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Request Prescription Drug Coverage
If a medication requires step-therapy or prior authorization, and your BCN patient does not meet our criteria, you can request coverage based on medical necessity. You can also ask BCN to waive quantity restrictions if the quantity allowed is not appropriate based on the member's condition.
Most BCN members do not have coverage for nonformulary drugs. Please use our Benefit Exception Form (PDF) to request coverage for a nonformulary drug when a formulary alternative will not work or it has the potential to cause the member an adverse event.
Generally, BCN will only approve your request for an exception if the alternative drugs included on the plan's formulary would not be as effective and/or would cause the member to have adverse medical effects. To request coverage, please complete the appropriate Benefit Exception or Medication Request Form below:
- Benefit Exception Form (Request for Formulary Exception* (PDF)
- DAW Request (PDF)
- Angiotensin Receptor Blockers (ARBs) Request* (PDF)
- Brand-Name Antidepressants Request* (PDF)
- Brand-Name NSAIDs Request* (PDF)
- Cholesterol-Lowering Medications Request* (PDF)
- Non-Sedating Antihistamines Request* (PDF)
- Proton Pump Inhibitors Request* (PDF)
- Standard Medication Request Form* (PDF)
- Weight Loss Products Request* (PDF)
- Erythropoietin Stimulating Agents (ESA) Request (PDF)
- Growth Stimulating Agents (PDF)
*To complete and submit these forms electronically, go to web-DENIS > BCN Provider Publications and Resources > Forms. If you need to send an attachment, please fax the form with the attachment rather than submitting electronically.
Fax completed form(s) to MedImpact at 858-790-7100.
