Prior Plan Approval
Prescription Drugs
Select the plan for which you would like to review prior review and quantity limitation information:
Blue Care®, Blue OptionsSM, 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:
| Drugs Requiring Prior Approval | Utilization Management Criteria | Physician Fax Request Form |
|---|---|---|
| Growth Hormones - update effective 3/1/12 | All Growth Hormones - updated UM criteria effective 3/1/12 |
Call 1-800-672-7897 for prior review |
| Insulin-like Growth Factors | All Insulin-like Growth Factors | Call 1-800-672-7897 for prior review |
| Cox 2 Inhibitors (e.g. Celebrex®) |
All Cox 2 Inhibitors | Use Cox 2 Fax Request Form |
| NSAID / Acid Reducers - Naproxen / esomeprazole (Vimovo®) (effective 10/1/10) - Ibuprofen / famotidine (Duexis®) (effective 10/1/11) |
Vimovo and Duexis |
Vimovo - effective 10/1/10 Duexis - effective 10/1/11 |
| Itraconazole (Sporanox ®) | Itraconazole | Use Itraconazole Fax Request Form |
| Disease Modifying Drugs for Multiple Sclerosis (MS)
- update effective 3/1/12 for new users - Betaseron® - Extavia® - Avonex® - Rebif® - Copaxone® - Gilenya® |
Disease Modifying Drugs for MS - updated criteria effective 3/1/12 for new users |
Disease Modifying Drugs for MS - effective 10/1/10 for new users |
| Natalizumab (Tysabri®) | Tysabri | Tysabri - effective 4/1/11 |
| Potassium Channel Blocker (Ampyra®) (effective 10/1/10) | Ampyra | Ampyra - effective 10/1/10 |
| Disease Modifying Antirheumatic Drugs (DMARD) - update effective 10/1/11 | ||
| - Actemra® - Orencia® - Remicade® - Rituxan® (for Rheumatoid Arthritis ONLY) |
||
| All Botulinum Toxins | FDA approved conditions | Call 1-800-672-7897 for prior review |
| Antipsoriatics - update effective 10/1/11 | ||
| Respiratory (Xolair®) |
Xolair® | Use Xolair® Fax Request Form |
| Intravenous (IVIG) and Subcutaneous (SCIG) Immune Globulins - Carimune® NF - Flebogamma® - Flegogamma® DIF - Gammagard® Liquid - Gammagard® S/D - Gammaplex® - Gamunex® - Gamunex®-C - Hizentra® - Octagam® - Privigen® - Vivaglobin® |
IV and SC immune globulin | Call 1-800-672-7897 for prior review |
| Fentanyl (Oral Transmucosal and Nasal) | Transmucosal and Nasal Fentanyl | Transmucosal and Nasal Fentanyl Fax Request Form |
| Respiratory Syncytial Virus (RSV) Prophylaxis: Palivizumab (Synagis®) (effective 7/1/2010) |
Synagis® | Synagis® - effective 7/1/10 |
| Drugs for Pulmonary Arterial Hypertension (PAH) - update effective 4/1/11 for new users - Tracleer® - Letairis® - Revatio® - Adcirca® - Flolan®, Veletri® (epoprostenol) - Remodulin® - Ventavis® - Tyvaso® |
|
|
| Antinarcoleptic Agents (effective 10/1/10) - Provigil® - Nuvigil® |
Antinarcoleptic Agents | Antinarcoleptic Agents - effective 10/1/10 |
| Cyclosporine ophthalmic emulsion (Restasis®) (effective 10/1/10 for new users) |
Restasis | Restasis - effective 10/1/10 for new users |
| Sipuleucel-T (Provenge®) | Cellular Immunotherapy for Prostate Cancer | |
| Collagenase clostridium histolyticum (Xiaflex®) |
Injectable Clostridial Collagenase for Fibroproliferative Disorders |
|
| Montelukast (Singulair®) (effective 4/1/11) |
Singulair |
Singulair - effective 4/1/11 |
Androgens (effective 7/1/11 for all users)
|
Androgens |
Androgens - effective 4/1/11 |
Anabolic Steroids (effective 4/1/11)
|
Oxandrolone (Oxandrin) Oxymetholone (Anadrol-50) |
Oxandrolone (Oxandrin) Oxymetholone (Anadrol-50) - effective 4/1/11 |
Immunomodulators (effective 7/1/11)
|
Revlimid Thalomid - effective 7/1/11 |
|
Lidocaine patch (Lidoderm®) |
Lidoderm | Lidoderm - effective 7/1/11 |
| Topical Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) (effective 7/1/11)
|
Voltaren Gel Flector Patch - effective 7/1/11 Pennsaid - effective 10/1/11 |
|
| Topical Retinoids Tretinoin Products (effective 7/1/11)
Tazarotene (Tazorac®) (effective 7/1/11) Adapalene Products (effective 7/1/11)
|
Topical Tretinoin Products Tazarotene (Tazorac) Adapalene Products - effective 7/1/11 |
|
Hepatitis C therapy - effective 10/1/11
|
Hepatitis (effective 10/1/11) |
|
| Sodium oxybate (Xyrem®) - effective 10/1/11 | Xyrem - effective 10/1/11 | |
| Teriparatide (Forteo®) - effective 10/1/11 | Forteo - effective 10/1/11 | |
| Denosumab (Prolia®, Xgeva®) - effective 10/1/11 | Prolia, Xgeva - effective 10/1/11 | |
| Belimumab (Benlysta®) - effective 10/1/11 | Benlysta - effective 10/1/11 | |
| Ipilimumab (Yervoy®) - effective 10/1/11 | Call 1-800-672-7897 for prior review | |
| Vemurafenib (Zelboraf®) - effective 9/1/11 | Zelboraf |
|
| Tadafil (Cialis®) - effective 12/1/11 | Cialis |
|
| Tesamorelin (Egrifta®) - effective 3/1/12 | Egrifta |
Restricted-Access Drugs
For the non-preferred 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.
