Important Information About IBC's Policies and Guidelines
- Benefits that Require Preapproval
- Specialty Drugs Requiring Precertification
- Inpatient Hospital Stays
- Utilization Review
- Continuity of Care
- Emergency Services
- Complaints and Grievances
- Procedures that Support Safe Prescribing
- Benefits Exclusions
- Preexisting Exclusion
Benefits that Require Preapproval
When you need services that require preapproval, your primary care physician or provider contacts the Clinical Services team and provides information to support the request for services. The Clinical Services team, made up of physicians and nurses, evaluates the proposed plan of care for payment of benefits. The Clinical Services team notifies your physician/provider if the services are approved for coverage. If the Clinical Services team does not have sufficient information or the information evaluated does not support coverage, you and your physician/provider are notified in writing of the decision. Members and providers acting on behalf of a member may appeal the decision. At any time during the evaluation process or the appeal, the provider or member may provide additional information to support the request.
Services that require preapproval include, but are not limited to:
- Inpatient services
- surgical and nonsurgical inpatient admissions
- acute rehabilitation
- skilled nursing facility
- inpatient hospice
- Outpatient facility/office services (other than inpatient)
- cataract surgery
- cochlear implant surgery
- comprehensive outpatient pain management programs (including epidural injections)
- CT/CTA scan
- day rehabilitation programs
- dental services as a result of accidental injury
- hyperbaric oxygen
- nasal surgery for submucous resection and septoplasty
- nuclear cardiac studies
- obesity surgery
- PET scans
- pain management procedures (including epidural injections, transforaminal epidural injections, paravertebral facet joint injections)
- transplants (except cornea)
- uvulopalatopharyngoplasty (including laser-assisted)
- All home-care services (including infusion therapy in the home)
- Infusion therapy drugs in an outpatient facility or in a professional provider’s office (see list included in your subscriber agreement)
- Maternity admission and birthing center (prenotification requested only)*
- Elective (nonemergency) ambulance transport
- Prosthetics and orthotics – Purchase items (including repairs and replacements) over $500 (except ostomy supplies)
- Durable medical equipment – Purchase items (including repairs and replacements) over $500 and all rentals (except oxygen, diabetic supplies, and unit dose medication for nebulizer)
- Reconstructive procedures and potentially cosmetic procedures
- breast: reconstruction, reduction, augmentation, mammoplasty, mastopexy, insertion, and removal of breast implants
- chemical peels
- excision of excessive skin and/or subcutaneous tissue
- genetically and bio-engineered skin substitutes for wound care
- hair transplant
- injectable dermal fillers
- keloid removal
- lipectomy/liposuction, or any other fat removal procedure
- orthognathic surgery procedures including but not limited to: bone graft, genioplasty, osteoplasty, mentoplasty, osteotomies
- scar revision
- skin closures including skin grafts, skin flaps, and tissue grafts
- sex reassignment surgery
- surgical treatment of gynecomastia
- surgery for varicose veins including perforators and sclerotherapy
- Covered services by a nonparticipating physician/provider for nonemergency services (in-network/referred care)*
*Applies to HMO plans only.
Specialty Drugs Requiring Precertification
Download a list of specialty drugs requiring precertification.
Inpatient Hospital Stays
During and after an approved hospital stay, Independence Blue Cross’s (IBC) Care Management and Coordination team monitors your stay. They review whether you are receiving medically appropriate care, see that a plan for your discharge is in place, and coordinate services that may be needed following discharge.
To assist IBC in making coverage determinations regarding the medical necessity and appropriateness of requested services, IBC uses medical guidelines based on clinically credible evidence. This is called utilization review. Utilization review can be done before a service is performed (prenotification/precertification/preservice); during a hospital stay (concurrent review); or after services have been performed (retrospective/post-service review). IBC follows applicable state/federal standards pertaining to how and when these reviews are performed.
Continuity of Care*
IBC offers members continuation of coverage for an ongoing course of treatment with a terminated provider (for reasons other than cause) for up to 90 days from the date that IBC notified the member of the provider termination. IBC will cover such continuing treatment under the same terms and conditions as if the treatment was being received from participating providers.
