Prior Authorization/Step Therapy

Certain covered drugs that have been approved by the U.S. Food and Drug Administration (FDA) for specific medical conditions require prior authorization. The approval criteria are developed and endorsed by our Pharmacy and Therapeutics Committee and are based on information from the FDA, manufacturer guidelines, medical literature, actively practicing consultant physicians, and appropriate external organizations.

In some cases, IBC requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, IBC may not cover Drug B unless you try Drug A first. If Drug A does not work for you, IBC will then cover Drug B.

Please see the bottom of the page for other types of requests such as:

Please find the drug in the appropriate formulary to determine if prior authorization is required.

How to Submit a Prior Authorization/Step Therapy Request

A request form is available for medications requiring prior authorization. Our pharmacy benefit manager, FutureScripts® Secure, reviews all requests. If you, your appointed representative or your prescriber would like to initiate a prior authorization request, please fill out the necessary information using the forms available below:

  • Coverage Determination Request online form
  • PDF icon Coverage Determination Request print form
    Y0041_HM_12_1109 File & Use 01/15/2012
    This form may also be printed and faxed to FutureScripts® Secure once completed at 1-888-671-5285 or completed online.
    Note: FutureScripts® Secure may need to reach out to your provider for additional information.

You, your doctor, or someone you’ve authorized may also make an oral or written request for a standard or expedited prior authorization:

  • Fax 1-888-671-5285.
  • Call 1-888-678-7015. Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m. However, please be aware that on weekends and holidays from February 15 to September 30, your call may be sent to voicemail. TTY/TTD 1-888-857-4816.
  • Write FutureScripts Secure
    P.O. Box 37694
    Philadelphia, PA 19103-0694

Providers:

  • Medication specific prior authorization forms are available on the FutureScripts® Secure site. By clicking this link you will be leaving the Medicare-specific web pages. These forms must be faxed to FutureScripts® Secure once completed at 1-888-671-5285.
  • A general form can be used for any drug, including those that do not have a specific form. This form may be printed and faxed to FutureScripts® Secure once completed at 1-888-671-5285 or completed online.
  • When filling out a prior authorization form, all requested information must be supplied. Incomplete requests will require an outreach to your office to obtain additional information.
  • Fax completed forms to FutureScripts® Secure for review at 1-888-671-5285. Make sure that your office telephone and fax numbers are included on the form.
  • You will be notified by fax if the request is approved or denied. You and your patient will also receive a denial letter if the request is denied.
  • If you have not received a response 72 hours after submitting complete information, contact FutureScripts Secure at 1-888-678-7015, Option 1.

Members:

  • Complete the prior authorization form. All requested information must be supplied. Note: FutureScripts® Secure may need to reach out to your provider for additional information.
  • You may take the appropriate request form to your physician to be completed and faxed to FutureScripts® Secure for review at 1-888-671-5285. If you have not received a response from FutureScripts® Secure after 72 hours, you may contact the provider who made the request on your behalf or FutureScripts® Secure directly at 1-888-678-7015.
  • If you have questions, please contact Customer Service.

Tiered Cost-Sharing and Formulary Exceptions

Tier Cost-Sharing

The plan puts each covered drug into one of several different cost-sharing tiers. How much you pay for your prescription depends in part on which cost-sharing tier your drug is in. For drugs in the non-preferred brand tier, you and your provider can ask the plan to make an exception to allow at the preferred brand tier drug so that you pay less for it. If your provider says that you have medical reasons that justify asking us for an exception, your provider can help you request an exception to the non-preferred tier. See instructions below for requesting an exception.

If the non-preferred request is approved, the drug will be processed at the appropriate preferred formulary benefit cost-sharing. If the request for access at the preferred tier is denied, you and your physician will receive a denial letter that explains the appeal process. You may still receive benefits for the drug at the non-preferred cost-sharing.

Please note that certain drugs in some of our cost-sharing tiers are not eligible for this type of exception. We do not lower the cost-sharing amount for drugs for the following:

  • Specialty tier
  • Cost-share based on coverage phases, such as the coverage gap.

