Why do I need prior authorization for a prescription drug?

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

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.

How do I find out if my prescription requires prior authorization?

Most Blue Cross Blue Shield of Michigan and Blue Care Network members can find out if a medication needs prior authorization by logging on to Member Secured Services. 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, select the Hospitals, Physicians and Medications tab. The link to Medco Online Pharmacy will take you directly to Express Scripts (Medco's old name). You won't have to log in again.
  
• In the left-hand column under “Prescriptions & benefits,” select “Price a medication” and follow the instructions. 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 Formulary Prior Authorization/Step Therapy Drug List (PDF)
  
• Clinical Formulary Prior Authorization/Step Therapy Drug List (PDF)
• Select Prior Authorization Drug List (PDF)
  

Blue Care Network (HMO) plans

• Blue Care Network Prior Authorization and Step Therapy Guidelines (PDF)
  

Medicare

• Blue Care Network Medicare (BCN Advantage℠) members
• Blue Cross Blue Shield of Michigan Medicare plan members

Related Items

• How do I know if my plan covers my prescription drug?
• How to save money on prescription drugs
• What are specialty drugs?
• How to read a drug list