If a member is in her second or third trimester of pregnancy at the time of the termination, the transitional period of authorization shall extend through post-partum care related to the delivery.
All authorized health care services provided during this transitional period would be covered by IBC under the same terms and conditions applicable for participating health care providers. The nonparticipating provider must agree that all authorized health care services provided during this transitional period would be covered by IBC under the same terms and conditions applicable for participating health care providers.
In order to initiate continuity of care, members must complete a Continuity of Care form and submit it to IBC’s Care Management and Coordination department. The form is available through Customer Service.
Nonparticipating health care providers (whose services are covered during the transitional period) must agree to be bound by the same terms and conditions as participating providers. The plan is not required to provide health care services that are not covered benefits.
*Continuity of care policy applies to HMO plans only.
An emergency is defined as the sudden and unexpected onset of a medical condition manifesting itself in acute symptoms of sufficient severity or severe pain that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in any of the following:
- placing the member’s health or, in the case of a pregnant member, the health of the unborn child in jeopardy;
- serious impairment to bodily functions;
- dysfunction of any bodily organ or part.
Emergency care includes covered services provided to a member in an emergency, including emergency transportation and related emergency services provided by a licensed ambulance service.
Complaints and Grievances
You have a right to appeal any adverse decision through the Complaint and Grievance Process. Instructions for the appeal will be described in the denial notifications and in the Subscriber Agreement.
At IBC, protecting your privacy is very important to us. That is why we have taken numerous steps to see that your Protected Health Information (PHI) is kept confidential. Protected health information is individually identifiable health information about you. This information may be in oral, written, or electronic form. IBC may obtain or create your PHI while conducting our business of providing you with health care benefits.
IBC has implemented policies and procedures regarding the collection, use, and release or disclosure of PHI by and within our organization. We continually review our policies and monitor our business processes to make sure that your information is protected while assuring that the information is available as needed for the provision of health care services. For example, our procedures include steps to assist us in verifying the identity of someone calling to request PHI, procedures to limit who on our staff has access to your PHI, and directions to share only the minimum amount of information when PHI must be disclosed. We also protect any PHI transmitted electronically outside our organization by using only secure networks or by using encryption technology if the information is sent by email.
We do not use or share your PHI without your permission unless the law allows us to do so. Before using or disclosing your PHI for other purposes, we’ll obtain your written permission, also called an authorization. You may also direct us to share your PHI with someone you choose by giving us your written authorization. However, this authorization must include certain specific information in order to be valid. You may print a copy of our Authorization to Release Information form from our website, www.ibx.com, or request a copy by calling our Privacy Office at 215-241-4735.
Procedures that Support Safe Prescribing
Independence Blue Cross utilizes an independent pharmacy benefits management (PBM) company, FutureScripts®, to manage the administration of its commercial prescription drug programs. As our PBM, FutureScripts is responsible for providing a network of participating pharmacies, administering pharmacy benefits, and providing customer service to our members and providers.
Independence Blue Cross requires prior authorization of certain covered drugs to ensure that the drug prescribed is medically necessary and appropriate and is being prescribed according to the U.S. Food and Drug Administration’s (FDA) guidelines. The approval criteria were developed and endorsed by the FutureScripts Pharmacy and Therapeutics Committee, which is an established group of medical directors and practicing area physicians and pharmacists.
Using these approved criteria, clinical pharmacists evaluate requests for these drugs based on clinical data, information submitted by the member’s prescribing physician, and the member’s available prescription drug therapy history. Their review includes a determination that there are no drug interactions or contraindications, that dosing and length of therapy are appropriate, and that other drug therapies, if necessary, were utilized.
Without prior authorization, the member’s prescription will not be covered at the retail or mail order pharmacy (see 96-Hour Temporary Supply Program below). The prior authorization process may take up to two working days once complete information from the prescribing physician has been received. Incomplete information will result in a delayed decision.
Prior authorization approvals for some drugs may be limited to 6 to 12 months. If the prior authorization for a drug is limited to a certain time frame, an expiration date will be given at the time the approval is made. If the physician wants a member to continue the drug therapy after the expiration date, a new prior authorization request will need to be submitted and approved in order for coverage to continue.
