Yes, prescription drugs are covered for all of the individual health plans offered by Independence Blue Cross. Please refer to your individual plan details for more information on covered prescription drugs.
The prescription drug benefits program is administered by an independent pharmacy benefits management (PBM) company. The PBM Pharmacy Benefit Network includes more than 68,000 retail pharmacies, including most national and regional chain pharmacies and many neighborhood pharmacies. Some plans utilize the PBM’s Preferred Pharmacy Network.
Each time you go to a participating pharmacy to fill a prescription, simply present your Independence Blue Cross ID card. How you will be charged will depend on your plan type:
You can fill or refill a medication at any one of the participating retail pharmacies. If you are taking a maintenance medication, you can use mail order.
To locate a participating retail pharmacy or begin mail order service, log in to the member site at www.ibx.com/login.
No. In accordance with health care reform provisions effective October 1, 2010, all of our plans have unlimited prescription drug benefits.
To locate a participating pharmacy, use the Provider Finder at ibx.com. You can also call us at 1-888-678-7012 (TTY:711).
A generic drug is comparable to a brand drug in form, dosage, strength, how it works, and how it is used. A brand drug has a patented marketing name. Learn more about generic vs. brand-name drugs and how you could save on prescription drugs.
Yes. Depending on the plan you select, you may be able to get a 90-day supply for the cost of a 60-day supply when using the mail order service. To get started with mail-order service, log in to ibx.com.
Yes. Birth control pills (oral contraceptives) and injectable contraceptives are examples of women’s preventive, wellness health services under the list of Essential Health Benefits and many are covered 100 percent by Independence Blue Cross health plans.
The drug formulary is a list of medications that have been selected by Independence Blue Cross for their medical effectiveness, positive results, and value. The formulary includes all generic medications and a defined list of brand medications. You maximize your benefits when you purchase formulary medications.
The Independence Pharmacy and Therapeutics Committee, which meets regularly, may amend the formularies and Preferred drug lists quarterly — in January, April, July, and October. Plan participants and physicians who will be affected are notified of these changes.
Yes. You have access to non-preferred drugs; however, you pay less when you select preferred or generic medications. You maximize cost savings when selecting a generic drug.
This 58,000-pharmacy network is a smaller version of the PBM’s Pharmacy Benefit Network. Pharmacies that are not part of the Preferred Pharmacy Network are considered non-participating or out-of-network pharmacies. The Preferred Pharmacy Network allows us to achieve greater cost savings and, ultimately, a lower premium for the member.
The Preferred Pharmacy Network is included in the following plans for 2024:
Members with the Preferred Pharmacy network have access to more than 58,000 pharmacies, such as CVS, Walmart, and Target, in addition to independent pharmacies.
To locate a participating pharmacy, use the Provider Finder at ibx.com. You can also call us at 1-888-678-7012 (TTY:711).
Yes, many of our health plans feature a low member cost-share for certain designated prescription drugs at participating retail and mail order pharmacies. 3 Your cost for these drugs would be $3 for a 30-day supply, or $6 for a 90-day supply via mail order. Generic drugs are as safe and effective as brand-name drugs and they could cost less. Learn more about the Low-cost Generic Program.
The Value Formulary provides a comprehensive list of medications that include generics, brands, and specialty drugs that have been evaluated for their medical effectiveness, positive results, and value. Drugs may not be covered when there are good alternatives used to treat the same condition at a lower cost. The 4-tier formulary is based on a defined list of generic, Preferred Brand, Non-preferred drug, and self-administered Specialty prescription drugs. The 5-tier formulary is based on a defined list of low-cost generics, other generics, Preferred Brand, Non-preferred, and Specialty drugs. The only difference between the 4-tier and 5-tier Formularies is the low-cost generic drugs.
The following plans utilize 5-tier formularies:
The Mandatory Generic Program encourages the use of affordable, effective generic drugs. If a member chooses to purchase a brand drug that is available in generic form, the member is responsible for paying the dispensing pharmacy the difference between the negotiated discount price for the generic drug and the brand drug, plus the appropriate cost-sharing for a brand drug.
| Copay | Discounted cost | You pay | |
|---|---|---|---|
| Generic | $20 | $100 | $20 |
| Brand | $60 | $300 | $260 (Discounted cost of brand - discounted cost of generic + copay) |
The formulary is designed to include all therapeutic categories and provide physicians with prescribing options. Drugs designated as non-formulary are not covered. Non-formulary drugs have covered equivalents and/or alternatives used to treat the same condition in a more cost-effective manner. Physicians may request coverage of a non-formulary drug by submitting a medical necessity request. Visit ibx.com/formularyexceptionspolicy for details about the formulary exception process.
Note: If a member’s prescription drug benefit includes the mandatory generic benefit and the formulary exception is approved for a brand drug that has a generic equivalent, the member will be responsible for paying the dispensing pharmacy the difference between the negotiated discount prices for the generic drug and the brand drug, plus the appropriate member cost-sharing for a brand drug.
Yes. You have access to Non-preferred drugs; however, you pay less when you select Preferred or generic medications. You maximize cost savings when selecting a generic drug.
You can review this information on the Plan Comparison page. Simply expand the plan details and click “Search for a drug” under the Prescription Drug section.
Some prescription drugs require special permission to obtain before your doctor can dispense them to you. If you need a drug that requires prior authorization, your doctor will take care of the paperwork. You may even receive a portion of your medication for free while the prior authorization is processed.
This information can be found within the Drug Formulary Look-up tool as well as within the Procedures that Prescription Drug Guidelines document. The form is also available through Independence Blue Cross Customer Service.
The preventive medication program provides complete coverage for certain preventive medications when provided by a participating retail or mail-order pharmacy. 2 Coverage includes certain generic and brand medications within the following drug categories, as described in the Patient Protection and Affordable Care Act:
These certain designated preventive medications will not be subject to any cost-sharing or deductibles, but will be subject to the terms and conditions of plan participant’s benefits contract, including age and gender requirements.
All covered self-administered Specialty medications except insulin will be provided through the convenient Optum Specialty Pharmacy Program, administered by OptumRx, for the appropriate cost sharing. Benefits are available for up to a 30-day supply. When you take advantage of the Optum Specialty Pharmacy, administered by OptumRx, you receive:
Certain specialty medications must be filled through Optum Specialty Pharmacy; these are called limited distribution drugs. Speak with your prescribing Specialist and ask if the specialty drug you are taking is a limited distribution drug.
Getting started with the Optum Specialty Pharmacy Program is easy. Once enrolled in an Independence Blue Cross plan, 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.
All covered self-administered specialty medications except insulin will be provided through the convenient Specialty Pharmacy Program for the appropriate cost-sharing indicated in your plan booklet. Benefits are available for up to a 30-day supply. If your doctor wants you to start the drug immediately, an initial 30-day supply may be obtained at a retail pharmacy. However, all subsequent fills must be purchased through the Specialty Pharmacy Program.
Independence Blue Cross 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.
1 HMO Silver Proactive Lite and HMO Silver Proactive Basic are only available for purchase through the Pennsylvania Insurance Exchange (Pennie).
2 HMO Silver Proactive Select and HMO Silver Proactive Value are not offered on the Pennsylvania Insurance Exchange (Pennie) and must be purchased through Independence directly.
3 Prescriptions may also be available for up to a 90-day supply at participating Act 207 retail pharmacies for the same mail order member cost. To learn more about mail order services and Act 207 pharmacies, call the pharmacy benefits phone number on the back of your ID card.
OptumRx is an Optum ® company — an independent company that provides home delivery, specialty, and infusion pharmacy services.