When you need services that require preapproval, your primary care physician (PCP) or provider contacts the Care Management and Coordination (CMC) team and provides information to support the request for services. The CMC team, made up of physicians and nurses, evaluates the proposed plan of care for payment of benefits. The CMC team notifies your physician/provider if the services are approved for coverage. If the CMC team does not have sufficient information or the information evaluated does not support coverage, you and your physician/provider are notified in writing of the decision. Members and providers acting on behalf of a member may appeal the decision. At any time during the evaluation process or the appeal, the provider or member may provide additional information to support the request.
Services that require preapproval include, but are not limited to:
*This applies to HMO, Direct Point-of-Service, and Point-of-Service members.
**This list applies to members with prescription drug plans. This list is subject to change.
When a Keystone Point-of-Service member seeks self-referred benefits, the member is required to preauthorize the following:
*Self referred care only applies to Point-of-Service and Direct Point-of-Service products.
**This applies to members with prescription drug plans. This list is subject to change.
Download a list of specialty drugs requiring precertification. (link to Specialty Drugs/Biotech pdf)
During and after an approved hospital stay, the CMC team monitors your stay. They review whether the care is being provided in an efficient manner and in the appropriate setting, see that a plan for your discharge is in place, and coordinate services that may be needed following discharge.
To assist IBC in making coverage determinations regarding the medical necessity and appropriateness of requested services, IBC uses medical guidelines based on clinically credible evidence. This is called utilization review. Utilization review can be done before a service is performed (prenotification/precertification/preservice); during a hospital stay (concurrent review); or after services have been performed (retrospective/post-service review). IBC follows applicable state/federal standards pertaining to how and when these reviews are performed.
For HMO, POS, and Direct POS members, IBC offers members continuation of coverage for an ongoing course of treatment with a terminated provider (for reasons other than cause) for up to 90 days from the date that IBC notified the member of the provider termination. IBC will cover such continuing treatment under the same terms and conditions as if the treatment was being received from participating providers.
If a member is in her second or third trimester of pregnancy at the time of the termination, the transitional period of authorization shall extend through post-partum care related to the delivery.
All authorized health care services provided during this transitional period would be covered by IBC under the same terms and conditions applicable for participating health care providers. The nonparticipating provider must agree that all authorized health care services provided during this transitional period would be covered by IBC under the same terms and conditions applicable for participating health care providers.
In order to initiate continuity of care, members must complete a Continuity of Care form and submit it to IBC’s Care Management and Coordination department. The form is available through Customer Service.
Nonparticipating health care providers (whose services are covered during the transitional period) must agree to be bound by the same terms and conditions as participating providers. The plan is not required to provide health care services that are not covered benefits.
New Keystone HMO, Keystone Point-of-Service, and PPO members may continue an ongoing course of treatment with a nonparticipating health care provider for a transitional period of up to 90 days from the effective date of enrollment into the plan subject to the requirements set forth herein and in the applicable group master contract.
If the new member is in her second or third trimester of pregnancy at the time of the effective date of enrollment, the transitional period of authorization shall extend through post-partum care related to the delivery.
The nonparticipating provider must agree that all authorized health care services provided during this transitional period shall be covered by Keystone under the same terms and conditions applicable for participating health care providers.
In order to initiate continuity of care, members must complete a Continuity of Care form and submit it to Keystone’s Care Management and Coordination department. The form will be in the enrollment materials and available through Customer Service.
Nonparticipating health care providers (whose services are covered during the transitional period) must agree to be bound by the same terms and conditions as participating providers. The plan is not required to provide health care services that are not covered benefits.
An emergency is defined as the sudden and unexpected onset of a medical condition manifesting itself in acute symptoms of sufficient severity or severe pain that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in any of the following:
Emergency care includes covered services provided to a member in an emergency, including emergency transportation and related emergency services provided by a licensed ambulance service.
You have a right to appeal any adverse decision through the Complaint and Grievance Process. Instructions for the appeal will be described in the denial notifications and in the Subscriber Agreement.