Currently, the drugs listed below are a part of the prior authorization program. Prior authorization applies to all formulations of these specific drugs, including, but not limited to tablet, capsule, and oral suspension. Abstral®, AcipHex®, Actiq®, AdcircaTM, Afinitor®, AlodoxTM, AltabaxTM, Ambien CR®, Amerge®, AmpyraTM, AMRIX®, AmturnideTM, Androderm®, Apidra®, SoloSTAR®, AplenzinTM, Atacand®/Atacand HCT®, Avapro®/Avalide®, Axiron®, Axert®, BanzelTM, Beconase AQ®, BiDil®, Byetta®, Caduet®, Capresla®, Caverject®, CaystonTM, Celebrex®, Cesamet®, Cialis®, Cimzia®, Cozaar®/Hyzaar®, DaytranaTM, Dexilant®, Diabetic Test Strips (except Autodisc®, Breeze® 2, Contour®, FreeStyle Lite®, and Precision Xtra®), EdarbiTM, Edex®, EdluarTM, EffientTM, EgriftaTM, Enbrel®, Exforge®, EXFORGE HCT®, Exjade®, FanaptTM, Fentora®, Flector® Patch, Flonase®, ForteoTM, FortestaTM, Frova®, Genotropin®, GilenyaTM, Gleevec®, GlumetzaTM, Humalog®, Humatrope®, Humira®, Humulin®, HYCAMTIN® Capsules, Imitrex®, IntunivTM, InvegaTM, Iressa®, Keppra XRTM, Kineret®, Lantus®, Levitra®, Livalo®, Lyrica®, MagnacetTM, Maxalt®, Micardis®/Micardis HCT®, Mobic®, MUSE®, Nasacort® AQ, Nexavar®, NexiclonTM, Norditropin®, Noxafil®, NucyntaTM, NuedextaTM, NutriDoxTM, Nutropin®, Nutropin AQ®, Nuvigil®, OfortaTM, Omnaris®, Omnitrope®, OnglyzaTM, OnsolisTM, Pennsaid®, Pradaxa®, PrandiMetTM, Prevacid®, Prevacid/NapraPAC®, Prilosec® Suspension, PristiqTM, Protonix®, Provigil®, PyleraTM, Qualaquin®, ReliOn®/Novalin®, Relpax®, Renvela®, Requip® XLTM, RevatioTM, Revlimid®, Rhinocort Aqua®, RozeremTM, RyzoltTM, Sabril®, Saizen®, SamscaTM, SavellaTM, Serostim®, Silenor®, SimponiTM, Sprycel®, StaxynTM, Striant®, Suboxone®, Subutex®, SumavelTM, Sutent®, SylatronTM, Symlin®, Taclonex®, Taclonex Scalp® Suspension, Tarceva®, Tasigna®, TekamloTM, Tekturna®/Tekturna HCT®, Temodar® Oral, Testim®, Teveten®/Teveten HCT®, Tev-Tropin®, Thalomid®, ToviazTM, TreximetTM, Twynsta®, Tykerb®, Uloric®, Ultram® ER, Valturna®, Veramyst®, Viagra®, Victoza®, VimovoTM, VimpatTM, Voltaren® Gel, VotrientTM, Vytorin®, VyvanseTM, XenazineTM, Xyzal®, Zegerid®, ZipsorTM, ZmaxTM, Zolinza®, ZolpimistTM, Zomig®, Zorbtive®, Zortress®, ZytigaTM, and Zyvox®. This list is subject to change.
