Why do I need prior authorization for a prescription drug?
Who is this for?
This information explains what it means if your doctor has prescribed a medication that requires prior authorization.
There are hundreds of different medications, with more becoming available every day. One way Blue Cross Blue Shield of Michigan and Blue Care Network make sure you get the safest, most effective and reasonably-priced prescription drug is by using programs like prior authorization.
What is prior authorization?
It means we need to review a medication before your plan will cover it. We want to know it’s the right medication for the right situation.
If you don’t get prior authorization, a medication may cost you more, or it may not be covered at all.
What kinds of drugs need prior authorization?
- Drugs that have dangerous side effects or can be harmful when combined with other drugs
- Drugs that should be used only for certain health conditions
- Drugs that are often misused or abused
- Drugs that are prescribed when less expensive drugs might work better
How do I find out if my medication needs prior authorization?
Some drugs are covered under the pharmacy part of your insurance; some are covered under the medical part of your insurance.
Pharmacy coverage drugs
If your drug will be filled with a prescription through a pharmacy, it’s probably billed under your pharmacy coverage.
Most Blue Cross Blue Shield of Michigan and Blue Care Network members can find out if a medication needs prior authorization by logging in to your account at bcbsm.com. You’ll need to know the name of the medication, the dosage, and how often you’ll be taking it.
- After you've logged in, hover over My Coverage in the blue bar at the top of the page.
- Select Medical from the drop down.
- Click Prescription Drugs in the left-hand column.
- Click the link for Price a drug and view additional benefit requirements. It will take you directly to Express Scripts (formerly Medco). You won't have to log in again.
- Enter the name of the drug and follow the instructions. You'll need to know the dosage and how often you'll be taking it.
- You'll get an alert if the medication needs a coverage review—that's what Express Scripts calls prior authorization. Your doctor can ask for a coverage review by calling 1-800-437-3803.
You can also look on your plan’s drug list (a list of approved medications). On a regular drug list, if your medication has a PA after its name, you need to get prior authorization. Most plans also have a special list of drugs that require prior authorization.
Blue Cross Blue Shield of Michigan (Traditional and PPO plans)
- Custom Select Drug List Prior Authorization and Step Therapy Guidelines (PDF)
- Custom Drug List Prior Authorization and Step Therapy Drug List (PDF)
- Clinical Drug List Prior Authorization and Step Therapy Drug List (PDF)
- Lite Prior Authorization Guidelines (PDF)
Blue Care Network (HMO) plans
- Blue Care Network Medicare (BCN Advantage℠) members
- Blue Cross Blue Shield of Michigan Medicare plan members
Medical coverage drugs
Your prescribed drug may be billed under your medical coverage rather than your pharmacy coverage if it is given to you:
- in your doctor’s office
- at a hospital outpatient facility
- in your home
- as an injection
- through an infusion, or IV
If you have a Blue Cross Blue Shield of Michigan PPO plan, our Prior Authorization Medical Coverage Drug List (PDF) shows the drugs under your medical coverage that have to be approved by us before you receive them.
If your drug is on this list, talk to your doctor about getting preapproval for it. This list doesn’t apply to Blue Care Network HMO or Medicare plans.
What should I do if my prescription needs prior authorization?
If your drug needs approval, either you or your pharmacist will need to let your doctor know. They might switch your therapy to another drug that doesn’t require approval from the health plan. Or your doctor will contact our Pharmacy Help Desk to start the approval process and tell us the information we need.
If the drug is on the medical part of your benefit, talk to your doctor about getting preapproval for it.
If you have an HMO plan with Blue Care Network, you can fill out our callback form. Once submitted, someone will contact you to help you request prior authorization for a medication.