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formular
www.ibx.com
In an effort to continue our commitment to provide you with comprehensive prescription drug coverage, a formulary feature is included in your prescription drug benefit. A formulary is a list of selected FDA-approved prescription medications reviewed by the FutureScripts® Pharmacy and Therapeutics Committee. These prescription medications have been selected for their reported medical effectiveness, safety, and value, while providing you with the highest level of coverage under your prescription program. The following information serves as a guide when reviewing the list of formulary drugs on the following pages:
Bolded drug = Formulary generic available at lowest copay.
• Non-bolded drug = Formulary brand available at middle copay.
• Drug in parenthesis ( ) = Non-formulary brand drug available at the highest copay. It is displayed next to the equivalent formulary generic
drug that is available at the lowest copay. For example: amoxicillin is the formulary generic drug available at the lowest copay. (Amoxil) is
the non-formulary brand available at the highest copay. In most cases when brand drugs have a generic equivalent, the generic version is
formulary and the brand version is non-formulary.
• Covered generic drugs not listed are formulary and are available at the lowest copay.
• Covered brand drugs not listed are non-formulary and are available at the highest copay.
PA = Prior authorization must be requested by the physician.
Q = Quantity level limits apply.
✓ = New formulary drug.
The above information is highlighted in a key box on every other page of the formulary list.
Our pharmacy benefits manager, FutureScripts, continuously monitors effectiveness and safety of drugs and drug prescribing patterns. Several procedures support safe prescribing patterns for our prescription drug programs, such as: • coverage for medications not on the formulary.
These procedures are designed to optimize your prescription drug benefit by promoting appropriate utilization. These procedures are based on U.S. Food and Drug Administration (FDA) guidelines, and the criteria are endorsed by the FutureScripts Pharmacy and Therapeutics Committee.
A detailed description of the procedures that support safe prescribing is included at the end of the formulary list.
Please note: Because prescription drug programs vary by group, the inclusion of a drug in this formulary does not imply
coverage. This formulary was current at the time of printing and is subject to change. Please call 1-888-678-7012 if
you have any questions about your prescription drug benefit. Please discuss any questions or concerns about your drug
therapy with your physician or pharmacist. Select Drug Program formulary information can also be obtained on the
Independence Blue Cross website: www.ibx.com

This is a listing of formulary medications to be considered for your patient, a Select Drug Program participant. Please refer to this formulary guide in order to choose a medication. Because prescription drug programs vary by group, the inclusion of a drug in this formulary does not imply coverage. This formulary was current at the time of printing and is subject to change.
Please understand that this formulary is not intended as a substitute for your independent professional judgment. Rather, it is offered as a tool to help plan members recognize formulary drugs. We hope that you will refer to the formulary as a guide to prescribing formulary drugs.
1. ANTIBIOTICS & OTHER DRUGS USED
doxycycline
FOR INFECTION
doxycycline
monohydrate
acyclovir
erythromycin delayed release ( Eryc, Ery-Tab)
amantadine
erythromycin ethylsuccinate ( EES, EryPed)
amoxicillin
erythromycin
stearate
amoxicillin
/clavulanate
erythromycin susp w/sulfa (Pediazole )
amoxicillin /clavulanate extended-release
ethambutol
famciclovir
ampicillin
fluconazole
azithromycin
cefaclor
cefaclor
ganciclovir
cefadroxil
cefdinir
griseofulvin microsize susp (Grifulvin V susp )
cefditoren
cefuroxime
cephalexin
chloroquine
phosphate
hydroxychloroquine
ciprofloxacin ER tabs (Cipro XR )
isoniazid
ciprofloxacin tabs (Cipro )
itraconazole
clarithromycin
ketoconazole
clarithromycin SR (Biaxin XL )
clindamycin
clotrimazole
mebendazole
mefloquine
methenamine
hippurate
metronidazole
demeclocycline
minocycline
dicloxacillin
minocycline
didanosine
Type of covered drug*
Bolded drug is a formulary generic.
• Non-bolded drug is a formulary brand.
• Drug in parenthesis ( ) is a non-formulary brand drug. It is displayed to help you identify the equivalent Highest copay formulary generic drug that is available at the lowest copay.
• Covered generic drugs not listed are formulary.
• Covered brand drugs not listed are non-formulary.
PA = Prior authorization must be requested by the physician.
Q = Quantity level limits apply.
✓ = New formulary drug.