Age and Gender Limits
The FDA has established specific procedures that govern prescription prescribing practices. These rules are designed to prevent potential harm to patients and ensure that the medication is being prescribed according to FDA guidelines. For example, some drugs are approved by the FDA only for individuals ages 14 and older, such as ciprofloxacin, or prescribed only for females, such as prenatal vitamins. The pharmacist’s computer provides up-to-date information about FDA rules. If the member’s prescription falls outside of the FDA guidelines, it will not be covered until prior authorization is obtained. The prescribing physician may request preapproval of restricted medications when medically necessary. The approval criteria for this review were developed and endorsed by the FutureScripts Pharmacy and Therapeutics Committee, which is an established group of medical directors and practicing area physicians and pharmacists. The member should contact the prescribing physician to request that he or she initiate the preapproval process. To determine if a covered prescription drug prescribed for you has an age or gender limit, call FutureScripts at 1-888-678-7012.
Quantity Level Limits
Quantity level limits are designed to allow a sufficient supply of medication based upon FDA-approved maximum daily doses and length of therapy of a particular drug. We have several different types of quantity level limits, which are explained in detail below.
- Rolling 30-day period. This quantity limit is based on dosing guidelines over a rolling 30-day period. Examples of quantity level limits per rolling 30-day period are Emend® (four 125mg capsules + eight 80mg capsules or four trifold packs [one 125mg capsule + two 80mg capsules]); Boniva® (two 150mg tablets); Avonex® (one kit, four injections); Betaseron® (15 vials); Copaxone® (32 vials); Fosamax Plus DTM (five tablets); Rebif® (12 injections); migraine drugs such as Amerge® (nine 2.5mg tablets), Imitrex® (36 50mg tablets), Maxalt® (12 10mg tablets), Migranal® (eight 4mg nasal spray units), Stadol NS® (four 10mg units), and Zomig® (nine 5mg tablets); fertility agents (if covered under the group contract) such as Fertinex® (60 ampules), Follistim® (60 ampules), Gonal-F® (60 ampules), Humegon® (60 ampules), Pergonal® (60 ampules), and Repronex® (60 ampules); sedative hypnotic drugs, such as Sonata® (14 capsules) and Ambien® (14 tablets); and oral narcotic drugs such as OxyContin® (90 units), Percocet® (180 units), and Percodan® (180 units). For example, if a member went to the pharmacy on April 1, 2010, for one of these medications, the computer system would have looked back 30 days to March 1, 2010, to see how much medication was dispensed. The purpose of these limits is to make certain that these drugs are being used appropriately and to guard against overuse or stockpiling.
- Refill too soon. With this quantity level limit, if a member used less than 75 percent of the total day supply dispensed, the claim will be rejected at the pharmacy. This will ensure that the medication is being taken in accordance with the prescribed dose and frequency of administration.
- Therapeutic drug class. This quantity level limit applies to some classes of drugs, such as narcotics. If a member uses more than one drug within the same class, he or she may be unsafely duplicating medications and would be affected by the total quantity limits for a therapeutic drug class. Members will be able to obtain only a 30-day total supply of any combination of drugs in the same therapeutic drug class each month.
If a physician requires that a member needs a medication therapy that exceeds any of the quantity level limits described above, the physician must request a quantity limit override. The member is required to contact the prescribing physician to initiate a preapproval request for an override.
Some drugs may have a time period for quantity limit exceptions of 6 to 12 months. If the exception for a drug is limited to a certain time frame, an expiration date will be given at the time the approval is made. If the physician wants a member to continue the drug therapy that exceeds a quantity limit after the expiration date, a new request for a quantity limit exception will need to be submitted and approved in order for coverage to continue.
To determine if a covered prescription drug prescribed for you has a quantity level limit, call FutureScripts at 1-888-678-7012.
96-Hour Temporary Supply Program
The 96-Hour Temporary Supply Program applies to the following covered medications:
- most medications that require prior authorization;
- medications that are subject to age limits (preapproval required for ages outside of recommended ranges);
- migraine medications with quantity level limits, such as Amerge®, Imitrex®, Maxalt®, Migranal®, Stadol® NS, and Zomig® (preapproval of quantity override required for amounts over the quantity level limits).
Under the 96-Hour Temporary Supply Program, if a member’s doctor writes a prescription for a drug that requires prior authorization, has an age limit, or exceeds the quantity level limit for a medication, and prior authorization/preapproval has not been obtained by the doctor, the following steps will occur:
- The participating retail pharmacy will be instructed to release a 96-hour supply of the drug to the member with no out-of-pocket cost-sharing at that time.*
- By the next business day, our PBM will contact the member’s doctor to request that he or she submit the necessary documentation of medical necessity or medical appropriateness for review.
