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Provider resources and information

Prior authorization and nonformulary requests

Prior authorization and nonformulary requests require members to meet certain clinical criteria prior to a drug being covered.

For prior authorization and nonformulary requests, the member or the member's prescribing physician may contact Blue Medicare HMO and Blue Medicare PPO. 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 using the applicable fax request form (see below) to request an exception. Please see the formulary for detailed information regarding covered drugs and drugs requiring prior approval. Download and submit the following forms to request prior approval or for a nonformulary drug request.

Nonformulary requests
Physician should list drug alternatives tried by member for the same condition and the clinical reason these drugs have not been as effective as the drug being requested.

Drugs that require prior approval
Drugs that can be covered under both Part B and Part D. Please see the formulary for a list of drugs that require prior authorization. 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 as before.

For information about and a listing of drugs covered under Part B, visit the Palmetto GBA Web site new window. This site includes access to the Region C Local Coverage Determinations. Blue Medicare HMO and Blue Medicare PPO providers may also visit the CMS Web site new window for additional information regarding Part B and Part D coverage.

Below is a list of medications/drug classes that can be covered under both Part B and Part D. Coverage is dependent upon indication and/or administration:

Drug/Drug Class Covered under Part B for the following indications
(Summary provided: See DMERC policies and CMS guidance for specific criteria):
Nebulized gentamicin
amikacindornase		 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–emetic 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 will 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

Quantity limitations 1 
The Quantity Limitations program sets quantity limits on a small number of medications. Blue Medicare HMO and Blue Medicare PPO will cover the drug up to the designated quantity. If the prescribing doctor feels it is medically necessary to exceed the set limit, they must get prior approval from Blue Medicare HMO or Blue Medicare PPO (1-888-296-9790) before the higher quantity can be covered. Refer to the member’s Evidence of Coverage for detailed information about their prescription drug benefits.

Quantity Limitations are designed to identify the excessive use of drugs which may be dangerous in large quantities and to highlight the potential need for a different type of treatment.

For patients who may require dosages in excess of the quantity limit (QL), please download and submit the appropriate fax request form listed below.

The following is a list of drugs with quantity limits:

Drugs that have quantity limits Utilization management criteria Physician request
Migranal® nasal spray Migranal Nasal Spray  Use Migranal Fax Request Form 
Stadol® nasal spray
(Butorphanol)		 Stadol Nasal Spray  Use Stadol Fax Request Form 
Toradol® tablets
(Ketorolac)		 Toradol Tablets  Use Toradol Fax Request Form 
Triptans Use Triptans Fax Request Form 

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Blue Cross and Blue Shield of North Carolina (BCBSNC) is a Medicare Advantage organization with a Medicare contract to provide HMO and PPO plans. BCBSNC does not discriminate based on color, gender, religion, national origin, age, race, disability, handicap, sexual orientation, genetic information, source of payment or health status as defined by the Centers for Medicare & Medicaid Services (CMS). All qualified Medicare beneficiaries 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 not otherwise paid for under Medicaid or another third party. BCBSNC is an independent licensee of the Blue Cross and Blue Shield Association.

1 A member or their prescribing physician can ask BCBSNC to make an exception to these restrictions or limits. Refer to "How do I make an exception request?"

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