Request Prescription Drug Coverage

If a medication requires step therapy, prior authorization or is not on a formulary and the patient has BCN Advantage℠ HMO-POS or BCN Advantage℠ HMO, you can request coverage based on medical necessity. If a medication has quantity restrictions, you can also ask us to waive quantity restrictions if the quantity allowed is not appropriate based on the member's condition.

If certain conditions are met, you can ask us to provide a higher level of coverage or reduce the copayment for drugs on Tier 2 (Generics), Tier 3 (Preferred brands) or Tier 4 (Non-preferred drugs).

For example: if the prescribed drug is considered Tier 4 (Non-preferred drugs), you can ask us to cover it at a reduced copayment of a Tier 3 (Preferred brand drug) instead. This would lower the member’s copayment required for the drug. BCNA does not consider requests to lower the copayment for drugs included on Tier 1 (Preferred generic drugs) or Tier 5 (Specialty drugs). Tiering exception requests are not allowed for drugs that are not on a formulary and approved through coverage determination process.

Copayment tiering exceptions may be considered if there is a drug to treat the same condition on a lower member cost share tier. Tier exception requests may be approved if documentation is provided that medications used to treat the condition in the lower cost sharing tier(s) were ineffective or are contraindicated. 

If the request is for a higher quantity of a medication than BCN allows, you must provide documentation showing that the allowed quantity is not adequate for the member’s condition.

To request coverage for your BCN Advantage member, please complete the Medicare Part D Coverage Determination Request Form (PDF) and fax the completed form to the BCN Clinical Pharmacy Help Desk at 1-800-459-8027.