Direct Ship Drug Program
Independence Blue Cross (Independence) offers a Direct Ship Drug Program to our in-network physicians. Under this program, physicians can order certain specialty drugs that are given in the office and are eligible for coverage under the member’s medical benefit when medical necessity criteria are met. Independence contracts with specific specialty drug vendors who provide these medications at no cost to our network physicians.
This program is available to all Independence in-network physicians whose offices are in the five-county area (Philadelphia, Bucks, Chester, Delaware, and Montgomery counties) or in the thirteen counties that are contiguous to the five-county area¹. Direct Ship to out-of-area physicians is subject to the BlueCard® rules for ancillary providers.
The advantages of using the Independence Direct Ship Drug Program include:
- Independence places the order with the vendor based on the physician’s request and handles all payments for the drugs.
- Physicians do not have to submit reimbursement forms for the cost of the drugs.
- Physicians do not have to dedicate office space to long-term drug storage.
To place an order, select the appropriate drug request form below. Fax the completed form, along with a valid prescription, to the number listed on the form. If the drug you are ordering is on the Independence direct ship drug list, but does not have a corresponding form below, use the general request form.
Requests are subject to the terms of the member’s benefit contract, as well as medical necessity review and precertification requirements set forth by Independence. For drugs that require precertification, the request forms below also serve as the precertification request. All drugs ordered through the Direct Ship Drug Program require prior authorization from Independence, even if they are not included on our precertification list. Requested quantities will be evaluated to ensure appropriate prescribing limits.
Specific drug request forms
These forms should only be used to request the specific drug(s) listed below.
- Botulinum toxins (Botox®, Dysport®, Myobloc®, Xeomin®)
- Fasenra™ (benralizumab)
- Hydroxyprogesterone Caproate Injection
- Nucala® (mepolizumab)
- Prolia®/Xgeva® (denosumab)
- Stelara® (ustekinumab)
- Synagis® (palivizumab) Print/Fax | Fillable
- Vivitrol® (naltrexone)
- Xolair® (omalizumab)
- BUY AND BILL ONLY, EFFECTIVE 4/1/2015 Viscosupplementation (hyaluronic acid products) (Orthovisc®, Synvisc®, Synvisc-One®, Euflexxa®, Gel-One®, GelSyn-3™, GenVisc 850®, Hyalgan®, Hymovis®, Monovisc®, Supartz®, VISCO-3™, Durolane®, TriVisc™, Synojoynt™, and Triluron™)
General request form
Requests for drugs not specified in the forms above should be submitted on the general request form below. Before completing this form, confirm that the drug you are requesting is on the direct ship drug list. Independence cannot facilitate direct ship delivery for any drug that is not on that list.
For more information, please contact Customer Service at 1-800-ASK-BLUE.
¹The thirteen contiguous counties are: Berks (PA), Burlington (NJ), Camden (NJ), Cecil (MD), Gloucester (NJ), Hunterdon (NJ), Lancaster (PA), Lehigh (PA), Mercer (NJ), New Castle (DE), Northampton (PA), Salem (NJ), and Warren (NJ).
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