At IBC, protecting your privacy is very important to us. That is why we have taken numerous steps to see that your Protected Health Information (PHI) is kept confidential. Protected health information is individually identifiable health information about you. This information may be in oral, written, or electronic form. IBC may obtain or create your PHI while conducting our business of providing you with health care benefits.
IBC has implemented policies and procedures regarding the collection, use, and release or disclosure of PHI by and within our organization. We continually review our policies and monitor our business processes to make sure that your information is protected while assuring that the information is available as needed for the provision of health care services. For example, our procedures include steps to assist us in verifying the identity of someone calling to request PHI, procedures to limit who on our staff has access to your PHI, and directions to share only the minimum amount of information when PHI must be disclosed. We also protect any PHI transmitted electronically outside our organization by using only secure networks or by using encryption technology if the information is sent by email.
We do not use or share your PHI without your permission unless the law allows us to do so. Before using or disclosing your PHI for other purposes, we’ll obtain your written permission, also called an authorization. You may also direct us to share your PHI with someone you choose by giving us your written authorization. However, this authorization must include certain specific information in order to be valid. You may print a copy of our Authorization to Release Information form from our website, www.ibx.com, or request a copy by calling our Privacy Office at 215-241-4735.
The following information applies to members who have a prescription drug plan with Independence Blue Cross.
Independence Blue Cross utilizes an independent pharmacy benefits management (PBM) company, FutureScripts®, to manage the administration of its commercial prescription drug programs. As our PBM, FutureScripts is responsible for providing a network of participating pharmacies, administering pharmacy benefits, and providing customer service to our members and providers.
Prior authorization is a requirement that your physician obtain approval from your health plan for coverage of, or payment for, your medication. Independence Blue Cross requires prior authorization of certain covered drugs to ensure that the drug prescribed is medically necessary and appropriate and is being prescribed according to the Food and Drug Administration (FDA) guidelines. The approval criteria were developed and endorsed by the FutureScripts Pharmacy and Therapeutics Committee, which is an established group of medical directors and practicing area physicians and pharmacists.
Using these approved criteria, clinical pharmacists evaluate requests for these drugs based on clinical data, information submitted by the member’s prescribing physician, and the member’s available prescription drug therapy history. Their review includes a determination that there are no drug interactions or contraindications, that dosing and length of therapy are appropriate, and that other drug therapies, if necessary, were utilized.
Without prior authorization, the member's prescription will not be covered at the retail or mail order pharmacy (see 96-Hour Temporary Supply Program). The prior authorization process may take up to two working days once complete information from the prescribing physician has been received. Incomplete information will result in a delayed decision.
Prior authorization approvals for some drugs may be limited to 6 to 12 months. If the prior authorization for a drug is limited to a certain time frame, an expiration date will be given at the time the approval is made. If the physician wants a member to continue the drug therapy after the expiration date, a new prior authorization request will need to be submitted and approved in order for coverage to continue.
