglyza®, and Symlin®)
- Diabetic Test Strips (LifeScan One Touch®, Accu-Check®)
- Direct Ship Injectable Form
- Effient®
- Erectile Dysfunction Agents (Viagra®, Caverject®/Edex®, MUSE®, Levitra®, and Cialis®)
- Exjade®
- Forteo® (Tepriparatide [rDNA origin] Injection)
- General Pharmacy (Gender Edit, Quantity Edit, Age Edit, Prior Authorization)
- Growth Hormone Enrollment Form
- Lyrica® (pregabalin)/Pristiq®/Savella®/Aplenzin®
- Medicare Administrative for Part B/D coverage
- Migraine Agents
- Non-formulary Exception Request
- Oral Chemotherapy Agents
- Paliperidone (Invega®)/Fanapt®/Saphris®/Quetiapine fumarate (Seroquel XR®)
- Proton Pump Inhibitors (Aciphex®, Nexium®, Prevacid®, Prevacid NapraPAC®, Protonix®, Pylera®, Zegerid ®, Prilosec® Suspension, and Kapidex® )
- Provigil® (modafinil)/Nuvigil® (armodafinil)
- Renvela ®
- Synagis® (palivizumab)
- Synvisc®, Supartz®, Hyalgan®, Euflexxa®, Orthovisc®, and Synvisc-One®
- Vyvanse®/Intuniv®/Daytrana®
- Xolair® (omalizumab)
Request Form Instructions
Providers:
- When filling out a prior authorization form, all requested information must be supplied. Incomplete requests will be faxed back to your office for completion, which will delay the review process.
- Fax completed forms to the Pharmacy Services Department for review. Make sure you include your office telephone and fax number.
- You will be notified by fax if the request is approved. You and your patient will receive a denial letter if the request is denied.
- If you have not gotten a response after two business days from submitting complete information, contact the Provider Services Department.
Members:
- Take the appropriate request form to your physician to be completed.
- You or your physician may fax the completed form to the Pharmacy Services Department for review.
- If you have not gotten a response after two business days from your provider submitting complete information, contact the provider who requested the prior authorization on your behalf.
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Philadelphia Area |
Outside Philadelphia |
| Pharmacy Services Department |
| Fax numbers: |
215-241-3073 |
1-888-671-5285 |
As with all our preauthorization requirements, a provider should complete the process fully to avoid delay. Any questions about precertification applications or process, providers should call Provider Services at 215-567-3590 or 1-800-227-3119 (outside the Philadelphia area). To receive a copy of our Select Drug and Standard formularies, please call 1-800-858-4728.
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