Prior authorization

Some medicines require prior authorization by Blue Cross Complete. Your doctor will need to submit a prior authorization request using one of the following forms:

• Prior authorization online form
• Prior authorization request form (PDF)

Your doctor must submit a request for a prior authorization for you. They must also submit an override of a drug restriction. Requests from pharmacists aren’t accepted.

Prior authorization process

Once we receive a request, we’ll review the information. After a decision has been made, you’ll receive a letter with the approval or denial. If it’s denied, we’ll let you know why. Your doctor will receive a letter or a fax with the same information.

We will cover the medicine if it’s medically necessary. If we don’t believe it’s medically necessary, we’ll send you a letter that tells you why. If you or your doctor disagree with our decision, you can appeal it.

Formulary medicines are preferred. If a non-formulary medicine is prescribed, we may require you to try the available formulary medicines first. If it doesn't work, or your doctor doesn’t think they’re appropriate for you, they can submit a prior authorization request for a non-formulary medicine.

If more assistance is needed, your doctor can call PerformRx Pharmacy Provider Services at 1-888-989-0057. Your doctor can fax a hard copy of the form to 1-855-811-9326.

Appeal of prior authorization denials

Your doctor, with your written approval, may ask us to review a prior authorization request that we denied:

Pharmacy prior authorization – emergency supply

A doctor might not get prior authorization. In some cases, you can work with your pharmacy to get an emergency supply of the medicine for three days. If we don't have enough information to make a decision, we'll ask for more information. All clinical information requests must be completed within 24 hours of this request.

Doctors may also ask for copies of the information that was used to make the prior authorization decision. They can contact PerformRx Pharmacy Provider Services at 1-888-989-0057.

Specialty medicines

All specialty medicines, such as those for complex diseases, require prior authorization. The Prior Authorization Request (PDF) form must be completed. The form should be submitted by following the steps on the form.