Blue cross blue shield medication prior authorization form

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To help make sure Blue Cross Blue Shield of Michigan and Blue Care Network members receive the most appropriate and cost-effective therapy, we sometimes require providers to take additional steps before certain drugs are covered. 

Prior authorization

We sometimes require providers request prior authorization for certain medicines, like specialty drugs, to ensure certain clinical criteria are met.

Submitting a request electronically

Providers can request prior authorization electronically for:

• Most medical benefit drugs, including CAR T-cell therapy drugs, through NovoLogix® by logging in to the secured provider portal
• Oncology and supportive care drugs through AIM Specialty Health®

You can find how to submit a request, details on specific drug requirements and additional resources on these pages:

• Medical benefit drugs for Blue Cross and Medicare Plus BlueSM 
• Medical benefit drugs for BCN and BCN AdvantageSM

Other ways to submit a request

• Calling 1-800-437-3803
  
• Faxing BCBSM at 1-866-601-4425
• Faxing BCN at 1-877-442-3778
• Writing: 
  Blue Cross Blue Shield of Michigan, Pharmacy Services
  Mail Code 512
  Detroit, MI 48226-2998

Step therapy requires that the member has tried an alternative therapy first, or that their physician has clinically documented why they cannot take the alternative therapy. Step therapy may include select over-the-counter products.

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

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Prior authorization (PA) and step therapy (ST) encourage safe, cost-effective medication use by allowing coverage when certain conditions are met. A team of physicians and pharmacists develops and approves the clinical programs and criteria for medications that are appropriate for PA and ST by reviewing U.S. Food and Drug Administration (FDA) approved labeling, scientific literature and nationally recognized guidelines. 

Prime Therapeutics, our pharmacy benefit manager, conducts all reviews of PA and ST requests from physicians for Blue Cross and Blue Shield of Illinois (BCBSIL) members with prescription drug coverage.

Physicians must complete and submit a request form for all PA and ST medications. Benefits will apply if the member meets specified criteria. If criteria are not met, the member may still choose to receive the medication and will be responsible for the full cost. The final decision regarding what medicines should be prescribed, regardless of benefit determination, is a decision between the patient and their physician. 

Not all prescription drug benefit plans include the PA/ST program, and the drug categories may vary depending on the member’s plan. If there are questions regarding prescription benefit coverage, please call the phone number on the back of the member’s BCBSIL ID card. 

Program Criteria Summaries and Request Forms

Physicians can access, complete and submit the uniform PA form . Here are instructions  for completing and submitting this uniform PA form.

For help completing section H (other pertinent information) of the uniform PA form, download the PA program criteria summaries from the Prime Therapeutics website using the following link:

• Prior Authorization Program Criteria Summary and Fax Form List 
  

Electronic request forms are on the CoverMyMeds® website:

• Submit an electronic prior authorization request 
  

Or, download ST program criteria summaries and fax forms from the Prime Therapeutics website using the following link:

• Step Therapy Program Criteria Summary and Fax Form List 
  

If you have questions or concerns regarding these programs, please call Prime Therapeutics at 800-285-9426. Review the prior authorization/step therapy program list  for a listing of all programs included in our standard utilization management package.

CoverMyMeds is a registered trademark of CoverMyMeds LLC, an independent third party vendor that is solely responsible for its products and services. BCBSIL makes no endorsement, representations or warranties regarding any products or services offered by independent third party vendors. If you have any questions regarding the products or services they offer, you should contact the vendor(s) directly. 

Prime Therapeutics LLC is a pharmacy benefit management company. BCBSIL contracts with Prime to provide pharmacy benefit management, prescription home delivery and specialty pharmacy services. BCBSIL, as well as other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime.

BCBSIL reserves the right to make exceptions to pharmacy program criteria that benefit the member when new medical information becomes available. When using pharmacy criteria to determine whether a medication will be covered, please note that member contract language will take precedence over the criteria when there is a conflict.

The purpose of the pharmacy criteria is to guide coverage decisions and is not intended to influence treatment decisions. Providers are expected to make treatment decisions based on their medical judgment.