Formulary Exception

If your drug is not on the plan’s List of Covered Drugs (Formulary) or is restricted, you can request an exception and ask the plan to cover the drug. You and your provider can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If your provider says that you have medical reasons that justify asking us for an exception, your provider can help you request an exception to the rule.

How to Submit a Tier Cost-Sharing or Formulary Exception Request

A request form is available for submitting an exception request. Our pharmacy benefit manager, FutureScripts® Secure, reviews all requests. If you, your appointed representative or your prescriber would like to initiate an exception request, please fill out the necessary information using the coverage determination forms available below.

  • Coverage Determination Request online form
  • PDF icon Coverage Determination Request print form
    Y0041_HM_12_1109 File & Use 01/15/2012
    This form may also be printed and faxed to FutureScripts® Secure once completed at 1-888-671-5285 or completed online.
    Note: A supporting statement from your physician is required for all exception requests. FutureScripts® Secure will need to reach out to your provider for additional information if that supporting statement is not included with the request.

You, your doctor, or someone you've authorized may make an oral or written, standard or expedited exception request:

  • Call 1-888-678-7015.Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m. However, please be aware that on weekends and holidays from February 15 to September 30, your call may be sent to voicemail
  • TTY/TTD 1-888-857-4816.
  • Fax 1-888-671-5285.
  • Write FutureScripts Secure
    P.O. Box 37694
    Philadelphia, PA 19103-0694

Providers:

  • You may use the Coverage Determination Form to request a formulary or tier cost-sharing exception. This form may be printed and faxed to FutureScripts® Secure once completed at 1-888-671-5285 or completed online.
  • When filling out a prior authorization form, all requested information must be supplied. Incomplete requests will require an outreach to your office to obtain additional information.
  • Fax completed forms to FutureScripts® Secure for review at 1-888-671-5285. Make sure that your office telephone and fax numbers are included on the form.
  • You will be notified by fax if the request is approved or denied. You and your patient will also receive a denial letter if the request is denied.
  • If you have not received a response 72 hours after submitting complete information, contact FutureScripts Secure at 1-888-678-7015, Option 1.

Members:

  • Complete the coverage determination form. All requested information must be supplied. Note: A supporting statement from your physician is needed in order to complete the review. FutureScripts® Secure may need to reach out to your provider for additional information.
  • You may take the appropriate request form to your physician to be completed and faxed to FutureScripts® Secure for review at 1-888-671-5285. If you have not received a response from FutureScripts® Secure after 72 hours, you may contact the provider who made the request on your behalf or FutureScripts® Secure directly at 1-888-678-7015.
  • If you have questions, please contact Customer Service.

Note: If you submit the request, a supporting statement is needed from your physician in order to complete the review. The physician may provide the supporting statement by calling the number above or by completing the PDF icon Coverage Determination Form Y0041_HM_12_1109 File & Use 01/15/2012 providing details to support use of the non-preferred/formulary medication and faxing the request to 1-888-671-5285. The Coverage Determination Form can also be obtained by calling 1-888-678-7015, Option 3.

It is important to select the appropriate option indicating the “Type of Coverage Determination Request.”

Medicare Part B vs. Part D Determinations

CMS limits coverage of some drugs to either the Part B or Part D benefit depending on how the drug is prescribed, dispensed and/or administered. Please refer to the appropriate formulary above to determine if your drug requires a Medicare Part B vs. Part D determination. Please complete the PDF icon Medicare Administrative Prior Authorization for Part B/D coverage form if needed. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

Certain drugs are generally only covered under the Part B benefit. These drugs typically will not be listed on the formulary. However, some Part B drugs require precertification. Please see the attachment below to determine if precertification is required:

PDF icon Specialty Drugs Requiring Precertification Y0041_HM_13_2891 Approved 8/12/2012

Your physician may refer to the Direct Ship Injectables Program for more information about certain injectable drugs covered under Medicare Part B benefit.

Redetermination

Upon denial, the member and the provider will receive a letter describing the decision, appeal rights and contact information. If you and/or your physician disagree with the decision, you need to call or write to your plan to ask for a formal redetermination. Please complete the appropriate form below:

For more information about redeterminations, visit our Organization Determination, Appeals, and Grievances page.


Website last updated: 6//30/2014
Y0041_HM_14_9866j Pending