* Unless specifically excluded from your contract.
1. ANTIBIOTICS & OTHER DRUGS USED
FOR INFECTION (cont.)
cyclophosphamide
cyclosporine
mycophenolate
nitrofurantoin
macrocrystals
etoposide
nystatin
ofloxacin
flutamide
penicillin
phenazopyridine
hydroxyurea
leucovorin
pyrazinamide
megestrol
ribavirin
mercaptopurine
rifampin
methotrexate
rimantadine
prednisone
stavudine
sulfamethoxazole/tmp
tacrolimus
sulfisoxazole
tamoxifen
terbinafine
thioguanine
tetracycline
tinidazole
3. PAIN, NERVOUS SYSTEM & PSYCH
valacyclovir
acetaminophen/butalbital
Q acetaminophen/codeine
acetazolamide
alprazolam
amantadine
amitriptyline
amoxapine
amphetamine aspartate/amphetamine sulfate/
zidovudine
dextroamphetamine (Adderall )
2. CANCER & ORGAN TRANSPLANT DRUGS
amphetamine aspartate/amphetamine sulfate/
dextroamphetamine ER (Adderall XR )
anastrazole
aspirin with codeine
azathioprine
benztropine
bicalutamide
bromocriptine
mesylate
3. PAIN, NERVOUS SYSTEM & PSYCH (cont.)
ergotamine/tartrate/caffeine
ethosuximide
etodolac
bupropion
fenoprofen
bupropion
Q, PA fentanyl citrate OTFC (Actiq)
bupropion
Q fentanyl
transdermal
buspirone
fluoxetine
Q butalbital/apap/caffeine
fluphenazine
Q butalbital/aspirin/caffeine
flurbiprofen
carbamazepine
fluvoxamine
carbamazepine
gabapentin
carbidopa/levodopa
galantamine
carbidopa/levodopa
galantamine
carbidopa/levodopa
haloperidol
Q hydrocodone/acetaminophen
chlorpromazine
Q hydrocodone/acetaminophen
choline magnesium trisalicylate
Q hydrocodone/acetaminophen
citalopram
Q hydrocodone/ibuprofen
clomipramine
Q hydromorphone
clonazepam
ibuprofen
/oxycodone
clozapine
imipramine
indomethacin
isometheptene/dichloralphenazone/apap
ketoprofen
ketorolac
desipramine
lamotrigine
dexmethylphenidate
levetiracetam
diazepam
diazepam rectal gel (Diastat )
carbonate
diazepam rectal gel (Diastat AcuDial )
lithium carbonate SR ( Eskalith CR, Lithobid)
diclofenac
potassium
lorazepam
diclofenac
loxapine
diflunisal
divalproex
maprotiline
divalproex sodium ER (Depakote ER )
divalproex sprinkle cap (Depakote Sprinkle Caps )
meclofenamate
Type of covered drug*
Bolded drug is a formulary generic.
• Non-bolded drug is a formulary brand.
• Drug in parenthesis ( ) is a non-formulary brand drug. It is displayed to help you identify the equivalent Highest copay formulary generic drug that is available at the lowest copay.
• Covered generic drugs not listed are formulary.
• Covered brand drugs not listed are non-formulary.
PA = Prior authorization must be requested by the physician.
Q = Quantity level limits apply.
✓ = New formulary drug.
* Unless specifically excluded from your contract.
3. PAIN, NERVOUS SYSTEM & PSYCH (cont.)
sertraline
sulindac
Q meperidine
Q, PA sumatriptan
methadone
Q temazepam
methamphetamine
thioridazine
methylphenidate
thiothixene
migergot
tolmetin
topiramate
mirtazapine
topiramate sprinkle cap (Topamax Sprinkle Capsules )
mirtazapine rapid dissolve tabs (Remeron SolTab )
tramadol
morphine sulfate , extended release (MS Contin )
PA tramadol
Q morphine
tranycypromine
morphine sulfate supp (RMS )
trazodone
nabumetone
Q, PA Treximet
trifluoperazine
naproxen
trihexyphenidyl
naproxen
valproic
naproxen sodium SA (Naprelan )
venlafaxine
Q, PA naratriptan
venlafaxine
Q zaleplon
nefazodone
Q zolpidem
tartrate
nortriptyline
oxaprozin
4. HEART, BLOOD PRESSURE & CHOLESTEROL
oxazepam
oxcarbazepine
acebutolol
Q oxycodone
amiloride
oxycodone /apap ( Roxicet, Percocet, Tylox)
amiloride
Q oxycodone
/aspirin
aminocaproic
oxycodone CR 12 hour tabs (OxyContin )
amiodarone
Q, oxymorphone
amlodipine
paroxetine
amlodipine
/benazepril
paroxetine HCl ext-release (Paxil CR )
