Prior Review and Limitations

Some medications require more than a prescription in order to be covered by BCBSNC.

The medications below require that members meet certain criteria and providers answer specific questions. This allows all of us to work together to provide members with the safest, most effect and cost efficient medications.


What You Need to Know:

Members benefit plans

A member's benefit will help you determine which requirements apply to them. The member's plan type is printed on the front of their member ID card and the formulary name is indicated on the bottom right of their card and is identified as follows:


Rx A, B, E, F = Enhanced Formulary
(both Enhanced 4 and Enhanced 5 tier plans have the same requirements below)
Rx C = Basic Closed Formulary
Rx D = Basic Open Formulary

Drug list guide (In general):

  • Blue Advantage, Blue Care or Blue Options (all types) – Use the Enhanced Formulary (this covers members on Enhanced 4-tier and Enhanced 5-tier plans)
  • Blue Value or Blue Select plans which had an original start date effective in 2013 – Use the Basic Closed Formulary
  • Blue Value or Blue Select, which had an original start date of Jan. 1, 2014, or after and Blue Local with Carolinas HealthCare – Use the Basic Open Formulary

*PLEASE NOTE: If a member changes benefit plans, you may need to verify again that the member has met our clinical criteria under that new policy.

Where a member can receive drugs

Some medications can be received through a retail pharmacy store, mail order pharmacy, a doctor's office or outpatient facility. Medications that are dispensed through a retail pharmacy store and/or mail order pharmacy may be covered under the pharmacy benefit, while medications administered in a doctor's office and/or an outpatient facility may be covered under the medical benefit.

Criteria

This tells you what conditions must be met in order for the member to receive the specific drug under their BCBSNC benefit.

The different types of review:

  • Prior Review (PA)*: Providers will need to review BCBSNC clinical criteria and verify that members meet the requirements so they may receive the medication prescribed.
  • Quantity Limitations (QL)*: Providers will need to review BCBSNC clinical criteria and verify that members meet the requirements so they may receive the total amount prescribed. Members can still receive the medicine without BCBSNC review and approval, if a prior authorization is not required, just not over a set amount.
  • Restricted Access/Step Therapy (RA/ST)*: Providers will need to confirm that members have tried specific, preferred medicine and that it was ineffective or harmful to them in the past (and the provider believes it will be ineffective or harmful again) before the member can receive other, non-preferred medicine.
  • Nonformulary Exception: This type of review only applies to members on the Basic Closed formulary. Providers will need to (1) determine that the nonformulary medication is medically necessary and appropriate for the member's condition; (2) notify BCBSNC that the member has tried medications available on the formulary and that they were ineffective or harmful in the past (and the provider believes they will be ineffective or harmful again); and (3) prescribe the medication in accordance with applicable BCBSNC clinical protocol or have it be approved as an exception through BCBSNC's exception process.

    The benefits for any nonformulary exception approvals will be as follows:
    • Generic drugs will be subject to tier 2 non-preferred generic benefit
    • Brand-name drugs will be subject to tier 4 non-preferred brand-name benefit
    • Specialty drugs will be subject to tier 5 specialty drug benefit
  • Specialty drugs*: Medications classified by BCBSNC which generally have a unique indication or use, require special dosing or administration, are typically prescribed by a specialist, or are significantly more expensive than alternative therapies. These medications are limited to a 30-day supply and must be obtained through an in-network specialty pharmacy in order to receive in-network benefit.

*For more information and plan definitions, please see "Glossary" in The Blue Book.

Searching for Drugs Which Require Review

The list below contains the majority of drugs which fall under the requirement of prior review, quantity limitations and restricted access / step therapy for the enhanced tier 4 and enhanced tier 5 [shown as enhanced], the basic closed and the basic open formularies. The list also identifies if any of these drugs are considered nonformulary under the basic closed formulary.  While we attempt to keep this website up to date, these lists are continually changing due to new medications coming to the market, so this list is not comprehensive.

