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Prior plan approval

Prescription drugs

Select the plan for which you would like to review prior approval and quantity limitation information:

Blue Care®, Blue OptionsSM, Blue Choice®, Blue Advantage®

To learn about prior approval or quantity limitations for enrolled federal and state employees, please visit the Federal Employee Plan site or the State Health Plan site.

To obtain prior approval for your patient, you should contact BCBSNC toll-free at 1-800-672-7897 or use the available fax request forms for approval before the prescription can be accepted for payment. Refer to your patient's Member Guide for detailed information about your patient's prescription drug benefits.

The following is a list of drugs that require prior approval:

Drugs That Require Prior Approval Utilization Management Criteria Physician Fax Request Form
Growth Hormones All Growth Hormones Call 1-800-672-7897 for prior approval
Insulin-like Growth Factors All Insulin-like Growth Factors Call 1-800-672-7897 for prior approval
Cox 2 Inhibitors
(e.g. Celebrex®)		 All Cox 2 Inhibitors Use Cox 2 Fax Request Form
Antifungals
(Lamisil®, Sporanox®)		 Antifungals Use Antifungal Fax Request Form
Disease Modifying Antirheumatic Drugs
All Botulinum Toxins FDA approved conditions Call 1-800-672-7897 for prior approval
Antipsoriatics
Respiratory
(Xolair®)		 Xolair® Use Xolair® Fax Request Form
Orencia®
Remicade®
Rituxan® (for Rheumatoid Arthritis ONLY)
Intravenous Immune Globulins (IVIg)
(Effective 1/1/2010)
- Carimune NF
- Flebogamma
- Flegogamma DIF
- Gammagard Liquid
- Gammagard S/D
- Gamunex
- Octagam
- Privigen
Subcutaneous Immune Globulins (SCIg)
(Effective 1/1/2010)
- Vivaglobin		 IV and SC immune globulin Prior review for immune globulins effective 1/1/2010
Transmucosal Fentanyl Transmucosal Fentanyl Use Transmucosal Fentanyl Fax Request Form
Proton Pump Inhibitors (PPIs)*
(updated 2/16/09)
  • Aciphex®
  • Kapidex™ 
  • Prilosec® for oral suspension
  • Lansoprazole Powder (for pharmacy
    compounding only; doesn't include
    Prevacid brand products)
  • Prevacid®  
  • Protonix® 40mg Suspension
  • Zegerid® 
 Use PPI Fax Request Form 
Requests DO NOT need to be submitted for the preferred PPIs omeprazole, pantoprazole, or Nexium-®
Intranasal Steroids* (effective 10/1/09)
  • Beconase AQ®
  • Nasacort AQ®
  • Omnaris®
  • Rhinocort Aqua®
  • Veramyst®
 Use Intranasal Steroids Fax Request Form
Requests DO NOT need to be submitted for the preferred intranasal steroids flunisolide, fluticasone propionate, or Nasonex.
Oral Bisphosphonates* (effective 10/1/09)
  • Actonel®
  • Actonel® with Calcium
 Use Oral Bisphosphonates Fax Request Form
Requests DO NOT need to be submitted for the preferred bisphosphonates alendronate, Fosamax Plus D, or Boniva.

*The nonpreferred PPIs, intranasal steroids and oral bisphosphonates listed will be considered restricted access drugs that require an initial physician certification prior to being covered.

Quantity limitations*

The Quantity Limitations program sets quantity limits on a small number of medications. BCBSNC will cover the drug up to the designated quantity. If you, as the prescribing doctor, feel it is medically necessary to exceed the set limit, you must get prior approval from BCBSNC (1-800-672-7897) before the higher quantity can be covered. Refer to your patient's Member Guide for detailed information about 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.

Effective March 1, 2007, hypnotic drugs will be removed from the Quantity Limitations program. A supply limit of 20 tablets per 30 days will be implemented, and no requests for excess quantities will be accepted or approved.

The following is a list of drugs with quantity limits:

Drugs That Have Quantity Limits Utilization Management Criteria Physician Request
Triptans Use Triptan Fax Request Form
Quantity limit requests need only be submitted for members to get MORE than the allowable amounts listed.
Transmucosal Fentanyl Transmucosal Fentanyl Fax Form
Quantity limits only apply if transmucosal fentanyl is approved through the prior approval process.

Drugs not covered as a prescription benefit

Drugs indicated as such are not covered under BCBSNC's prescription drug benefit. Although, some of these drugs may be covered under BCBSNC's medical benefit. To find out whether a drug is covered under your patient's medical benefit, call the Customer Service telephone number listed on their ID card. For more information on prescription drug coverage and restrictions, see your patient's Member Guide.
The following are possible reasons why a drug may not be covered as a prescription drug benefit.

  • Benefit Exclusion (e.g. certain weight loss drugs, drugs used for cosmetic purposes, etc.)
  • Non Self-administered Injectable Medication (See Injectable Medication)
  • Vaccines
  • Allergy Sera
  • Biologicals, blood or blood plasma

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* 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.