- Once the completed medical documentation is received by our PBM, the review will be completed and the medication will be approved or denied.
- If approved, the remainder of the prescription order will be filled, and the appropriate prescription drug out-of-pocket cost-sharing will be applied.*
- If denied, notification will be sent to the doctor and the member.
Obtaining a 96-hour temporary supply does not guarantee that the prior authorization/preapproval request will be approved. Some medications are not eligible for the 96-Hour Temporary Supply Program due to packaging or other limitations, such as Retin-A® (tube), Enbrel® (2-week injection kit), medroxyprogesterone acetate (monthly injectable), and erectile dysfunction drugs. Additionally, certain drugs to treat hemophilia (antihemophilic factors) are not usually purchased at the pharmacy and must be special-ordered; therefore, they are not eligible for the 96-hour temporary supply.
The process for requesting a prior authorization/preapproval or override is as follows:
- The physician prescribing the medication completes a prior authorization form or writes a letter of medical necessity and submits it to our PBM by fax at 215-241-3073 or 1-888-671-5285. A member’s physician can request the form by calling 1-888-678-7012. Members can request the form through Customer Service on behalf of their physician, but it must be completed and submitted by the doctor.
- The PBM will review the prior authorization request or letter of medical necessity. If a clinical pharmacist cannot approve the request based on established criteria, a medical director will review the document.
- A decision is made regarding the request.
- If approved, the prescribing physician will be notified of approval via fax or telephone, and the Rx Claim System will be coded with the approval.
- The member may call the Customer Service phone number on his or her identification card to determine if the prescription is approved.
- If denied, the prescribing physician will be notified via letter, fax, or telephone.
- The member is also notified of all denied requests via letter.
- The appeals process will be detailed on the denial letters sent to the member and physician.
*Members with an integrated drug benefit (e.g., CMM and Major Medical) will pay the discounted cost of the 96-hour supply as well as the remainder of the prescription order (if approved) at the time of purchase, and the medical claim for reimbursement will be processed through standard procedures.
Coverage for Medications not on the Formulary*
Providers may request formulary coverage of a covered non-formulary medication when all formulary alternatives have been exhausted or there are contraindications to using the formulary alternatives. The provider should complete the covered non-formulary appeal form providing detail to support use of the covered non-formulary medication and fax the request to 215-241-3073 or 1-888-671-5285. If the nonformulary request is approved, the drug will be paid at the appropriate formulary benefit level. If the request is denied, the member and provider will receive a denial letter with the appropriate appeals language. Whether or not an appeal is filed, the member may always obtain benefits for the covered non-formulary drug at the appropriate non-formulary benefit level. Out-of-pocket expenses for non-formulary drugs are higher than for formulary drugs.
*Specific to Select Drug Program® members only.
Appealing a Decision
If a request for prior authorization/preapproval or override results in a denial, the member, or the physician on the member’s behalf, may file an appeal. Both the member and his or her provider will receive written notification of a denial, which will include the appropriate telephone number and address to direct an appeal. In all cases, the physician needs to be involved in the appeal process to provide the required medical information for the basis of the appeal.
Prescription Drug Program Provider Payment Information
A pharmacy benefits management (PBM) company administers our prescription drug benefits and is responsible for providing a network of participating pharmacies and processing pharmacy claims. The PBM also negotiates price discounts with pharmaceutical manufacturers and provides drug utilization and quality reviews. Price discounts may include rebates from a drug manufacturer based on the volume purchased. Independence Blue Cross anticipates that it will pass on a high percentage of the expected rebates it receives from its PBM through reductions in the overall cost of pharmacy benefits. Under most benefit plans, prescription drugs are subject to a member copayment.
The benefits summaries available online and via mail represent only a partial listing of benefits and exclusions of the plans. Benefits and exclusions may be further defined by medical policy. This managed care plan may not cover all your health care expenses. Read your contract carefully to determine which health care services are covered. If you need more information, please call 1-800-263-1410.