Currently, the drugs listed below are a part of the prior authorization program. Prior authorization applies to all formulations of these specific drugs, including, but not limited to, tablet, capsule, and oral suspension. AcipHex®, Actiq®, AdcircaTM, Afinitor®, AlodoxTM, AltabaxTM, Alvesco®, Ambien CR®, AmeviveTM, AmpyraTM, AMRIX®, Apidra®, Apidra® SoloSTAR®, AplenzinTM, Atacand®/Atacand HCT®, Avapro®/Avalide®, AvidoxyTMDK, AZOR®, BanzelTM, Benicar®/Benicar HCT®, BepreveTM, BiDil®, Botox®, Byetta®, Caduet®, Caverject®, CaystonTM, Celebrex®, Cesamet®, Cialis®, Cimzia®, ColcrysTM, Cozaar®/Hyzaar®, Crestor®, Cymbalta®, DaytranaTM, Diabetic Test Strips (except Autodisc®, Breeze® 2, Contour®, FreeStyle Lite® and Precision Xtra®), Diovan®/Diovan HCT®, Edex®, EdluarTM, EffientTM, Enbrel®, ExalgoTM, Exforge®, EXFORGE HCT®, Exjade®, FanaptTM, Fentora®, Flector® Patch, ForteoTM, Genotropin®, Gleevec®, GlumetzaTM, Humalog®, Humatrope®, Humira®, Humulin®, HYCAMTIN® Capsules, IntunivTM, InvegaTM, Iressa®, JanumetTM, JanuviaTM, KapidexTM, Keppra XRTM, Kineret®, Levitra®, Lipitor®, Lunesta®, Lyrica®, MagnacetTM, Micardis®/Micardis HCT®, Mirapex ER®, Mobic®, MUSE®, Myobloc®, Nexavar®, Nexium®, Norditropin®, Noxafil®, NucyntaTM, NutriDoxTM, Nutropin®, Nutropin AQ®, Nuvigil®, OfortaTM, Omnitrope®, OnglyzaTM, OnsolisTM, Opana®/Opana®ER, Oracea®, PatadayTM, Pennsaid®, PrandiMetTM, Prevacid®, Prevacid/NapraPAC®, Prilosec® Suspension, PristiqTM, Protonix®, Provigil®, PyleraTM, Qualaquin®, Ranexa®, ReliOn®/Novalin®, Renvela®, Requip® XLTM, RevatioTM, Revlimid®, RozeremTM, RyzoltTM, Sabril®, Saizen®, SamscaTM, Saphris®, SavellaTM, Seroquel XR®, Serostim®, Silenor®, Simcor®, SimponiTM, Singulair®, Sprycel®, Suboxone®, Subutex®, SumavelTM, Sutent®, Symlin®, Taclonex®, Taclonex Scalp® Suspension, Tarceva®, Tasigna®, Tekturna®/Tekturna HCT®, Temodar® Oral, Teveten®/Teveten HCT®, Tev-Tropin®, Thalomid®, ToviazTM, TreximetTM, TrilipixTM, Twynsta®, Tykerb®, Uloric®, Ultram® ER, Valturna®, VecticalTM, VeramystTM, Viagra®, Victoza®, VimpatTM, Voltaren® Gel, VotrientTM, Vytorin®, VyvanseTM, XenazineTM, Xyzal®, Zelapar®, ZipsorTM, ZmaxTM, Zolinza®, Zorbtive and Zyvox®. This list is subject to change.
The FDA has established specific procedures that govern prescription prescribing practices. These rules are designed to prevent potential harm to patients and to ensure that the medication is being prescribed according to FDA guidelines. For example, some drugs are approved by the FDA only for individuals 14 and older, such as ciprofloxacin, or prescribed only for females, such as prenatal vitamins. The pharmacist’s computer provides up-to-date information about FDA rules. If the member’s prescription falls outside of the FDA guidelines, it will not be covered until prior authorization is obtained. The prescribing physician may request preapproval of restricted medications when medically necessary. The approval criteria for this review were developed and endorsed by the FutureScripts Pharmacy and Therapeutics Committee, which is an established group of medical directors and practicing area physicians and pharmacists. The member should contact the prescribing physician to request that he or she initiate the preapproval process. To determine if a covered prescription drug prescribed for you has an age or gender limit, call FutureScripts at 1-888-678-7012.
Quantity level limits are designed to allow a sufficient supply of medication based upon FDA-approved maximum daily doses and length of therapy of a particular drug. We have several different types of quantity level limits that are explained in detail below.
This quantity limit is based on dosing guidelines over a rolling 30-day period. Examples of quantity level limits per rolling 30-day period are Emend® (four 125mg capsules + eight 80mg capsules or four trifold packs [one 125mg capsule + two 80mg capsules]); Boniva® (two 150mg tablets); Avonex® (one kit, four injections); Betaseron® (15 vials); Copaxone® (32 vials); Fosamax Plus DTM (five tablets); and Rebif® (12 injections); migraine drugs such as:
Amerge® (nine 2.5mg tablets), Imitrex® (36 50mg tablets), Maxalt® (12 10mg tablets), Migranal® (eight 4mg nasal spray units), Stadol NS® (four 10mg units), and Zomig® (nine 5mg tablets); sedative hypnotic drugs, such as Sonata® (14 capsules) and Ambien® (14 tablets); and oral narcotic drugs such as OxyContin® (90 units), Percocet® (180 units), and Percodan® (180 units). For example, if a member went to the pharmacy on October 1, 2009, for one of these medications, the computer system would have looked back 30 days to September 1, 2009, to see how much medication was dispensed. The purpose of these limits is to make certain that these drugs are being used appropriately and to guard against overuse or stockpiling.
