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 below.
Please note: Medications administered by doctors and other health care providers should use the forms on the Health Plans page.
Visit the CuraScript website for prior authorization fax forms for specialty drugs. CuraScript is an independent company that administers the specialty pharmacy program on behalf of BlueCross.
You can also call Care Continuum at 866-544-0857 or fax forms to 866-576-3869. Care Continuum is an independent company that processes specialty drug prior authorizations on behalf of BlueCross.
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:
Adoxa Advicor Altoprev Ambien
Atacand Atacand HCT
Atralin Avalide Avapro
Avita Beconase AQ
Celebrex 400 mg
Crestor Detrol Detrol LA
Diovan Diovan HCT Ditropan XL
Doryx Dymista Edarbi Edarbyclor
Fentora Flonase Fortamet
Forteo FreeStyle Diabetic Test Strips Glumetza Gralise
Hyzaar Intermezzo JentaDueto Lamisil
Lazanda Lescol Lescol XL Lipitor Lumigan Lunesta
Monodox Mybetriq Nasacort AQ
Nuvigil Oleptro Olux-E Omnaris
Rhinocort AQ Riomet Sanctura
Sanctura XR Silenor Sonata
Tekturna Tekturna HCT Testiml Teveten Teveten HCT Toviaz Tradjenta
Tretin-X Veramyst Vytorin
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.
butorphanol nasal spray
Exalgo Frova Imitrex Injectable
Kytril Maxalt MS Contin Nexium
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.
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.
The State Health Plan provides prescription drug coverage through Medco. Medco is an independent company that assists in the administration of the program on behalf of the State Health Plan. Call Medco at 800-211-1456 or visit Medco's website for more information.
*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.
Some links on this page lead to third party websites. Those parties are solely responsible for the contents and privacy policies on their sites.