Drugs Requiring Approval

  • For some drugs that you prescribe, Premera reviews 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 a plan's drug list, but it requires an authorization before the prescription is covered.
    • Quantity limit—The drug is on a plan's drug list, but we limit the amount of the drug that we will cover.
    • Step therapy—The drug is on a 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 a plan's drug list, but you have prescribed it.
    • Pharmacy exception—The patient is covered by a Washington state fully insured group plan, and a prescription was not covered because of a formulary exception, step therapy, dosage limitation, or therapeutic substitution.

    Here's how to navigate that process.

    Checking the drug

    Start by checking the plan's list of covered drugs. The Rx Plan number can be found on the front of the patient’s ID card.

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

    A1   A2   B3   B4   E1   E4   M1   M2   M4

    Check the drug list for the drug you 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.

    For instance, medications for certain conditions—such as migraines, diabetes, or high blood pressure—may need to meet certain requirements before a prescription is covered.

    Requesting approval

    If an approval is needed, you or the pharmacy needs to contact us with that request. There are several ways to submit it:

    • Calling our Pharmacy Services Center at 888-261-1756.
    • Using electronic prior authorization (ePA) in the electronic health record or by visiting CoverMyMeds or ExpressPAth.
    • Completing and faxing the Prior Authorization form.
    • Checking our pre-approval drug list to learn more about our requirements and policy and to generate a partially completed fax form.

    Type in the name of the drug to view pre-approval criteria, the drug's corresponding medical policy, and a link to an online fax form.

     

    If the medication is urgently needed, sometimes a pharmacy can request a one-time emergency override for up to a 7-day supply.

    We review most standard requests within 5 calendar days. If we need additional information, the review could take longer. If you mark the 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 sufficient clinical information to approve the request, it may be denied.

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

    Requesting a formulary or pharmacy exception

    A formulary exception review is required if the Rx Plan listed on the member’s ID card is M1, M2, M4, or B2 and they have been prescribed a drug that is not on that list of covered drugs. For these drugs, submit the Pharmacy Exception Request form by fax.

    If the member is covered by a Washington state fully insured plan, the prescription may be subject to a set of guidelines and rules (formulary exception, step therapy, dosage limitations, or therapeutic substitution) that consider whether that drug is appropriate for treating them and their condition. If the prescription is rejected under these guidelines, you may request an exception by submitting the Pharmacy Exception Request form by fax. For these pharmacy exception reviews, we apply this medical policy as of January 1, 2021.

    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.

    Pharmacy management information

  • Pharmacy reviewers at Premera apply company medical policy to assist in the determination of medical necessity. Our medical policies are available to contracted physicians and providers upon request. Specific criteria related to a medical decision for a patient can be requested by calling Pharmacy Services at 888-261-1756, option 2. View our medical policies.

    Our formulary, including prior authorization criteria, restrictions and preferences, and plan limits on dispensing quantities or duration of therapy are available via Rx search.

    Providers can contact pharmacy management staff at 888-261-1756, option 1, to discuss specific prior authorization, step therapy, quantity limits, exception request criteria for unusual cases, and other utilization management requirements/procedures for drugs covered under the pharmacy benefit. Review requests for medical necessity can also be faxed to 888-260-9836. Formulary updates are communicated on a quarterly basis in provider news.

    Premera updates the formulary and pharmacy prior authorization criteria routinely throughout the year. The Pharmacy and Therapeutics Committee approves all formularies in May. To see the most current information, visit our pharmacy pages.

    Premera has added new review criteria based on clinical best practices and approval by an independent pharmacy and therapeutics committee. The program is designed to promote appropriate drug selection, length of therapy, and utilization of specific drugs while improving the overall quality of care.

    Drugs may be added or deleted from this list without prior notification. If you have questions concerning the Pharmacy Prior Authorization Edit Program, please call the Pharmacy Services Center at 888-261-1756 or fax 888-260-9836, Monday through Friday, 8 a.m. to 5 p.m. Pacific Time

    Note: This information does not apply to our Premera Blue Cross Medicare Advantage plans. For more information on the Premera Blue Cross Medicare Advantage formulary, Prior Authorization Criteria, or Pharmacy Network, see our prescription drug documents and forms.

  • Opioid policy and form

    For School Employees Benefits Board (SEBB) members only: Premera is committed to safe pain management. As of May 1, 2020, an opioid attestation form is required when patients begin chronic opioid use and/or daily doses exceed 120 morphine milligram equivalents. Patients undergoing active cancer treatment, hospice, palliative care, end-of-life, or medically necessary care might be exempt from quantity limits. Expedited authorization codes can be provided in these cases. For more information or expedited authorization codes, call Premera Blue Cross pharmacy services at 888-261-1756.

    View opioid attestation form