Pharmacy Benefit Drugs: How to determine requirements and submit requests

Below, you'll find information on how to determine utilization management requirements for pharmacy benefit drugs and on how to submit prior authorization requests for pharmacy benefit drugs.

How to determine utilization management requirements

Plan	How to Determine Requirements
Blue Cross Blue Shield of Michigan commercial or Blue Care Network commercial	Identify commercial utilization management (step therapy or prior authorization) requirements by reviewing the following: Blue Cross Blue Shield of Michigan and Blue Care Network: Prior authorization and step therapy coverage criteria Blue Cross Blue Shield of Michigan and Blue Care Network: Preferred Drug List Prior Authorization and Step Therapy Coverage Criteria Note: To determine which commercial self-funded groups have requirements for oncology pharmacy benefit drugs, see the Oncology Value Management program participation list for self-funded groups
Medicare Plus Blue^℠ or BCN Advantage^℠	Access the Medicare Advantage utilization management (step therapy or prior authorization) requirements by doing the following: Visit the Drug Lists for Medicare Members webpage and select the member’s plan from the drop-down list. Click the link to open the appropriate prior authorization and step therapy drug list.

Plan

How to Determine Requirements

Blue Cross Blue Shield of Michigan commercial or Blue Care Network commercial

Identify commercial utilization management (step therapy or prior authorization) requirements by reviewing the following:

Note: To determine which commercial self-funded groups have requirements for oncology pharmacy benefit drugs, see the Oncology Value Management program participation list for self-funded groups

Medicare Plus Blue^℠ or BCN Advantage^℠

Access the Medicare Advantage utilization management (step therapy or prior authorization) requirements by doing the following:

Visit the Drug Lists for Medicare Members webpage and select the member’s plan from the drop-down list.
Click the link to open the appropriate prior authorization and step therapy drug list.

How to submit prior authorization requests through the Medical and Pharmacy Drug PA Portal for most pharmacy benefit drugs

Submit prior authorization requests through the Medical and Pharmacy Drug PA Portal, which you can access by clicking the Medical and Pharmacy Benefit Drug Prior Auth tile in our provider portal (availity.com).

To learn how to use the Medical and Pharmacy Drug PA Portal, view a recorded demo by going to Blue Cross and BCN's Provider Training site, searching on drugs and launching the "Medical and Pharmacy Drug PA Portal Overview Mini Module." (For detailed information about accessing the Provider Training site, see the "Online training" section of the Training Tools page.)

If you experience issues while working in the Medical and Pharmacy Drug PA Portal, click Contact Us near the upper right corner of the Medical and Pharmacy Drug PA Portal.

Additional resource: Get Member-Specific Information with Real-Time Prescription Benefit Check

For questions about utilization management requirements, call the Blue Cross / BCN Pharmacy Clinical Help Desk at 1-800-437-3803.

How to submit prior authorization requests through ePA tools for most pharmacy benefit drugs

Alternately, providers can submit prior authorization requests using CoverMyMeds^® and other free electronic prior authorization (ePA) tools such as Surescripts^®. In addition, an ePA tool can be integrated into your current electronic health record workflow. Check with your vendor to see if you have software that accommodates an ePA tool.

To learn to use the CoverMyMeds web tool:

See the CoverMyMeds Prescriber Demonstration.
See the CoverMyMeds Support page at covermymeds.com/main/support.

Additional resources:

For questions about utilization management requirements, call the Blue Cross / BCN Pharmacy Clinical Help Desk at 1-800-437-3803.

For questions about the CoverMyMeds web tool, call the CoverMyMeds support center at 1-866-452-5017.

How to submit prior authorization requests for oncology drugs to OncoHealth

For members who have requirements under the Oncology Value Management program, submit prior authorization requests to OncoHealth by clicking the OncoHealth Provider Portal tile in the BCBSM and BCN payer space in Availity Essentials^™. For more information, see the Oncology Value Management program through OncoHealth: FAQs for providers

To learn how to use the OncoHealth OneUM^™ portal, view a recorded training by going to Blue Cross and BCN’s Provider Training site, searching on oncology and launching the OncoHealth presentation. (For detailed information about accessing the Provider Training site, see the "Online training" section of the Training Tools page.)

For questions about oncology drugs or working in the OncoHealth OneUM provider portal, call OncoHealth at 1-888-916-2616.

Alternate methods for submitting prior authorization requests for pharmacy benefit drugs

If you’re experiencing temporary technical problems (such as a power or internet outage) that prevent you from submitting prior authorization requests electronically, see Alternate methods for submitting prior authorization requests for medical and pharmacy benefit drugs

Utilization Management Criteria

Visit our Utilization Management Criteria page.

Availity^® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal and electronic data interchange services.

OncoHealth is an independent company supporting Blue Cross Blue Shield of Michigan and Blue Care Network by providing cancer support services.