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 BlueShield of South Carolina. 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. 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, 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 ACA/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 800-294-5979, 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  |  Admelos  |  Aimovig  |  Altoprev  |  Ambien/Ambien CR  |  Amitiza  |  Amrix  |  Anadrol-50  

Apidra  |  armodafinil  |  Avalide  |  Avapro  |  Basaglar  |  Beconase AQ  |  Belsomra  |  Benznidazole  

Bydureon/BCISE  |  Byetta  |  Compound Drugs  |  Cozaar  |  Crestor  |  Detrol/Detrol LA  |  Diabetic Test Strips

Diovan/Diovan HCT  |  Ditropan XL  |  Dulera  |  Dymista  |  Edarbi  |  Edarbyclor  |  Edluar  |  Epanova  |  Evekeo

Fentora  |  Flector patch  |  Flonase  |  Freestyle Libre  |  Gralise  |  Humalog  |  Humulin (except U-500)  |  Hyzaar

Incruse Ellipta  |  Intermezzo  |  Invokamet/Invokamet XR  |  Invokana  |  Jentadueto/Jentadueto XR  |  Kazano

Kenalog  |  Lazanda   |  Lescol/Lescol XL  |  Levemir  |  Lidocaine (generic)  |  Lipitor   |  Livalo   |  Lovaza

Lumigan  |  Mevacor  |  Micardis/Micardis HCT  |  modafinil  |  Motegrity  |  Myrbetriq  |  Naprelan  |  Nasacort AQ

Nesina  |  Novolin Relion  |  Oleptro   |  Olux-E  |  Omnaris  |  Omtryg  |  Onsolis

Opioid Management - Immediate Release Products  |  Opioid Management - Extended Release Products

Opioid Management - Combination Products  |  Oseni  |  Oxandrin  |  Oxytrol  |  Pradaxa  |  Pravachol

Prevacid Solutabs  |  Qnasl   |  Rayos   | Rexulti  |  Rhinocort AQ  |  Riomet  |  Santyl  |  Sanctura/Sanctura XR

Savaysa  |  Seebri Neohaler  |  Silenor  |  Sonata  |  Soriatane  |  Sporanox Oral Capsules & Oral Solution

Subsys  |  Sustol  |  Tanzeum  |  Tekturna/Tekturna HCT  |  Teveten/Teveten HCT  |  Tobacco Cessation  |  Toviaz

Tradjenta  |  Tresiba  |  Tudorza Pressair  |  Vascepa  |  Viberzi  |  Xifaxan 550 mg  |  Zetonna  |  Zocor  |  Zolpimist


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. 

Aloxi  |  Alsuma  |  Amerge  |  Anzemet  |  Avinza  |  Axert  |  butorphanol nasal spray  |  Embeda  |  Emend

Frova  |  Imitrex  |  Kadian  |  Kytril  |  Maxalt/Maxalt MLT  |  MS Contin  |  Oramorph  |  Relpax  |  Sancuso

Sumavel DosePro  |  Topical Corticosteroids  |  Treximet  |  Zofran  |  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.

Avita  |  Clozaril  |  Desvenlafaxine ER  |  Differin  |  Epiduo/Epiduo Forte  |  Fabior   |  Fanapt  |  Fazaclo

Fenoglide  |  Fetzima  |  Fibricor  |  Geodon  |  Invega  |  Khedezla  |  Latuda  |  Lipofen  |  Oxiconazole

Ozempic  |  Risperdal  |  Saphris  |  Tazorac  |  Tretin-X  |  Tricor  |  Trilipix  |  Trulicity  |  Uloric  |  Veltin

Versacloz  |  Victoza  |  Vyarlar  |  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.