MedicareBlue Rx coverage requires prior authorization for certain covered drugs that have been approved by the Food and Drug Administration (FDA) for specific medical conditions.

Forms you will need for Prior Authorization

Request a coverage decision (sometimes called a prior authorization or exception) for a drug if your health care provider or pharmacist tells you a prescription drug is not covered in your treatment plan: get more information on coverage determination.

• Coverage Determination: Use the online form or printable version if this is your first coverage request for a drug and you want to submit it online.
• Coverage Redetermination: Use the online form or printable version if you are appealing a previously denied request and you want to submit it online.

• Quantity Limit Exception Fax Form
  • Request coverage of a quantity in excess of plan quantity limits
• Step Therapy Exception Fax Form
  • Request an exception to the plan step therapy requirement
• Tiering Exception Fax Form
  • Request coverage of a brand or generic in a higher cost sharing tier at a lower cost sharing tier
• Formulary Exception Fax Exception
  • Request coverage of a drug that is not on the formulary

Prior authorization program guidelines:

• The prescribing physician can fax the applicable form to MedicareBlue Rx for any drug that appears on the step therapy list.
• Contact Customer Service for MedicareBlue Rx:
  • Toll Free 1-888-832-0075
  • TTY hearing impaired users call 711
• Once the drug is authorized, it can be filled at any participating pharmacy (except for the few drugs which may require a specialty pharmacy; check with your pharmacist or physician).

Search the drug list (formulary) to find out if your drug requires prior authorization.