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 drug list the member's plan uses:

• Clinical Drug List Prior Authorization/Step Therapy Drug Categories (PDF)
• Custom Drug List Prior Authorization/Step Therapy Drug Categories (PDF)
• Custom Select Drug List Prior Authorization and Step Therapy Guidelines (PDF)
• Lite Prior Authorization Drug List (PDF)
  

How to request approval

Physicians can request approval one of four ways:

• Online: Log in as a provider on bcbsm.com, then select "Pharmacy Benefit - Medication Prior Authorization"
  
• Call: 1-800-437-3803
• Fax: 1-866-601-4425
  
• Write: Blue Cross Blue Shield of Michigan, Pharmacy Services, P.O. Box 2320, Detroit, MI 48231-2320

Questions? We can help!

To verify a member's benefit plan or get answers to your pharmacy-related questions, please contact us.