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.
In 2016, CVS/specialty will become our preferred specialty pharmacy. CVS/caremark is a division of CVS Health, an independent company that provides pharmacy benefit management and specialty pharmacy services on behalf of BlueCross. CVS/specialty will also review prior authorization requests for specialty drugs. Requests can be made by calling 800-237-2767 or faxing 800-323-3445.
Immediate update for 2015 - 2016 Synagis season: CVS/specialty will review prior authorizations for Synagis only beginning November 1, 2015. Please complete the Synagis Enrollment Form
For the remainder of 2015, visit the Accredo website for prior authorization fax forms for specialty drugs. (This link leads to a third party website. That company is solely responsible for the content and privacy policies on its site.) Accredo is an independent company that administers the specialty pharmacy program on behalf of BlueCross.
You can also call Care Continuum at 866-544-0857 or fax forms to 866-576-3869. Care Continuum is an independent company that processes specialty drug prior authorizations on behalf of BlueCross.
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 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 Farxiga Fentora Flonase Fortamet Forteo Glumetza
Gralise Humalog Humulin Hyzaar Intermezzo JentaDueto Kazano Lazanda Lescol Lescol XL
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 Toviaz Tradjenta Tretin-X Trulicity Vascepa Veramyst Vimovo Vogelxo Vytorin
Xigduo XR Zetonna Ziana Zipsor Zocor Zohydro ER Zolpimist Zorvolex Zubsolv
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 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 Catamaran. Catamaran is an independent company that contracts directly with the State Health Plan. Call Catamaran at 855-902-7322 or visit Catamaran's website (This link leads to a third party website. That company is solely responsible for the content and privacy policies on its site.)
*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.