CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Drug Prior Authorization (Pharmacy Benefit)

Explains the prior authorization program for pharmacy-covered medications for members of Blue Cross Blue Shield - South Carolina, including when PA is required, how to request it, and outcomes. Affects prescribers, pharmacists, and members under the pharmacy benefit.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyDrug Prior Authorization (Pharmacy Benefit)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionCall 855-811-2218 to request prior authorization for drugs covered under the pharmacy benefit.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

855-811-2218PA phone

≤5 daysshort-term supply limit

online search toolhow to find drug info

multiplelanguage support

Coverage & Authorization Criteria

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General PA approval conditions: The member's prescribed drug is included in the prior authorization program and the PA request meets program requirements based on FDA/manufacturer guidelines, medical literature, safety, accepted medical practice, appropriate use, and benefit design.

Approval may be granted for up to one year or more; member and prescriber will be notified in writing upon approval.

Some specialty drugs that are billed under the medical benefit — rather than dispensed through the pharmacy benefit — may still require prior authorization (PA) under the medical benefit. Consult the Medical Drug List to determine whether a given specialty drug requires PA through the medical benefit instead of the pharmacy benefit.

If the PA requirements are not met, the prior authorization request will be denied and the drug will not be covered. Likewise, if the prescriber fails to submit requested information within the specified time frame, the PA will be denied. Denial notices are sent to both the member and the provider and will include instructions on how to appeal the decision or pursue alternative treatment options.

What Providers Must Do

Prior Authorization

Prior Authorization Required

Prior authorization (PA) is required for some specialty and non‑specialty drugs under the pharmacy benefit and, in some cases, for specialty drugs covered under the medical benefit. PA promotes appropriate, safe, and cost‑effective medication use and is based on FDA/manufacturer guidance, medical literature, safety, accepted practice, and benefit design. If a prescribed drug is included in the PA program, providers must obtain approval before the plan will cover the medication.

Call 855-811-2218 to request PA for pharmacy‑benefit drugs.
Some plans require PA for medical‑benefit specialty drugs — check the Medical Drug List.

Step Therapy

Step Therapy / Try Preferred Alternatives

Before coverage will be provided for certain drugs, members must try one or more covered alternatives (step therapy). Providers should document prior trials of preferred medications and rationale for why alternatives are not appropriate if requesting an exception.

Try covered preferred alternatives first per the drug list and step therapy rules.
When requesting an exception, include documentation of prior medication trials and clinical rationale.

Documentation Required

Requested Information Submission — Risk of Denial

The prior authorization request must include all requested clinical information. If the prescriber does not submit the required documentation within the timeframe given, the PA will be denied. Denials will be sent to both the member and the provider and will include appeal instructions.

A complete PA request includes clinical justification and any prior treatment history requested.
Failure to submit requested information within the required period will result in denial and notice with appeal rights.

Denial Risk

Denial Triggers

A PA request will be denied if the member or practitioner fails to meet policy requirements or timelines. Common denial triggers include not meeting clinical criteria, not trying required alternatives, or failing to supply requested information in time. Denials include instructions on how to appeal.

Denial triggers: unmet clinical criteria, lack of required step‑therapy trials, missing or late documentation.

Program Background

Prior authorization is a utilization management program intended to promote the proper, safe, and cost-effective use of certain medications. Decisions about PA are based on FDA and manufacturer guidelines, medical literature, safety considerations, accepted medical practice, appropriate use, and benefit design, and approvals may be issued for up to one year or more.

Key Definitions

Prior authorization (PA) — definition

TermPrior authorization (PA)

DefinitionA quality and safety program that promotes the proper use of certain medications; requires prior approval before the plan will cover medications included in the PA program.

Basis for decisionsDecisions are based on FDA and manufacturer guidelines, medical literature, safety, accepted medical practice, appropriate use, and benefit design.

When requiredWhen a prescribed medication is included in the prior authorization program, PA must be obtained before coverage.

Patient guidanceMembers are encouraged to discuss treatment and medication options with their doctor and can call the phone number on their member ID card with questions about the PA process.

Requirement	Policy detail
Step therapy requirement
Before the plan will cover some drugs, the member must try one or more covered alternatives first.

Short-term Supply & Quantity Limits

Short-term supply — 5-day details

Short-term supply limit5 days or less

How to obtainCheck with your pharmacy to request a short-term supply; you may also ask your doctor if a sample is available.

Member costMember is responsible for the full cost of the short-term supply at that time.

Follow-upIf the prior authorization is later approved, the pharmacist can fill the remainder of the prescription.