Some drugs require prior authorization
We monitor the use of certain medications to ensure that members receive the most appropriate and cost-effective drug therapy.
Prior authorization
Prior authorization means that certain clinical criteria must be met before coverage is provided. The criteria for authorization are based on current medical information and the recommendations of BCN’s Pharmacy and Therapeutics Committee. You may be required to pay additional out-of-pocket costs or a higher copayment if you do not have prior authorization. Your pharmacist or physician can request prior authorization on your behalf by calling our pharmacy help desk.
Step therapy
Drugs that require step therapy, for example, may require previous treatment with one or more formulary agents prior to coverage. Drugs that require step therapy or prior authorization are included in BCN’s Quality Interchange program (see below).
What if the drug is not in the formulary?
Your drug rider or amendment may not cover nonformulary drugs. If it doesn’t and your doctor determines that none of the formulary alternatives (PDF) will work for you and that the nonformulary drug is the best treatment for you, your doctor may request authorization for coverage. Your doctor must call the pharmacy help desk to make that request. If the request is approved, you will only have to pay your usual copayment amount for the nonformulary drug.
When a drug is not a covered benefit
A drug that’s not in our formulary, that requires prior authorization or is not covered under your drug plan may not be a covered benefit. BCN reviews all physician and member requests to determine if the drug is medically necessary and that there aren’t equally effective alternative drugs on the formulary. BCN will notify both you and your doctor in writing if the request is denied. We will include information on how to appeal our decision, and either you or your doctor can initiate the appeal process. Please call Customer Service if you have questions regarding a drug authorization, a drug claim or your eligibility.
Quality Interchange Program
This program helps ensure that safe, high-quality cost-effective drug therapy is prescribed prior to the use of more expensive agents that may not have proven value over current formulary medications. Learn more about the Blue Care Network Quality Interchange Program (PDF) .
Quantity limits
There are quantity limits on many prescriptions. This document, BCN Quantity Limits (PDF) provides specific details.
page modified 02/23/2009