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Prescription drugs (Part D)

The following information can help you get the most from your prescription drug (Part D) coverage. Just click on the links below to learn more about your benefits or to request the forms you need.

To review your prescription drug benefits, log in to ibx.com/login to find drug pricing and information, manage mail-order service, use the pharmacy locator, view claims, and more.

Learn more:

Independence Blue Cross contracts with FutureScripts® Secure to provide Medicare Part D prescription benefit management services.

Prescription drug formularies

A formulary is a list of covered drugs. This list of drugs is carefully selected by the plan with help from a team of doctors and pharmacists. Medicare reviews, updates, and approves the drug list throughout the year.

Find a prescription drug

To find covered prescription drugs, select your health plan below.

2021 formularies for individual members

Scroll or swipe to reveal all table data.

2021 formularies for group members

See the Coverage determination for Part D drugs section to learn how to obtain an exception to the formulary.

The Independence Blue Cross pharmacy network

The Independence Blue Cross pharmacy network allows you to get your prescription filled at over 60,000 locations. These include:

  • National chain pharmacies
  • Local independent pharmacies
  • Grocery store pharmacies
  • Long-term care and home-infusion pharmacies
  • A network mail-order pharmacy service

The Independence Blue Cross network includes both preferred and standard pharmacies. Our preferred pharmacies often charge you lower copayments for your medications.

  • Tier 1 and 2 prescriptions (which include most generic drugs) will have lower copayments when you have them filled at preferred pharmacies.
  • Tier 3, 4, and 5 prescriptions (which include brand-name, specialty, and high-cost generic drugs) will have the same copayments at both preferred and standard pharmacy locations.

Standard pharmacies are available to support the greatest level of access and convenience for Independence Blue Cross members.

Preferred pharmaciesStandard pharmacies
 

CVS
Giant
ShopRite
Target
Walgreens
Wegmans
Other independent pharmacies

Acme
Costco
Rite Aid
Sam's Club
Walmart
Other independent pharmacies

Find a network pharmacy

To locate or confirm that a pharmacy is currently in our network:

Find a pharmacy

If you need to use an out-of-network pharmacy in special circumstances, including illness while traveling you may submit a Direct Member Reimbursement for review.

To request a reimbursement, please use the Direct Member Reimbursement Form.

Please note that we cannot pay for any prescriptions that are filled by pharmacies outside of the United States, even for a medical emergency.


Vaccines

Vaccines (shots) are an important step in protecting your health. Medicare covers certain vaccines under Parts B and D.

Part B vaccines — available at no cost!

  • Flu shot (influenza)
  • Pneumonia (pneumococcal)
  • Hepatitis B (for intermediate or high-risk individuals)

The following are covered to treat an injury or because of direct exposure to a disease or condition:

  • Tetanus
  • Rabies
  • Botulin antitoxin
  • Antivenin sera

Part D vaccines — copayment or coinsurance will vary for the vaccines listed below. Please refer to the formulary (list of covered drugs) for more information.

  • Shingles
  • Human papillomavirus (HPV)
  • Measles, mumps, rubella (MMR)
  • Diphtheria
  • Pertussis

If you do not meet the Part B coverage rules above, the following are covered under Part D:

  • Tetanus
  • Rabies
  • Botulin antitoxin
  • Antivenin sera

Where you get your Part B or Part D vaccine matters

Part B vaccines

  • We recommend getting a Part B vaccination at an in-network doctor or pharmacy.
  • If you get a Part B vaccination during a doctor’s office visit where you’ve received a separate additional non-preventive evaluation and/or service, a copayment will apply. The copayment amount depends on the provider type or place of service.
  • Part B vaccines are also available at some pharmacies, but you may have to pay out of pocket and submit for reimbursement.

Part D vaccines

  • To ensure that you’re charged the correct Part D cost-share, we recommend you get your Part D vaccines at a pharmacy, rather than at your doctor’s office.
  • If you get a Part D vaccine at a doctor’s office, cost-share amounts may vary, and you may have to request reimbursement.

How to request reimbursement if you pay out of pocket for a vaccine

Part B vaccines

If you receive the flu shot at an out-of-network provider or pharmacy and paid out of pocket, you can submit the following form to apply for reimbursement.

Part D vaccines

To request a reimbursement for a vaccine and/or a vaccine administration fee, please use the Vaccine and Administration Direct Member Reimbursement Form. This form is for Part D vaccines only and should not be used for Part B vaccines.


