Why Do I Need Prior Authorization for Medication?
There are hundreds of different medications with more becoming available every day. Blue Cross Blue Shield of Michigan and Blue Care Network use prior authorization to make sure you get the right medication.
This means we need to review some medications before your plan will cover them. We want to know if the medication is medically necessary and appropriate for your situation.
If a service requires prior authorization, it's important to make sure that your provider receives the prior authorization before you receive the services. If you receive those services without prior authorization, the service may not be covered. If a service isn't covered, we'll pay nothing and you may have to pay up to the full amount of the provider’s charge.
If you don’t get prior authorization, a medication may cost you more, or we may not cover it.
If you file an urgent request, we will have a decision provided in 72 hours or less. A standard non-urgent request may take up to seven days for us to make a decision.
Learn more about the review of a non-covered drug, one not on our drug list.
We cover certain drugs under the pharmacy part of your health plan and others under the medical part of your health plan.
If you go to a pharmacy to fill your prescription, it's most likely billed to your pharmacy coverage.
You can find out if a medication needs prior authorization by logging in to your account at bcbsm.com. You’ll need to know the name of the medication, the dosage and how often you’ll be taking it.
You can also look on your plan’s drug list (a list of approved medications). On a regular drug list, if your medication has a PA after its name, you need to get prior authorization. Most plans also have a special list of drugs that need prior authorization.
For Medicare members, locate your plan on our Medicare drug list page. You'll be able to find your plan's prior authorization and step therapy guidelines there.
What should I do if my prescription needs prior authorization?
If your drug needs approval, either you or your pharmacist will need to let your doctor know. Your doctor might switch you to another drug that doesn’t need prior approval. They can also submit for a coverage review electronically (PDF) or by contacting our Pharmacy Help Desk at 1-800-437-3803.
Prior Authorization Medical Coverage Drug List (PDF)
What should I do if my prescription drug isn't covered?
If you review your drug list and determine that your prescription drug isn't covered, you can request a review.
If you go to a pharmacy to fill your prescription, it's most likely billed to your pharmacy coverage.
You can find out if a medication needs prior authorization by logging in to your account at bcbsm.com. You’ll need to know the name of the medication, the dosage and how often you’ll be taking it.
You can also look on your plan’s drug list (a list of approved medications). On a regular drug list, if your medication has a PA after its name, you need to get prior authorization. Most plans also have a special list of drugs that need prior authorization.
For Medicare members, locate your plan on our Medicare drug list page. You'll be able to find your plan's prior authorization and step therapy guidelines there.
What should I do if my prescription needs prior authorization?
If your drug needs approval, either you or your pharmacist will need to let your doctor know. Your doctor might switch you to another drug that doesn’t need prior approval. They can also submit for a coverage review electronically (PDF) or by contacting our Pharmacy Help Desk at 1-800-437-3803.
Prior Authorization Medical Coverage Drug List (PDF)
What should I do if my prescription drug isn't covered?
If you review your drug list and determine that your prescription drug isn't covered, you can request a review.