Precertification and cost-share requirements

Medical benefit

Precertification for commercial, Medicare Advantage, and Keystone HMO CHIP members

Certain services require precertification from Independence Blue Cross (Independence) prior to being performed. This includes certain injectable and infusion specialty drugs that are administered by providers and eligible for coverage under the medical benefit.

For services or drugs that require precertification, please call 1-800-ASK-BLUE and follow the prompts for authorizations. Members with Personal Choice^® PPO who plan to obtain services from out-of-network providers are responsible for assuring that precertification is obtained when necessary. Participating providers are required to be registered with the Provider Engagement, Analytics & Reporting (PEAR) portal and should submit requests electronically through PEAR Practice Management (PM) for services to be rendered at an acute care facility, ambulatory surgical center, or office setting.

The Independence Utilization Management department will evaluate all precertification requests and will notify the provider once a decision has been reached for those cases that require clinical review. Each request has a precertification reference number based on the determination.

Failure to obtain required precertification may result in a reduction in payment or nonpayment to the provider for the services or drugs not precertified.

Providers and members may appeal our decision or provide additional information to support the request at any time during the evaluation process. Providers can refer to the Clinical Services — Utilization Management section of the Provider Manual for Participating Professional Providers or the Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers for more information.

Services and injectable/infusion drugs that require precertification

Note: This information is updated regularly, but is subject to change. For the most up-to-date information, refer to PEAR PM and select “Authorization Submission” from the Transactions menu.

Drug cost-sharing for commercial members

Members who are enrolled in Commercial FLEX products and certain customized plans are subject to applicable cost-sharing for select specialty drugs eligible for coverage under the medical benefit. The list of these drugs is provided below.

Note: This list is subject to change. The member’s cost-sharing amount is based on the terms of the member’s benefit contract. Individual benefits should be verified. If you have questions about member cost-sharing, please call 1-800-ASK-BLUE.

Pharmacy benefit

Prescription drug coverage

Prescription drugs covered under the pharmacy benefit are typically drugs that members can give to themselves. Examples of these drugs include oral drugs, topical drugs, and certain self-injectable drugs that members or their caregivers can be taught to administer. For Independence members with our pharmacy benefit, prescription drug coverage is provided by an independent pharmacy benefits management (PBM) company.

For Independence pharmacy benefit plans, view our drug formularies:

Drug formularies