Mail-order pharmacy service

Your benefit includes the option to receive prescription drugs shipped to your home through our network mail-order delivery program, which is administered by FutureScripts® Secure. Whether it’s a new prescription or one you have been filling for years, mail order is an easy way to get the medications you take regularly.

Mail order offers you:

  • Cost savings. You may pay less than retail.
  • Convenience. Up to a 90-day supply of maintenance medications and free shipping.
  • 24/7 access. Speak to a pharmacist at any time, any day.

How do I order prescriptions?

If you fill a prescription at a retail pharmacy and would like to switch to mail order:

  • Log in to ibx.com/login to transfer a retail prescription or call 1-888-678-7015 (TTY/TDD: 711) to find out if the prescription is eligible and ask to change to mail order.
  • If you call, provide your name, address, prescription number (located on your prescription bottle or package), and billing information.

If you have a new prescription:

  • Ask your doctor to send the prescription to be filled by the FutureScripts pharmacy — OptumRx® home delivery.
  • OptumRx® home delivery will call you to confirm any details. Pharmacies must get consent prior to shipping or delivering any prescriptions that your prescriber sends.
  • Log in to ibx.com/login to track the status of your mail-order prescription.

If you need to refill a mail-order prescription:

  • Log in to ibx.com/login or call 1-888-678-7015 (TTY/TDD: 711) and request a refill.
  • Confirm your information.
  • Please note, FutureScripts does not offer automatic refills.

You can also fill out and send in the Prescription Mail-order Form.

Your prescriptions from FutureScripts should arrive within 7 to 10 business days after we receive the complete order.

Questions? Please call FutureScripts at 1-888-678-7015 (TTY/TDD: 711), 7 days a week, 24 hours a day.


Prior authorization and coverage determination for Part D drugs

For certain drugs, the plan requires more information from your provider to approve coverage. This is called "prior authorization." This requirement helps to guide appropriate use of certain drugs.

Please reference your plan's formulary for a list of drugs that require prior authorization.

Prior authorization approval criteria are developed and endorsed by our Pharmacy and Therapeutics Committee and are based on information from the Food and Drug Administration, manufacturer guidelines, medical literature, actively practicing consultant physicians, and appropriate external organizations.

Step therapy

Step therapy is a type of coverage determination that applies to certain drugs. Step therapy requires you to first try certain drugs to treat your medical condition before the plan will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Independence Blue Cross may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Independence Blue Cross will then cover Drug B.

How to submit a prior authorization/step therapy request

You may submit a request form for medications requiring prior authorization/step therapy. Our pharmacy benefits manager, FutureScripts® Secure, reviews all requests. If you, your appointed representative, or your prescriber would like to initiate a prior authorization request, please submit a coverage determination. A standard coverage decision takes 72 hours after we receive a request. An urgent coverage decision means we will answer within 24 hours after we receive a request.

2021 prior authorization and coverage determination process

  • For more information on Keystone 65 Rx HMO’s prior authorization process and what services require prior authorization, please reference Chapter 5, Section 4.2 on page 127 in your EOC or view Keystone 65 Rx HMO Part D Prior Authorization.

Non-formulary exception and quantity limit exception

If your drug is not on the plan's List of Covered Drugs (Formulary), or is on the list with a quantity limit, you can request an exception by asking the plan to cover the drug. Or, you can ask the plan to cover a greater quantity of the drug than what the plan allows.

You and your provider can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If your provider says that you have medical reasons that justify asking us for a quantity limit exception, your provider can help you request an exception to the rule.

Drugs approved for a formulary exception will be covered at the non-preferred tier and cannot be approved for tier exception.

Tier cost-sharing

The plan puts each covered drug into one of several different cost-sharing tiers. How much you pay for your prescription depends on which cost-sharing tier your drug is in.

If your drug is in the non-preferred tier, you or your provider can ask the plan to make an exception to allow the drug at the preferred tier, so you pay less for it. If your provider says that you have medical reasons that justify asking us for an exception, your provider can help you request an exception to the non-preferred tier. See the instructions below for requesting an exception.

If we approve the non-preferred request, the drug will be processed at the appropriate preferred formulary benefit cost-sharing tier. If we deny the request for access at the preferred tier, you and your physician will receive a denial letter that explains the appeal process. You may still receive benefits for the drug at the non-preferred cost-sharing level.

