Prior Authorization is when certain covered drugs that have been approved by the U.S. Food and Drug Administration (FDA) for specific medical conditions require prior approval before use. The approval criteria are developed and endorsed by our Pharmacy and Therapeutics Committee and are based on information from the FDA, manufacturer guidelines, medical literature, actively practicing consultant physicians, and appropriate external organizations.
Step Therapy is when Independence requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Independence may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Independence will then cover Drug B.
A request form is available for medications requiring prior authorization. Our pharmacy benefit 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. For more information on coverage determinations, including how to submit, please reference the Coverage Determinations for Part D section of our website.
The plan puts each covered drug into one of several different cost-sharing tiers. How much you pay for your prescription depends in part on which cost-sharing tier your drug is in. For drugs in the non-preferred brand tier, you and your provider can ask the plan to make an exception to allow at the preferred brand drug tier so that 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 instructions below for requesting an exception.
If the non-preferred request is approved, the drug will be processed at the appropriate preferred formulary benefit cost-sharing. If the request for access at the preferred tier is denied, 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.
Please note that certain drugs in some of our cost-sharing tiers are not eligible for this type of exception. We do not lower the cost-sharing amount for drugs for the following:
If your drug is not on the plan's List of Covered Drugs (Formulary) or is on the list but has a quantity limit, you can request an exception and ask the plan to cover the drug or 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.
A request form is available for submitting an exception request. Our pharmacy benefit 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 Determinations for Part D section of our website.
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. Information may need to be submitted describing the use and setting of the drug to make the determination.
Certain drugs are generally only covered 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 attachment below to determine if precertification is required:
Your physician may refer to the Direct Ship Injectables Program for more information about certain injectable drugs covered under Medicare Part B benefit.
Effective July 18, 2014, the Centers for Medicare & Medicaid Services (CMS) adjusted prescription coverage guidelines for Medicare members with Part D coverage who are under hospice care.
CMS requires Medicare beneficiaries with Part D coverage who are under hospice care to get prior authorization for prescriptions that fall under these four classes of medications: analgesics, anti-nauseants (anti-emetics), laxatives and anti-anxiety 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 benefit manager, FutureScripts ® Secure, reviews all requests.
Website last updated: 6/23/2016
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*Please note that on weekends and holidays from April 1 through September 30, your call may be sent to voicemail.
To file an appeal or grievance for your medical benefit coverage or your prescription drug coverage, contact Keystone 65 Customer Service at 1-800-645-3965 or Personal Choice 65 Customer Service at 1-888-718-3333; TTY/TDD users should call 711, 7 days a week, 8 a.m. to 8 p.m.; or you can complete and submit online the Request for Medicare Prescription Drug Coverage Determination or the Request for Redetermination of Medicare Prescription Drug Denial.
For additional information from the Centers for Medicare and Medicaid Services (CMS) visit http://www.medicare.gov. If you prefer to file a grievance through CMS, please complete the Medicare Complaint Form. For additional assistance, visit The Office of the Medicare Ombudsman.
Independence Blue Cross offers Medicare Advantage plans with a Medicare contract. Enrollment in Independence Medicare Advantage plans depends on contract renewal.
Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East and QCC Insurance Company — independent licensees of the Blue Cross and Blue Shield Association.
Medicare beneficiaries may also enroll in Keystone 65 HMO, Personal Choice 65 SM PPO, or Select Option ® PDP through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.
Keystone 65 HMO and Personal Choice 65 SM PPO: For accommodation of persons with special needs at meetings call toll-free 1-877-393-6733 (711 for the speech- and hearing-impaired).
Every year, Medicare evaluates plans based on a 5-Star rating system.
MedigapFreedom: To join, you must be enrolled in Medicare Parts A and B. Plan F and Plan N are available only to applicants who enroll within six months following enrollment in Medicare Part B or who are guaranteed the right to purchase these plans under applicable federal or state laws. You must continue to pay Medicare Part A (if applicable) and Part B premiums.
COVERED PERSON means a Medicare beneficiary who is enrolled in Medicare Part A and Part B, made the appropriate payment in consideration for this Policy, and is eligible for benefits under this Policy.
Non-tobacco rates apply to applications submitted during the six-month open enrollment or in a guaranteed issue situation. Applicants NOT enrolling during the six-month open enrollment period or in a guaranteed issue situation will be evaluated for tobacco usage and charged the corresponding tobacco or non-tobacco rates. All rates are subject to change with the approval of the Pennsylvania Insurance Department. Any rate change will apply to all policies in our service area and cannot be changed or canceled because of poor health. QCC Insurance Company has the right to change premiums based on your attained age and the table of rate changes. We will give a 30-day notice of a premium change.
Benefits underwritten by QCC Insurance Company, a subsidiary of Independence Blue Cross—independent licensees of the Blue Cross and Blue Shield Association.
Not connected with or endorsed by the U.S. Government or the federal Medicare program.
The SilverSneakers ® fitness program is provided by Tivity Health, Inc., an independent company. ©2019. All rights reserved.
TruHearing ® is a registered trademark of TruHearing, Inc., an independent company.
FutureScripts ® is an independent company that provides pharmacy benefit management services.
The Independence Blue Cross OTC benefit is underwritten by Keystone Health Plan East/QCC and is administered by Convey Health Solutions, Inc., an independent company.
Telemedicine is provided by MDLIVE, an independent company. MDLIVE may not be available in certain states and is subject to state regulations. MDLIVE does not replace the primary care physician, is not an insurance product and may not be able to substitute for traditional in-person care in every case or for every condition. MDLIVE does not prescribe DEA-controlled substances and may not prescribe non-therapeutic drugs and certain other drugs, which may be harmful because of their potential for abuse. MDLIVE does not guarantee patients will receive a prescription. Health care professionals using the platform have the right to deny care if based on professional judgment a case is inappropriate for telehealth or for misuse of services. MDLIVE and the MDLIVE logo are registered trademarks of MDLIVE, Inc. and may not be used without written permission. For complete terms of use visit https://www.mdlive.com/terms-of-use/.
Out-of-network/non-contracted providers are under no obligation to treat Independence Blue Cross Medicare members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2020, and from time to time during the year.
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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.
