Drug Management

Many of our prescription drug plans include Drug Management programs that promote quality, safety and proper use of certain medications. We base the Drug Management programs on U.S. Food and Drug Administration and manufacturer guidelines, medical literature, safety, accepted medical practice, appropriate use and benefit design. 

  • Prior Authorization – Drugs in this program require prior approval before the plan will cover them. Please Note: Certain specialty drugs billed under the medical benefit will also require prior authorization. View our Prior Authorization Drug List
  • Quantity Management – This program limits the amount we cover for certain drugs. We provide medical necessity exceptions for some of these limits when you request and receive prior authorization for them. View our Quantity Management Drug List.
  • Step Therapy – Step Therapy requires members to try cost-effective “First Choice” medications before trying (or “stepping up to”) more expensive “Second Choice” medications. We provide medical necessity exceptions when you request and receive prior authorization for them. View our Step Therapy Drug List.
  • Opioid Management Program – Opioid Management consists of daily quantity limits specific to each covered opioid drug and prior authorization requirements for certain prescribing situations. View the Opioid Management Program List.

Medical Necessity Exception Requests for Prior Authorization and Step Therapy

To request prior authorization or an exception for a medical necessity, please find the appropriate fax form for non-specialty drugs

For specialty drugs billed under the pharmacy benefit, CVS Specialty will review prior authorization requests. CVS Specialty is a division of CVS Health, an independent company that provides pharmacy benefit management and specialty pharmacy services on behalf of BlueCross. You can make requests by calling 800-237-2767 or faxing 800-323-3445. Certain specialty pharmacy drugs billed under the medical benefit will require prior authorization through CVS Caremark's Novologix medical prior authorization system.


 

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