Please note that certain drugs in some of our cost-sharing tiers are not eligible for this exception. Such scenarios include:

  • Generic drugs that are already on our lowest generic tier (preferred generic)
  • Brand drugs that are already on our lowest brand tier (preferred brand)
  • Drugs that are on our specialty tier
  • Cost-share based on coverage phases, such as the Coverage Gap
  • Drugs that were already approved through the formulary exception process

 

How to submit a tier cost-sharing or formulary exception request

You may submit a request for a formulary exception. Our pharmacy benefits manager, FutureScripts® Secure, reviews all requests. If you, your appointed representative, or your prescriber would like to initiate an exception request, please submit a coverage determination.

Please note that if you are approved for a formulary exception, you are not permitted to also request a tier exception for that same drug. For more information on coverage determinations, including how to submit, please reference the coverage determination section.

Medicare Part B vs. Part D determinations

Centers for Medicare and Medicaid Services (CMS) limits coverage of some drugs to either the Part B or Part D benefit depending on how the drug is prescribed, dispensed, and/or administered.

Please refer to the appropriate formulary to determine if your drug requires a Medicare Part B vs. Part D determination. Please complete the Medicare Administrative Prior Authorization for Part B/D coverage form if needed. This drug may be covered under Medicare Part B or D depending upon the circumstances. You may need to provide information such as the use and setting of the drug so we can make the determination.

Certain drugs are generally covered only under the Part B benefit. These drugs typically will not be listed on the formulary. However, some Part B drugs require precertification. Please see the link below to determine if precertification is required:

Specialty Drugs Requiring Precertification under Medicare Part B

Your physician may refer to the Direct Ship Injectables Program for more information about certain injectable drugs covered under the Medicare Part B benefit.

Hospice Medicare coverage

CMS requires Medicare beneficiaries under hospice care with Part D coverage to get prior authorization for prescriptions that fall under these four classes of medications:

  • Analgesics (drugs used for pain)
  • Antiemetics (drugs used for nausea)
  • Laxatives
  • Antianxiety drugs

These medications will be covered under Medicare Part D only if they are prescribed for diagnoses unrelated to the member's terminal illness.

If you, your appointed representative, or your prescriber would like to initiate a prior authorization request, please fill out the necessary information using the Hospice Information for Medicare Part D request form. Our pharmacy benefits manager, FutureScripts® Secure, reviews all requests.

Providers:

  • You may print and fax your completed Hospice Information for Medicare Part D request form to FutureScripts® Secure for review at 1-888-671-5285. Make sure to include your office telephone and fax number on the form.
  • When filling out a prior authorization form, please supply all the requested information. Incomplete requests will require an outreach to your office to obtain additional information.
  • You will be notified by fax if the request is approved or denied. You and your patient will also receive a denial letter.
  • If you have not received a response 72 hours after submitting complete information, contact FutureScripts® Secure at 1-888-678-7015, option 1.

Members:

  • You, your authorized representative, or your physician may fax the Hospice Information for Medicare Part D request form to FutureScripts® Secure for review at 1-888-671-5285.
  • Complete the prior authorization form. Please supply all requested information. Note: FutureScripts® Secure may need to reach out to your provider for additional information.
  • You may take the appropriate request form to your physician to complete and fax to FutureScripts® Secure for review at 1-888-671-5285.
  • If you have not received a response from FutureScripts® Secure after 72 hours, you may contact the provider who made the request on your behalf, or call FutureScripts® Secure directly at 1-888-678-7015 (TTY/TDD: 711).
  • If you have questions, please contact our Member Help Team.

 


Transition supply process

What if there are changes to the way my current prescription is covered?

As a member of the plan, you should have received your Annual Notice of Change (ANOC) by September 30. You may notice that a formulary medication that you are currently taking is either not on the upcoming year's formulary or that coverage is limited in the upcoming year. In either case, we will provide a transition fill, typically a one-time 30-day supply of a drug you were taking. Doing this gives you time to talk with your doctor about the change in coverage. Please note that not all medications qualify for a transition supply.

Independence Blue Cross can only offer a temporary transition supply of drugs that are eligible for coverage under Medicare Part D. Drugs that are excluded from Part D coverage are not eligible for a transition supply.

For more information on excluded drugs, please reference your Evidence of Coverage (EOC). If you have more questions about our transition policy or need help asking for a coverage determination, call the Member Help Team.


Coverage determination for Part D drugs

Coverage determination is the process by which the plan decides whether a Part D drug prescribed for you is covered. It also decides the amount, if any, you are required to pay. An initial coverage decision about your Part D drugs is called a coverage determination. You, your doctor, or someone you've authorized may make an oral or written, standard or expedited request.

If you are a Keystone 65 Rx HMO or Personal Choice 65SM Rx PPO member, you can file a coverage determination by using one of the methods below.

