Pharmacy Benefit Drugs

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?

Michigan’s prior authorization law* requires health care providers to submit prior authorization requests electronically for commercial members. Alternate submission methods are allowed in the case of temporary technological problems, such as power or internet outages; see the information about submitting prior authorization requests through alternate methods below.

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 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:

Other resources

Audaire Health™:

  

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):

  1. Visit the Medicare 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 the link to open the Prior Authorization and Step Therapy Program drug list.

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 Save time and submit your prior authorization requests electronically for pharmacy benefit drugs (PDF)

Training resources

To help you learn to use the CoverMyMeds web tool:

Other resources

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)

Alternate methods for submitting prior authorization requests for pharmacy benefit drugs

If you’re experiencing temporary technical problems (such as a power or internet outage) that prevent you from submitting prior authorization requests through an ePA tool, submit prior authorization requests to Blue Cross or BCN using one of the following methods:

  • For Blue Cross commercial members, fax to 1-866-601-4425.
  • For Medicare Plus Blue members, fax to 1-866-601-4428.
  • Call the Blue Cross and BCN Pharmacy Clinical Help Desk at 1-800-437-3803.
  • For Blue Cross commercial members only, mail the request to:
    BCBSM Clinical Help Desk
    P.O. Box 312320
    Detroit, MI 48231-2320

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.