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Prior authorization, tier exceptions, nonformulary exceptions, step therapy, and quantity limitations

Prior authorization, step therapy, and exception requests require members to meet certain clinical criteria prior to a drug being covered. For prior authorization, step therapy, and exception requests, the member or the member's prescribing physician may contact Blue Medicare HMO, Blue Medicare PPO and Blue Medicare Rx. A physician's supporting statement is required for all requests before the prescription can be approved for payment. Physicians may contact the plan by calling Blue Medicare HMO or Blue Medicare PPO at 1-888-296-9790 or Blue Medicare Rx at 1-888-298-7552 or using the applicable fax request form (see below) to request an exception. After normal business hours messages can be left on the Part D After Hours Exception voice mail. Please see the member's formulary for detailed information regarding covered drugs and drugs requiring prior approval.

Exception requests

Requests for non-formulary drugs (those not covered by the member's plan) and requests that a nonpreferred drug be covered at a lower co-payment can be made with the non-formulary or the tier exception request form. These forms should list formulary drug alternatives that may have been tried by the member for the same condition, what the outcomes of those drugs were, or the clinical reason these drugs would not be expected to be as effective or safe as the drug being requested. Please provide all information requested on the forms to ensure a prompt review. Incomplete forms can result in a denial of the exception request.

Non-formulary drug requests must meet Part D drug coverage criteria, i.e., the drug must be medically necessary and must be prescribed for an approved indication.

Drugs that require prior authorization

Certain drugs require prior authorization before coverage. Prior authorization is a program that requires members to meet certain criteria prior to a drug being covered. Prior authorization may be used to encourage the appropriate use and dose of prescribed medication based on the U.S. Food and Drug Administration (FDA) approved labeling and other medical literature. Prior authorization may also be used to determine if a drug's use meets criteria for coverage under Medicare Part B or Part D. Please see the member's formulary for drugs that require prior authorization. These drugs will have “PA” or “prior authorization required” listed next to the drug. Information may need to be submitted describing the use and setting of the drug to make the determination.

Drugs that are currently authorized by law as covered under Part B will remain covered under Part B and should be billed to the Part B payer. (See the CMS Coverage database at https://www.cms.gov/medicare-coverage-database/ or DME-MAC Jurisdiction C at http://www.cgsmedicare.com/ for Part B drug coverage clarification.)

Below is a list of medications/drug classes that may be covered under Medicare Part B or Part D (Blue Medicare HMO, Blue Medicare PPO, and Blue Medicare Rx) depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

Drug/Drug Class	Covered Under Part B for the following indications (Summary provided: See DMERC policies and CMS guidance for specific criteria):
Nebulized gentamicin amikacin dornase	Cystic fibrosis
Nebulized tobramycin (TOBI)	Cystic fibrosis Bronchiectasis
Nebulized pentamidine (Nebupent)	HIV Pneumocystosis Complications of organ transplant
Inhalation drugs	Certain inhalation drugs are generally covered when used with a nebulizer in the home. (SNF and others cannot be considered "home" (see CMS guidance)
Immunosuppressive drugs	For a beneficiary who has received a Medicare-covered organ transplant
Oral anti-emetics drugs	Oral anti-nausea drugs used as part of an anticancer chemotherapeutic regimen as a full therapeutic replacement for an IV anti-emetic drug within 48 hours of chemo administration.
Hepatitis B vaccine	The vaccine is 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)	Provided in the home for a diagnosis of primary immune deficiency disease
Parenteral nutrition	For patients who cannot absorb nutrition through their intestinal tract (nonfunctioning digestive tract)
Infusable drugs	Infused using an implantable pump or infused using an external pump in the home (SNF and others cannot be considered "home")
Osteoporosis	Provided by a home health agency to females meeting coverage criteria for home health benefit and criteria found in the MA Benefit Policy Manual, Section 50.4.3

If these medications are not eligible for coverage under Part B, they may be covered under Part D with prior approval by the plan. Examples of drugs always covered under Part B:

• Pneumococcal vaccine
• Influenza vaccine
• Antigens
• Blood clotting factors

Step therapy

In some cases, members are required to first try one drug to treat their condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B. These drugs will have "ST" or "step therapy required" listed next to the drug.

Quantity limitations

The Quantity Limitations program sets quantity limits on certain medications. Blue Medicare HMO, Blue Medicare PPO and Blue Medicare Rx will cover the drug up to the designated quantity. For some of these medications, if the prescribing doctor feels it is medically necessary to exceed the set limit, he/she must get prior approval before the higher quantity can be covered.

Quantity Limitations 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 or requirements set by the manufacturer and the Food and Drug Administration.

Some drugs with quantity limitations have specific criteria that will be used in determining coverage for higher quantities. Drugs with specific criteria include “triptan” medications (used for migraines) and butorphanol nasal spray. For patients who may require dosages in excess of the quantity limit, please download and submit the appropriate fax request form listed below.

Drugs that have Quantity Limits	Utilization Management Criteria	Physician Request Form
Butorphanol nasal spray (formerly Stadol NS)	Butorphanol nasal spray criteria	Butorphanol Fax Request Form
Triptans	Triptan criteria	Triptans Fax Request Form
Opioids		Opioids Fax Request Form
All other drugs with Quantity Limits		General Quantity Limitations Fax Request Form

Drugs that have Quantity Limits	Utilization Management Criteria	Physician Request Form
Butorphanol nasal spray (formerly Stadol NS)	Butorphanol nasal spray criteria	Butorphanol Fax Request Form
Triptans	Triptan criteria	Triptans Fax Request Form
Opioids		Opioids Fax Request Form
All other drugs with Quantity Limits		General Quantity Limitations Fax Request Form

 

 

 

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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.

Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year. Please contact BCBSNC for details.

Blue Cross Blue Shield of North Carolina (BCBSNC) is a Medicare Advantage organization with a Medicare contract to provide HMO and PPO plans. BCBSNC is a Medicare-approved Part D sponsor. BCBSNC does not discriminate based on race, ethnicity, national origin, religion, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability or geographic location within the service area. All BCBSNC items and services are available to all eligible beneficiaries in the service area.

Limitations, copayments, and restrictions may apply. You must be entitled to Medicare Part A and enrolled in Medicare Part B and must reside in the CMS-approved service area. You must continue to pay your Medicare Part B premium.

If you would like Medicare Advantage or Part D documents in a different language or format, or your coverage has ended and you need proof of coverage or a Certification of Health Insurance Coverage, you can call us 7 days a week, 8a.m. to 8 p.m.

The information on this page is current as of 1/5/2013.

Y0079_6107 CMS Approved 01082013