Provider Secured Services

Requesting Prescription Drug Coverage

If a medication requires step-therapy or prior authorization, and your BCN Advantage patient does not meet our criteria, you can request coverage based on medical necessity. You can also ask us to waive quantity restrictions if the quantity allowed is not appropriate based on the member's condition.

And, you can ask us to provide a higher level of coverage or reduce the copayment for drugs on Tier 3.

For example, if the prescribed drug is considered Tier 3 (non-preferred), you can ask us to cover it or reduce the copayment as a Tier 2 (Formulary Option) instead. This would lower the copayment amount required for the drug.

Generally, we will approve your request for an exception if the alternative drug is included on our formulary or the lower-tiered drug would not be as effective and/or would cause the member to have adverse medical effects.

To request coverage for your BCN Advantage member, please complete the Medicare Part D Coverage Determination Request Form (PDF) and fax the completed form to the BCN Clinical Pharmacy Help Desk at: 1-800-459-8027.

Contacts
Physicians: For medication prior authorization and benefit exception requests, contact the BCN Clinical Pharmacy Help Desk at 1-800-437-3803.

Pharmacies: For pharmacy claims and other inquiries, contact Medco Pharmacy Services at 1-800-922-1557.

If you have questions regarding our grievance or appeals process, please contact our BCN Advantage Service Center at 1-800-450-3680, seven days a week, from 8 a.m. to 8 p.m. Please note that BCN Advantage Option 1 members do not have Part D prescription drug coverage.