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Prior Authorization/Step Therapy Program
To help make sure our members receive the most appropriate and cost-effective therapy, some benefit plans require that additional steps be taken before certain drugs are covered. One or both of these steps may be required, depending on the drug:
- Prior Authorization: Certain clinical criteria must be met before some drugs are covered.
- Step Therapy: Requires that the member has tried an alternative therapy first, or that their physician has clinically documented why they cannot take the alternative therapy. Step therapy may include select over-the-counter products.
Which drugs require prior authorization or step therapy?
Drugs that require prior authorization or step therapy differ based on the formulary the member's plan uses:
- Clinical Formulary Prior Authorization/Step Therapy Drug Categories (PDF)
- Custom Formulary Prior Authorization/Step Therapy Drug Categories (PDF)
Medication Request Forms
The Medication Request Forms used to request prior authorization are available on Web-DENIS. They are located on the Provider Publications and Resources page. First click on "BCBSM Provider Publications and Resources," choose "BCBSM Newsletters and Resources" and the link is in the left-hand navigation — "Pharmacy Prior Authorization/Step Therapy forms."
Questions? We can help!
To verify a member's benefit plan or get answers to your pharmacy-related questions, please contact us.
