Pharmacy Benefit Drugs

Some drugs require prior authorization before they can be dispensed to a Blue Cross' PPO (commercial) or Medicare Plus BlueSM PPO 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:

  • Faster response times on your requests
  • Approvals within minutes (Some requests require more time.)
  • Reduced administrative time
  • Streamlined questions, asking only those needed for the authorization
  • The ability to attach documentation if required
  • Clinical criteria to guide you in submitting the proper information
  • Secure and efficient prior authorization administration all in one place
  • The capability of renewing existing authorizations up to 60 days before they expire

Below, you'll find information on how to submit a pharmacy drug prior authorization request electronically for Blue Cross' PPO 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' PPO (commercial)

For Blue Cross PPO (commercial) members, select from below:

How to identify utilization management requirements for Blue Cross' PPO

Identify Blue Cross' PPO 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 utlization management (step therapy or authorization requirements):

  1. Visit the Medicare Advantage drug lists webpage and:
    • For individual plans, scroll down to the heading “If you're buying your own insurance, use these drug lists.” Click Medicare Plus Blue PPO plans.
    • For group plans, scroll down to the heading "If you get your insurance through an employer, union or other group, use these drug lists." Click Medicare Plus Blue Group PPO plans.
  2. Click 2020 Prior Authorization and Step Therapy Program.

How to submit an electronic prior authorization, or ePA, request

You can use CoverMyMeds® and other free ePA tools such as Surescripts®* and ExpressPAth®* 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 submit an ePA request using CoverMyMeds, follow these steps:

First, go to covermymeds.com/signup*. Create a free account online if you don't already have one.

To start the request:

  1. Click New Request.
  2. Select Michigan in the Patient Insurance State field.
  3. Enter 610014 as the RxBIN for Blue Cross or Medicare Plus Blue.
  4. Find the RxGroup on the member’s ID card:
    • For Blue Cross, enter either BCBSMRX1 or BCBSMAN.
    • For Medicare Plus Blue, enter BCBSMAN.
  5. Enter the medication.
  6. Select the appropriate form.
  7. Click Start Request.

Next, complete the request:

  1. Complete all information fields marked Required.
  2. Click Send to Plan.
  3. Complete all patent-specific clinical questions displayed that are marked Required.

Finally, confirm that you've completed the request by clicking Send to Plan again.

After Blue Cross has reviewed the request you submitted, the determination will appear in your CoverMyMeds account. CoverMyMeds often returns approval decisions within minutes of submission, depending on the complexity of the request or the need for additional review.

Training resources

To help you learn to use the CoverMyMeds web tool:

Other resources

Pharmacy services webpage

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 required to let you know we're not responsible for its content.