anagrelide
perphenazine
atenolol
phenobarbital
atenolol
/chlorthalidone
phenytoin
phenytoin
benazepril
piroxicam
benazepril
pramipexole
primidone
propoxyphene
HCl/apap
betaxolol
Q propoxyphene
napsylate/apap
bisoprolol/HCTZ
pyridostigmine
bumetanide
risperidone
captopril
rivastigmine
captopril
ropinirole
carvedilol
salsalate
chlorothiazide
selegiline
chlorthalidone
4. HEART, BLOOD PRESSURE & CHOLESTEROL (cont.)
hydrochlorothiazide
indapamide
isosorbide
dinitrate
cholestyramine
isosorbide dinitrate ER
cilostazol
isosorbide
mononitrate
clonidine
isosorbide mononitrate ER (Imdur )
clonidine
isradipine
colestipol
labetalol
lisinopril
lisinopril /HCTZ (Prinzide )
PA losartan
diltiazem
PA losartan-HCTZ
diltiazem extended release ( Cardizem CD, Dilacor XR)
lovastatin
diltiazem ER 24 hour (Tiazac )
diltiazem
methyldopa
diltiazem SR (Cardizem SR )
metolazone
metoprolol
tartrate
metoprolol
succinate
dipyridamole
mexiletine
disopyramide
minoxidil
disopyramide CR 150mg (Norpace CR )
moexipril/HCTZ
doxazosin
mesylate
enalapril
nadolol-bendroflume
thiazide
enalapril /HCTZ (Vaseretic )
eplerenone
nifedipine
felodipine
fenofibrate
nisoldipine
fenofibric
flecainide
nitroglycerin
fosinopril
nitroglycerin
furosemide
nitroglycerin
gemfibrozil
pentoxifylline
guanabenz
perindopril
guanfacine
hydralazine
Type of covered drug*
Bolded drug is a formulary generic.
• Non-bolded drug is a formulary brand.
• Drug in parenthesis ( ) is a non-formulary brand drug. It is displayed to help you identify the equivalent Highest copay formulary generic drug that is available at the lowest copay.
• Covered generic drugs not listed are formulary.
• Covered brand drugs not listed are non-formulary.
PA = Prior authorization must be requested by the physician.
Q = Quantity level limits apply.
✓ = New formulary drug.
* Unless specifically excluded from your contract.
4. HEART, BLOOD PRESSURE & CHOLESTEROL (cont.)
betamethasone/clotrimazole
calcipotriene
ciclopirox cream, susp (Loprox )
pindolol
ciclopirox
pravastatin
ciclopirox
solution
prazosin
clindamycin
procainamide
clindamycin-benzoyl peroxide gel (BenzaClin )
clindamycin
phosphate
propafenone
clobetasol
propranolol
propranolol
desoximetasone
quinapril
diflorasone
diacetate
quinapril/HCTZ
econazole
quinapril
gluconate
quinidine gluconate ER
quinidine
erythromycin
ramipril
erythromycin
solution
simvastatin
erythromycin
fluocinolone acetonide cream, soln (Synalar )
spironolactone
fluocinonide gel, oint, cream ( Lidex, Lidex E)
spironolactone
terazosin
fluorouracil
solution
ticlopidine
fluticasone
propionate
gentamicin topical cream, oint
torsemide
HC acetate/lidocaine HCl (Senatec HC )
trandolapril
hydrocortisone 2.5% (Hytone )
trandolapril-verapamil
extended-release
hydrocortisone butyrate 0.1% (Locoid )
triamterene/HCTZ
hydrocortisone valerate 0.2% (Westcort )
imiquimod
isotretinoin
ketoconazole
ketoconazole
verapamil
lidocaine
warfarin
MEDICATIONS
malathion
mometasone
adapalene
metronidazole
alclometasone dipropionate cream (Aclovate )
metronidazole
amcinonide
mupirocin
anthralin
nystatin
nystatin
/triamcinolone
bencort lotion kit (Vanoxide-HC )
benzoyl peroxide gel (Brevoxyl gel )
peroxide
/erythromycin
permethrin
peroxide
podofilox
betamethasone
dipropionate
prednicarbate
ointment
betamethasone dipropionate augmented
prilocaine/lidocaine
prutect topical emulsion (Biafine )
