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Prior Review and Limitations

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

This page provides details regarding the following:

  • What You Need To Know: General information regarding your patient’s plan and associated formulary (i.e., drug list)
  • Utilization Management: You may need to give BCBSNC additional information for your patient to receive specific drugs under their benefits. This allows all of us to work together to provide the safest, most effective and cost-efficient drugs.
  • Drug Benefit Limitations: Some drugs are subject to specific limitations.

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 corner of the card. These letters represent a formulary, or drug list, 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

Accessing Your Formulary

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

Step 1: Go to the provider page and Click on Pharmacy Program.

Step 2: Under Prescription Drug Information, click on the link “search.” This will take you to “Find a Drug".

Step 3: Select the member’s formulary name [see Member Benefit Plan and Formulary].

Step 4: Enter the drug name and dosage information. Once this information populates, you will see "Related Documents." Click on the pdf with the name of the formulary. This document lists drugs that are on the formulary along 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 BCBSNC will cover them. A list of these drugs is provided below. While we try to keep this list up-to-date, this list changes due to new drugs coming to the market. In order to know for sure if these requirements apply to a particular drug, search the formulary for the specific drug name in question. The requirements for approval will be listed under the criteria of each drug listing. For steps on how to access your patient’s formulary see Accessing the Formulary above.

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 have your provider use this criteria. If your patient meets the criteria, 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 drug cannot be used in its place, please use this criteria. If your patient meets the criteria, submit this completed fax form to the fax number on the bottom of the form.

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.

Drug Search

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.

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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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 BCBSNC benefit.

  • The different types of review:
    • Prior Review (PA)*:You will need to review BCBSNC clinical criteria and verify that your patient meets the requirements so they may receive the drug prescribed.
    • Quantity Limitations (QL)*:You will need to review BCBSNC clinical criteria and verify that your patient meets the requirements so they may receive the total amount prescribed. Your patient can still receive the medicine without BCBSNC review and approval, just not over a set amount.
    • Restricted Access/Step Therapy (RA/ST)*: You will need to confirm that your patient has tried specific, non-restricted access medicines first and that it was ineffective or harmful to them in the past (and you believe it will be ineffective or harmful again) before your patient can receive the other, non- restricted access medicine.
    • Nonformulary Exception: This type of review only applies to members on the Basic Closed formulary. You will need to (1) determine that the nonformulary drug is medically necessary and appropriate for your patient’s condition; (2) notify BCBSNC that your patient has tried drugs available on the formulary and that they were ineffective or harmful in the past (and you believe they will be ineffective or harmful again); and (3) prescribe the drug 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*: Drugs 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 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. In-network pharmacy options will vary based on your plan specific benefits.

*For more information and plan definitions, please see "Covered Services" and "Glossary" in your benefit booklet.

Submitting Requests to BCBSNC

Your patient may start a request for a drug by phone, or by downloading a fax form by searching for it in the Drug Search section. 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. 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 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.

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.

Drug Benefit Limitations

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, 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 gel) (104.4mg)
  • Progestins(e.g. Progesterone suppositories, Endometrium suppositories) (90 units)
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.