Step Therapy Programs for Members on the Balanced Drug List
Defines step therapy programs that may apply to members' prescription drugs listed on the payer's Balanced Drug List and explains how members or providers may request an exception. Affects Blue Cross Blue Shield - Oklahoma members and their prescribing providers.
No material clinical or coverage changes in this revision.
Coverage Criteria
If a medication is not listed on the payer's Balanced Drug List, the member or the prescribing provider may request an exception review. These documents show examples of drug categories and specific medications and note that programs may change and additional drugs may be added.
As part of an exception review, the member may be required to meet the drug's step therapy program criteria before the request can be approved. To initiate an exception review, call the phone number on the Member ID card or have the prescriber start the process online at bcbsok.com/provider.
Provider Actions & How to Request an Exception
Exception review and potential prior authorization
If the prescribed medication is subject to the plan’s step therapy requirements, an exception review may be requested. To initiate an exception review or prior authorization, contact the phone number on the member’s ID card or have the prescribing provider submit the request through the BCBSOK provider portal at bcbsok.com/provider. The review may determine that prior authorization (PA) is required before the drug will be covered.
- Call the number on the member ID card or submit via bcbsok.com/provider
- The review may trigger a prior authorization requirement
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