Prior Authorization and Step Therapy
Safety is Our Priority
New drugs and new drug information come to the market at an astounding pace. Additionally, a record number of drugs have been taken off the market because of safety issues that were identified after marketing.
In order to help assure our members have access to safe, effective drug therapy and to protect against inappropriate use and waste, we require prior authorization and step therapy on selected prescription medications.
Prior AuthorizationCertain medications require prior authorization. This means that you will need to get approval before you fill your prescriptions. If you don't get approval, the drug may not be covered.
- 2024 Medicare Part D Prior Authorization PolicyOpen a PDF
- 2023 Medicare Part D Prior Authorization PolicyOpen a PDF
- 2024 Dual Special Needs Plan (D-SNP) Prior Authorization PolicyOpen a PDF
- 2023 Dual Special Needs Plan (D-SNP) Prior Authorization PolicyOpen a PDF
Step TherapyIn some cases, we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.
- 2024 Medicare Part D Step Therapy PolicyOpen a PDF
- 2023 Medicare Part D Step Therapy PolicyOpen a PDF
- 2024 Dual Special Needs Plan (D-SNP) Step Therapy PolicyOpen a PDF
- 2023 Dual Special Needs Plan (D-SNP) Step Therapy PolicyOpen a PDF
- Medicare Part B Step Therapy PolicyOpen a PDF
Drugs that require Prior Authorization/Step Therapy are indicated on our drug list. To check if prior authorization or step therapy applies, search one of our online drug lists.
We have an exception process in place for drugs with prior authorization, step therapy, or other requirements or limits on coverage. If your healthcare provider determines that you need a medication that has a requirement or limit, he/she must submit a request supporting your need. Access the forms to request an exception.
Excellus BlueCross BlueShield is an HMO plan and PPO plan with a Medicare contract. Enrollment in Excellus BlueCross BlueShield depends on contract renewal. Submit a complaint about your Medicare plan at www.Medicare.gov or learn about filing a complaint by contacting the Medicare Ombudsman. Y0028_9775_C.
This page last updated 10-01-2023.