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 HMO^SM 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:

• On the Blue Cross Medical Benefit Drugs-Pharmacy page within the ereferrals.bcbsm.com website. Look under the For Blue Cross commercial members heading.
• On the BCN Medical Benefit Drugs-Pharmacy page on the ereferrals.bcbsm.com website
• Within Provider Secured Services:
  • Log in.
  • Click BCBSM Provider Publications and Resources (on the right).
  • Click Newsletters and Resources.
  • Click Forms.
  • Click Physician administered medications.
  • Click Requirements for drugs covered under the medical benefit – BCN HMO and Blue Cross PPO.
• In the medical policy, precertification and preauthorization router, enter quantity limit in the Keyword/Phrase field and click Search.

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 Advantage^SM, Medicare Plus Blue^SM PPO or Federal Employee Program^® members.