Prior Approval and Quantity Limitations

Prior Approval

Some medications require prior approval from BCBSNC before the prescription can be accepted for payment.

Blue Care^SM, Blue Options^SM, Blue Choice^SM, and Blue Advantage^SM

Prior approval requires that your physician contact BCBSNC at 1-800-672-7897 or fax a request form to 1-800-795-9403.

Drugs Requiring Prior Approval	Utilization Management Criteria	Physician Fax Request Form
Growth Hormones	All Growth Hormones	Call 1-800-672-7897 for prior approval
Insulin-like Growth Factors	All Insulin-like Growth Factors	Call 1-800-672-7897 for prior approval
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	Enbrel® KineretTM Humira® Cimzia® Simponi®	Enbrel® KineretTM Humira® Cimzia® Simponi® effective 10/1/09
All Botulinum Toxins	FDA approved conditions	Call 1-800-672-7897 for prior approval
Antipsoriatics	Amevive® Enbrel® Humira®	Amevive® Enbrel® Humira®
Respiratory (Xolair®)	Xolair®	Use Xolair® Fax Request Form
Orencia® Remicade® Rituxan® (for Rheumatoid Arthritis ONLY)	Orencia® Remicade® Rituxan® (Prior Approval required for Rheumatoid Arthritis ONLY)	Orencia® Remicade® Rituxan® (Prior Approval required 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 approval
Transmucosal Fentanyl	Transmucosal Fentanyl	Use Transmucosal Fentanyl Fax Request Form

Restricted-Access Drugs

The nonpreferred drugs listed below are considered restricted-access drugs that require an initial physician certification prior to being covered.

Restricted-Access Drug Classes	Nonpreferred drugs	Physician Fax Request Form
Proton Pump Inhibitors (PPIs) (updated 11/09)	Aciphex® Kapidex™ Lansoprazole Powder (for pharmacy compounding only; doesn't include Prevacid brand products) Prevacid® SoluTabs; granules for suspension Prilosec® for oral 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

BCBSNC covers certain medications up to a set quantity. Quantity limitations are designed to help identify excessive usage of drugs.

If a physician feels it is medically necessary to exceed quantity limitations on your medication, they must get prior approval 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	Amerge® Axert® Frova® Sumatriptan (Imitrex® Sumavel™ DosePro™) Maxalt® Relpax® Zomig® Treximet®	Use Triptans Fax Request Form Quantity limit requests need only be submitted for members to get MORE than the allowable amounts listed.
Transmucosal Fentanyl	Actiq/fentanyl lozenges and Fentora®	Transmucosal Fentanyl Fax Form Quantity limits only apply if transmucosal fentanyl is approved through the prior approval process.

To learn more about prior approval or quantity limitations for enrolled federal and state employees, please visit the Federal Employee Plan site or the State Health Plan site.