betamethasone
valerate
selenium
5. SKIN MEDICATIONS (cont.)
sulfadiazine
sodium sulfacetamide lotion (Klaron )
sulfacetamide/sulfur
sulfacetamide
sulfacetamide sodium /urea lotion (Carmol scalp lotion )
calcitriol
capsules
tretinoin
triamcinolone
desmopressin
dexamethasone
fludrocortisone
6. EAR, NOSE & THROAT MEDICATIONS
acetic acid HC (Acetasol HC )
glimepiride
glipizide
benzocaine/antipyrine
glipizide
chlorhexidine
gluconate
glyburide
flunisolide
glyburide
micronized
fluticasone propionate nasal susp (Flonase )
ipratropium
hydrocortisone
neomycin/polymyxin/hydrocortisone
ofloxacin
triamcinolone
levothyroxine
7. DIABETES, THYROID, STEROIDS & OTHER
liothyronine
MISCELLANEOUS HORMONES
metformin
metformin
acarbose
metformin
/glyburide
methimazole
methylprednisolone
Type of covered drug*
Bolded drug is a formulary generic.
• Non-bolded drug is a formulary brand.
• Drug in parenthesis ( ) is a non-formulary brand drug. It is displayed to help you identify the equivalent Highest copay formulary generic drug that is available at the lowest copay.
• Covered generic drugs not listed are formulary.
• Covered brand drugs not listed are non-formulary.
PA = Prior authorization must be requested by the physician.
Q = Quantity level limits apply.
✓ = New formulary drug.
* Unless specifically excluded from your contract.
7. DIABETES, THYROID, STEROIDS & OTHER
omeprazole
MISCELLANEOUS HORMONES (cont.)
PA omeprazole-sodium
bicarbonate
ondansetron
pancrelipase
nateglinide
PA pantoprazole
PEG 3350 & electrolytes (Nulytely )
phenobarb/hyoscyamine/atrop/scop
prochlorperazine
oxandrolone
promethazine
ranitidine
sucralfate
sulfasalazine
prednisolone sodium phosphate ( Pediapred, Orapred)
trimethobenzamide
prednisolone
ursodiol
prednisone
propylthiouracil
9. BIOTECHNOLOGY
tolbutamide
enoxaparin
8. STOMACH, ULCER & BOWEL MEDS
balsalazide
10. BONES, JOINTS & MUSCLES
chlordiazepoxide/clidinium
Q alendronate
cimetidine
allopurinol
dicyclomine
azathioprine
diphenoxylate
HCl/atropine
baclofen
dronabinol
calcitonin-salmon (rDNA origin) nasal spray
famotidine
carisoprodol
famotidine
suspension
chlorzoxazone
choline magnesium trisalicylate
granisetron
colchicine
hydrocortisone
cyclobenzaprine
hydrocortisone /pramoxine kit (Analpram E Kit )
dexamethasone
hydrocortisone retention enema (Colocort )
diazepam
hyoscyamine
diclofenac
potassium
diclofenac
lactulose
diflunisal
PA lansoprazole
mesalamine rectal susp (Rowasa )
etodolac
metoclopramide
misoprostol
fenoprofen
flurbiprofen
nizatidine
10. BONES, JOINTS & MUSCLES (cont.)
11. FEMALE, HORMONE REPLACEMENT &
BIRTH CONTROL
hydrocortisone
hydroxychloroquine
ibuprofen
indomethacin
clindamycin
indomethacin
ketoprofen
ketoprofen SR (Oruvail )
desogestrel/ethinyl
estradiol
ketorolac
esterified
estrogens/methyltestosterone
leflunomide
meclofenamate
estradiol
PA meloxicam
estradiol
transdermal
metaxalone
methocarbamol
methotrexate
estropipate
methylprednisolone
estradiol/drospirenone
nabumetone
naproxen
fluconazole
naproxen
naproxen sodium SA (Naprelan )
oxaprozin
piroxicam
levonorgestrel/ethinyl
estradiol
prednisolone sodium phosphate ( Pediapred, Orapred)
prednisolone
prednisone
medroxyprogesterone
probenecid
salsalate
sulfasalazine
sulfinpyrazone
sulindac
metronidazole vaginal gel (Metrogel )
tizanidine
norethindrone
tolmetin
norethindrone
norethindrone acetate /ethinyl estradiol /
ferrous fumarate
(Estrostep FE )
norethindrone
/ethinyl
estradiol
Type of covered drug*
Bolded drug is a formulary generic.
