Request Prescription Drug Coverage
If a medication requires step-therapy or prior authorization, and your Blue Care Network patient does not meet our criteria, you can request coverage based on medical necessity. Blue Care Network's criteria for coverage are described in the Prior Authorization and Step-Therapy Guidelines. You can also ask Blue Care Network to waive Quantity Limits if the quantity allowed is not appropriate based on the member's condition.
Most Blue Care Network members do not have coverage for nonformulary drugs. Generally, Blue Care Network 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 and if the member meets the established prior authorization criteria for the drug. There are two ways to request coverage:
- Call the 24/7 Pharmacy Clinical Help Desk at 1-800-437-3803. Please be ready to provide your NPI number and contract number or enrollee ID of the member you are calling about in order to access account information. Once this information has been authenticated it will take you to the provider menu serviced by the appropriate clinical help desk. After arriving in the provider menu you may either say "authorization" or select option 1 for prior authorization requests. This is the preferred and most efficient method to generate a medication coverage request. In most cases, our certified pharmacy technicians will be able to take the clinical information right over the phone so please be ready to answer some questions related to the member's medical history. This facilitates the review process and helps prevent any delay in processing.
- An alternative process is using the forms available through web-DENIS. After you log in, click on BCN Provider Publications and Resources, then on Forms and scroll down to the Pharmacy section. Fax the completed document to the number identified on the request form. Remember, this alternative process often results in a request to the provider's office for additional information before the coverage request is reviewed.
Blue Care Network does not accept requests for coverage that are submitted on forms that have not been approved by Blue Care Network.
Please call Blue Care Network Pharmacy Services at 248-455-3559 if you suspect fraudulent misrepresentations or use of Blue Care Network medication request forms or any other suspicious behavior relating to solicitation of a Blue Care Network prior authorization.