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.
Please note: Medications administered by doctors and other health care providers should use the forms on the Health Plans page.
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.
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 Adoxa Advicor Altoprev Ambien Ambien CR Amitiza Amnesteem Anadrol-50 Androgel Apidra Atacand Atacand HCT Atralin Avalide Avapro Avita Beconase AQ Breo Elipta Buprenorphine SL Celebrex 400 mg Claravis Cozaar Crestor Detrol Detrol LA Differin Diovan Diovan HCT Ditropan XL Doryx Dymista Edarbi Edarbyclor Edular Emend Fentora Flonase Fortamet Forteo FreeStyle Diabetic Test Strips Glumetza Gralise Humalog Humulin Hyzaar Intermezzo JentaDueto Kazano Lamisil Lazanda Lescol Lescol XL Lipitor Liptruzet Livalo Lumigan Lunesta Mevacor Monodox Mybetriq Nasacort AQ Nesina Nuvigil Oleptro Olux-E Omnaris Onsolis Oseni Oxandrin Oyxtrol Pradaxa Pravachol Provigil Qnasl Rayos Regranex Retin-A Rhinocort AQ Riomet Sanctura Sanctura XR Silenor Sonata Soriatane Sotret Sporanox Suboxone Subsys Subutex Tekturna Tekturna HCT Testiml Teveten Teveten HCT Toviaz Tradjenta Tretin-X Veramyst Vytorin Zetonna Ziana Zocor 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 Amerge Anzemet Avinza Axert butorphanol nasal spray Celebrex Dexilant Duragesic
Embeda Emend Exalgo Frova Imitrex Injectable Imitrex Oral Kadian Kytril Maxalt MS Contin Nexium
Nexium-MtVernonMills Opana Oramorph Oxycontin Prevacid Prilosec Protonix Relpax Sancuso Sumavel Treximet Zegerid Zofran Zomig 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.
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.
Some links on this page lead to third party websites. Those parties are solely responsible for the contents and privacy policies on their sites.