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Important Legal Information and Disclaimers

Blue Medicare HMO, Blue Medicare PPO, and Blue Medicare Rx (PDP) Members

Policies and Procedures

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Some drugs require more than a provider's prescription in order to be covered by BCBSNC Blue Medicare plans.

This page provides details regarding the following; click on any link below to be taken to the specific section:

  • Prior Authorization / Quantity Limitations / Step Therapy: Members must meet certain clinical criteria prior to a drug being covered. This is where most fax forms will be found.
  • Non-Formulary and Tier Exceptions: Requests for drugs not covered on the formulary, or that a Tier 2 or Tier 4 drug be covered at the next lower copayment level.
  • Hospice Requests: Requests for coverage of prescription drugs under Medicare Part D when the member is in Hospice care and it is believed the drugs should not be covered under the Medicare Part A hospice benefit.
  • Medicare Part B or Medicare Part D Drugs: Depending on the circumstances, some drugs may be covered under Medicare Part B or Medicare Part D (Blue Medicare HMO, Blue Medicare PPO and Blue Medicare Rx).
  • Drugs Excluded from Coverage: Certain drugs are not covered under Medicare Part D; this section gives you information about which drugs fall under this list.

What You Need to Know:

You can access the member's formulary for detailed information regarding covered drugs and drugs requiring review by BCBSNC.

Members may contact Customer Service at BCBSNC (Blue Medicare HMO 888-310-4110; Blue Medicare PPO 877-494-7647; Blue Medicare Rx 888-247-4142) in order to request a medication. All requests require a physician's supporting statement before the drug can be approved for payment.

The member's prescribing provider may initiate a request with the plan in one of the following ways:

  • Electronic request (preferred): We have teamed with CoverMyMeds to offer electronic review submissions.
  • Fax: Specific fax forms are listed below. Faxes can be sent to the fax number on the bottom of the form.
  • Telephone: Calling the plan (Blue Medicare HMO 888-310-4110; Blue Medicare PPO 888-296-9790; Blue Medicare Rx 888-298-7552). After normal business hours, messages can be left on the Medicare Part D After-Hours Exception voicemail.

Prior Authorization or Step Therapy reviews

Prior Authorization is a program that requires members to meet certain criteria prior to a drug being covered. It may be used to encourage the appropriate use and dose of prescribed drugs based on the U.S. Food and Drug Administration (FDA) approved labeling and other medical literature. It may also be used to determine if a drug’s use meets criteria for Medicare Part B or Medicare Part D. Please see the member's formulary for drugs that require review. Information may need to be submitted describing the use (where and how the drug will be received or administered) in order to make a decision.

Prior Authorization Criteria

In some cases, members are required to first try one drug to treat their condition before BCBSNC will cover another drug for that condition. This type of review is called Step Therapy.

Step Therapy Criteria

The easiest way to find the appropriate fax form and criteria for your member's plan is to use the Search box below. You can search below for a drug by the letter it starts with, or type in the first few letters in the name. The criteria and corresponding fax form will be displayed, along with details on which plans require the review.

Drug Search For Prior Authorization and Step Therapy


Or click the first letter of your drug to view lists:

To find a drug, use the search above or select a letter from the list above.

Drug Name: {{header}}


Prior Authorization Required On Prior Authorization Not Required
,
Quantity Limits Apply On Quantity Limits Do Not Apply
,
Step Therapy On Step Therapy Does Not Apply
,
Formulary Exception On Formulary Exceptions Do Not Apply
,
Criteria
,
Fax Forms Fax Form
,



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Quantity Limitation

Certain medications have a designated quantity that will be covered. These limits are designed to identify the excessive use of drugs which may be harmful in large quantities, to highlight the potential need for a different type of treatment, and to match dosing recommendations / requirements set by the manufacturer and the FDA. For some of these medications, if the prescriber feels it is medically necessary to exceed the set limit, he/she must get prior approval before the higher quantity can be covered. Requests can be submitted to BCBSNC using the Quantity Limit Fax Form.

Quantity Limit Fax form.