  • Submit an online request.
  • Print and mail or fax the drug-specific coverage determination form.
    If you do not see a specific form for your request, please use our generic coverage determination request form.
  • Call 1-888-678-7015 (TTY/TDD: 711).
    Calls to this number are free. Representatives are available seven days a week from 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 through September 30, your call may be sent to voicemail.
  • Fax: 1-888-671-5285
  • Write: FutureScripts® Secure
    1650 Arch Street
    Suite 2600
    Philadelphia, PA 19103

During the coverage determination process, you can ask us to make an exception. This includes requesting coverage of a drug that is not on the formulary, waiving restrictions on the plan's coverage for a drug, or asking to pay a lower cost-sharing amount. This process is called a formulary or tier cost-sharing exception. You may use the coverage determination form to request an exception.

2021 coverage determination process

 


Part D appeals

If you, your doctor, or your representative disagree with the outcome of the initial coverage determination, you can appeal the decision by requesting a redetermination.

Ways to file an appeal for Keystone 65 HMO members

  • Call 1-800-645-3965 (TTY/TDD: 711) for expedited appeals only.
    Calls to this number are free. Representatives are available seven days a week from 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 through September 30, your call may be sent to voicemail.
  • Complete the online Coverage Redetermination Request Submission Form
  • Download and print the Coverage Redetermination Request Form to send by fax, mail, or deliver in person:
    • Fax: 1-888-289-3008
    • Mail to:
      Keystone 65 Rx Medicare Member Appeals Unit
      PO Box 13652
      Philadelphia, PA 19101-3652

Ways to file an appeal for Personal Choice 65 PPO members

  • Call 1-888-718-3333 (TTY/TDD: 711) for expedited appeals only.
    Calls to this number are free. Representatives are available seven days a week from 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 through September 30, your call may be sent to voicemail.
  • Complete the online Coverage Redetermination Request Form
  • Download and print the Coverage Redetermination Request Form to send by fax, mail, or deliver in person.
    • Fax: 1-888-289-3008
    • Mail to:
      Personal Choice 65 Rx Medicare Member Appeals Unit
      PO Box 13652
      Philadelphia, PA 19101-3652

If our answer is yes to part or all of what you requested:

  • If we approve a coverage request, we must provide the coverage we have agreed upon as quickly as your health requires, but no later than seven calendar days after we receive your appeal.
  • If we approve a request to pay you back for a drug you already bought, we are required to send payment to you within 30 calendar days after we receive your appeal request.
  • If we approve an expedited (or fast) coverage request, we must provide the coverage we have agreed upon as quickly as your health requires, but no later than 72 hours after we receive your appeal.

If our answer is no to part or all of what you requested:

  • We will send you a written statement that explains why we said no and how to appeal our decision.

2021 Part D appeals process

 


Part D grievances

A grievance is a formal complaint or dispute. You can file a grievance if you are dissatisfied with any aspect of the operations, activities or behavior of Independence Blue Cross or its network pharmacies. If you disagree with a coverage determination decision, please see the Part D Appeals section above.

You will receive a resolution within 30 days of filing a grievance. Once a decision is rendered, we will notify you.

Ways to file a complaint for Keystone 65 HMO members

  • Call: 1-800-645-3965 (TTY/TDD: 711)
    Calls to this number are free. Representatives are available seven days a week from 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 through September 30, your call may be sent to voicemail.
  • Fax: 1-888-289-3008
  • Write:
    Keystone 65 Rx Medicare Member Appeals Unit
    PO Box 13652
    Philadelphia, PA 19101-3652

Ways to file a complaint for Personal Choice 65 PPO members

  • Call: 1-888-718-3333 (TTY/TDD: 711)
    Calls to this number are free. Representatives are available seven days a week from 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 through September 30, your call may be sent to voicemail.
  • Fax: 1-888-289-3008
  • Write:
    Personal Choice 65 Rx Medicare Member Appeals Unit
    PO Box 13652
    Philadelphia, PA 19101-3652

2021 Part D grievances process

Appointment of a representative

If you want someone other than your provider to act on your behalf, please complete the Appointment of Representative (AOR) form.

