Many of our prescription drug plans have drug management programs for medications* dispensed by pharmacies. We provide many of the prior authorization forms and exception request forms here.
Beginning January 2016, CVS/specialty is our preferred specialty pharmacy. CVS/specialty is a division of CVS Health, an independent company that provides pharmacy benefit management and specialty pharmacy services on behalf of BlueCross. Many of our members are required to use our preferred specialty pharmacy for oral and self-injectable specialty drugs to have coverage under their pharmacy benefit. CVS/specialty will also review prior authorization requests for specialty drugs. Requests can be made by calling 800-237-2767 or faxing 866-249-6155. View the specialty drug list.
Some of our members have a Dispense as Written (DAW) generic program as part of their prescription drug benefits. This means if a member has a prescription for a particular brand-name drug that is also available in generic form, he or she will pay more for that brand-name drug if he or she opts to fill it instead of the generic version. If you feel that the generic version is not appropriate for a particular member, please complete this Generic Program Exception form to request an exception detailing why this member must have the brand-name drug over the generic version. This exception process is only applicable to members whose benefits are subject to the rules under the Affordable Care Act/essential health benefits for prescription drug coverage.
We require prior approval for drugs included in our prior authorization program for most members. To request prior authorization for non-specialty drugs, call Caremark's Prior Authorization department at 866-814-5506, or print the required prior authorization form and fax it to Caremark at 888-836-0730. Caremark is an independent company that assists in the administration of the program on behalf of BlueCross.
These are fax forms for drugs in our prior authorization program:
Abstral Actiq Acticlate Adoxa Advicor Altoprev Ambien Ambien CR Amitiza Amrix Anadrol-50
Androgel Apidra Atacand Atacand HCT Atralin Avalide Avapro Avita Beconase AQ Belsomra
Bunavail buprenorphine SL Byetta Celebrex 400 mg Compounds Cozaar Crestor Detrol Detrol LA
Diabetic Test Strips Differin Diovan Diovan HCT Ditropan XL Doryx Duexis Dulera Dymista
Edarbi Edarbyclor Edular Emend Epanova Evekeo Fentora Flonase Fortamet Forteo Fortesta
Glumetza Gralise Humalog Humulin Hyzaar Intermezzo Invokana Invokamet JentaDueto Kazano
Lazanda Lescol Lescol XL Levemir Lipitor Liptruzet Livalo Lovaza Lumigan Lunesta Mevacor
Monodox Mybetriq Naprelan Nasacort AQ Natesto Nesina Nexium Nuvigil Oleptro Olux-E Omnaris
Omtryg Onmel Onsolis Oseni Oxandrin Oyxtrol Pravachol Provigil Qnasl Rayos Regranex Retin-A
Rhinocort AQ Riomet Sanctura Sanctura XR Silenor Sonata Soriatane Sporanox oral capsules
Sporanox oral solution Sprix Subsys Suboxone Subutex Tanzeum Tekturna Tekturna HCT Testim
Teveten Teveten HCT Tobacco Cessation Toujeo Toviaz Tradjenta Tretin-X Trulicity Vascepa
Veramyst Vimovo Vogelxo Vytorin Zecuity Zetonna Ziana Zipsor Zocor Zohydro ER Zolpimist
We limit the amount we cover for medications included in the quantity management program for many members. We cover higher quantities for some medications, when medical necessity is documented.
Aciphex Aloxi Alsuma Amerge Anzemet Avinza Axert butorphanol nasal spray Celebrex Dexilant
Duragesic Embeda Emend Exalgo Frova Imitrex Kadian Kytril Maxalt Maxalt MLT MS Contin
Nexium Nexium-MtVernonMills Opana ER Oramorph Oxycontin Prevacid Prilosec Protonix Relpax
Sancuso Sumavel Treximet Zegerid Zofran Zohydro ER Zomig Zomig MLT Zuplenz
We require a generic or over-the-counter alternative trial before we cover medications included in the step therapy program for most members. We waive this requirement when medical necessity is documented.
Abilify Aciphex Antara Atralin Avita Clarinex Clarinex-D Clozaril Desvenlafaxine ER Dexilant
Differin Esomeprazole Strontium Fabior Fanapt Fenoglide Fetzima Fibricor First Omeprazole
Geodon Invega Khedezla Lansoprazole Suspension Latuda Lipofen Lofibra omeprazole/bicarb
Prevacid Prilosec Pristiq Protonix Retin-A Risperdal Saphris Seroquel Solodyn Tazorac Tretin-X
Tricor Triglide Trilipix Uloric Veltin Versacloz Xyzal Zegerid Ziana Zyprexa
Providers who need a prior authorization form that is not available online should call Caremark's Prior Authorization department. For non-specialty drugs, call 800-294-5979. You can also fax a form request to Caremark at 888-836-0730.
The State Health Plan provides prescription drug coverage through Express Scripts. Express Scripts is an independent company that contracts directly with the State Health Plan. Call Express Scripts at 855-612-3128.
*The medication names listed above may be the registered or unregistered trademarks of independent third-party pharmaceutical companies. These trademarks are included for informational purposes only and are not intended to imply or suggest any third-party affiliation.