​Independence Blue Cross (IBX) seeks to ensure that members receive high-quality, cost-effective prescription drug coverage. This includes access to a formulary, which is a list of U.S. Food and Drug Administration (FDA) approved drugs selected by a Pharmacy and Therapeutics (P&T) Committee based on medical effectiveness, safety, and value.

The pharmacy benefit manager (PBM) administers claims, collaborates with pharmacies, and monitors drug safety and prescribing patterns. The PBM also works with community, mail-order, and specialty pharmacies to provide medications and customer service to our members and providers.​​​

Formularies and coverage tiers

Select Drug Program®

The formulary is divided into cost-sharing tiers:

• Low-cost generic: Lower copays for certain chronic condition medications.
• Generic: Lowest cost-sharing for most generic drugs.
• Preferred brand: Higher cost-sharing for preferred brand-name drugs.
• Non-preferred drug: Highest cost-sharing for non-preferred drugs.

Brand-name drugs with generic equivalents are typically covered at the non-preferred level, while generics are covered at the lowest tier. Download the latest Select Drug Program Formulary or call 1-800-ASK-BLUE (1-800-275-2583) for a printed copy.

Value Formulary

Organized similarly to the Select Drug Program, drugs not included are considered non-formulary, with covered equivalents and/or alternatives available. New drugs are added after P&T Committee review.

Non-formulary exceptions: Providers may request coverage for non-formulary drugs after trials or contraindications of at least three formulary alternatives when available. Approved requests are covered at the highest cost-sharing tier. Fax exception requests to 1-888-671-5285. You can download the latest Value Formulary from the IBX webpage. To request a printed copy, call 1-800-ASK-BLUE (1-800-275-2583).

Cost-saving options

Generic equivalent drugs

Generic drugs, approved by the FDA, are equivalent to brand-name drugs in active ingredients, safety, and effectiveness but cost up to 70 percent less. Pharmacists may substitute generics unless “dispense as written" or “brand medically necessary" is specified. If a brand-name drug is prescribed in place of a generic drug, prior authorization may be needed before the drug is dispensed, and the member will be responsible for the higher cost-sharing associated with a brand-name drug.

Therapeutic alternatives

Drugs in the same therapeutic class can be substituted for similar treatment outcomes (e.g., Dulera® alternatives include Advair® HFA, Symbicort®, and Breo-Ellipta®).

Although they are not the exact chemical equivalents of the brand-name drugs, therapeutic alternatives treat medical conditions in a similar way.

Mail-order services

Members can receive medications through mail-order services, which may require prior authorization. Use the Formulary Lookup Tool on the IBX website to check drug requirements. To access, go to Drug Formularies, select the member's formulary and then select Find a Formulary Drug. For Value Formulary members, the provider will also need to select a tier level before accessing the Lookup Tool. ​

Specialty drugs

Specialty drugs treat rare, complex, or chronic conditions and require special handling or monitoring. Specialty drugs covered under the pharmacy benefit may be managed by the pharmacy benefit manager. Benefits may vary, and many plans cover specialty drugs on a specialty tier with higher cost-sharing.​

Exceptions and prior authorizations

Formulary tier exceptions

Providers may request an exception for a non-preferred drug to be covered at a preferred level of cost-sharing when there has been a trial of, or contraindications to, at least three formulary alternatives. This option is available based on benefit design for both Select Drug Program and Value Formulary members. The following restrictions apply:

• Drugs on the generic, preferred brand, and the specialty tiers are not eligible for a change to cost-share.
• Non-formulary drugs on the Value Formulary are not eligible for change to a lower cost-share. If approved for non-formulary exception, the member will pay the highest level of cost-sharing for these drugs.
• Brand-name drugs are not eligible for coverage on the generic tier.

The provider should complete the formulary exception form, providing details to support the request and fax it to the pharmacy benefit manager at 1-888-671-5285. If the tier exception request is approved, the provider will receive a fax notification, and the drug will be processed at the appropriate formulary level of cost-sharing. If the request is denied, the provider and member will receive a denial letter.

Prior authorization

Certain drugs require prior approval to ensure medical necessity. The process involves clinical evaluation of alternatives, dosing, and potential interactions. Coverage of certain drugs on the formulary, with or without prior authorization (e.g., weight loss drugs), may be limited based on the member's prescription drug benefit design. Claim dollar limits are placed to require review for clinical appropriateness on prescription claims exceeding a defined dollar limit threshold. The member's provider will need to submit a prior authorization request to any claim exceeding $10,000. Providers can access platforms such as CoverMyMeds® and SureScripts™ that support electronic prior authorization (ePA) to submit a prior authorization request. Alternatively, the provider can complete a prior authorization form and fax all supporting medical information to the pharmacy benefit manager at 1-888-671-5285.​

Safe prescribing procedures

Safety edits

Designed to ensure appropriate drug use, safety edits include:

• Age Limits: Applied to drugs with age-specific safety concerns.
• Quantity Limits: Restrict supply based on FDA-approved dosing.
• Morphine Milligram Equivalent (MME) Limits: Limit daily opioid dosages to 90 MME; higher doses require prior authorization.
• Cumulative Stimulant Limits: Monitor central nervous system stimulant use to reduce cardiac risks.
• Concurrent Drug Utilization Review (cDUR): Identifies potential drug interactions or duplications at the point of sale.​

Additional information

Visit the Pharmacy section of our website for additional information on pharmacy policies and programs.

IBX uses an independent company to provide pharmacy benefits management services.

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