If you are filing an AOR for a coverage determination, please submit the form to:

  • FutureScripts® Secure
    1650 Arch Street
    Suite 2600
    Philadelphia, PA 19103

If you are filing an AOR for an appeal or a grievance for Keystone 65 HMO, please submit the form to:

  • Keystone 65 Rx Medicare Member Appeals Unit
    PO Box 13652
    Philadelphia, PA 19101-3652

If you are filing an AOR for an appeal or a grievance for Personal Choice 65 PPO, please submit the form to:

  • Personal Choice 65 Rx Medicare Member Appeals Unit
    PO Box 13652
    Philadelphia, PA 19101-3652

Contact information

Members and providers who have questions about the exceptions and appeals processes, or would like to inquire about the status of a coverage determination or appeal request, please contact the Member Help Team.

To obtain an aggregate number of grievances, appeals, and exceptions filed with Independence Blue Cross, please mail a written request to:

  • Medicare Member Appeals Unit
    PO Box 13652
    Philadelphia, PA 19101-3652

If you prefer to file a grievance through CMS, please complete the Medicare Complaint Form.


Quality assurance policies and procedures

Independence Blue Cross has developed a system of checks and balances to help ensure that you get the right medications, in the right amounts, at the right times. Our goal is to avoid potential health risks to you, to keep the plan affordable, and to help members manage their medications.

Independence Blue Cross complies with the CMS requirement to apply additional safety measures to opioid products.

Members who were newly prescribed an opioid medication will be limited to a 7-day supply for their first fill. All other prescription fills for opioid medications will be limited to a 30-day supply.

Please note that individual pharmacies may have additional limitations on opioid medications.

Independence Blue Cross limits the total daily dose of opioids through a measurement called the Morphine Milligram Equivalent (MME) dose. MME is a number that is calculated from the number of opioid drugs, their potencies, and the duration of therapy. It is used to determine and compare the potency of opioid medications, and it helps to identify when additional caution is needed.

Pharmacies have safety interventions based upon the MME dose, which may require intervention from your pharmacy or require a prior authorization.


Medication Therapy Management (MTM) program

In collaboration with PerformRx, we offer a Medication Therapy Management (MTM) program to ensure that you receive the most effective medications. MTM also helps to reduce the risk of side effects and interactions and lower your out-of-pocket costs. Your plan pays for the program, at no cost to you. This program is not considered a benefit. MTM does not change your insurance benefits, copayments, prescription coverage, or available doctors or pharmacies. Specially trained pharmacists will work closely with you and your doctors to solve any problems related to your medications and to help you get the best results.

Who is eligible for the MTM program?

The MTM program is designed to help you get the most from your medications if you meet all the following criteria:

  • You have three or more chronic diseases, including:
    • Bone/joint disease (i.e., osteoporosis)
    • Chronic heart failure (CHF)
    • Diabetes
    • High cholesterol
    • Chronic obstructive pulmonary disease (COPD)
    • Conditions that require treatment with anticoagulants
    • Cancer
    • Multiple sclerosis or
    • Atrial fibrillation
  • You take six or more maintenance medications for chronic conditions.
  • You spend $4,376 or more per year on Medicare Part D covered medications.

What happens if you qualify for the program?

1. You will receive an introduction letter that describes the program to you.

2. You will receive a comprehensive medication review:

  • A specially trained clinical pharmacist will contact you for an interactive person-to-person medication consultation to review all your medications and answer any questions that you may have.
  • Following the consultation, you will receive a summary of your comprehensive medication review. The summary will contain a medication action plan for you to take notes or write down any follow-up questions.

3. Your medications will be reviewed on an ongoing basis.

  • A comprehensive medication review will be offered once a year.
  • At least every three months, your medicines will be reviewed, and your MTM pharmacist will work with you and your doctor(s) if any changes are needed.

Medicare requires that MTM programs automatically enroll those who qualify throughout the calendar year, but participation is voluntary, and you may opt out at any time. Once you are enrolled, you will remain enrolled through the calendar year unless you opt out or leave our plan.

If you have any questions about the MTM program, please call PerformRx at 1-888-349-0501 (TTY/TDD: 1-888-765-6351) between 8:30 a.m. and 5 p.m. (EST), Monday through Friday.


Understanding the donut hole

If you're enrolled in a Medicare Part D prescription plan, you've likely heard about the Coverage Gap — sometimes called the “donut hole.” It’s one of the four phases of Part D coverage, and it's important to understand how it works and when it could apply to you. View our infographic to learn more about the Medicare Part D coverage phases.


Contact information

For more information, contact the Member Help Team.

Keystone 65 HMO members: call 1-800-645-3965 (TTY/TDD: 711)

Personal Choice 65 PPO members: call 1-888-718-3333 (TTY/TDD: 711)

Representatives are available seven days a week from 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 through September 30, your call may be sent to voicemail.

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Website last modified: 5/05/2021