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.