| Restricted-Access Drug Classes | Nonpreferred Drugs | Physician Fax Request Form |
|---|---|---|
| Angiotensin Receptor Blockers (ARBs) - (effective 7/1/11) |
|
Use Restricted-Access Drugs Request Form. Requests DO NOT need to be submitted for the preferred ARBs losartan, losartan/HCTZ, Diovan, Diovan HCT, Micardis, and Micardis HCT. |
| Renin Inhibitors - (effective 3/1/12 New users only) |
|
Requests DO NOT need to be submitted for the preferred ARBs losartan, losartan/HCTZ, Diovan, Diovan HCT, Micardis, and Micardis HCT |
| Tetracyclines |
|
Use Restricted-Access Drugs Request Form. Requests WILL NOT need to be submitted for the preferred tetracyclines doxycycline/hyclate (generic) and minocycline (generic). |
| Proton Pump Inhibitors (PPIs) |
|
Use Restricted-Access Drugs Request Form Requests DO NOT need to be submitted for the preferred PPIs omeprazole, pantoprazole, lansoprazole, omeprazole/sodium bicarbonate caps, and Nexium-® |
| Intranasal Steroids |
|
Use Restricted-Access Drugs Request Form Requests DO NOT need to be submitted for the preferred intranasal steroids flunisolide, fluticasone propionate, or Nasonex. |
| Oral Bisphosphonates - (updated 7/11) |
|
Use Restricted-Access Drugs Request Form Requests DO NOT need to be submitted for the preferred bisphosphonates alendronate, Fosamax Plus D, or Boniva. |
| Selective Serotonin Reuptake Inhibitors (SSRI) Antidepressants1 |
|
Use Anti-Depressant Restricted Access Certification Fax Form Requests DO NOT need to be submitted for the preferred SSRIs citalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline. |
| Serotonin-Norepinephrine Reuptake Inhibitor (SNRI) Antidepressant1 |
|
Use Anti-Depressant Restricted Access Certification Fax Form Requests DO NOT need to be submitted for the preferred SNRI antidepressant venlafaxine. |
| Drugs for Migraines (Triptans) Quantity Limitations may also apply to all triptans. See Quantity Limitations below. |
|
Use Triptans Fax Request Form Requests DO NOT need to be submitted for the preferred Triptans sumatriptan, naratriptan, Maxalt/MLT, and Relpax. |
| Hypnotic Agents A benefit limit may apply to hypnotic agents. |
|
Use Restricted-Access Drugs Request Form Requests DO NOT need to be submitted for the preferred Hypnotic Agents zaleplon and zolpidem. |
Topical Retinoids - (effective 7/1/11) |
Brand-name:
|
Use the appropriate prior approval fax request form: |
1Certification is not required for patients already taking a nonpreferred SSRI antidepressant (prescription claim within the past 12 months).
Quantity Limitations
BCBSNC covers certain medications up to a set quantity. Quantity limitations are designed to help identify excessive use of drugs.
If a physician feels it is medically necessary to exceed quantity limitations on your medication, he must get prior review from BCBSNC at 1-800-672-7897 before a higher quantity will be covered.
The following is a list of drugs with quantity limits:
| Drugs with 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. |
|
| Fentanyl (Oral Transmucosal and Nasal) | Transmucosal and Nasal Fentanyl Fax Request Form Quantity limits only apply if transmucosal fentanyl is approved through the prior review process. |
|
Lidocaine patch (Lidoderm®)- |
Lidoderm Fax Form Quantity Limits only apply if Lidoderm is approved through the prior review process. |
|
| Disease Modifying Antirheumatic Drugs (DMARD) - effective 10/1/11 | Effective 10/1/11. Quantity Limits only apply if the DMARD is approved through the prior review process.
|
Benefit Limits
Certain 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.
| Drug Type | Benefit Limit |
|---|---|
| Hypnotics ("sleeping pills," e.g., Ambien®, Lunesta®, Sonata®, Zolpidem, Intermezzo) | 20 tablets or capsules per 30 days* |
| Infertility Drugs | $5,000 per benefit period (usually a calendar year) |
| Sexual Dysfunction Drugs (e.g., Cialis®, Viagra®, Caverject®) | 4 tablets or units per 30 days |
| Smoking Cessation Drugs | 1 treatment episode per year, 2 treatment episodes per lifetime* |
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.
