Providers and members often have questions about how medical drugs are covered by Independence, how drugbenefits are structured, and how much their drugs will cost. It is important that providers and their office staffremember that member benefits may vary, particularly in terms of cost-sharing amounts (e.g., copayment, deductible,coinsurance) associated with certain drugs. Therefore, member benefits should always be verified prior to renderingservices.

Each member's benefit plan dictates the terms under which Independence provides drug coverage. There aredifferent cost-sharing responsibilities based on how Independence classifies each drug. The terms of the benefit planalso vary based on the type of product in which the member is enrolled (e.g., HMO v. PPO; commercial v. MedicareAdvantage).

We offer a variety of online tools to assist you in identifying the terms, requirements, and cost-sharing amountsassociated with our benefit plans.

Verifying cost-sharing amounts

Many of our plans require members to pay a portion of the cost toward their treatment. The cost-sharing amount is dictated by the terms of each member?s benefit plan. For members enrolled in Flex products and select customized plans, the cost-sharing amount typically applies to certain high-cost specialty drugs, sometimes referred to as ?biotech drugs.? For a complete list of drugs that Independence designates as biotech drugs, view the Specialty Drugs with Cost-Sharing document. This list is subject to change.

For members enrolled in a Keystone HMO Proactive plan, Medicare Advantage plan, high deductible health plan, or other self-funded customer tiered network programs, cost-sharing may apply for all medical drugs, including the high-cost specialty biotech drugs mentioned above.

For drugs that are part of a multiple-dose regimen, the member is responsible for the cost-sharing amount for each date of service that he or she receives the injection from the health care provider. To determine if a provider should collect cost-sharing from a member for these drugs, providers may use the Eligibility and Benefits Inquiry transaction on the NaviNet^® web portal.

Step 1: From the Eligibility and Benefits Details screen, select the <Product Name> Provisions link to confirm any applicable Deductible and/or Coinsurance for which the member is responsible.

Step 2: Return to the Eligibility and Benefits Details screen and select the Professional Services link. Scroll down the screen to Other Services to view the member's benefits for Injections.

When the "Injections" benefit displays as "Coverage = Yes" and there is no other copayment or coinsuranceinformation listed, and the Biotech/Specialty Injections does not appear separately, then the In-Network Deductibleand/or Coinsurance would apply to both Biotech/Specialty Injections and Standard Injections.

Note: If the plan has a deductible but the deductible does not apply to the specific service, "Deductible = No" will bedisplayed.

Medicare Advantage members

Unlike commercial coverage, you will not find the detailed coinsurance for Medicare Part B drugs listed underInjections. The Injections benefit will be listed as "Coverage = Yes"; however, you will find the coinsurance listed undera separate Prescription Drugs benefit within the Professional Services screen.

Precertification requirements

Independence requires our providers to obtain precertification approval for certain drugs prior to members receivingthem. Precertification approval is required for members enrolled in all Independence products. The current list ofdrugs that require precertification approval from Independence is located on page 3 of the Preapproval/Precertification list.

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