Some drugs require prior authorization before they can be dispensed to a Blue Cross commercial or Medicare Plus BlueSM member.
This page offers resources for providers requesting prior authorization or an exception from other utilization management requirements for drugs covered under the pharmacy benefit.
Did you know?
When you submit your pharmacy drug authorization requests electronically, there are many benefits compared to faxing your request:
Below, you'll find information on how to submit a pharmacy drug prior authorization request electronically for Blue Cross commercial and Medicare Plus Blue members. You'll also find other helpful resources.
IMPORTANT! Always verify eligibility and benefits for each member at each visit.
Blue Cross commercial
For Blue Cross commercial members, select from below:
How to identify utilization management requirements for Blue Cross commercial
Identify Blue Cross commercial utilization management (step therapy or authorization) requirements by reviewing the following:
Medicare Plus Blue
For Medicare Plus Blue members, select from below:
How to identify utilization management requirements for Medicare Plus Blue
To access the Medicare Plus Blue utilization management (step therapy or authorization requirements):
How to submit an electronic prior authorization, or ePA, request
You can use CoverMyMeds® and other free ePA tools such as Surescripts®* to submit prior authorization requests for most pharmacy benefit drugs. In addition, an ePA tool can be integrated into your current electronic health record workflow. Check your vendor to see if you have software that accommodates an ePA tool.
To learn how to submit an ePA request using CoverMyMeds, see the following documents:
- For Blue Cross commercial and BCN commercial: Save time and submit your prior authorization requests electronically for pharmacy benefit drugs (PDF)
- For Medicare Plus Blue and BCN Advantage: Save time and submit your prior authorization requests electronically for pharmacy benefit drugs (PDF)
To help you learn to use the CoverMyMeds web tool:
- See the CoverMyMeds Prescriber Demonstration*.
- Register for a complimentary 15-minute webinar held every Tuesday, Wednesday and Thursday: CoverMyMeds physician office training*.
For Providers: Drug Lists page on bcbsm.com
Coverage Request Form — for nonformulary or benefit exception requests
Quality Limit Request form (PDF)
Michigan Authorization Request Form for Prescription Drugs* (PDF)
Drugs: For medication adherence, medical benefit drugs and pharmacy benefit drugs (PDF)
Need additional assistance?
Here's who you can call:
- For questions about utilization management requirements, call the Blue Cross / BCN Pharmacy Clinical Help Desk at 1-800-437-3803.
- For questions about the CoverMyMeds web tool, call the CoverMyMeds support center at 1-866-452-5017.
*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're not responsible for its content.