This page provides details regarding the following; click on any link below to be taken to the specific section:
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:
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.
2016 Prior Authorization Criteria
2017 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.
2016 Step Therapy Criteria
2017 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.
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.
2017 Quantity Limitations are listed in the Formulary Guides below.
2016 Quantity Limitations are listed in the Formulary Guides below.
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.
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.
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.
Examples of drugs always covered under Medicare Part B:
|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-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
Medicare Part D benefits exclude the following types of drugs or drug classes from coverage:
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.
The information on this page is current as of 10/1/2016.
Y0079_7520 CMS 10042016