  Provider resources and informationPrior authorization and quantity limitationsSome prescription drugs on the formulary have specific restrictions. These include: Prior approvalBlue Medicare HMO and Blue Medicare PPO plans require providers to get prior authorization for certain drugs. Providers may need prior authorization for drugs that are on the formulary or drugs that are not on the formulary and were approved for coverage through the exception process. This means that providers will need to get approval from Blue Medicare HMO or Blue Medicare PPO before members can fill their prescriptions. If providers don’t get approval, Blue Medicare HMO or Blue Medicare PPO may not cover the drug. For a list of drugs that require prior approval and for instruction on how to request prior approval or coverage of a nonformulary drug, review our prior authorization and nonformulary requests page. Quantity limitationsFor certain drugs, Blue Medicare HMO and Blue Medicare PPO plans limit the amount of the drugs that will be covered. For example, both plans provide 9 tablets per prescription for Imitrex 100mg. Quantity limits may be more restrictive than the standard 30- or 90-day supply. For a list of drugs that are subject to quantity limits and for instructions on how your physician can request quantities in excess of the limits, review the quantity limitations section. Covered under Part B and DCoverage is provided under Medicare Part B and D. Coverage is dependent upon drug’s use, where it is administered, or how it is administered. These medications are eligible for Part D coverage in circumstances where Part B coverage does not apply. These agents may be subject to prior authorization.
Blue Medicare HMO and Blue Medicare PPO plans are offered by PARTNERS National Health Plans of North Carolina, Inc., a subsidiary of Blue Cross and Blue Shield of North Carolina (BCBSNC). PARTNERS is a Medicare Advantage organization with a Medicare contract to provide HMO and PPO plans. Plans are administered by BCBSNC. BCBSNC and PARTNERS do 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 and PARTNERS are independent licensees of the Blue Cross and Blue Shield Association. |
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