Premium Formulary

The drugs on the Premium Formulary have been selected for their clinical effectiveness, safety, and maximized savings. The Premium Formulary maintains affordable medication access and promotes the use of lower-cost alternatives for members of self-funded groups.

The Premium Formulary differs from the Select Drug Program Formulary in that it excludes 80 medications, which all have clinical alternatives included in the Premium Formulary.

Effective Use of the Formulary

Help your Independence patients make the most of their health care dollars. Before prescribing a medication to an Independence member that has the Premium Formulary, please consider whether the drug is included or if a generic equivalent or similar drug is available.

The Premium Formulary is managed and maintained by FutureScripts* – Independence does not control how the Premium Formulary is comprised or administered.

Frequently Asked Questions

How are newly launched medications handled?

What does the clinical evaluation consist of?

Is drug coverage grandfathering available when implementing the Premium Formulary?

Is Prior Authorization grandfathering available when implementing the Premium Formulary?

What happens at the retail pharmacy if a member tries to fill a prescription for an excluded drug?

What tools are available to help members and their doctors choose medications that are covered?

How do we notify members who are taking a drug that will be switching to a higher cost-sharing tier or will be excluded?

Do the Premium Formulary prior authorization criteria differ from the Select Drug Formulary?

What should a member do if he needs to start taking a medication that requires prior authorization that has not yet been obtained?

How are newly launched medications handled?
The Premium Formulary excludes new medications at their market launch for six months to allow for appropriate review of evidence and overall clinical value when compared to other formulary alternatives. This minimizes member disruption if the medication is permanently excluded, because members have not utilized their pharmacy benefit for that medication and may already be using a covered alternative.

What does the clinical evaluation consist of?

  • Medications may be considered for exclusion if they are deemed therapeutically equivalent or in the same class as a clinically similar product on the formulary.
  • Products must undergo a rigorous clinical and financial evaluation process before they can be included or excluded.
  • As new clinical information is introduced, prices shift, or other dynamics change, included or excluded medications may be re-evaluated for coverage.
  • Clients and members utilizing drugs that are changing will be notified of updates to the list of excluded drugs and drugs that change tiers prior to January 1 and July 1, at which times formulary updates take place.

Is drug coverage grandfathering available when implementing the Premium Formulary?
No, there is no coverage grandfathering with the Premium Formulary. There is, however, a formulary exclusions exceptions process available to verify medical necessity if the formulary alternatives are not appropriate for the member. If an exception is approved, the member will be allowed to obtain the medication at the highest cost-­share level.

Is Prior Authorization grandfathering available when implementing the Premium Formulary?
Prior Authorization grandfathering is not allowed except for covered drugs in these categories: immunomodulators; multiple sclerosis; hepatitis C; and PCSK-9 inhibitors. Additionally, for existing Independence clients transitioning from the Select Drug Program formulary to the Premium Formulary, any open Prior Authorizations on covered drugs will be grandfathered for those members taking these drugs.

What happens at the retail pharmacy if a member tries to fill a prescription for an excluded drug?
If a claim for an excluded drug is submitted, the member will be notified that the drug is not covered under his/her plan.

What tools are available to help members and their doctors choose medications that are covered?

  • Online at ibxpress.com: Members can search for medications and confirm coverage.
  • Member Services: Customer Service representatives are available to educate members about their pharmacy benefit. Members should call the phone number on the back of their ID cards.

How do you notify members who are taking a drug that will be switched to a higher cost-sharing tier or will be excluded?

  • Notification letters: When applicable, we notify members before a medication is excluded and inform them of covered alternatives to discuss with their physicians.
  • Formulary updates: When applicable, we notify members before a medication switches to a higher cost-sharing tier.

Do the Premium Formulary prior authorization criteria differ from the Select Drug Formulary?
Yes, the prior authorization criteria are specific to the Premium Formulary and differ from those of the Select Drug Program. The Premium Formulary guide identifies drugs with prior authorization, step therapy, and quantity limits. Physicians can contact FutureScripts to request the Premium Formulary prior authorization criteria.

What should a member do if he or she needs to take a medication that requires prior authorization that has not yet been obtained?
Two options are available. First, members can ask their doctor if a sample is available. If not, members can request a short-term supply of five days or less from their pharmacy — keep in mind that members will be responsible for the full cost at that time. If the prior authorization request is approved for coverage, then the member's pharmacist can dispense the rest of the prescription.

*FutureScripts® is an independent company and serves as Independence Blue Cross’ pharmacy benefits manager.