2016 Quantity Limitations are listed in the Formulary Guides below.

Non-Formulary and Tier Exceptions

The necessary information to process a request for drug(s) not covered on the formulary, or that a Tier 2 or Tier 4 drug be covered at the next lower copayment level, is outlined in the criteria and on the forms below. The provider must provide all information requested on the form to ensure a prompt review. Incomplete forms can result in a denial of the exception request.

Non-formulary criteria
Non-formulary request form

Tier Exception criteria
Tier Exception request form

Hospice requests

The form below contain the necessary information for requests of coverage for prescription drugs under Medicare Part D when the member is in Hospice care, and it is believed the drugs should not be covered under the Medicare Part A hospice benefit.

Hospice Fax form

Medicare Part B or Medicare Part D drugs

The table below lists when specific medications would be covered under Medicare Part B. See the CMS Coverage database at https://www.cms.gov/medicare-coverage-database/ or DME-MAC Jurisdiction C at http://www.cgsmedicare.com/ for Medicare Part B drug coverage clarification.

If these medications are not eligible for coverage under Medicare Part B, they may be covered under Medicare Part D with prior approval by the plan. These requests should be submitted on the Medicare Part B vs Part D fax form below.

Medicare Part B vs Part D Fax Form

Examples of drugs always covered under Medicare Part B:

  • Pneumococcal vaccine (e.g. Pneumovax and Prevnar 13)
  • Influenza vaccine (flu shot)
  • Antigens (allergy shots)
  • Blood clotting factors
Drug Category Covered under Medicare Part B for the following indications*
Rapid-acting insulins When used in an insulin pump
End Stage Renal Disease
(ESRD)
ESRD-related prescription drugs included in the bundled prospective dialysis facility payment
Inhalation drugs used in a nebulizer Certain inhalation drugs are generally covered when used with a nebulizer in the home (SNF and others cannot be considered "home" - see Medicare Prescription Drug Benefit Manual, Chapter 6, Appendix C, Attachment 1)
Immunosuppressive drugs For a beneficiary who has received a Medicare-covered organ transplant (kidney transplant limited to first 36 months if ESRD)
Oral anti-emetics drugs Oral anti-nausea drugs related to cancer treatment, when the oral anti-emetic drug is a full replacement for an IV anti-emetic drug, within 48 hours of cancer treatment
Hepatitis B vaccine Administered to a beneficiary who is at high or intermediate risk of contracting hepatitis B
Erythropoietin For the treatment of anemia for persons with chronic renal failure who are on dialysis
Intravenous immune globulin (IVIG) For a diagnosis of primary immune deficiency disease when IVIG is provided in the home
Parenteral nutrition For patients who have a non-functioning digestive tract (cannot absorb nutrition through their intestinal tract)
Infusable drugs Infused using an implantable pump, or infused using an external pump in the home if they are included in the local coverage policy of the applicable Medicare DME MAC (SNF and others cannot be considered "home" - see Medicare Prescription Drug Benefit Manual, Chapter 6, Appendix C, Attachment 1)
Osteoporosis Provided by a home health agency to females meeting coverage criteria for home health benefit and criteria (see Medicare Benefit Policy Manual, Chapter 7, Section 50.4.3)

*This table represents a summary. See DMERC policies and CMS guidance for specific criteria

Drugs Excluded from Coverage

Medicare Part D benefits exclude the following types of drugs or drug classes from coverage:

  • Agents when used for anorexia, weight loss, or weight gain (even if used for a non-cosmetic purpose such as morbid obesity)
  • Agents when used to promote fertility
  • Agents when used for cosmetic purposes or hair growth
  • Agents when used for the symptomatic relief of cough and colds
  • Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
  • Nonprescription drugs
  • Covered outpatient drugs which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee
  • Agents when used for the treatment of sexual or erectile dysfunction

BCBSNC is responsible to make sure that all drugs covered under Part D are prescribed for medically-accepted indications, and that each prescription drug has a drug product national drug code properly listed with the Food and Drug Administration.

Refer to the Excluded Drugs list: please keep in mind the attached list is updated quarterly and is not all inclusive. You can also refer to your Evidence of Coverage for more information.



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1 All services are subject to the allowed amount charge. When using out-of-network providers, any amount charged over the allowed amount may be your responsibility.

Important Legal Information and Disclaimers

The information on this page is current as of 5/9/16.

Y0079_7469 CMS Pending