Drugs administered in a clinical setting (such as a doctor's office, hospital, or infusion clinic) are typically covered under the patient's (member's) medical benefit. For Independence Blue Cross (IBX) patients (members) receiving infusion therapies, providers should confirm coverage and applicable guidelines under their medical benefit plan to ensure safe and affordable access to medications.
What providers need to know:
- Check which drugs are covered by the member's plan.
- Determine if prior authorization is required.
- Review Dosage and Frequency Guidelines for certain drugs.
- Submit coverage requests for drugs not listed under medical benefit guidelines.
- Members can appeal coverage decisions.
- Verify drug coverage via the Provider Engagement, Analytics & Reporting (PEAR) portal, or call 1-800-ASK-BLUE (1-800-275-2583).
Precertification
Precertification means that providers must obtain approval from IBX before certain drugs are covered or paid for. This process ensures that prescribed medications — such as those for cancer and multiple sclerosis — are medically necessary, clinically appropriate, and used according to FDA-approved or medically accepted guidelines.
IBX nurses and physicians review requests based on medical policy and the clinical information submitted, considering factors like dosing, therapy duration, and potential drug interactions. For details on which specialty drugs require precertification, consult the Precertification and cost-share requirements.
How to submit a precertification request
Providers must be registered with the PEAR portal and submit precertification requests electronically through PEAR Practice Management (PM) for services at acute care facilities, ambulatory surgical centers, or office settings.
IBX Utilization Management reviews each request; if a nurse cannot approve it, a medical director will review. Approvals are communicated via the PEAR portal or phone, often in real time. If denied, providers and members are notified, and appeals information is detailed in the denial letter.
Medical policy
Medical policies can be accessed through our Medical and Claim Payment Policy Portal. To view a specific policy, select Commercial or Medicare Advantage in the search field and type the drug name.
Step therapy
IBX requires step therapy for certain drugs, meaning patients (members) must first try preferred medications before coverage is approved for alternatives. If the initial (preferred) drug is not effective, coverage for another (nonpreferred) drug may then be considered.
For example, if Drug A and Drug B both treat the medical condition, IBX may not cover Drug B unless a member tries Drug A first. If Drug A does not work for a member, IBX will then cover Drug B.
Dosage and frequency limits
IBX reviews the dosage and frequency of certain specialty drugs under the Dosage and Frequency Program to ensure regimens meet medical necessity and safe prescribing limits. This review is part of the precertification process for all IBX medical plans. Providers can find dosing guidelines in the Medical and Claim Payment Policy Portal, with more details available on the Dosage and Frequency page of the IBX website.
Most Cost-Effective Setting (MCES)
IBX's MCES Program reviews treatment settings for certain specialty drugs to ensure care is provided in safe, cost-effective locations. This review is part of the precertification process for IBX commercial medical plans.
For the drugs in this program, IBX considers the following settings to be safe and cost-effective:
- A physician's office
- The member's home, when administered by an in-network home infusion provider
- An ambulatory (freestanding), independent infusion suite
View the complete list of drugs eligible through the MCES program.
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