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Prior Authorization and Step Therapy
To ensure that members receive the most appropriate and cost-effective drug therapy, some plans require that additional steps be taken before certain drugs are covered:
- Prior Authorization: Certain clinical criteria must be met before some drugs are covered. Your doctor should call our pharmacy help desk to request prior authorization for these drugs.
- Step Therapy: Requires that you have tried an alternative therapy first or that your doctor has clinically documented why you cannot take the alternate therapy. Step therapy may include select covered over-the-counter products.
Which drugs require prior authorization or step therapy?
The type of coverage you have determines where you can locate this information.
If the front of your member ID card includes RxGrp BCBSMRX1 - as indicated on the sample card - use the lists below to determine your coverage.
Each type of formulary has its own list of drugs that require prior authorization or step therapy.
- Custom Formulary Prior Authorization/Step Therapy Drug List (PDF)
- Clinical Formulary Prior Authorization/Step Therapy Drug List (PDF)
If the front of your card does not include RxGrp BCBSMRX1, your prior authorization is located on the Medco Online Pharmacy. To access the Medco Online Pharmacy, log in to Member Secured Services and click the Hospitals, Physicians and Medication tab.
Questions? We can help!
Not sure which formulary you should refer to or which Prior Authorization/Step Therapy list above applies to you? Have other questions about your pharmacy benefits? Contact customer service.
