If a medication requires step therapy, prior authorization or is not on a formulary and the patient has BCN Advantage℠ HMO-POS or BCN Advantage℠ HMO, you can request coverage based on medical necessity. If a medication has quantity restrictions, you can also ask us to waive quantity restrictions if the quantity allowed is not appropriate based on the member's condition.

Also, If certain conditions are met, you can ask us to provide a higher level of coverage or reduce the copayment for drugs on Tier 2 (generics), Tier 3 (preferred brands) or Tier 4 (non-preferred drugs). Copayment tiering exceptions may be considered if there is a drug to treat the same condition on a lower member cost-share tier. Tier exception requests may be approved if documentation is provided that medications used to treat the condition in the lower cost-sharing tiers were ineffective or are contraindicated.

Unsure of which tier a drug is on? Take a look at our drug lists.

To request coverage for your BCN Advantage member:

• Preferred method: Submit your request online. Learn more by reading our Electronic Prior Authorization Flyer (PDF).
• Fax a completed Medicare Part D Coverage Determination Request form (PDF) to the BCN Clinical Pharmacy Help Desk at 1-866-601-4428.