Request Prescription Drug Coverage

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

And, you can ask us to provide a higher level of coverage or reduce the copayment for drugs on Tier 4 (non-preferred brand) or Tier 2 (non-preferred generic).

For example, if the prescribed drug is considered Tier 4 (non-preferred brand), you can ask us to cover it or reduce the copayment as a Tier 3 (preferred brand) instead. This would lower the copayment amount required for the drug. BCN does not consider requests to lower the copayment amount for drugs included on Tier 1, Tier 3, or Tier 5. Copayment exception requests are not allowed for drugs approved through the nonformulary drug approval process.

Generally, we will approve your request for an exception if documentation is provided regarding the reason a formulary alternative is not appropriate for the member. If the request is for a higher quantity of a medication than BCN allows, the physician must provide documentation showing that the allowed quantity is not adequate for the member’s condition. Copayment exception requests may be approved if documentation is provided that medications used to treat the condition in our preferred drug class are ineffective.

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.

Contacts

Physicians: For medication prior authorization and benefit exception requests, contact the BCN Clinical Pharmacy Help Desk at 1-800-437-3803.

Pharmacies: For pharmacy claims and other inquiries, contact Express Scripts Pharmacy Services at 1-800-922-1557.

If you have questions regarding our grievance or appeals process, please contact our BCN Advantage Service Center at 1-800-450-3680, seven days a week, from 8 a.m. to 8 p.m. Please note that members with BCN Advantage Elements do not have Part D prescription drug coverage.

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