Home Administrative Billing & Reimbursement BlueCard® Health and Wellness Medical PEAR portal Pharmacy Products Quality Management

Updates to Direct Ship Drug Program request forms

June 11, 2018

The Independence Direct Ship Drug Program is a service that allows our network providers to order select office-based drugs eligible for coverage under the medical benefit without paying an additional fee. Independence works directly with our specialty drug vendors to handle processing, payment, and delivery.

Direct ship drug request form updates

We have updated the general drug request form, which is used to request all direct ship drugs that do not have a specific order form.

In addition, updates have been made to the following five direct ship request forms for specific drugs, which reflect new medical policy criteria or new formulation options:

  • Hydroxyprogesterone Caproate
  • Nucala? (mepolizumab)
  • Stelara? (ustekinumab)
  • Viscosupplementation (hyaluronate acid products) (Orthovisc?, Synvisc?, Synvisc-One?, Euflexxa?, Gel-One?, GelSyn-3TM, GenVisc 850?, Hyalgan?, Hymovis?, Monovisc?, Supartz?, VISCO-3TM, Durolane?, and TriViscTM)
  • Xolair? (omalizumab)

If your office has previous versions of these forms, please discard them and use the updated forms, which are available for download on our website and can be identified by the April 2018 date at the bottom-right corner.

New direct ship drug request forms

New forms have been created for the following drugs:

  • Vivitrol? (naltrexone)
  • FasenraTM (benralizumab)

These forms are available for download on our website. Please add these new direct ship request forms to your office's form library.

For more information

For more information on the Direct Ship Drug Program, including the list of medical benefit drugs available under this program or to download the forms, go to our website.


This content was prepared for the Provider News Center and may not be reproduced in any way without the express written permission of Independence Blue Cross. Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association.
Connect with us     Facebook     Twitter     Flickr     YouTube     Walk the Talk    Independence Pinterest    Independence LinkedIn    Independence Instagram Site Map        Anti-Fraud        Privacy Policy        Legal        Disclaimer
© 2023 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.