The best way for members to stay current with the requirements for their formulary is to sign in under Member Services and go to "Find a Drug."  Providers can locate additional specific requirements in the printed formularies under “Find a Drug.”

If a drug on the Basic Open Formulary indicates a requirement for prior review and step therapy (PA, ST) but is not in the list of drugs below, please use this criteria. If the member meets the criteria, have the provider submit the completed form to the fax number on the bottom of the form.

Some drugs are not included on the Basic Closed Formulary. If a drug is not listed under "Find a drug" for the Basic Closed Formulary and another medication cannot be used in its place, please use this criteria. If the member meets the criteria, have the provider submit this completed fax form to the fax number on the bottom of the form.

Submitting Requests to BCBSNC

Members may start a request for a medication by phone, or by downloading a fax form by searching for it in the Search section below. However, in order for the review process to be completed, your physician must provide information on each fax form, including their signature. We have found the most efficient way to accomplish this is for your provider to submit the forms directly to us. This can be done in the following ways:

Electronic (preferred): We have teamed with CoverMyMeds to offer electronic review submissions, which allows for fast processing, and for some medications to be immediately determined. If a medication is approved through the system, the pharmacy will have your authorization in less than 2 hours.

Fax: They can fax a completed copy to us. Faxes can be sent to the fax number on the bottom of the form, or 1-800-795-9403.

Once BCBSNC has all information to make a decision, your provider will hear back from us within three business days. If there are questions about submitting a review, or its status, we can be reached at 1-800-672-7897.

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Drug Benefit Limitations

Some drugs have benefit limitations. View drug benefit limitation list.


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

Brand Drug Name: {{header}}


  • Generic Drug Name:
  • Benefit: ,
  • Specialty:
  • Prior Review Required On: ,
  • Prior Review Required:
  • Quantity Limits Required On: ,
  • Quantity Limits:
  • Restricted Access/Step Therapy On: ,
  • Restricted Access/Step Therapy:
  • Non-formulary Exception Review Required On: Basic Closed Formulary
  • Criteria: ,
  • Fax Form: ,
  • Note:


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Benefit Limits

Drug Type Benefit Limit
Hypnotics ("sleeping pills," e.g., Ambien®, Lunesta®, Sonata®, Zolpidem, Intermezzo) Individual & family plans and Underwritten groups: No limit
Self funded / ASO groups: Refer to member guide or contact Customer service
Infertility Drugs For groups which in 2013 had a $5000 lifetime maximum and were able to carry this over due to updates to the Affordable Care Act, this benefit will remain available. Otherwise, the benefit is as follows (call Customer Service to confirm):

Underwritten and Individual/Family plans:
Infertility drugs are limited to the following lifetime maximum per member:
  • Follitropins (e.g. Bravelle, Follistim, Follistim AQ) (3000 units)
  • Oral ovulation stimulants (Clomid) (360 tablets)
  • Subcutaneous injectable ovulation stimulants (e.g. Ovidrel) (1,000 micrograms)
  • Subcutaneous injectable ovulation stimulants (e.g. Luveris) (1500 units)
  • Intramuscular injectable ovulation stimulants (e.g. Novarel, Pregnyl) (40,000 units)
  • Menotropins (e.g. Repronex) (1500 units)
  • Gonadotropin-releasing hormone antagonists (e.g. Cetrotide, Ganirelix) (3mg)
Self funded / ASO groups:
Call customer service to confirm
Sexual Dysfunction Drugs Related to Organic Disease (e.g., Cialis®, Viagra®, Caverject®) Underwritten and Individual / Family plans:
4 tablets or units per 30 days
Self funded / ASO groups:
Call customer service to confirm
Sexual Dysfunction Drugs Unrelated to Organic Disease All:
Not covered
Smoking Cessation Drugs Individual & family plans and Underwritten groups: No limit
Self funded / ASO groups: Refer to member guide or contact Customer service



If you are unsure whether your group is an underwritten or self funded/ASO group, call the customer service number listed on the back of your ID card for assistance.

 

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