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 prior authorization) requirements by reviewing the following:

Note: To determine which commercial self-funded groups have requirements for oncology pharmacy benefit drugs, see the Oncology Value Management program participation list for commercial self-funded groups (PDF).

Other resources

For Providers: Drug Lists page on bcbsm.com

Audaire Health™:

  

Medicare Plus Blue

For Medicare Plus Blue members, select from below:

How to identify utilization management requirements for Medicare Plus Blue

Access the Medicare Plus Blue utilization management (step therapy or authorization) requirements by reviewing the following:

  1. Visit the Drug List for Medicare Members webpage and select the member's plan from the drop-down list.
  2. Click the link to open the appropriate prior authorization and step therapy drug list.

How to submit prior authorization requests through ePA tools for most pharmacy benefit drugs

Submit prior authorization requests using CoverMyMeds®* and other free electronic prior authorization (ePA) tools such as Surescripts®.* In addition, an ePA tool can be integrated into your current electronic health record workflow. Check with your vendor to see if you have software that accommodates an ePA tool.

To help you learn to use the CoverMyMeds web tool:

Additional resources:

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.

How to submit prior authorization requests for oncology drugs to OncoHealth

Submit prior authorization requests to OncoHealth by clicking the OncoHealth Provider Portal tile in the BCBSM and BCN payer space in Availity Essentials™. For more information, see the Oncology Value Management program through OncoHealth: FAQs for providers (PDF).

To help you learn how to use the OncoHealth OneUM portal, view a recorded training by going to Blue Cross and BCN's Provider Training site, searching on oncology and launching the OncoHealth presentation. (For detailed information about accessing the Provider Training site, see the "Online training" section of the Training Tools page on ereferrals.bcbsm.com.)

For questions about oncology drugs or working in the OncoHealth OneUM™ provider portal: Call OncoHealth at 1-888-916-2616.

Other resources

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 electronically:

  • For most pharmacy benefit drugs:
    • 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
  • For oncology drugs:
    • Fax to OncoHealth at 1-800-264-6128
    • Call OncoHealth at 1-888-916-2616

*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.

OncoHealth is an independent company supporting Blue Cross Blue Shield of Michigan and Blue Care Network by providing cancer support services.