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Prior Review and Limitations

Some drugs require more than a provider's prescription in order to be covered by Blue Cross NC.

This page provides details regarding the following; click on blue terms to take you to a specific section:

What You Need to Know:

Member benefit plan and formulary

Your patient's benefit plan and the associated formulary, or drug list, will help you determine which requirements apply to your patient when accessing their pharmacy benefits. The type of plan your patient has is printed on the front of their member ID card. The ID card also identifies the type of formulary, or drug list, with an Rx and a letter on the bottom-right of the card. These letters represent a formulary, or drug list, as follows:

Rx A, B, E, F, G, H, S, T = Enhanced Formulary
(both Enhanced 4 and Enhanced 5 tier plans have the same requirements below. Additionally, both Enhanced Commercial (C) and Enhanced Qualified Health Plan (Q) plans have the same requirements below)
Rx D, J, K = Basic Open Formulary
(both Basic Open Commercial (C) and Basic Open Qualified Health Plan (Q) plans have the same requirements below)
Rx L, M, N, P, U = Essential Formulary
(both Essential Commercial (C) and Essential Qualified Health Plan (Q) plans have the same requirements below)
Rx Q, R, V = Net Results Formulary

Accessing The Formulary

You can access your patient’s formulary, or drug list, by taking the following steps:

Step 1: From the provider homepage at, click on "Pharmacy Program." Under Prescription Drug Information, click on "search."

Step 2: On the Find a Drug or Pharmacy page, select Employers & Employee plans to list all possible formularies, then answer the question about the date on the ID card. Click in the drop down box to select the member's formulary, based on the letter on their ID card. Click in the drop down box to select the member's formulary, based on the letter on their ID card.

Step 3: Click on "See Drug Coverage."

Step 4: Enter the drug name in the search field, and provide dosage information. Then hit Submit. You will see if the medication is on the member's formulary and at what tier. Underneath this information, you will see "Helpful Documents." Click on the pdf with the name of the formulary. This document lists most drugs on the formulary with specific requirements like prior review. Definitions of possible terms you might see are located here.


Utilization Management

Some drugs need additional information from you before Blue Cross NC will cover them. A list of the majority of these drugs is provided below. In order to ensure that you have the most comprehensive list of requirements, we encourage you to look at your patient's specific formulary, or drug list. For steps on how to access your patient’s formulary see What You Need To Know.

The medications listed below under "Drug Search" are the drugs most frequently used by our members. The information provided will tell you per formulary what type of review is required. The criteria will tell you when Blue Cross NC will cover the medication per your patient's pharmacy benefits. A fax form is also listed, which indicates the information Blue Cross NC needs from you to process the medication request.

If you find the formulary indicates prior review and step therapy (PA, ST) are required for a medication on the Basic Open or Essential Formularies, but the drug is not listed below in the "Drug Search," please use this criteria. In order to send information to Blue Cross NC, this fax form should be used.

Explanation of terms in Drug Search

  • Criteria - This tells you what conditions must be met for your patient to receive the specific drug under their Blue Cross NC benefit.

  • The different types of review:
    • Prior Review: Your doctor will have to tell Blue Cross NC in writing that you meet our medical necessity criteria.

    • Quantity limitations (limits in the amount of medicine your insurance will cover): To encourage appropriate use, Blue Cross NC may set limits on how much medication can be received . This may include decreasing the number of pills taken per day without changing the total amount of medication. For example, moving from two 20 mg pills per day to one 40 mg pill per day. Your doctor will need to tell Blue Cross NC in writing that you meet our medical necessity criteria to get above the set amount.

    • Restricted access / step therapy: Blue Cross NC requires that you first try a drug (or device) that is not restricted before a restricted drug will be approved. You may be covered for a restricted drug if your doctor tells Blue Cross NC in writing that:
      • You have already used the non-restricted drug, and the non-restricted drug was not effective in treating the same condition.
      • Or, if your doctor thinks the non-restricted drug is likely to be harmful to your health or not effective in treating your condition.

    • Nonformulary (NF): You will need to confirm your patient has tried formulary alternatives first and they were ineffective or harmful. Additionally, medication specific clinical criteria must be met prior to approval (available in the Drug Search). A nonformulary medication is one which is not included in the list of drugs that are eligible for benefits under your Blue Cross NC plan. Not all formularies have nonformulary drugs.
  • Specialty drugs: Drugs classified by Blue Cross NC 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 drugs are limited to a 30-day supply and must be obtained through an in-network specialty pharmacy in order to receive in-network benefit

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

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

To find a drug, use the search above or select a letter from the list above.

