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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 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:

Drugs That Require Prior Review Utilization Management Criteria Physician Fax Request Form
Growth Hormones All Growth Hormones 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
Antifungals
(Lamisil®, Sporanox®)		 Antifungals Use Antifungal Fax Request Form
Disease Modifying Antirheumatic Drugs
All Botulinum Toxins FDA approved conditions Call 1-800-672-7897 for prior review
Antipsoriatics
Respiratory
(Xolair®)		 Xolair® Use Xolair® Fax Request Form
Orencia®
Remicade®
Rituxan® (for Rheumatoid Arthritis ONLY)
Intravenous Immune Globulins (IVIg)
(Effective 1/1/2010)
- Carimune NF
- Flebogamma
- Flegogamma DIF
- Gammagard Liquid
- Gammagard S/D
- Gamunex
- Octagam
- Privigen
Subcutaneous Immune Globulins (SCIg)
(Effective 1/1/2010)
- Vivaglobin		 IV and SC immune globulin Call 1-800-672-7897 for prior review
Transmucosal Fentanyl Transmucosal Fentanyl Use Transmucosal Fentanyl Fax Request Form


Restricted-Access Drugs

For 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.

Restricted-Access Drug Classes Nonpreferred drugs Physician Fax Request Form
Proton Pump Inhibitors (PPIs)
(updated 11/09)
  • Aciphex®
  • Kapidex™ 
  • Prilosec® for oral suspension
  • Lansoprazole Powder (for pharmacy
    compounding only; doesn't include
    Prevacid brand products)
  • Prevacid®SoluTabs; granules for suspension  
  • Protonix® 40mg Suspension
  • Zegerid® 
 Use Restricted-Access Drugs Request Form 
Requests DO NOT need to be submitted for the preferred PPIs omeprazole, pantoprazole, lansoprazole, and Nexium-®
Intranasal Steroids (effective 10/1/09)
  • Beconase AQ®
  • Nasacort AQ®
  • Omnaris®
  • Rhinocort Aqua®
  • Veramyst®
 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 (effective 10/1/09)
  • Actonel®
  • Actonel® with Calcium
 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) Antidepressants (effective 4/1/10)1
  • Lexapro®
  • Luvox CR®
  • Pexeva®
 Use Restricted-Access Drugs Request Form
Requests DO NOT need to be submitted for the preferred SSRIs citalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline.
Drugs for Migraines (Triptans) (effective 4/1/10) Quantity Limitations may also apply to all triptans. See Quantity Limitations below.
  • Amerge®
  • Axert®
  • Frova®
  • Sumavel™ DosePro™
  • Treximet®
  • Zomig, Zomig ZMT®
 Use Triptans Fax Request Form
Requests DO NOT need to be submitted for the preferred Triptans sumatriptan, Maxalt/MLT, and Relpax.
Hypnotic Agents (effective 4/1/10) A benefit limit may apply to hypnotic agents.
  • Ambien CR®
  • Edluar®
  • Lunesta®
  • Rozerem®
  • Zolpimist®
 Use Restricted-Access Drugs Request Form
Requests DO NOT need to be submitted for the preferred Hypnotic Agents zaleplon and zolpidem.

1Certification is not required for patients already taking a nonpreferred SSRI antidepressant (prescription claim within the past 12 months).

Quantity limitations

The 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:

Drugs That Have 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.
Transmucosal Fentanyl Transmucosal Fentanyl Fax Form
Quantity limits only apply if transmucosal fentanyl 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) 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

Drugs not covered as a prescription benefit

Drugs 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.
The following are possible reasons why a drug may not be covered as a prescription drug benefit.

  • Benefit Exclusion (e.g. certain weight loss drugs, drugs used for cosmetic purposes, etc.)
  • Non Self-administered Injectable Medication (See Injectable Medication)
  • Vaccines
  • Allergy Sera
  • Biologicals, blood or blood plasma

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* 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.