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)
- Select Prior Authorization Drug List (PDF)
Medication Request Forms
The Medication Request Forms used to request prior authorization are available on Web-DENIS. They are located under Provider Publications and Resources. Click "BCBSM Provider Publications and Resources" and choose "Commercial Pharmacy Prior Authorization and 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.