CurrentBlue Cross Blue Shield - MississippiPolicy N/A

Pharmaceutical Management Procedures (Formularies, Prior Authorization, Quantity Limits, Step Therapy)

Governs Blue Cross & Blue Shield of Mississippi prescription drug formularies, utilization management (prior authorization, quantity limits, step therapy), and exception processes for members and prescribing providers.

Policy Summary

PayerBlue Cross Blue Shield - Mississippi

PolicyPharmaceutical Management Procedures (Formularies, Prior Authorization, Quantity Limits, Step Therapy)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization request form to BCBSMS when prescribing drugs that require prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

quarterlyP&T review cadence

four- or five-tierTier structure

generic-firstStep therapy

enforcedQuantity limits

annualAnnual governance review

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General formulary coverage and utilization management

Covered when ALL of the following high‑level formulary and utilization management requirements are met:

Formulary inclusion: Drug must be listed on the applicable Prescription Drug, Maintenance Drug, or Disease Specific Drug Formulary to be covered by BCBSMS unless covered under the medical benefits of the Health and Wellness Benefit Plan.

Based on chunk 2

Quantity limits: No benefits will be provided for Prescription Drugs, Maintenance Drugs, or Disease Specific Drugs prescribed or dispensed beyond the established Quantity Limits; limits are based on FDA‑approved prescribing information and clinical practice guidelines and may reflect duration-of-use restrictions.

Based on chunk 8

Prior authorization: Certain Prescription Drugs, Maintenance Drugs, and Disease Specific Drugs require prior authorization; the prescribing provider must submit a completed prior authorization request form to BCBSMS for drugs that require authorization.

Based on chunk 10

Step therapy (Generic‑first): Drugs that have a generic alternative may require a trial of the generic alternative for a specified period before benefits are available for the prescribed (brand) drug; failure to meet step‑therapy conditions will cause the pharmacy claim to reject for lack of prior authorization.

Based on chunk 9

Exceptions process and documentation: Members or their prescribing providers may request a Prescription Drug coverage exception; provider requests must include a valid BCBSMS Member ID and a valid prescribing National Provider Identifier (providers may call the Health and Wellness Team or submit written requests as specified).

Based on chunk 11

Coverage is limited to drugs that are listed on the applicable formulary. Specifically, the Prescription Drug Formulary, Maintenance Drug Formulary, and Disease Specific Drug Formulary define which products are covered. If a drug is not on the applicable formulary and it is not covered under the medical benefits of the Health and Wellness Benefit Plan, then it is not covered by BCBSMS. For drug-specific coverage details, providers may check the BCBSMS website or contact the Health and Wellness Team.

Provider Requirements, Prior Authorization, and Exceptions

Prior Authorization

Prior Authorization Required

Prior authorization may be required before certain Prescription Drugs, Maintenance Drugs, and/or Disease-Specific Drugs are covered. Drugs that require authorization may be recommended for limited diagnoses and/or may not be suggested as the first-line treatment option. Prior authorization helps ensure that drugs are prescribed and used in the most appropriate and cost-effective manner. To obtain prior authorization, the prescribing provider must submit a completed prior authorization request form to BCBSMS.

Submit completed Prior Authorization Request Form to BCBSMS
Prior authorization may limit coverage to specific diagnoses or durations

Step Therapy

Generic-first (Step Therapy) — Pharmacy Claim Rejection Risk

Certain prescribed drugs that have a generic alternative may be subject to a trial of the generic alternative (step therapy) for a specified period before benefits are available for the prescribed (non‑generic) drug. If the step therapy requirement or prior authorization is not met, pharmacy claims will reject at the point of sale.

Pharmacy claims will reject if step therapy trial or prior authorization requirements are unmet
Prescribers may request authorization or an exception prior to dispensing to avoid claim denial at the pharmacy

Documentation Required

Exception Request Documentation

A member or their healthcare provider may request a Prescription Drug coverage exception. To complete an exception request, the request must include a valid BCBSMS Member Identification Number and the prescribing provider's National Provider Identifier (NPI). Non-network providers can initiate a request via the BCBSMS provider portal instructions.

Member may call Health and Wellness Team: 601-664-4590 or 1-800-942-0278
Mail written requests to: 3545 Lakeland Drive, Flowood, Mississippi 39232-9799
Provider-initiated requests must include: valid BCBSMS Member ID and Prescribing Provider NPI
Non-network providers: use the "I'm a Provider" link then "Provider Information" on www.bcbsms.com to submit an appeal/request

Step	Requirement	Failure consequence	Provider action
1
Trial of the generic alternative for a specified period before coverage of the prescribed (brand) drug
Claim will reject at the pharmacy for failure to receive prior authorization when the generic-first requirement is not met
Prescribing provider must submit a completed prior authorization request form to BCBSMS to obtain coverage for the prescribed drug

Quantity Limit Rules

Quantity Limits (unspecified — applies where set)

ScopeQuantity limits apply to Prescription Drugs, Maintenance Drugs, and Disease Specific Drugs as specified by the formulary.

EnforcementNo benefits will be provided for drugs prescribed or dispensed beyond the Quantity Limits.

Basis for limitsQuantity Limits are based on FDA‑approved prescribing information and clinical practice guidelines.

Duration restrictionsCertain drugs are subject to clinically appropriate duration‑of‑use restrictions based on usual course of treatment.

Where definedSpecific quantity limits are defined in the applicable formulary for each drug.

Formulary Definitions

Prescription / Maintenance / Disease Specific Drug Formularies

Prescription Drug FormularyA list of covered Prescription Drugs; provides coverage, clinical and cost comparison information to providers.

Maintenance Drug FormularyA list of covered Maintenance Drugs used for ongoing therapy; coverage information is provided in the formulary.

Disease Specific Drug FormularyA list of covered Disease Specific Drugs; used to indicate drugs for particular conditions.

Coverage ruleIf a drug is not in the applicable formulary and is not covered under the Health and Wellness medical benefits, it is not covered by BCBSMS.

How to check coverageTo obtain coverage information for a specific drug, visit www.bcbsms.com or call the Health and Wellness Team at 601‑664‑4590 or 1‑800‑942‑0278.

Policy Background

This policy describes administrative formulary management rather than clinical treatment recommendations. The three formularies maintained by BCBSMS — Prescription Drug, Maintenance Drug, and Disease Specific Drug — provide coverage, clinical, and cost-comparison information to providers. Formulary placement determines coverage status and is the primary mechanism used to apply utilization management requirements such as prior authorization, step therapy, and quantity limits.