Please note: The forms on this page do not apply to our Affordable Care Act (ACA) plans. For ACA members, please call 855-582-2022 for more information.

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

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. Beginning June 1, 2016, some members have a plan that will block certain self-injectable drugs under the medical benefit and only cover them under the pharmacy benefit. Some specialty drugs require prior authorization. Please see the specialty drug list to determine where to request prior authorization, based on whether the drug will be billed under the member's medical or pharmacy benefit. Also beginning June 1, certain specialty pharmacy drugs billed under the medical benefit will require prior authorization through CVS/caremark's Novologix medical prior authorization system. 

Generic Program Exception Process

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.

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:

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   Myrbetriq   Naprelan   Nasacort AQ   Natesto   Nesina   Nexium   Nuvigil   Oleptro   Olux-E   Omnaris

Omtryg   Onmel   Onsolis   Oseni   Oxandrin   Oyxtrol   Pennsaid   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   Zorvolex   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 ER   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 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.