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The guidelines explain how prior authorization reviews certain medications before coverage, typically for set periods such as one year, and how step therapy requires trying preferred drugs before approval of higher-cost alternatives. They also describe which drug types may trigger these requirements, how criteria are based on medical information and the Pharmacy and Therapeutics Committee, and how plan coverage can differ between prescription and medical benefits. Coverage details, electronic review processes, and oncology pathways are included, along with updated drug criteria and effective dates.",{"@graph":63,"@context":122},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":51,"@type":70,"position":76},"https://docshare.wps.com/template/general/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/prior-authorization-and-step-therapy-guidelines-blue-cross-blue-shield-of-michigan-and-blue-care-network/288886/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/prior-authorization-and-step-therapy-guidelines-blue-cross-blue-shield-of-michigan-and-blue-care-network/288886.png","ImageObject",442,249,{"name":88,"@type":89},"Ivy","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-21","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":79},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114,118],{"name":105,"@type":106,"acceptedAnswer":107},"What is prior authorization and how does it affect coverage?","Question",{"text":108,"@type":109},"Prior authorization requires a review of certain medications before your plan will cover them. If your doctor does not obtain it when required, the drug may not be covered and you should discuss alternative therapy with your doctor.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What is step therapy and what happens if criteria are not met?",{"text":113,"@type":109},"Step therapy requires trying one or more preferred drugs before coverage for a more expensive alternative is approved. If your treatment does not meet the step therapy criteria, it may not be covered, and you should consult your doctor about alternatives.",{"name":115,"@type":106,"acceptedAnswer":116},"Which medications may require prior authorization or step therapy?",{"text":117,"@type":109},"Requirements may apply to drugs with dangerous side effects or harmful interactions, drugs intended only for certain conditions, drugs that can be misused or abused, and drugs prescribed when equally effective preferred options are available.",{"name":119,"@type":106,"acceptedAnswer":120},"How are oncology requests handled under these guidelines?",{"text":121,"@type":109},"For oncology and supportive care drugs covered under the pharmacy benefit, prior authorization is required through the Oncology Value Management program administered by OncoHealth. Your doctor can submit requests through Availity, and approvals are granted for at least 60 days up to six months, consistent with FDA-approved or specified guideline-based off-label use.","https://schema.org",{"og:url":78,"og:type":124,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":126,"canonical":78},"index,follow",{"doc_id":128,"site_id":56},288886,1789634157,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":88,"user_avatar":133,"doc_module":9,"category_id":50,"category_name":51,"doc_title":59,"doc_description":61,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":79,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":139,"language":140,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":61,"update_tm":129,"read_time":144},549758252649,"https://ap-avatar.wpscdn.com/avatar/8000253669c5317157?_k=1778319167496531819","Blue Cross Blue Shield of Michigan and Blue Care Network work to make sure you get the safest, most effective and most reasonably priced prescription drugs. Our pharmacists do this in many different ways. Prior authorization and step therapy are two of our tools.  \nWhat is prior authorization?  \nBlue Cross and BCN require a review of certain medications before your plan will cover them, which is called prior authorization. This ensures you’ve tried the preferred alternatives—drugs with a proven track record that may be better tolerated, less expensive or less likely to cause interactions—and the drug is being prescribed appropriately. If your doctor doesn’t get prior authorization when required, your drug may not be covered. You should consult with your doctor about an alternative therapy in those cases. Most approved prior authorizations last for a set period of time , usually one year. Once they expire, your doctor must request prior authorization again for future coverage.  \nWhat is step therapy?  \nStep therapy requires that you try one or more preferred drugs before coverage for a more expensive alternative is approved. This ensures all clinically sound and cost-effective treatment options are tried before more expensive medications. If your prescribed treatment doesn’t meet the step therapy criteria, it may not be covered. You should consult with your doctor about an alternative therapy.  \nWhat kinds of drugs need prior authorization or step therapy?  \nBlue Cross and BCN may require prior authorization or step therapy for drugs that:  \n• Have dangerous side effects or can be harmful when combined with other drugs  \n• Should only be used for certain health conditions  \n• Can be misused or abused  \n• Are prescribed when there are preferred drugs available that are just as effective  \nThe criteria for medications that need prior authorization or step therapy are based on current medical information and the recommendations of Blue Cross and BCN’s Pharmacy and Therapeutics Committee, a group of physicians, pharmacists and other experts.  \nCoverage of drugs depends on your prescription drug plan. Not all drugs included in these prior authorization and step therapy guidelines are necessarily covered by your plan. Also, some medications excluded from your prescription drug plan may be covered under your medical plan. Examples include medications that are generally administered in a physician’s office or other sites of care , rather than at home by the patient. For drugs covered under commercial Blue Cross or BCN medical benefits , please see the Blue Cross and BCN Utilization Management Medical Drug List. Requests for medications not covered by your prescription drug plan are reviewed by Blue Cross and BCN to determine if they are medically necessary for you or if there are other equally effective treatments already covered by your drug plan. In rare cases, Blue Cross and BCN may approve medications that aren’t covered by your drug plan.  \nPrior authorization and pharmacy programs listed in this guideline:  \n•  BCN Custom Drug List  \n•  BCBSM Custom Drug List  \n•  BCBSM Clinical Drug List  \n•  BCN Custom Select Drug List  \n•  BCBSM Custom Select Drug List  \n• Lite Prior Authorization Program  \n• Preferred Therapy Program—This program encourages using more cost-effective drugs rather than higher-priced, brand-name drugs if a prescription for the brand-name drug hasn’t been filled in the last 180 days.  \n• Off-Label and High-Cost Specialty program—Off-label means a drug is being used in a way that hasn’t been approved by the U.S. Food and Drug Administration. Drugs with potential for off-label use and high-cost specialty drugs on this list require prior authorization for Blue Cross to cover them.  \nQuestions?  \nPlease call the Customer Service number on the back of your Blue Cross or BCN member ID card if you have questions about:  \n• Your drug plan’s coverage or how these pharmacy programs apply  \n• A drug claim  \nElectronic prior","cbCaimcW2ujjMlxT","https://ap.wps.com/l/cbCaimcW2ujjMlxT","pdf",2394649,220,"English","# Prior authorization\n## Step therapy\n# Drugs that may require review\n## Coverage depends on your drug plan\n# Pharmacy programs and electronic requests\n## Oncology Value Management and Availity\n# New coverage criteria for certain drugs\n## Example updates by drug name","[{\"question\":\"What is prior authorization and how does it affect coverage?\",\"answer\":\"Prior authorization requires a review of certain medications before your plan will cover them. If your doctor does not obtain it when required, the drug may not be covered and you should discuss alternative therapy with your doctor.\"},{\"question\":\"What is step therapy and what happens if criteria are not met?\",\"answer\":\"Step therapy requires trying one or more preferred drugs before coverage for a more expensive alternative is approved. If your treatment does not meet the step therapy criteria, it may not be covered, and you should consult your doctor about alternatives.\"},{\"question\":\"Which medications may require prior authorization or step therapy?\",\"answer\":\"Requirements may apply to drugs with dangerous side effects or harmful interactions, drugs intended only for certain conditions, drugs that can be misused or abused, and drugs prescribed when equally effective preferred options are available.\"},{\"question\":\"How are oncology requests handled under these guidelines?\",\"answer\":\"For oncology and supportive care drugs covered under the pharmacy benefit, prior authorization is required through the Oncology Value Management program administered by OncoHealth. Your doctor can submit requests through Availity, and approvals are granted for at least 60 days up to six months, consistent with FDA-approved or specified guideline-based off-label use.\"}]","Prior Authorization and Step Therapy Guidelines - Blue Cross Blue Shield of Michigan and Blue Care Network | PDF",77]