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July 2019

Comprehensive lists of requirements for medical specialty drugs and pharmacy benefit drugs available

We’ve developed comprehensive lists of requirements for medical specialty drugs and pharmacy benefit drugs for Blue Cross Blue Shield of Michigan PPO and Blue Care Network HMOSM commercial members. These lists, which are typically updated monthly, include the most current information on utilization management requirements.

Medical benefit drugs

The medical specialty drug list identifies medical drugs targeted in the prior authorization and site-of-care programs, and includes the following information about them:

  • Medical necessity criteria
  • Quantity limits
  • Step therapy requirements

The medical specialty drug list is available online in the following locations:

Pharmacy benefit drugs

To improve efficiency, we’ve combined the list of requirements for prior authorization and step therapy for pharmacy benefit drugs for Blue Cross PPO and BCN HMO commercial members. Previously, Blue Cross and BCN each had a separate list.

To access the list, click here.

The utilization management requirements listed in these documents apply only to groups participating in the standard commercial prior authorization program for drugs administered under the medical benefit or pharmacy benefit.

Notes: A prior authorization approval isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members. These utilization management requirements don’t apply to BCN AdvantageSM, Medicare Plus BlueSM PPO or Federal Employee Program® members.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2018 American Medical Association. All rights reserved.