• Non-bolded drug is a formulary brand.
• Drug in parenthesis ( ) is a non-formulary brand drug. It is displayed to help you identify the equivalent Highest copay formulary generic drug that is available at the lowest copay.
• Covered generic drugs not listed are formulary.
• Covered brand drugs not listed are non-formulary.
PA = Prior authorization must be requested by the physician.
Q = Quantity level limits apply.
✓ = New formulary drug.
* Unless specifically excluded from your contract.
11. FEMALE, HORMONE REPLACEMENT &
BIRTH CONTROL (cont.)
homatropine
ketorolac opth soln (Acular/Acular LS )
levobunolol
norethindrone /ethinyl estradiol , Fe
norethindrone
/mestranol
norgestimate/ethinyl
estradiol
methazolamide
norgestrel/ethinyl
estradiol
neomycin/polymyxin
B/dexamethasone
ofloxacin
nystatin
pilocarpine
polymyxin
B/neo/bacitracin
polymyxin
B/neo/gramicidin
prednisolone
prednisolone sodium phosphate (Inflamase Forte )
prednisolone/sodium
sulfacetamide
terconazole
sulfacetamide
tri-lo-sprintec
timolol ophth (Timoptic )
12. EYE MEDICATIONS
tobramycin
tobramycin-dexamethasone
acetazolamide
trifluridine
acetazolamide
trimethoprim sulfate/polymyxin B (Polytrim )
tropicamide
atropine
azelastine HCL drops (Optivar )
bacitracin
13. ALLERGY, COUGH, COLD & LUNG MEDS
bacitracin/polymyxin B ophth oint (Polysporin )
acetylcysteine
betaxolol
albuterol
albuterol
brimonidine
tartrate
carbachol
aminophylline
carteolol
ciprofloxacin
azelastine nasal spray (Astelin Nasal Spray )
cromolyn
cyclopentolate
benzonatate
dexamethasone
brompheniramine/phenylephrine
diclofenac
budesonide
dipivefrin
chlorpheniramine/phenylephrine
dorzolamide HCl 2% (Trusopt )
chlorpheniramine/phenylephrine
dorzolamide-timolol
methscopolamine chewable tabs, syrup (Extendryl )
erythromycin
chlorpheniramine/phenylephrine
fluorometholone
methscopolamine extended release (Hista-Vent DA )
gentamicin
13. ALLERGY, COUGH, COLD & LUNG MEDS (cont.)
phenylephrine
HCl/COD/prometh
cromolyn inhalation soln (Intal soln )
cyproheptadine
phenylephrinecarbinoxamine
w/hydrocodone
dexamethasone
liquid (Max HC )
phenylephrine/cpm/hydrocodone
epinephrine pen injector (AdrenaClick )
phenylephrine/hydrocodone/BPM
phenylephrine/hydrocodone/CP
prednisolone sodium phosphate ( Pediapred, Orapred)
prednisolone
fexofenadine
prednisone
fexofenadine-PSE
promethazine
promethazine
/codeine
flunisolide
promethazine
/dextromethorphan
promethazine
/phenylephrine/codeine
guaifenesin/codeine
guaifenesin/codeine
/pseudopephedrine
pseudoephedrine/brompheniramine/
guaifenesin/hydrocodone
hydrocodone liquid (Brovex HC )
guaifenesin/phenylephrine/hydrocodone
pseudoephedrine/chlorpheniramine
pseudoephedrine/cpm/codeine
guaifenesin/pseudoephedrine/codeine
pseudoephedrine/guaifenesin extended release
hydrocodone-chlorpheniramine
hydrocodone/homatropine
hydrocortisone
hydroxyzine
hydroxyzine
ipratropium-albuterol
ipratropium inhalation soln (Atrovent soln )
terbutaline sulfate tabs (Brethine )
levalbuterol inhalation solution
theophylline extended release ( Theochron, Uniphyl)
metaproterenol tabs, syrup, inh soln
methylprednisolone
Type of covered drug*
Bolded drug is a formulary generic.
• Non-bolded drug is a formulary brand.