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  • Specialty:
  • Prior Review Required On: ,
  • Prior Review Required:
  • Quantity Limits Required On: ,
  • Quantity Limits:
  • Restricted Access/Step Therapy On: ,
  • Restricted Access/Step Therapy:
  • Nonformulary on: ,
  • Nonformulary:
  • Criteria: ,
  • Fax Form: ,
  • Note:

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Requests for Drugs Not Listed on the Formulary — Essential and Net Results Only

If you recommend a drug that is not listed on the formulary, please check to see if there are any appropriate alternative medications which are part of your patient's formulary, or drug list. If not, a nonformulary exception request can be submitted to Blue Cross NC, which will need to meet this this criteria. Please keep in mind that if a medication has other utilization management requirements (such as, but not limited to, quantity limitations), those requirements will apply if the medication is approved through the nonformulary exception process. You may also include a request for quantity limitation exception when the request for the nonformulary exception is sent to Blue Cross NC for review.

In order for the review process to be completed, you must give all necessary information on the fax form, including your signature. We have found the most efficient way to accomplish this is for you to submit the forms directly to us. However, depending on your patient's plan, there may be different options; please read below.

For members whose ID card show L, M, N, P, Q, R, U or V after the letters Rx, the following formulary exception process would apply:

  • You can follow the instructions under "Submitting Requests to Blue Cross NC" OR
  • A member can submit a request; however, Blue Cross NC will need to contact you to obtain the necessary clinical information to review the request. We encourage you to work with your patient and determine the most appropriate method of submitting a request.
    • Once Blue Cross NC receives the member's request, we will contact you to obtain the necessary clinical information to review the request. You have 5 calendar days to submit the necessary clinical information.
Blue Cross NC will begin processing the request once sufficient information to make a decision is received, or within 5 calendar days of requesting the information from you, whichever is earlier. For members whose ID card shows N,P,Q or R after the letters Rx, Blue Cross NC will notify you of our decision within three business days. For members whose ID card shows L or M after the letters Rx, standard requests will be processed within 72 hours. For requests which meet the definition of urgent*, they will be processed within 24 hours.

*A request is defined as urgent when, in the prescriber's opinion, a delay would seriously jeopardize the life or health of the patient, the patient's ability to regain maximum function, or would subject the patient to severe pain that cannot be adequately managed without the care or treatment requested.

For all members on Essential or Net Results, if the request of the non-formulary drug is approved, the following tiers and associated benefits (listed in the member's benefit booklet) will apply:

Drug Type and Formulary Tier Assigned to Approved Nonformulary Drug
Non-specialty drug on Essential 5 tier formulary Tier 4
Non-specialty drug on Essential 6 tier formulary Tier 4
Non-specialty drug on Net Results formulary Tier 4
Specialty drug on Essential 5 tier formulary Tier 5
Specialty drug on Essential 6 tier formulary Tier 6
Specialty drug on Net Results formulary Tier 5

Submitting Utilization Management Requests to Blue Cross NC

Utilization Management Requests may include, but are not limited to, prior authorization for a prescription drug or requests for coverage of a restricted access drug or non-formulary drug. Members may start a request for coverage directly with Blue Cross NC (either by phone at 1-800-672-7897 or by submitting information on the fax form and faxing to the number on the bottom of the fax form). However, in order for the review process to be completed, you must give all necessary information on each fax form, including your signature. We have found the most efficient way to accomplish this is for you to submit the forms directly to us.

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

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

Unless otherwise noted, once Blue Cross NC has all information to make a decision, you 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.

Drug Benefit Limitations

Please be aware that not all benefit limits are listed in the table below. Self-funded / ASO group members should refer to their unique member guide or contact customer services for additional benefit limits which may apply to them (e.g. hypnotics, smoking cessation).

Drug Type Benefit Limit
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, Gonal-F) (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, Menopur) (1500 units)
  • Gonadotropin-releasing hormone antagonists (e.g. Cetrotide, Ganirelix) (3mg)
  • Progestins (e.g. Crinone 8% gel) (101.25g or 90 syringes/applicators)
  • Progestins (e.g. Progesterone suppositories, Endometrium suppositories) (90 units)
Sexual Dysfunction Drugs Related to Organic Disease (e.g., Cialis®, Viagra®, Caverject®) Underwritten and Individual / Family plans:
4 tablets or units per 30 days
Sexual Dysfunction Drugs Unrelated to Organic Disease All:
Not covered
Non-Food and Drug Administration (FDA) Approved Drugs All: Not covered; please see list for specific drugs that are not covered

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

Reviews on Specific Charges

  • Difference between brand and generic drugs - depending on your member's benefits, they may be charged more if they receive a brand drug when a generic is available. If there is a medical reason your patient must take the brand drug, Blue Cross NC may not require them to pay the difference if:
    • You send in a document to the Food and Drug Administration, informing them of your patient's inability to take the generic and giving the medical reasons why. Instructions and form to submit can be found at
    • You review the attached criteria, and if your patient meets these guidelines, submit information via this fax form or through CoverMyMeds.