If a physician requires that a member needs a medication therapy that exceeds any of the quantity level limits described above, the physician must request a quantity limit override. The member is required to contact the prescribing physician to initiate a preapproval request for an override.
Some drugs may have a time period for quantity limit exceptions of 6 to 12 months. If the exception for a drug is limited to a certain time frame, an expiration date will be given at the time the approval is made. If the physician wants a member to continue the drug therapy that exceeds a quantity limit after the expiration date, a new request for a quantity limit exception will need to be submitted and approved in order for coverage to continue.
To determine if a covered prescription drug prescribed for you has a quantity level limit, call FutureScripts® at 1-888-678-7012.
The 96-hour Temporary Supply Program applies to the following covered medications:
Under the 96-hour Temporary Supply Program, if a member’s doctor writes a prescription for a drug that requires prior authorization, has an age limit, or exceeds the quantity level limit for a medication, and prior authorization/preapproval has not been obtained by the doctor, the following steps will occur:
1Members with an integrated drug benefit (e.g., CMM and Major Medical) will pay the discounted cost of the 96-hour supply as well as the remainder of the prescription order (if approved) at the time of purchase, and the medical claim for reimbursement will be processed through standard procedures.
Obtaining a 96-hour temporary supply does not guarantee that the prior authorization/preapproval request will be approved. Some medications are not eligible for the 96-hour temporary supply program due to packaging or other limitations such as Retin-A® (tube), Enbrel® (2-week injection kit), medroxyprogesterone acetate (monthly injectable), and erectile dysfunction drugs. Additionally, certain drugs to treat hemophilia (antihemophilic factors) are not usually purchased at the pharmacy and must be special-ordered; therefore, they are not eligible for the 96-hour temporary supply.
Providers may request formulary coverage of a covered non-formulary medication when all formulary alternatives have been exhausted or there are contraindications to using the formulary alternatives. The provider should complete the covered non-formulary appeal form providing detail to support use of the covered non-formulary medication and should fax the request to 215-241-3073 or 1-888-671-5285. If the non-formulary request is approved, the drug will be paid at the appropriate formulary benefit level. If the request is denied, the member and provider will receive a denial letter with the appropriate appeals language. Whether or not an appeal is filed, the member may always obtain benefits for the covered non-formulary drug at the appropriate non-formulary benefit level. Out-of-pocket expenses for non-formulary drugs are higher than for formulary drugs.
*Specific to Select Drug Program memebers only.
If a request for prior authorization/preapproval or override results in a denial, the member or physician, on the member’s behalf, may file an appeal. Both the member and his or her provider will receive written notification of a denial, which will include the appropriate telephone number and address to direct an appeal. In all cases, the physician needs to be involved in the appeals process to provide the required medical information for the basis of the appeal.
A pharmacy benefits management company (PBM), administers our prescription drug benefits, and is responsible for providing a network of participating pharmacies and processing pharmacy claims. The PBM also negotiates price discounts with pharmaceutical manufacturers and provides drug utilization and quality reviews. Price discounts may include rebates from a drug manufacturer based on the volume purchased. Independence Blue Cross anticipates that it will pass on a high percentage of the expected rebates it receives from its PBM through reductions in the overall cost of pharmacy benefits. Under most benefit plans, prescription drugs are subject to a member copayment.
What’s not covered?
*This applies to HMO members only.
This summary represents only a partial listing of the benefits and exclusions of your plan. If your employer purchases another program, the benefits and exclusions may differ. Also, benefits and exclusions may be further defined by medical policy. As a result, this managed care plan may not cover all of your health care expenses. Read your benefit booklet carefully for a complete listing of the terms, limitations, and exclusions of the program. If you need more information, please call 1-800-ASK-BLUE (1-800-275-2583).