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Drugs Requiring Approval

Everything you need to know about medications that require prior authorization.

For some drugs that your provider prescribes, Premera Blue Cross and its affiliate Premera Blue Cross HMO review the circumstances before deciding whether to cover the drug.

This approval process can be triggered by several different situations:

  • Prior authorization—The drug is on your plan's drug list, but it requires an authorization before the prescription is covered.
  • Quantity limit—The drug is on your plan's drug list, but we limit the amount of the drug that we will cover.
  • Step therapy—The drug is on your plan's drug list, but we require that you first try a different drug before authorizing the drug prescribed.
  • Formulary exception—The drug is not on your plan's drug list, but your provider has prescribed it.
  • Pharmacy exception—You are covered by a Washington state fully insured group plan, and your prescription was not covered because of a formulary exception, step therapy, dosage limitation, or therapeutic substitution.

Here's how to navigate that process.

Rx search tool

Select a drug

Note: The Rx search tool shows drugs that require pharmacy prior authorization common to all plans. For drug review requirement specific to a customer's plan, Members can log in to My Rx Choices via MyPharmacyPlus™ to view drug review requirements specific to their plan.

Covered drug lists

You can use our Covered drug lists to see if a drug falls into one or more of these categories.

To request a prior authorization review, the pharmacy or the provider must contact our pharmacy services center at 888-261-1756 or submit a drug specific Pharmacy Prior Authorization Request fax form (individual | group).

Sometimes a pharmacy can also do a one-time override for urgently needed medication. Learn more about emergency prescriptions.

Prior authorization drugs

Select the name of the drug in the RX search tool (right) to view prior authorization criteria, the drug's corresponding medical policy, and a link to an online fax form.
As another option, you can use the Pharmacy Prior Authorization Request fax form to submit all types of pharmacy authorization requests.

Formulary exception review

A formulary exception review is required if the Rx Plan listed on the member's ID card is B3, M1, M2, or M4 and the drug you've selected in the Rx Search tool (right) displays the non-formulary symbol. For these drugs, submit a review using the Pharmacy Formulary Exception Request fax form (individual | group). If we approve the exception, your cost will be charged, based on whether the drug is generic, brand, or specialty.

Standard versus urgent review requests

  • Standard: We review most standard requests within 72 business hours. If we need additional information, the review could take longer.
  • Urgent: We typically handle these within 24 hours, even if there isn't adequate clinical information to make a decision. In cases without sufficient clinical information, the request may be denied.

Once the medication is reviewed, we fax a decision to the requesting provider and send the member a confirmation letter about the prescription coverage decision.

  • If we approve the request, the medication is covered by the customer's prescription benefits and can be filled at the pharmacy.
  • If we deny the request, the medication isn't covered by the customer's prescription benefits. The customer should then talk to his or her provider about choosing a different drug that's covered.

Quantity limit or step therapy reviews

Medications for certain conditions, such as migraines, diabetes, or high blood pressure, may need to meet certain requirements before a prescription is covered. See the Prior Authorization Drugs section above to see if the drug requires a prior authorization, quantity limit, or step therapy review.

HIV PrEP drug cost share exception

If you think a member’s HIV pre-exposure prophylaxis (PrEP) drug should be available at no cost under their health plan, you may request an exception by submitting the Pharmacy Formulary Exception Request form  (individual | group) by fax. For these pharmacy exception reviews, we apply this Benefit Coverage Guideline. We review most standard exception requests within 72 hours and urgent requests within 24 hours.