• Drug in parenthesis ( ) is a non-formulary brand drug. It is displayed to help you identify the equivalent Highest copay formulary generic drug that is available at the lowest copay.
• Covered generic drugs not listed are formulary.
• Covered brand drugs not listed are non-formulary.
PA = Prior authorization must be requested by the physician.
Q = Quantity level limits apply.
✓ = New formulary drug.
* Unless specifically excluded from your contract.
13. ALLERGY, COUGH, COLD & LUNG MEDS (cont.)
15. VITAMINS & ELECTROLYTES
ergocalciferol
fluoride
14. URINARY & PROSTATE MEDS
iron, carbonyl 15mg (Icar )
bethanechol
Multigen
doxazosin
mesylate
Multigen
multivitamin with fluoride drops, tabs
finasteride
(Tri-Vi-Flor, Poly-Vi-Flor with and without iron ) flavoxate
potassium bicarbonate/potassium citrate
methenamine/methylene blue/benzoic acid/
effervescent (K-Lyte )
salicylic acid/atropine (Prosed EC tab )
potassium
chloride
methenamine/phenylsalicylate/atropine/
hyoscyamine /benzoic acid/methylene blue (Urised )
sodium fluoride drops (Luride drops )
16. DIAGNOSTICS & MISCELLANEOUS AGENTS
oxybutynin
oxybutynin
phenazopyridine
peroxide
potassium
Q, PA buprenorphine
tamsulosin
terazosin
etidronate
disodium
midodrine
Q, PA Viagra
pilocarpine
Q, PA Suboxone
Q, PA Suboxone Sublingual Film
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.
Prior authorization
Prior authorization is a requirement that your physician obtain approval from your health plan for coverage of, or payment for, your medication.
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 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” on page 17)
. 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.
* All diabetic test strips require prior authorization except the following: Autodisc®, Breeze® 2, Contour®, FreeStyle Lite®, and Precision XTRA®.
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 to ensure that the medication is being prescribed according to FDA guidelines. For example, some drugs are approved by the FDA
only for individuals age 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 that 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); and
Rebif®(12 injections);

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);

Sonata® (14 capsules) and Ambien® (14 tablets);
OxyContin® (90 units), Percocet® (180 units), and Percodan® (180 units).
For example, if a member went to the pharmacy on October 1, 2010, for one of these medications, the computer system would have looked back 30 days to September 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 (i.e., short-acting and long-acting). 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: 1. 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 2. 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.
3. Once the completed medical documentation is received by our PBM, the review will be completed, and the medication will be approved 4. If approved, the remainder of the prescription order will be filled, and the appropriate prescription drug out-of-pocket cost-sharing will be applied.* 5. 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®
(two-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 may request the form by calling 1-888-678-7012. Members may request the form through Customer Service on behalf of their physician, but it must be completed and submitted by the doctor.
* 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.
• 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 claims system will be coded with the approval.
• The member may call the Customer Service phone number on his or her ID 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 members and physicians.
Coverage for medications not on the formulary (specific to Select Drug Program members only)
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 should fax the request to 215-241-3073 or 1-888-671-5285. If the non-formulary
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.
Appealing a decision
If a request for prior authorization/preapproval or override results in a denial, the member, or 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 appeals process to provide the required medical information
for the basis of the appeal.
