FAQ: Prescription drugs

Yes, prescription drugs are covered for all of the individual health plans offered by Independence Blue Cross (IBX). 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 (IBX) ID card. How you will be charged will depend on your plan type:

• Standard prescription drug plans: You will pay either the copay or coinsurance specified for the generic, preferred brand, non-preferred drug, or self-administered specialty drug you have been prescribed. If your health plan has a maximum copay amount, that means that IBX will cover any expenses beyond that amount for a particular prescription and you only need to pay that maximum copay amount. If you use an out-of-network pharmacy, then you will be required to pay 70 percent coinsurance.
• HSA-qualified plans: HSA health plans have a prescription deductible that is integrated with the medical deductible. This means that you pay for prescriptions in full until your medical deductible has been reached. Once the deductible has been met, you are covered (at the appropriate cost sharing) for generic drug, preferred brand, non-preferred drug, or self-administered specialty drugs from in-network pharmacies. If you use an out-of-network pharmacy, then you will be required to pay 70 percent coinsurance, after deductible.
• High-deductible health plans (HDHPs): HDHPs also have a prescription deductible that is integrated with the medical deductible. This means that you pay for prescriptions in full until your medical deductible has been reached. Once the deductible has been met, you are covered (at the appropriate cost sharing) for generic drug, preferred brand, non-preferred drug, or self-administered specialty drugs from in-network pharmacies. On these plans, there is no coverage for out-of-network pharmacies and you will be required to pay the full cost of the prescription.

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/home delivery.

To locate a participating retail pharmacy or begin mail-order/home delivery 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/home delivery service. To get started with mail-order/home delivery 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 2025:

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/home delivery pharmacies.³ 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.

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 medications program provides complete coverage for certain preventive medications when provided by a participating retail or mail-order/home delivery pharmacy.² Coverage includes certain generic and brand medications within the following drug categories, as described in the Patient Protection and Affordable Care Act:

• Aspirin for adults age 50-59 to prevent cardiovascular disease; low dose (81mg) for women after 12 weeks gestation who are at high risk for preeclampsia
• Breast cancer chemo prevention for women
• Fluoride supplementation for children aged six months to 16 years
• Folic acid supplementation for women planning or capable of pregnancy
• Lovastatin (40mg or less) for cardiovascular disease prevention in adults age 40-75 with no history of cardiovascular disease
• Tobacco interventions for adults who use tobacco products

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.

Please refer to our preventive flyer for additional details.

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:

• 24/7 video consultations. Pharmacists are available anytime via secure web video to answer questions, provide medication self-administration training, and help members follow personalized treatment plans.
• Ongoing patient education and support. Members receive educational materials and, when appropriate, Optum Specialty Pharmacy staff communicate with a member’s other health care providers regarding follow-up to help them manage their condition more effectively.
• Confidential, convenient order and delivery. Order medications by phone for delivery anywhere in the U.S. with no shipping charges.
• Refill reminders. Members receive a phone call before their medication refill date to schedule the next delivery and help them adhere to their treatment without disruption.
• Cost savings. Members can realize additional cost savings because Optum Specialty Pharmacy, administered by OptumRx, provides better discounts on most specialty drugs compared to pricing at retail pharmacies.

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.

Learn more about the Direct Ship Drug Program.