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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 Blue Cross and Blue Shield of North Carolina (Blue Cross NC) Blue Medicare plans.

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

What You Need to Know:

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

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

Blue Cross NC is responsible to make sure 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.

2018 Formulary Guides

The list of drugs covered on each plan, along with any restrictions for those drugs, can be found in the formulary guides below.

2017 Formulary Guides

The list of drugs covered on each plan, along with any restrictions for those drugs, can be found in the formulary guides below.

Prior Authorization and Step Therapy

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 of prescribed drugs based on the U.S. Food and Drug Administration (FDA) approved labeling and other medical literature. Please see the member's formulary for drugs that require review.

2018 Prior Authorization Criteria

2017 Prior Authorization Criteria

Step Therapy is a program that requires members to first try one drug to treat their condition before Blue Cross NC will cover another drug for that condition. Please see the member's formulary for drugs that require review.

2018 Step Therapy Criteria

2017 Step Therapy Criteria

Drug Search for Prior Authorization and Step Therapy

The easiest way to find the appropriate fax form and criteria for your member's plan is to use the search box below. The criteria and corresponding fax form will be displayed, along with details on which plans require the review.

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

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 Limitations

Certain drugs 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 drugs, if the provider feels it is medically necessary to exceed the set limit, he/she must request prior approval before the higher quantity can be covered. 2018 Quantity Limitations are listed in the Formulary Guides above. Requests can be submitted to Blue Cross NC using the Quantity Limit fax form below.

Quantity Limit Exception criteria form
Quantity Limit Exception fax form

Non-Formulary Exceptions

The necessary information to process a request for drugs not covered on the formulary is outlined in the criteria below. Please be advised that incomplete forms may delay processing.

Non-formulary Exception criteria
Non-formulary Exception fax form

Tier Exceptions

The necessary information to process a request that a Tier 2 or Tier 4 drug be covered at the next lower copayment level is outlined in the criteria below. Please be advised that incomplete forms may delay processing.

Tier Exception criteria
Tier Exception fax form

Medicare Part B or Medicare Part D Drugs

There are some situations when certain drugs are 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 drugs 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

Compounded Drugs

Compounded drugs require review for consideration of payment. As a whole, compounded drugs do not satisfy the definition of a Medicare Part D drug, as outlined in Chapter 6 of the Medicare Prescription Drug Manual (Section 10.4). Therefore, each individual ingredient of a compounded drug must be reviewed. Please note, bulk powders do not satisfy the definition of a Medicare Part D drug and are not covered by Medicare Part D. Requests for coverage of a compounded drug should be submitted on the Compounded Drugs fax form below.

Compounded Drugs fax form

Hospice requests

The form below contains 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

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

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 10/1/2017.

Y0079_7833 CMS Approved 10172017