amantadine 3, 4
Ambien 6, 16
Amerge 6, 15, 16, 17
acetazolamide 4, 12
amoxicillin/clavulanate extended-release 3 Anaprox DS 6, 11
Ansaid 5, 10
benzoyl peroxide 8, 14
Autodisc 9, 15
Avonex 10, 16
azathioprine 4, 10
betaxolol 6, 12
Azulfidine 10, 11
Bactroban 8, 9
Byetta 9, 15
Cafergot 5, 6
choline magnesium trisalicylate 5, 10
Cardura 7, 14
Cipro 3, 9
ciprofloxacin 3, 12
Cataflam 5, 10
Cleocin 3, 8, 11
clindamycin 3, 8, 11
Clinoril 6, 11
danazol 4, 9
Danocrine 4, 9
Daypro 6, 11
Decadron 9, 10, 13
Deltasone 4, 10, 11, 13
Copaxone 10, 16
Cortef 9, 11, 13
dexamethasone 9, 10, 12, 13
Crestor 7, 15
doxazosin mesylate 7, 14
diazepam 5, 10
diclofenac potassium 5, 10
diclofenac sodium 5, 10, 12
Diflucan 3, 11
diflunisal 5, 10
Emend 10, 16
Enbrel 15, 17
Dolobid 5, 10
Feldene 6, 11
erythromycin 3, 8, 12
fenoprofen calcium 5, 10
esterified estrogens/methyltestosterone 11 Floxin 4, 9
fluconazole 3, 11
etodolac 5, 10
flunisolide 9, 13
Extendryl 12, 13
flurbiprofen 5, 10
fluticasone propionate 8, 9
FreeStyle Lite Test Strips 9FreeStyle Meter 9 Humatrope 9, 15
Humira 10, 15
Gleevec 4, 15
hydrocortisone 8, 9, 10, 11, 13
hydroxychloroquine 3, 11
hyoscyamine 10, 14
Hytrin 8, 14
ibuprofen 5, 11
Imitrex 6, 15, 16, 17
Imuran 4, 10
Indocin 5, 11
ketoprofen 5, 11
Indocin SR 5, 11
indomethacin 5, 11
ketorolac 5, 11, 12
ipratropium 9, 13
ipratropium-albuterol 13ipratropium inhalation soln 13 Maxalt 5, 15, 16, 17
meclofenamate 5, 11
Lodine XL 5, 10
Medrol 9, 11, 13
medroxyprogesterone acetate 11, 17
methotrexate 4, 11
methylprednisolone 9, 11, 13
multivitamin with fluoride drops, tabs 14 Muse 14, 15
metronidazole 3, 8, 11
Mycostatin 4, 8
nabumetone 6, 11
Nalfon 5, 10
Naprelan 6, 11
Migranal 16, 17
Naprosyn 6, 11
naproxen 6, 11
naproxen sodium 6, 11
naproxen sodium SA 6, 11
Nasacort AQ 9, 13
Nasarel 9, 13
Nasonex 9, 13
Mobic 11, 15
Neurontin 5, 6
nystatin 4, 8, 12
Nexium 10, 15
ofloxacin 4, 9, 12
Orapred 10, 11, 13
Norditropin 10, 15
norethindrone 11, 12
norethindrone/ethinyl estradiol 11, 12
Oruvail 5, 11
oxaprozin 6, 11
OxyContin 6, 16
piroxicam 6, 11
Plaquenil 3, 11
Pediapred 10, 11, 13
Percocet 6, 16
Percodan 6, 16
prednisolone sodium phosphate 10, 11, 12, 13
prednisolone syrup 10, 11, 13
prednisone 4, 10, 11, 13
phenazopyridine 4, 14
prednisone tabs 10, 11, 13
Phenergan 10, 13
Prelone 10, 11, 13
Prevacid 10, 15
pilocarpine 12, 14
Prograf 4
promethazine 10, 13
Relafen 6, 11
Protonix 10, 15
Proventil 12, 13
Retin-A 9, 17
pseudoephedrine/guaifenesin extended release 13 Pyridium 4, 14
Sonata 6, 16
Stadol NS 16, 17
salsalate 6, 11
Suboxone 14, 15
Suboxone Sublingual Film 14, 15
Subutex 14, 15
sulfacetamide 9, 12
sulfasalazine 10, 11
Symlin 10, 15
Symmetrel 3, 4
Singulair 13, 15
tolmetin 6, 11
Toradol oral 5, 11
terazosin 8, 14
trandolapril-verapamil extended-release 8 Treximet 6, 16
Tribenzor 8, 16
timolol 8, 12
Tri-Vi-Flor, Poly-Vi-Flor with and without iron 14 Ultram ER 6, 16
Voltaren 5, 10, 12
Voltaren XR 5, 10
Valium 5, 10
Valturna 8, 16
Viagra 14, 16
Videx 3, 4
Zegerid 10, 16
Zetia 8
Ziac 6
Ziagen 4
zidovudine 4
Zipsor 16
Zithromax 3
Zmax 16
Zocor 8
Zoderm 8
Zofran 10
Zolinza 16
Zoloft 6
zolpidem tartrate 6
Zomig 16, 17
Zorbtive 16
Zovirax 3, 9
Zovirax oint 9
Zyloprim 10
Zyprexa 6
Zyvox 16
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 benefits plans, prescription drugs are subject to a member copayment.
Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.
Produced by Independence Blue Cross Business Services Center

Source: https://moore.edu/uploads/files/a1media2744-independence-blue-cross-select-drug-program-formulary.pdf

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