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Frequently Asked Questions
Select Drug Program®
How do I find a network pharmacy?
IBC’s pharmacy benefits are administered by FutureScripts, an independent company. More than 60,000 participating retail pharmacies in the U.S. recognize and accept FutureScripts prescription ID cards, including large chains and many neighborhood pharmacies.
To locate a participating pharmacy, call 1-888-678-7012 or go to the FutureScripts website.
What is the mail-order program?
Plan participants whose plan includes a mail-order program benefit may choose to receive certain prescriptions by mail, which offers convenience and cost-effectiveness. Under this program, plan participants should receive two separate prescriptions from their physician — one prescription is for the first 30-day supply, which the plan participant may fill immediately at a retail pharmacy, and the second is for the mail-order service and can be written for up to a 90-day supply of medication.
Are physicians required to prescribe medications only on the formulary?
Physicians may prescribe any covered medication, regardless of whether the drug is on the formulary or not. The formulary is a list of clinically appropriate medications intended to help plan participants receive pharmaceutical coverage at a lower out-of-pocket expense. Be aware that medications on this list may be subject to the plan participant’s benefit exclusions and other pharmacy edits.
What is the Pharmacy and Therapeutics Committee?
The Pharmacy and Therapeutics Committee was formed to oversee our pharmacy policies and procedures and to promote the selection of clinically safe, clinically effective, and economically advantageous medications for our plan participants. The Committee also reviews and approves FutureScripts pharmacy and related medical policies. The Committee is made up of practicing physicians and pharmacists.
The Committee meets regularly and may amend formularies and preferred drug lists quarterly — in January, April, July, and October.
What is prior authorization?
Prior authorization is required for certain covered drugs that have been approved by the U.S. Food and Drug Administration (FDA) for specific medical conditions. The approval criteria was developed and endorsed by the Pharmacy and Therapeutics Committee and is based on scientific and clinical evidence and information from the FDA’s current medical literature.
Clinical pharmacists evaluate requests for these drugs based on clinical data and information submitted by the prescribing physician and available prescription drug history. The clinical pharmacists determine whether the request meets the FDA-approved criteria, whether there are any potential drug interactions or contraindications, and whether dosing and length of therapy are appropriate and clinical options are evaluated.
If the request cannot be approved by applying established review criteria, a medical director will review the request. Without this approval, drugs requiring prior authorization will not be covered at a retail or mail-order pharmacy.
What are your procedures for safe prescribing?
The effectiveness and safety of drugs and drug-prescribing patterns are monitored. Several procedures, such as prior authorization, have been established to support safe prescribing patterns.
What are age and gender limits?
Age and gender limits are restrictions on coverage of drugs designed to prevent potential harm to plan participants and promote appropriate utilization. The approval criteria are based on information from the FDA, medical literature, actively practicing consultant physicians and pharmacists, and appropriate external organizations, and are endorsed by the Pharmacy and Therapeutics Committee. For example, some drugs are only approved by the FDA for individuals older than age 14, such as ciprofloxacin, or if prescribed only for females, such as prenatal vitamins.
Systems are linked to network pharmacies, which provide up-to-date information regarding age and gender limits. If the plan participant’s prescription does not meet the FDA age and gender guidelines, it will not be covered unless an exception is obtained. To request an age or gender limit exception, the physician may submit appropriate documentation of medical necessity for review.
What are quantity limits?
Quantity limits are designed to allow a sufficient supply of medication based on FDA recommendations and endorsement from the Pharmacy and Therapeutics Committee. The first type of quantity limit is based on a 30-day supply of a medication per fill. If the prescription exceeds the quantity limit, the pharmacist will fill for the allowed supply and then the plan participant must follow up with his or her physician regarding future prescriptions. The prescribing physician may request a quantity limit exception if the plan participant’s therapy requires a larger daily dose of medication.
Another type of quantity limit is based on FDA dosing guidelines over a rolling 30-day period. For example, quantity limits per a rolling 30-day period apply to migraine medications and some fertility agents (if covered under the group contract).
If the quantity of medication prescribed exceeds the quantity limit, the prescribing physician must submit supporting information to demonstrate the need for an increased quantity. The plan participant should contact the prescribing physician to initiate a request for a quantity exception. The purpose of these edits is to make certain that these drugs are used as prescribed.
Another type of quantity limit is called “Refill Too Soon”. If a plan participant used less than 75 percent of the total supply of a previously filed prescription, the refill request will be rejected at the pharmacy. This limit helps ensure that medication is being taken in accordance with the prescribed dose and frequency of administration.
How do I request an exception to an age, gender, or quantity limit?
To request consideration for an age, gender, or quantity limit exception, your physician must submit appropriate documentation of medical necessity. This information is reviewed as described in question number 5.
How do I appeal a decision (coverage or limits)?
If a request for prior authorization or formulary coverage for a non-formulary medication is denied, either a plan participant or a physician may appeal the decision with the member’s consent. Both parties will receive written notification of a denial, which will include the appropriate correspondence information to initiate an appeal. In all cases, physicians should be involved in the appeal process to provide any additional clinical information that may support the request for approval.
What is a 96-hour temporary supply?
There may be times when a prescription is denied at the pharmacy because a prior authorization is required. If this should occur after business hours or on a weekend or holiday, or if your physician is not available, network pharmacies will provide a 96-hour temporary supply of the drug until a prior authorization request can be submitted and a determination can be made. The 96-hour temporary supply is not a guarantee that the prior authorization will be approved. A one-time, 96-hour supply may be obtained for medications with the exception of:
- products for which manufacturer’s packaging precludes dispensing a 96-hour temporary supply (e.g., Enbrel®, topical retinoid products, antihemophilic factor, Nimotop®, and Depo-Provera®);
- drugs not covered under the plan participant’s pharmacy benefit;
- drugs for erectile dysfunction.
The retail pharmacy will receive an online message advising them to call for assistance in processing the claim for the supply of medication. The plan participant will not be charged cost-sharing for this supply.
The prescribing physician will be contacted the next business day to obtain information needed to initiate the prior authorization. The request will be processed upon receipt of complete information.
How frequently does the formulary change?
The Pharmacy and Therapeutics Committee, which meets regularly, may amend the formulary and preferred drug lists quarterly — in January, April, July, and October. Affected plan participants and physicians are notified of these changes.
What is Specialty Pharmacy?
Specialty Pharmacy refers to a pharmacy that provides self-injectables and certain oral specialty medications that can be administered at home or in a physician’s office. These complex and costly medications usually require special storage and handling and may not be readily available at your local drug store.
How do I get started with the Specialty Pharmacy Program?
Getting started with the Specialty Pharmacy Program is easy. Simply call the pharmacy number on the back of your member ID card, select 1 for members, and follow the phone menu prompts for Specialty Pharmacy.
*FutureScripts® is an independent company and serves as Independence Blue Cross’ pharmacy benefits manager.