Prior Authorization Required

Some covered drugs require prior authorization before the plan will pay. Prescribers must obtain prior authorization (PA) per Blue Cross Blue Shield - South Carolina procedures for drugs flagged PA or PA NSO in the formulary. Failure to obtain required PA may result in denial of coverage.

• PA and PA NSO flags in the formulary indicate an authorization is required prior to dispensing.
• PA NSO items (Prior Authorization — Network/Site Only) require submission and approval per the plan's network/site-specific process.
• If PA is not obtained, the claim may be denied and the plan may not cover the drug.

PA and PA NSO for High‑Tier / Specialty Drugs

Many specialty, oncology, high‑tier and selected branded agents have PA or PA NSO requirements and/or quantity limits (QL). Examples in the formulary include high‑cost agents such as BRIVIACT, EPIDIOLEX, ARIKAYCE, many antineoplastics (e.g., IBRANCE, XALKORI), specialty biologics (e.g., STELARA, COSENTYX), and other products annotated PA NSO.

• Selected high‑tier examples: BRIVIACT, EPIDIOLEX, DIACOMIT, XCOPRI (many marked PA NSO).
• Specialty/oncology examples with PA NSO: IBRANCE, XALKORI, XPOVIO, many oncology therapy packs.
• Immunologic and biologic specialty agents (e.g., DUPIXENT, STELARA, SKYRIZI) list PA and often QL entries.

Follow PA, QL and Step Therapy Rules

Quantity limits (QL), step therapy (ST or ST NSO), and PA entries shown in the formulary are binding rules for coverage. Providers must follow the Requirements/Limits column and use the formulary symbol definitions in the introduction when preparing PA requests and when submitting claims.

• QL entries specify the allowed amount and time period (for example, QL(30 EA per 30 days)).
• ST and ST NSO indicate step therapy requirements; ST NSO may apply to new starts only or network/site‑specific starts.
• Use the introduction pages to interpret symbols (PA, QL, ST, NDS, B/D).

Denial Risk for Missing PA or Exceeding QL

Prior authorization and quantity‑limit rules are common denial triggers. Claims for drugs listed with PA, PA NSO, or with exceeded QL may be denied if the required authorization or documentation is not submitted.

• Denials may occur when PA is missing or when the dispensed quantity exceeds the QL specified in the formulary.
• PA NSO items may require additional network/site‑specific documentation — check plan procedures before submitting.
• When requesting an exception, the prescriber must provide a supporting statement explaining the medical rationale; expedited review may apply when clinically necessary.

Exceptions and Prescriber Supporting Statement

If you seek an exception to a formulary rule (e.g., to waive PA, ST, or a quantity limit, or to request tiering/coverage level changes), the prescriber must submit a supporting statement describing the medical necessity. Standard decisions are generally made within 72 hours of receiving the prescriber's documentation; expedited decisions within 24 hours when appropriate.

• Exceptions may permit coverage of non‑formulary drugs or waive PA/QL/ST when the prescriber documents that alternatives are ineffective or would cause harm.
• Prescriber supporting statement should explain why the member requires the exception and include relevant clinical information.

Cost Sharing and Dispensing Channel

Apply member cost‑sharing per the plan's tier and dispensing channel (retail, mail order, LTC) as shown in the formulary. Cost sharing (copay, coinsurance, deductible) varies by tier and by channel and must be applied even when PA is required.

• Check the formulary header and channel‑specific sections for the applicable copay/coinsurance and deductible rules.
• A PA approval does not change the applicable tier/cost‑sharing unless an approved tiering exception specifies otherwise.

Apply channel‑specific copay/coinsurance (retail, mail order, LTC)

Retail, mail order, and long‑term care dispensing channels have differing copay/coinsurance amounts by tier; apply the formulary's channel‑specific cost‑sharing when processing prescriptions.

• Mail order and long‑term care cost‑sharing and supply rules are listed separately.
• Tier‑based copays/coinsurance differ by channel.

Check site‑of‑care/network requirements for PA NSO items

PA NSO annotations may indicate network/site specialty restrictions (for example many PA NSO oncology and specialty entries); providers should verify site‑of‑care requirements with the plan when placing orders for infusion or specialty administration.

• LUPRON DEPOT and many oncology therapy packs are marked PA NSO.
• PA NSO can imply network or site‑of‑care constraints though exact rules may not be fully specified in this excerpt.