To help make sure Blue Cross Blue Shield of Michigan and Blue Care Network members receive the most appropriate and cost-effective therapy, we require providers to take additional steps before certain drugs are eligible for reimbursement. 

Prior authorization requirements

We require providers to request prior authorization for certain medicines, such as specialty drugs, to ensure certain clinical criteria are met.

Submitting prior authorization requests

For drugs that require prior authorization, providers should submit requests as follows.

For most medical and pharmacy benefit drugs, including gene and cellular therapies: 

• Submit requests through the Medical and Pharmacy Drug PA Portal for both commercial and Medicare Advantage members. To submit requests, select the Medical and Pharmacy Benefit Drug Prior Auth tile on the provider portal. 
• Learn about submitting requests electronically and through other methods on the Drugs pages on authorizations.bcbsm.com. Alternately, you can submit requests for pharmacy benefit drugs through CoverMyMeds and other electronic prior authorization, or ePA, tools.

For oncology drugs: 

• For Blue Cross commercial UAW Retiree Medical Benefits Trust members, submit prior authorization requests for oncology and supportive care drugs covered under the medical benefit to Carelon Medical Benefits Management. Learn about submitting requests on the Medical Benefit Drugs page on authorizations.bcbsm.com.
• For all other members who have requirements under the Oncology Value Management program, submit prior authorization requests for oncology and supportive care drugs covered under the medical benefit or under the pharmacy benefit to OncoHealth. Learn about submitting requests to OncoHealth on the Drugs pages on authorizations.bcbsm.com.

Step therapy requirements

Step therapy requires that the member has tried an alternative therapy first, or that the prescriber has clinically documented why the member cannot take the alternative therapy. In some cases, step therapy requirements may require members to first try over-the-counter products.