What’s not covered?
- services not medically necessary;
- any treatment of substance abuse or mental illness, including serious mental illness;
- services or supplies that are experimental or investigative, except routine costs associated with qualifying clinical trials;
- hearing aids, hearing examinations/tests for the prescription/fitting of hearing aids, and cochlear electromagnetic hearing devices;
- assisted fertilization techniques, such as in vitro fertilization, GIFT, and ZIFT;
- reversal of voluntary sterilization;
- alternative therapies, such as acupuncture;
- dental care, including dental implants or dentures, and nonsurgical treatment of temporomandibular joint syndrome (TMJ);
- treatment of obesity, except for surgical treatment of morbid obesity when medically necessary;
- routine foot care, except for medically necessary treatment of peripheral vascular disease and/or peripheral neuropathic disease including, but not limited to, diabetes;
- foot orthotics, except for orthotics and podiatric appliances required for the prevention of complications associated with diabetes;
- routine physical exams for nonpreventive purposes, such as insurance or employment applications, college, or premarital examinations;
- contraceptive devices;
- immunizations for travel or employment;
- services or supplies payable under Workers’ compensation, motor vehicle insurance, or other legislation of similar purpose;
- cosmetic services/supplies;
- outpatient services that are not performed by your primary care physician’s designated provider;
- private duty nursing;
- charges related to any medical condition or illness for which medical advice or treatment was recommended or received during a certain amount of time (90 days for HMO, 12 months for PPO) preceding the effective date of your plan policy is excluded for the first 12 months. If you have been continuously insured for 12 months by a participating Blue Cross or Blue Shield plan, or the past 18 months by another plan (without a break in coverage of more than 63 days prior to the current application), you may be able to receive credit for all or part of the 12 month exclusion. To learn more about preexisting condition exclusions and how they can be reduced through creditable coverage, see the Preexisting Exclusion section that follows.
In addition, the following benefits are not covered for PPO plans:
- maternity care
- routine eye care
NOTE: Eligible dependent children are generally covered up to age 26. See contract for additional details.
Please note: These plans exclude coverage for preexisting conditions for the first 12 months of coverage except for applicants under 19 and dependent children under 19. However, if you meet the requirements for creditable coverage, you may be able to reduce or waive the waiting period for your preexisting condition.
For HMO plans, we will look at any services received 90 days prior to the effective date of coverage to determine if there are any preexisting conditions. For PPO plans, we will look at any services received 12 months prior to the effective date of coverage.
There are two ways in which you may be able to waive or reduce the waiting period for a preexisting condition — through a Blue-to-Blue transfer or creditable coverage.
For a Blue-to-Blue transfer, you must have coverage through a Blue Cross® or Blue Shield® plan. The plan must have been in force for 12 months without a break in coverage prior to the current application. You may receive credit for each month of prior coverage up to the entire exclusion period of 12 months.
Prior enrollment in another Blue plan does not guarantee acceptance into this medically underwritten program. All applications are subject to underwriting approval.
You may qualify for creditable coverage if you had coverage through another plan. This plan must have been in force for 18 months without a break in coverage of more than 63 days prior to the current application. You may receive credit for the entire exclusion period of 12 months.
Prior creditable coverage does not guarantee acceptance into this medically underwritten program. All applications are subject to underwriting approval.
Plans that qualify as creditable coverage include:
- group or individual health plans, including governmental plans
- COBRA continuation coverage
- state high-risk pools
- Indian Health Service
- public health plans (such as a plan offered by a state)
- federal or state employee benefits
Plans that do not count as creditable coverage include:
- accident or accident-only
- dental- or vision-only
- disability or liability plans
- auto or homeowners’ plans
- hospital indemnity
- Workers’ compensation
- specified disease policies (e.g., cancer policies)
What is needed to be considered for a reduction or waiver of the preexisting condition exclusion period?
- Applicant must complete all parts of Section G (Other insurance).
- Applicant must also submit a Certificate of Creditable Coverage for each qualifying individual to be covered on the plan.