Why Do I Need Prior Authorization for a Prescription Drug?

There are hundreds of different medications with more becoming available every day. Blue Cross Blue Shield of Michigan and Blue Care Network use prior authorization to make sure you get the right medication.

What is prior authorization?

This means we need to review some medications before your plan will cover them. We want to know if the medication is medically necessary and appropriate for your situation. 

If you don’t get prior authorization, a medication may cost you more, or we may not cover it.

If you file an urgent request, we will have a decision provided in 72 hours or less. For an urgent review of a non-covered drug, one not on your drug list, we will have a decision in 24 hours or less. A standard request may take up to nine days for us to make a decision.

What kinds of drugs need prior authorization?

  • Drugs that have dangerous side effects
  • Drugs that are harmful when combined with other drugs
  • Drugs that you should use only for certain health conditions
  • Drugs that are often misused or abused
  • Drugs that a doctor prescribes when less expensive drugs might work better

How do I find out if I need prior authorization?

We cover certain drugs under the pharmacy part of your insurance and others under the medical part of your insurance.

If you go to a pharmacy to fill your prescription, it's most likely billed to your pharmacy coverage.

You 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.

  1. After you've logged in, hover over My Coverage in the blue bar at the top of the page.
  2. Select Prescription Drugs from the drop down.
  3. Click the link price a drug and view additional benefit requirements. 
  4. Enter the name of the drug and follow the instructions.
  5. You'll get a coverage alert if the medication needs prior authorization. Your doctor can request prior authorization electronically (PDF) or by calling our Pharmacy Help Desk at 1-800-437-3803. They can use those same methods to request a coverage review.

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 need prior authorization.

For Medicare members, locate your plan on our Medicare drug list page. You'll be able to find your plan's prior authorization and step therapy guidelines there.

If you go to a pharmacy to fill your prescription, it's most likely billed to your pharmacy coverage.

You 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.

  1. After you've logged in, hover over My Coverage in the blue bar at the top of the page.
  2. Select Prescription Drugs from the drop down.
  3. Click the link price a drug and view additional benefit requirements. 
  4. Enter the name of the drug and follow the instructions.
  5. You'll get a coverage alert if the medication needs prior authorization. Your doctor can request prior authorization electronically (PDF) or by calling our Pharmacy Help Desk at 1-800-437-3803. They can use those same methods to request a coverage review.

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 need prior authorization.

For Medicare members, locate your plan on our Medicare drug list page. You'll be able to find your plan's prior authorization and step therapy guidelines there.

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