Prescription Plans

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.

Specialty Drugs

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.

Non-Specialty Drug Prior Authorization Program

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:

Acticlate   Adoxa   Advicor   Altoprev   Ambien   Ambien CR   Anadrol-50   Androgel   Apidra   Atacand   

Atacand HCT   Atralin   Avalide   Avapro   Avita   Beconase AQ   Breo Ellipta   buprenorphine SL  

Celebrex 400 mg  Compounds  Cozaar   Crestor   Detrol   Detrol LA   Differin   Diovan   Diovan HCT  

Ditropan XL   Doryx   Dymista   Edarbi   Edarbyclor   Edular   Emend   Epanova   Flonase  Fortamet   Forteo  

FreeStyle Diabetic Test Strips   Glumetza   Gralise  Humalog   Humulin  Hyzaar   Intermezzo  JentaDueto  

Kazano  Lescol   Lescol XL  Lipitor   Liptruzet  Livalo   Lovaza   Lumigan   Lunesta   Mevacor   Monodox  

Mybetriq   Nasacort AQ   Nesina   Nuvigil   Oleptro  Olux-E   Omnaris  Omtryg   Onmel   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   Suboxone  Subutex  Tekturna   

Tekturna HCT   Testim   Teveten   Teveten HCT   Toviaz   Tradjenta  Tretin-X   Vascepa  Veramyst   Vogelxo  

 Vytorin   Zetonna   Ziana   Zocor   Zohydro ER   Zolpimist  Zubsolv

Quantity Management Program

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

Step Therapy Program

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

Prior Authorization Forms Request

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.

State Health Plan Prescription Drug Coverage

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.