Prior plan approvalPrescription drugsSelect the plan for which you would like to review prior review and quantity limitation information: Blue Care®, Blue OptionsSM, Blue Choice®, Blue Advantage®To learn about prior review 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 review 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 review:
Restricted-Access DrugsFor the nonpreferred prescription drugs listed below, BCBSNC requires that the member has tried a preferred drug or device. Coverage for these prescription drugs may be provided without the use of a preferred drug or device if the provider certifies in writing that the member has previously used a preferred drug or device and the preferred drug or device has been detrimental to the member's health or has been ineffective in treating the same condition and, in the opinion of the provider, is likely to be detrimental to the member's health or ineffective in treating the condition in the future.
1Certification is not required for patients already taking a nonpreferred SSRI antidepressant (prescription claim within the past 12 months). Quantity limitationsThe 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 review 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. The following is a list of drugs with quantity limits:
Benefit LimitsCertain medications have set quantity limits per days supply that are not available for physician override but are set supply limitations per a member’s plan benefit. The following list contains standard benefit limits. Some groups may have different amounts according how the specific benefit was designed.
To learn more about prior review or quantity limitations for enrolled federal and state employees, please visit the Federal Employee Plan site or the State Health Plan site. * This standard benefit limit no longer applies for underwritten groups effective July 1, 2010 (regardless of the group's renewal/effective date) due to the Mental Health Parity Addiction and Equity Act (MHPAEA) and associated regulations. Effective July 1, 2010, the standard benefit for underwritten groups will be no benefit limit; however, clinical and safety limits may apply. For self-funded/ASO groups, check your benefit booklet or call customer service to confirm the benefit limit. Drugs not covered as a prescription benefitDrugs 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.
* 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. |
