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Health Plans

Prescription Drugs

A formulary is the list of drugs covered by a Part D Plan. The Independence Blue Cross Medicare Drug Formulary is a list of covered FDA-approved drugs for our Keystone 65 HMO, Personal Choice 65 PPO, and Select Option PDP Medicare Plans. Our Pharmacy and Therapeutics Committee has carefully chosen these drugs for their medical effectiveness and value. We may periodically add or remove covered drugs, change coverage limitations on certain drugs, or change how much you pay for a drug.

Find a Prescription Drug

To find covered prescription drugs, select your health plan below. You can search Independence Drug Formularies alphabetically by drug name and check for drugs recently added to or removed from the formulary.

2017 Formularies for Individual Members

Scroll or swipe to reveal all table data.



See Coverage Determination for Part D Drugs, Part D Appeals, and Part D Grievances to learn how to obtain an exception to the plan's formulary.

For Utilization Management tool information please visit our Quality Assurance page. For Tiered Cost-Sharing information please visit our Prior Authorization page.

The Independence Pharmacy Network

Independence Blue Cross contracts with FutureScripts® Secure to provide Medicare Part D prescription benefit management services.

The Network Includes:

  • national chain and independent retail pharmacies;
  • long-term care and home-infusion pharmacies;
  • Indian Health Service/Tribal/Urban Indian Health (I/T/U) Program pharmacies;
  • a network mail order pharmacy service

Independence has contracts with pharmacies that meet or exceed Centers for Medicare & Medicaid Services (CMS) requirements for pharmacy access in your area.

In order to receive benefits through the plan, prescriptions generally must be filled at a network pharmacy.

2017 Standard and Preferred Pharmacies

Some pharmacies contract with our plan to offer lower cost-sharing to plan members. This is known as preferred pharmacy cost-sharing. You may fill your prescriptions at either a preferred or standard pharmacy. You can save money on certain prescriptions by using a preferred pharmacy:

  • Tier 1 and 2 prescriptions (which include most generic drugs) will have lower copayments when you have them filled at preferred pharmacies.
  • Tier 3, 4 and 5 prescriptions (which include brand-name, specialty and high-cost generic drugs) will have the same copayments at both preferred and standard pharmacy locations.

Preferred Pharmacies

Standard Pharmacies

CVS
Giant
Sam's Club
ShopRite
Target
Walmart
Other independent pharmacies

Acme
Costco
Kmart
Rite Aid
Walgreens
Wegmans
Other independent pharmacies

Find a Network Pharmacy

To locate or confirm that a pharmacy is currently in our network:
Find a Pharmacy

Out-of-Network Coverage

Covered Part D drugs are available at out-of-network pharmacies in special circumstances, including illness while traveling outside of the plan's service area where there is no network pharmacy. We may cover your prescription at an out-of-network pharmacy for up to a 30-day supply if at least one of the following applies:

  • If the prescriptions are related to care for a medical emergency or urgent care;
  • If you are unable to obtain a covered drug in a timely manner within our service area because there are no network pharmacies within a reasonable driving distance that provide 24-hour service;
  • If you are trying to fill a prescription drug that is not regularly stocked at an accessible network retail or mail-order pharmacy (including high-cost and unique drugs).

You may have to pay more than your normal cost-sharing amount, and will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement. We will consider your request and make a coverage decision. If we decide that the drug is covered and you followed all the rules for getting the drug, we will pay for our share of the cost.

We cannot pay for any prescriptions that are filled by pharmacies outside the United States, even for a medical emergency.

How to Submit a Paper Claim

When you go to a network pharmacy, your claim is automatically submitted to us by the pharmacy. However, if you go to an out-of-network pharmacy for one of the reasons listed above, the pharmacy may not be able to submit the claim directly to us. When that happens, you will have to pay the full cost of your prescription. When you return home, simply submit a claim form and your receipt. Please note that we can only reimburse up to our allowed amount. Please call the Member Help Team for more information on paper claims.

To request a reimbursement, please use the Direct Member Reimbursement Form.

To request a reimbursement specifically for a vaccine and/or a vaccine administration fee, please use the Vaccine and Administration Direct Member Reimbursement Form. This form is for Part D vaccines only and should not be used for Part B vaccines such as the flu shot.

For the Influenza Vaccine Reimbursement Form, please see the Claim Reimbursement Forms section.

Mail Order Pharmacy Service

Your benefit includes the option to receive prescription drugs shipped to your home through our network mail-order delivery program.

Pharmacies are required to obtain consent prior to shipping or delivering any prescriptions that the beneficiary did not personally initiate. FutureScripts does not offer automated mail-order delivery. Our plan's mail-order service allows you to order up to a 90-day supply for certain prescriptions. Please note that due to package sizes, some prescriptions may not be available for our 90-day supply mail-order service.

To get order forms and information about filling your prescriptions by mail please call FutureScripts Secure at 1-888-678-7015 (TTY/TDD: 711), 7 days a week, 24 hours a day. Your copay is the same for anything between a 31-90 day supply at mail order. If you use a mail-order pharmacy that is not in the plan's network, your prescription will not be covered. Usually a mail-order pharmacy order will get to you in no more than 14 days. If you should not receive your prescription drugs, please call FutureScripts Secure at 1-888-678-7015, 7 days a week, 24 hours a day.

Website Last Updated: 5/11/2017
Y0041_HM_17_43499f Approved 1/6/2017