Premera Blue Cross logo
Go to the Alaska website

Drugs Requiring Approval

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.

Checking your drug

Start by checking your plan's list of covered drugs by finding the Rx Plan number on the front of your ID card.

Select the Rx Plan number here, to view your drug list:

For details about the drug lists, see Covered Drugs.

Check your drug list for the drug you were prescribed, under its brand or generic name, to see whether a review is needed for that drug. Look for these labels: PA for prior authorization, QL for quantity limit, or ST for step therapy.

Requesting approval

If an approval is needed, your provider or pharmacy needs to contact us with that request. There are several ways they can submit it by:

Select the drug name

Find out more about our requirements and policy and to generate a partially completed fax form.

Loading drug list…

If the medication is urgently needed, sometimes a pharmacy can request a one-time emergency override for up to a seven-day supply.

We review most standard requests within five calendar days. If we need additional information, the review could take longer. If your provider marks your request as urgent, we typically handle these within 48 hours, whether or not adequate clinical information is available to make a decision. If there's not enough clinical information to approve the request, it may be denied.

Once the medication is reviewed, we fax a decision to the requesting provider. We'll also send you a confirmation letter about the drug coverage decision. If the request is approved, the medication is covered by your prescription benefits and can be filled at the pharmacy. If the request is denied, the medication is not covered by your prescription benefits. You should then talk to your provider about choosing a different drug that is covered.

Requesting a formulary or pharmacy exception

If your medicine isn’t on your plan’s list of covered drugs, you may need a special review called a formulary exception. This applies if the Rx Plan on your member ID card is E1, E3, E4, M1, M2, or M4, or if you have a Washington state fully insured plan–even if you live outside of Washington.

Washington state plans may also have extra rules like step therapy, dosage limits, or switching to a similar drug to make sure the medicine is right for you. If your prescription is denied under these rules, your doctor can ask for an exception by sending the correct form for your plan by fax.

We review most standard formulary and pharmacy exception requests within 72 hours and urgent requests within 24 hours. If we need additional information, the review could take longer.

Requesting a HIV PrEP (human immunodeficiency virus pre-exposure prophylaxis) drug cost share exception

If you have preventive benefits and you think your HIV PrEP drug should be available at no cost under your health plan, your provider may request an exception by submitting the appropriate form by fax:

For these pharmacy exception reviews, we follow these guidelines below. We review most standard exception requests within 72 hours and urgent requests within 24 hours.