Blue RX Prior Approval
Your Blue RX plan helps ensure you have the right drug at the right dose at the right time by providing safe, high quality prescription drugs at an affordable price. Drugs are reviewed by our in-house and external experts for safety, clinical effectiveness, and place in therapy.
Based on the outcome of these reviews, some drugs require approval before they can be covered under your Blue RX plan. This process ensures the most widely used treatments for a condition (i.e. first line therapies) have been considered. Depending on the drug, approval may be required either by Pacific Blue Cross or by the BC PharmaCare Special Authority program.
Drugs that require PBC Prior Authorization
Effective June 1, 2020, PBC has automated the prior approval process for drugs used to treat asthma or chronic obstructive pulmonary disorder (COPD), depression, and diabetes.
How it works. When a claim for a second-line drug for one of these categories is submitted, our system will review your claim history and automatically approve the claim if eligibility has been met. This means you’ll have immediate access to the drugs you need without having to apply for prior approval.
Members without a claims history with PBC, or who don’t meet criteria required for automated prior approval, can still complete a PBC Prior Authorization form to request coverage. Here’s how:
- Find the form you need in the PBC Prior Approval tab below.
- Select the appropriate drug to download the form.
- Have your prescriber complete the form and send it to Pacific Blue Cross to determine eligibility.
NOTE: For some drugs, prescribing doctors that are specialists in that therapeutic area (e.g., a respirologist for asthma) don’t have to fill out the form. However, you’ll still need to complete the top portion of the form. Be sure to follow the instructions carefully.
Drugs that require BC PharmaCare Special Authority
Here is a complete list of drugs requiring BC PharmaCare Special Authority. If the drug you need is listed, here’s how you can request coverage:
- Go to Special Authority Forms on the BC PharmaCare website, find the drug you need, and download the appropriate form.
- Have your doctor complete the form on your behalf and submit it to BC PharmaCare.
If approved by BC PharmaCare, you can fill your prescription as normal—you don’t have to send this approval to us for confirmation (we can read the BC PharmaCare approval in real time at point of sale with the claim).
Drugs Requiring BC PharmaCare Approval
For certain drugs, your doctor needs to apply to BC PharmaCare for Special Authority approval before they are eligible for coverage with your plan.
If your drug has not been approved
If your prescription has not been approved for coverage through the Pacific Blue Cross Blue RX Prior Authorization or the BC PharmaCare Special Authority Program, use the Drug Eligibility Inquiry Form to trigger an inquiry about drug coverage eligibility under your plan.
Drug coverage can vary from plan to plan. Our Pharmacy Services division will review your coverage and the reasons behind denial of your claim to determine if there is any way the drug can be covered under the provisions of your Extended Health Care plan
Completion of the forms above does NOT imply approval for the drug. Coverage is based on the provisions of your Extended Health Care plan.